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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:
Checking the catheter tubing for kinks or twisting helps to maintain a patent urinary drainage system, preventing urinary stasis that can lead to infection.
Choice B rationale:
Irrigating the catheter once each shift is not recommended as it can introduce bacteria into the bladder.
Choice C rationale:
Cleaning the perineal area with an antiseptic solution daily can disrupt the normal flora and cause irritation, potentially leading to infection.
Choice D rationale:
Replacing the catheter every 3 days is not recommended as it can increase the risk of urinary tract infection.

A. Hemorrhagic stroke. B. Thrombotic stroke. C. Embolic stroke. D. Transient ischemic attack (TIA).

Correct Answer is A

Explanation

Choice A rationale:
Hemorrhagic stroke is characterized by sudden, severe headache, vomiting, and a significant increase in blood pressure, all of which are present in the client. This type of stroke occurs when a weakened blood vessel ruptures and bleeds into the surrounding brain.
Choice B rationale:
Thrombotic stroke is caused by a clot that develops in a blood vessel within the brain. It typically presents with less severe symptoms and a gradual onset, not a sudden one.
Choice C rationale:
Embolic stroke is caused by a clot that travels to the brain from another part of the body. Like thrombotic stroke, it typically has a more gradual onset.
Choice D rationale:
Transient ischemic attack (TIA) is a temporary blockage of blood flow to the brain. It usually lasts less than an hour and does not cause permanent damage.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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