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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Primary provider: The primary provider is responsible for assessing a client’s capacity to make their own medical decisions. They determine whether the client is able to understand the nature of their condition and the treatment options available.
B. Charge nurse: While the charge nurse plays an important role in overseeing nursing care and ensuring proper communication, the decision about whether a client is capable of making their own medical decisions falls to the primary provider, not the charge nurse.
C. Health care surrogate: A health care surrogate is an individual designated to make medical decisions for a client when they are unable to do so themselves. However, the primary provider is responsible for determining if the client has the capacity to make decisions before a surrogate is involved.
D. Social worker: Social workers provide support and assistance with advance directives and decision-making, but the responsibility for evaluating whether the client can make medical decisions lies with the primary provider, not the social worker.
Correct Answer is B
Explanation
A. "You should follow a low cholesterol diet.": While managing cholesterol is important in diabetes care, the primary focus for type 2 diabetes management is controlling blood sugar levels through a balanced diet. Cholesterol management is secondary.
B. "You should follow a balanced intake of carbohydrates, fats, and proteins.": A balanced intake of carbohydrates, fats, and proteins helps regulate blood glucose levels. Carbohydrate counting and distribution are key in diabetes management, and balancing all macronutrients supports optimal blood sugar control and overall health.
C. "You should follow a diet high in vegetables, fiber, and uncooked fruit.": While high fiber intake is beneficial in diabetes management, focusing on vegetables, fiber, and uncooked fruit may limit the client's nutrient intake. A well-rounded, balanced diet is essential.
D. "You should follow a low sodium diet.": Reducing sodium intake is beneficial for heart health, especially in diabetic clients with hypertension. However, controlling blood glucose through a balanced diet should take precedence as the primary focus in managing type 2 DM.
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