A nurse is initiating bladder retraining for a client who has urge urinary incontinence. Which of the following instructions should the nurse give the client?

"Decrease your intake of cranberry juice."

"Limit your fluid intake to 500 milliliters per day."

"Plan to urinate every 3 hours while you are awake."

"Take your diuretic medication with your evening meal."

Answer and Explanation

The Correct Answer is C

Rationale:

A. "Decrease your intake of cranberry juice.": Cranberry juice is not known to worsen urge incontinence. It is more commonly used for urinary tract health. There is no need to reduce it unless the client finds it personally irritating.

B. "Limit your fluid intake to 500 milliliters per day.": Severely restricting fluids can lead to dehydration and concentrated urine, which may irritate the bladder and worsen incontinence. Adequate hydration is essential for bladder health.

C. "Plan to urinate every 3 hours while you are awake.": Scheduled voiding helps retrain the bladder by establishing regular emptying times and reducing urgency. Over time, this improves bladder control and reduces incontinence episodes.

D. "Take your diuretic medication with your evening meal.": Diuretics should be taken in the morning to avoid nocturia and sleep disturbances. Evening dosing increases the risk of nighttime incontinence due to increased urine production during sleep.

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Correct Answer is A

Explanation

Rationale:

A. Administer diuretics: The client's symptoms, moist lung sounds, bounding pulse, elevated blood pressure, and pitting edema indicate fluid volume overload. Administering prescribed diuretics is the priority intervention to rapidly reduce intravascular and interstitial fluid volume and relieve pulmonary congestion.

B. Limit the client's fluid intake: Fluid restriction helps manage ongoing fluid retention but does not address the immediate concern of volume overload. It is a supportive measure rather than the initial priority in acute decompensated heart failure.

C. Insert an indwelling urinary catheter: While catheterization may help monitor output, it does not treat the underlying fluid excess. Inserting a catheter without addressing the fluid accumulation first does not provide immediate symptom relief.

D. Place the client on a low-sodium diet: A low-sodium diet is important for long-term management of heart failure, but it does not provide the prompt fluid removal needed in this acute situation. Immediate diuresis is necessary to reduce cardiac workload and respiratory distress.

A. "Your child can return to school once the fever has subsided." B. "Your child can return to school after a negative titer result." C. "Your child can return to school once the lesions have crusted over." D. "Your child can return to school 24 hours after beginning antibiotics."

Correct Answer is C

Explanation

Rationale:

A. "Your child can return to school once the fever has subsided.": The absence of fever does not indicate the child is no longer contagious. The child can still transmit the varicella-zoster virus until all lesions have crusted, even if fever has resolved.

B. "Your child can return to school after a negative titer result.": Titer testing is not used to determine contagiousness in active varicella infection. It is typically used to confirm immunity, especially after vaccination or past exposure.

C. "Your child can return to school once the lesions have crusted over.": Varicella is contagious until all lesions have crusted, which usually occurs about 5–7 days after the onset of rash. Crusting marks the end of the infectious period, making it safe for the child to return to school.

D. "Your child can return to school 24 hours after beginning antibiotics.": Varicella is a viral illness, not treated with antibiotics unless there is a secondary bacterial infection. Antibiotics do not impact the contagious period of the viral illness.

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A nurse is initiating bladder retraining for a client who has urge urinary incontinence. Which of the following instructions should the nurse give the client?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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