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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Soiled linens are placed on the floor.

Soiled linens placed on the floor can potentially harbor pathogens and serve as a source of infection. It is important to handle soiled linens properly by placing them in designated containers or bags for proper disposal or laundering.

Dampened cloths used for dusting the area in (option B) is incorrect because it may be a source of infection if they are not properly cleaned and disinfected between uses. It is important to use clean and dry cloths for dusting, or if dampened cloths are used, they should be washed and disinfected regularly.

Uncapped sharps put in a puncture-resistant container in (option C) is incorrect because are not a direct source of infection. However, it is crucial to handle sharps safely to prevent accidental needlestick injuries and potential transmission of bloodborne pathogens. Proper disposal of sharps in puncture-resistant containers is important for safety and infection control.

Waste containers lined with single bags in (option D) is incorrect because they are not a direct source of infection. Using single bags in waste containers helps with proper disposal and prevents leakage or spillage of waste materials. It is important to handle and dispose of waste according to institutional policies and infection control guidelines.

In summary, when caring for an immunocompromised client, the nurse should be vigilant about sources of infection. Placing soiled linens on the floor can be a potential source of infection and should be avoided. Proper handling of sharps, using clean cloths for dusting, and following appropriate waste disposal practices are also important for infection control.

A. Apply a warm compress. B. Document the infiltration. C. Stop the infusion. D. Elevate the arm.

Correct Answer is C

Explanation

The presence of edema and coolness around the catheter's insertion site suggests that infiltration may have occurred. Infiltration refers to the unintended leakage of fluid into the surrounding tissues instead of flowing into the vein. It can lead to tissue damage and compromised circulation. Stopping the infusion is the initial priority to prevent further infiltration and minimize potential harm to the client.
A. Applying a warm compress may be appropriate to promote comfort and circulation in some cases, but it should be done after stopping the infusion and assessing the severity of the infiltration.
B. Documenting the infiltration is necessary for accurate record-keeping and to communicate the occurrence to the healthcare team. However, it is not the first immediate action required in this situation.
D. Elevating the arm can help reduce swelling and promote venous return. It can be done after stopping the infusion, but it is not the first action to address the potential infiltration.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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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?