A nurse is planning care for a client who has urinary incontinence. Which of the following interventions should the nurse include in the client's plan of care?

Apply a moisture barrier ointment to the area in contact with urine.

Assist with toileting every 4 hr while awake.

Instruct the client to consume fluids between 0600 and 2200.

Cleanse the skin with antibacterial soap and hot water after each incontinence episode.

Answer and Explanation

The Correct Answer is A

A. Apply a moisture barrier ointment to the area in contact with urine: Applying a moisture barrier ointment is an essential intervention to protect the skin from moisture-related irritation and breakdown. This helps prevent skin damage from prolonged exposure to urine.

B. Assist with toileting every 4 hr while awake: While regular toileting is important for managing urinary incontinence, the client should be encouraged to use the bathroom based on individual needs. Toileting every 4 hours may not meet the client’s needs for more frequent voiding.

C. Instruct the client to consume fluids between 0600 and 2200: Limiting fluid intake to specific hours is not recommended unless there is a medical need. Adequate hydration is essential, and restricting fluid intake could lead to dehydration or urinary tract infections.

D. Cleanse the skin with antibacterial soap and hot water after each incontinence episode: Antibacterial soap and hot water can be too harsh on the skin, potentially leading to dryness and irritation. It’s better to use mild soap and warm water to cleanse the skin gently.

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Correct Answer is B

Explanation

A. "I'm sure your family will be here soon.": While this response tries to reassure the client, it does not address the client’s current feelings or provide immediate support. It might also come across as dismissive since the nurse cannot be sure when the family will arrive.

B. "I will be available for you until your family arrives.": This response acknowledges the client’s anxiety and offers support in the meantime. It shows the nurse’s availability and commitment to making the client feel safe and supported while waiting for their family.

C. "Why do you think your family is delayed?": This question might make the client feel pressured or defensive and focuses on the delay rather than offering reassurance or emotional support. It does not directly address the client’s emotional needs.

D. "You'll feel better once this procedure is over.": While this response aims to reassure the client, it might minimize their current feelings of anxiety. It focuses on the future rather than addressing the immediate emotional needs of the client.

A. Slowly pull the catheter out of urethral canal. B. Don clean gloves. C. Withdraw the solution from the balloon. D. Dry the perineal area. E. Attach the syringe to the balloon injection port.

Correct Answer is B,E,C,A,D

Explanation

B. Don clean gloves: The nurse should first don clean gloves to ensure proper hygiene and to reduce the risk of infection during the procedure. This protects both the client and the nurse from any potential contamination.

E. Attach the syringe to the balloon injection port: After gloves are on, the next step is to attach the syringe to the balloon injection port of the catheter. This is the part where sterile fluid (usually saline) was used to inflate the balloon that keeps the catheter in place.

C. Withdraw the solution from the balloon: Once the syringe is attached, the nurse slowly withdraws the fluid from the balloon. This is necessary to deflate the balloon, which allows the catheter to be removed easily and without causing injury to the urethral canal.

A. Slowly pull the catheter out of urethral canal: After the balloon is deflated, the nurse gently and slowly pulls the catheter out of the urethral canal. This should be done carefully to avoid causing trauma to the urethra and surrounding tissues. The catheter should be removed in a smooth, controlled motion.

D. Dry the perineal area: After the catheter is removed, the nurse should clean and dry the perineal area to ensure hygiene. This step helps prevent skin irritation and infection after the catheter removal, ensuring that the area is properly cared for and free of moisture.

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A nurse is planning care for a client who has urinary incontinence. Which of the following interventions should the nurse include in the client's plan of care?

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Naxlex Comprehensive Predictor Exams

A nurse in an urgent care center is caring for a young adult client who requires suturing of a laceration. The client tells the nurse, "My family should have been here by now. I can't go through this without them." Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is preparing to remove an indwelling urinary catheter from a client. In what order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is B,E,C,A,D

Explanation

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