A nurse is implementing a bladder-training program for a client. For which of the following actions by the assistive personnel (AP) who is helping with the client's care should the nurse intervene?
Encourages oral fluid intake during waking hours
Assists the client to the bathroom every 2 hr
Offers the opportunity to urinate 15 min prior to bathing
Instructs the client to urinate whenever the urge occurs
The Correct Answer is D
Choice A reason: Encourages oral fluid intake during waking hours is not an action that the nurse should intervene. Encouraging oral fluid intake during waking hours is a part of a bladder-training program, as it helps to maintain adequate hydration and prevent urinary tract infections. The nurse should instruct the AP to limit the client's fluid intake before bedtime, as it may cause nocturia and disrupt the bladder-training schedule.
Choice B reason: Assists the client to the bathroom every 2 hr is not an action that the nurse should intervene. Assisting the client to the bathroom every 2 hr is a part of a bladder-training program, as it helps to establish a regular pattern of voiding and reduce the risk of incontinence. The nurse should instruct the AP to gradually increase the interval between bathroom visits, as the client's bladder capacity and control improve.
Choice C reason: Offers the opportunity to urinate 15 min prior to bathing is not an action that the nurse should intervene. Offering the opportunity to urinate 15 min prior to bathing is a part of a bladder-training program, as it helps to prevent the stimulation of the micturition reflex by warm water and reduce the risk of accidental voiding. The nurse should instruct the AP to avoid giving the client diuretics, caffeine, or alcohol, as they may increase the urine output and frequency.
Choice D reason: Instructs the client to urinate whenever the urge occurs is an action that the nurse should intervene. Instructing the client to urinate whenever the urge occurs is not a part of a bladder-training program, as it does not help to improve the bladder function and may worsen the urge incontinence. The nurse should instruct the AP to teach the client some techniques to suppress the urge, such as pelvic floor exercises, deep breathing, or distraction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Bacteria are not detected by the stool guaiac test. The stool guaiac test is a chemical test that reacts with hemoglobin, a protein found in red blood cells. Bacteria are microorganisms that do not contain hemoglobin.
Choice B reason: Fat is not detected by the stool guaiac test. The stool guaiac test is a chemical test that reacts with hemoglobin, a protein found in red blood cells. Fat is a lipid that does not contain hemoglobin.
Choice C reason: Parasites are not detected by the stool guaiac test. The stool guaiac test is a chemical test that reacts with hemoglobin, a protein found in red blood cells. Parasites are organisms that live in or on another host and do not contain hemoglobin.
Choice D reason: Blood is detected by the stool guaiac test. The stool guaiac test is a chemical test that reacts with hemoglobin, a protein found in red blood cells. Blood can indicate bleeding in the gastrointestinal tract, which can be caused by various conditions such as ulcers, polyps, or cancer.
Correct Answer is B
Explanation
Choice A reason: Respiratory rate 28/min is not a sign of effective oxygen therapy, as it indicates tachypnea, which is a rapid breathing rate. Tachypnea can be caused by hypoxia, anxiety, fever, or pain.
Choice B reason: Pink mucous membranes are a sign of effective oxygen therapy, as they indicate adequate oxygenation of the tissues. Pink mucous membranes are a normal finding, while pale, cyanotic, or jaundiced mucous membranes can indicate hypoxia or other problems.
Choice C reason: Heart rate 110/min is not a sign of effective oxygen therapy, as it indicates tachycardia, which is a rapid heart rate. Tachycardia can be caused by hypoxia, stress, dehydration, or infection.
Choice D reason: Restlessness is not a sign of effective oxygen therapy, as it indicates agitation, anxiety, or discomfort. Restlessness can be caused by hypoxia, pain, or medication side effects.
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