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.
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Related Questions
Correct Answer is C
Explanation
When prioritizing care, the nurse should consider the urgency and potential complications associated with each client's condition. Based on the given information, the nurse should plan to see the client who has a femur fracture and reports numbness of the toes first.
The client with a femur fracture and numbness of the toes is experiencing a potential neurovascular compromise. Numbness can indicate impaired circulation or nerve damage, which requires immediate assessment and intervention to prevent further complications.
The other clients also require attention, but their conditions are not as urgent as a potential neurovascular compromise. Here's a brief explanation of the other options:
Option A, A client who has cirrhosis and severe pruritus is incorrect: Pruritus (severe itching) can be distressing for the client, but it is not an immediate life-threatening condition that requires immediate intervention.
Option B, A client who had a laparoscopic appendectomy 8 hr ago and is awaiting discharge is incorrect: This client has already undergone surgery and is in the postoperative period. While they may require routine assessments and care, they are stable and can wait for the nurse's attention.
Option D A client who had a renal biopsy 3 hr ago and has pink-tinged urine is incorrect: Pink-tinged urine following a renal biopsy can be expected due to blood in the urine. While the nurse should monitor the client's condition closely, it is not an immediate concern unless there is excessive bleeding or signs of complications.
Correct Answer is D
No explanation
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