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

Bright red vaginal bleeding

Placenta previa is a condition in which the placenta partially or completely covers the opening of the cervix. One of the hallmark findings of placenta previa is painless, bright red vaginal bleeding, typically occurring in the later stages of pregnancy. This bleeding can be sudden and heavy or intermittent. It is important for the nurse to recognize this sign and promptly report it to the healthcare provider.

Increased fetal movement in (option A) is incorrect: Fetal movement is not directly related to placenta previa and may vary depending on the individual fetus.

Persistent uterine contractions in (option B): Persistent uterine contractions are more commonly associated with conditions such as preterm labour or uterine irritability, rather than placenta previa.

Rigid abdomen in (option C): A rigid abdomen may indicate uterine hypertonus or other complications, but it is not a specific finding of placenta previa.

A. Encourage prolonged dangling before ambulation. B. Irrigate the indwelling catheter with 500 mL of fluid. C. Administer an enema. D. Assist the client with a sitz bath. E. Encourage oral fluid intake.

Correct Answer is D

Explanation

D. Assist the client with a sitz bath:A sitz bath can relieve perineal discomfort and promote relaxation of the pelvic floor muscles, which may help ease bowel movements. This is appropriate given the client's report of abdominal cramping and painful bowel movements.

E. Encourage oral fluid intake:The client had a total fluid intake of 1800 mL and urine output of 1400 mL over 12 hours. Encouraging adequate fluid intake is essential to maintain hydration, promote urine flow, and help prevent constipation, which the client is experiencing.

Incorrect Options:

A. Encourage prolonged dangling before ambulation:Prolonged dangling before ambulation is unnecessary in this case. The client is ambulating independently and does not exhibit signs of orthostatic hypotension that would require prolonged dangling.

B. Irrigate the indwelling catheter with 500 mL of fluid:There is no indication of a blocked catheter or need for irrigation. The pink urine suggests post-surgical changes but does not require immediate catheter irrigation.

C. Administer an enema:Although the client reports abdominal cramping and painful bowel movements, an enema is not the first-line intervention. Increasing fluid intake and using non-invasive measures like a sitz bath are preferable initial steps.

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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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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?