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 D

Explanation

Wearing shoes with rubber soles can minimize noise and provide a quieter environment for the clients. It helps reduce disruptions caused by footsteps, especially during nighttime when clients are trying to sleep.

Conducting change-of-shift reports near the clients' rooms can lead to increased noise levels and disturb clients' sleep. It is best to conduct reports in a designated area away from patient rooms to minimize disruptions.

Turning on overhead lights briefly when checking IV lines can disturb clients' sleep, especially if done during nighttime. The use of alternative light sources or dimmed lighting can be less disruptive.

Opening curtains between clients in semiprivate rooms can compromise privacy and contribute to increased noise levels. It is important to provide privacy for clients, especially during their rest periods.

A. "Client stated, "I lost my balance and fell when I got out of bed to go to the bathroom!" B. "The client fell because the assistive personnel did not place nonskid slippers on the client." C. The client does not appear to have any injuries resulting from the fall." D. "An incident report has been completed and sent to risk management."

Correct Answer is A

Explanation

This statement accurately reflects the client's own account of what happened, providing important information about the circumstances leading to the fall. Including the client's statement helps document the client's perspective and can contribute to a more comprehensive understanding of the event.
B. "The client fell because the assistive personnel did not place nonskid slippers on the client." This statement assigns blame to the assistive personnel without sufficient evidence. It is important to maintain objectivity and avoid making assumptions or assigning fault without proper investigation or documentation of facts.
C. "The client does not appear to have any injuries resulting from the fall." While it is important to assess the client for any injuries after a fall, documenting this information may be more appropriate in the client's assessment or nursing notes rather than in the specific documentation about the fall incident itself.
D. "An incident report has been completed and sent to risk management." While it is important to report falls and complete an incident report for quality improvement and risk management purposes, this information is more relevant to internal documentation and reporting processes rather than inclusion in the medical record for the client's care.

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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?