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 A
Explanation
Choice A reason: This is the correct meal selection, because chicken breast and corn on the cob are low in cholesterol and saturated fat, which can help lower the risk of heart disease.
Choice B reason: This is an incorrect meal selection, because shrimp and rice are high in cholesterol and refined carbohydrates, which can increase the blood cholesterol and glucose levels.
Choice C reason: This is an incorrect meal selection, because cheese omelet and turkey bacon are high in cholesterol and sodium, which can raise the blood pressure and worsen the cardiac function.
Choice D reason: This is an incorrect meal selection, because liver and onions are high in cholesterol and iron, which can contribute to the formation of plaque and clots in the arteries.
Correct Answer is C
Explanation
Choice A reason: Irrigating the catheter with sterile water is an incorrect action, because the catheter should be irrigated with sterile normal saline (0.9% sodium chloride) to prevent hemolysis of the red blood cells.
Choice B reason: Clamping the drainage catheter during ambulation is an incorrect action, because the catheter should be kept patent and unclamped at all times to prevent obstruction and infection.
Choice C reason: Reporting viscous drainage with clots to the provider is a correct action, because it indicates that the irrigation is not effective and the client may need manual irrigation or surgical intervention.
Choice D reason: Removing the catheter if the client feels a strong urge to urinate is an incorrect action, because the catheter should be left in place until the provider orders its removal. The client may feel a sensation of bladder fullness or spasms due to the irrigation fluid, which can be relieved by medication or adjustment of the flow rate.
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