A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care?
Obtain a prescription for an indwelling urinary catheter.
Offer the client the bedpan every 2 hr.
Cleanse the perineum from back to front.
Encourage fluid intake at and between meals.
The Correct Answer is D
Choice A rationale:
Indwelling urinary catheters can actually increase the risk of UTIs.
Choice B rationale:
Offering the bedpan every 2 hours may not be necessary or practical for all patients.
Choice C rationale:
Cleaning the perineum from back to front can introduce bacteria to the urinary tract, increasing UTI risk.
Choice D rationale:
Adequate hydration can help flush bacteria out of the urinary tract, reducing UTI risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Behavioral indicators are the most reliable way to assess pain in a client with expressive aphasia as they may not be able to verbally communicate their pain.
Choice B rationale:
Scheduled treatments and client illness do not directly indicate the client’s pain level.
Choice C rationale:
Pulse and blood pressure findings can be influenced by many factors and are not the most reliable indicators of pain.
Choice D rationale:
A self-report pain rating scale would not be effective for a client with expressive aphasia as they may have difficulty understanding and using the scale.
Correct Answer is D
Explanation
Choice A rationale:
A WBC count of 5,000/mm³ is within the normal range (4,500 to 11,000 cells/mm³) and is not a priority.
Choice B rationale:
A platelet count of 150,000/mm³ is within the normal range (150,000 to 450,000/mm³) and is not a priority.
Choice C rationale:
A positive Western blot test confirms HIV infection, but it is not a priority in this case.
Choice D rationale:
A CD4-T-cell count of 180 cells/mm³ is below the normal range (500 to 1,500 cells/mm³), indicating severe immune system damage in a client with HIV. This is the nurse’s priority.
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