A nurse is contributing to the plan of care for a client who had a stroke. The client has hemiplegia and occasional urinary incontinence. Which of the following interventions should the nurse recommend?
Offer the client a bedpan every 2 hr.
Limit the client's daily fluid intake until he is no longer incontinent.
Request a prescription for an indwelling urinary catheter from the client's provider.
Ambulate the client to the bathroom every 30 min.
The Correct Answer is A
Choice A reason: This is the best intervention, because offering the client a bedpan every 2 hr can help prevent urinary retention, bladder distension, and infection, which can worsen the incontinence. It can also help maintain the client's dignity and comfort, and promote bladder retraining.
Choice B reason: This is an incorrect intervention, because limiting the client's daily fluid intake can cause dehydration, constipation, and urinary tract infection, which can aggravate the incontinence. The client should drink adequate fluids, unless the provider instructs otherwise.
Choice C reason: This is an incorrect intervention, because requesting a prescription for an indwelling urinary catheter is not recommended for a client who has occasional urinary incontinence. An indwelling urinary catheter can increase the risk of infection, trauma, and obstruction, and interfere with the bladder function. The nurse should use other methods of bladder management, such as intermittent catheterization, external catheter, or incontinence pads.
Choice D reason: This is an incorrect intervention, because ambulating the client to the bathroom every 30 min can be unrealistic, exhausting, and unsafe for a client who has hemiplegia, or paralysis of one side of the body, due to a stroke. The client may not be able to walk or transfer without assistance, and may fall or injure themselves. The nurse should assess the client's mobility and ability to use the bathroom, and provide appropriate aids and support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is an incorrect statement, because the client should avoid any body piercings, tattoos, or other procedures that can cause skin or mucosal trauma and increase the risk of bacterial infection and endocarditis. The client should also seek medical attention if they have a fever or other signs of infection.
Choice B reason: This is a correct statement, because the client should notify their doctor before they have dental procedures, such as cleaning, filling, or extraction, that can cause bleeding and introduce bacteria into the bloodstream. The client may need prophylactic antibiotics to prevent endocarditis.
Choice C reason: This is a partially correct statement, because the client should floss their teeth twice a day as a part of their oral care, but this is not enough to prevent recurrence of endocarditis. The client should also brush their teeth with a soft toothbrush after each meal, use an antiseptic mouthwash, and visit their dentist regularly.
Choice D reason: This is an unnecessary statement, because the client does not need to wear a mask when they go out in public, unless they have a respiratory infection or are exposed to someone who has one. Endocarditis is not transmitted by airborne or droplet routes, but by direct contact with the infected heart valves or blood.
Correct Answer is B
Explanation
Choice A reason: This is an important data, but not the first one. The nurse should first assess the client's airway, breathing, and circulation, which are the priorities in any emergency situation.
Choice B reason: This is the correct data, because the nurse should first collect the respiratory rate to determine if the client has any signs of airway obstruction, inhalation injury, or respiratory distress, which are life-threatening complications of facial burns.
Choice C reason: This is a relevant data, but not the first one. The nurse should collect the presence of bowel sounds later, after ensuring the client's airway, breathing, and circulation are stable, to assess the client's gastrointestinal function and possible paralytic ileus.
Choice D reason: This is a significant data, but not the first one. The nurse should collect the level of pain later, after ensuring the client's airway, breathing, and circulation are stable, to provide adequate analgesia and comfort measures.
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