A nurse is implementing a bladder retraining program for a client. Which of the following actions should the nurse take?

Assist the client to the bathroom every 2 hr.

Encourage the client to hold her urine when feeling the urge to urinate.

Restrict oral fluid intake during waking hours.

Provide adult diapers until bladder retraining is successful.

Answer and Explanation

The Correct Answer is B

A. Assisting the client to the bathroom every 2 hours may not support bladder retraining, which aims to increase the time between voids and encourage the client to recognize the need to urinate.

B. Encouraging the client to hold her urine when feeling the urge is a key component of bladder retraining, as it helps to increase bladder capacity and promotes a normal voiding pattern.

C. Restricting oral fluid intake is not recommended, as it can lead to dehydration and may not effectively aid in bladder retraining. Adequate fluid intake is essential for bladder health.

D. Providing adult diapers does not promote bladder retraining; it may enable continued incontinence rather than encouraging the client to regain control over bladder function.

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Correct Answer is B

Explanation

A. Being male is not a significant risk factor for developing pressure ulcers. Pressure ulcers are more related to factors like immobility, nutritional status, and circulation.

B. Immobility is a major risk factor for pressure ulcer development. Clients who are immobile or confined to bed, especially for prolonged periods, are at higher risk due to continuous pressure on certain body areas, leading to skin breakdown.

C. Adequate hydration helps maintain skin integrity and is not a risk factor for pressure ulcers. Dehydration, rather than adequate hydration, can contribute to skin breakdown.

D. Anemia can impact tissue oxygenation, but immobility is a more direct risk factor for pressure ulcer development. Although anemia can slow healing, immobility leads to constant pressure on the skin, causing tissue breakdown and ulceration.

A. Sanguineous B. Serosanguineous C. Serous D. Purulent

Correct Answer is B

Explanation

A. Sanguineous drainage is characterized by bright red blood; it indicates fresh bleeding and does not include watery components.

B. Serosanguineous drainage is a combination of clear, watery fluid and blood, often appearing light pink to red. The description of watery red drainage fits this category, making it the correct choice.

C. Serous drainage is clear, pale yellow fluid without blood, indicating a non-bloody exudate. It does not match the description of watery red drainage.

D. Purulent drainage is thick, opaque, and often yellow, green, or brown due to the presence of pus and infection. It does not apply here as the drainage is described as watery red.

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A nurse is implementing a bladder retraining program for a client. Which of the following actions should the nurse take?

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