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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Increasing fluid intake can help replace cerebrospinal fluid lost during a lumbar puncture, which can alleviate a post-lumbar puncture headache.
Choice B rationale:
Elevating the head of the bed can actually worsen a post-lumbar puncture headache by increasing the loss of cerebrospinal fluid.
Choice C rationale:
While pain medication can provide temporary relief, it does not address the underlying cause of the headache.
Choice D rationale:
Darkening the room and closing the door can help reduce sensory stimulation, but it does not directly address the cause of the headache.
Correct Answer is A
Explanation
Choice A rationale:
Hemoglobin of 10 g/dL and hematocrit of 30% are lower than the normal ranges (Hemoglobin: 13.5-17.5 g/dL for men, 12.0-15.5 g/dL for women; Hematocrit: 38.8-50.0% for men, 34.9-44.5% for women). This can lead to cellular hypoxia as there are fewer red blood cells to carry oxygen.
Choice B rationale:
These lab values do not directly indicate a risk for prolonged bleeding.
Choice C rationale:
These lab values do not directly indicate a risk for fluid retention.
Choice D rationale:
While severe anemia can affect the immune response, these values do not directly indicate impaired immunity.
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