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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Doing wheelchair exercises sitting in the chair is a correct statement, as it helps to prevent pressure ulcers, improve circulation, and maintain muscle tone.

Choice B reason: Using a suppository every night to have a bowel movement is an incorrect statement, as it indicates a dependence on laxatives and a lack of bowel training. The adolescent should be taught to establish a regular bowel routine, use natural methods such as abdominal massage and digital stimulation, and avoid overuse of laxatives.

Choice C reason: Needing to catheterize oneself twice a day is a correct statement, as it helps to prevent urinary tract infections, bladder distension, and kidney damage.

Choice D reason: Carrying a water bottle with me because I drink a lot of water is a correct statement, as it helps to prevent dehydration, constipation, and urinary tract infections.

A. Dry skin B. Abdominal pain C. Diarrhea D. Numbness of fingers

Correct Answer is D

Explanation

Choice A reason: Dry skin is not a sign of respiratory alkalosis. It can be caused by other conditions such as dehydration, eczema, or hypothyroidism.

Choice B reason: Abdominal pain is not a sign of respiratory alkalosis. It can be caused by other conditions such as gastritis, appendicitis, or gallstones.

Choice C reason: Diarrhea is not a sign of respiratory alkalosis. It can be caused by other conditions such as infection, inflammation, or food intolerance.

Choice D reason: Numbness of fingers is a sign of respiratory alkalosis, as it indicates a low level of calcium in the blood (hypocalcemia). Hypocalcemia can result from the alkalosis, as it causes the calcium to bind to proteins and become less available. Numbness of fingers can also affect the toes and lips.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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