A nurse is contributing to the plan of care for a client who has urinary incontinence.
Which of the following interventions should the nurse include in the plan?
Keep the head of the client's bed elevated to 45".
Limit periods of sitting in a chair to 4 hr.
Use a no-rinse perineal cleanser after incontinence.
Avoid the use of draw sheets for repositioning.
The Correct Answer is C
Urinary incontinence is the involuntary loss of urine, and it can have various causes and contributing factors. When developing a plan of care for a client with urinary incontinence, it is important to address interventions that promote comfort, hygiene, and prevention of complications.
using a no-rinse perineal cleanser after incontinence, is an appropriate intervention for maintaining skin hygiene and preventing skin breakdown. Cleansing the perineal area after episodes of urinary incontinence helps to remove any urine residue and reduce the risk of skin irritation or infection. No-rinse cleansers are often preferred as they are gentle on the skin and do not require rinsing, which can be more convenient for the client.
keeping the head of the client's bed elevated to 45 degrees in (option A) is incorrect because it, is not directly related to managing urinary incontinence. This intervention is typically used for clients at risk for aspiration or to improve respiratory function.
limiting periods of sitting in a chair to 4 hours in (option B) is incorrect because it, may be beneficial to prevent prolonged pressure on the pelvic floor muscles and promote circulation. However, it does not specifically address managing urinary incontinence.
avoiding the use of draw sheets for repositioning in (option D) is incorrect because it, is not directly related to managing urinary incontinence. Draw sheets are commonly used to assist with repositioning and transferring clients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Diminished pulses in the affected extremity can indicate compromised circulation, which is a serious concern. It could suggest the development of compartment syndrome, a condition characterized by increased pressure within the muscles and tissues of the leg. Compartment syndrome can lead to tissue damage and potentially jeopardize the client's limb. Therefore, it is crucial for the nurse to recognize and address this finding promptly.
One fingerbreadth of space between the cast and the skin is generally considered an appropriate amount of space to allow for swelling and adequate circulation. However, it should still be monitored for any changes or signs of compartment syndrome.
Ecchymosis on the inner left thigh may indicate bruising, which could be related to the injury or the application of the cast. While it should be documented and monitored, it does not pose an immediate threat to the client's well-being.
The client reported that muscle spasms of the left leg can be a common occurrence due to muscle immobility and discomfort associated with the cast. Although it should be assessed and managed for the client's comfort, it is not as urgent as addressing compromised circulation.
Correct Answer is B
Explanation
Incident report
When a nurse makes a medication error, such as administering an incorrect dose or an extra dose, it is important to document the incident in an incident report. Incident reports are confidential documents that provide a record of the event, facilitate communication among healthcare providers, and allow for further investigation and analysis to prevent future errors.
Provider's progress notes in (option A) is incorrect. The provider's progress notes are typically used to document the provider's assessment, diagnosis, treatment plan, and progress of the client. Medication errors made by nursing staff are not typically documented in the provider's progress notes.
Controlled substance inventory record in (option C) is incorrect. The controlled substance inventory record is used to track the administration and use of controlled substances. It may not be the appropriate location to document a medication error. However, it is important to follow institutional policies regarding the documentation of medication errors involving controlled substances.
Nursing care plan in (option D) is incorrect. The nursing care plan is a document that outlines the nursing diagnoses, goals, interventions, and evaluations related to the client's care. While medication administration may be a part of the nursing care plan, documenting a medication error in this location is not the standard practice. Incident reports are specifically designed for reporting and documenting errors or incidents that occur during client care.
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