A nurse is planning care for an older adult 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 in a thick layer to the vulnerable skin areas.

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

Toilet the client every 4 hr while the client is awake.

Reduce the client's daily fluid intake.

Answer and Explanation

The Correct Answer is A

A.   Applying a moisture barrier helps protect the skin from irritation and breakdown due to prolonged exposure to moisture.
B.   Cleansing the skin with antibacterial soap and hot water may be too harsh and can contribute to skin irritation; gentle cleaning with a mild cleanser is preferable.
C.   Toileting the client every 4 hours may not be frequent enough to prevent skin breakdown; a more frequent toileting schedule should be implemented.
D.   Reducing the client's daily fluid intake is not a recommended intervention for urinary incontinence, as it may lead to dehydration and other health issues.

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Correct Answer is D

Explanation

A. Tilted head forward is not necessary during inhaler use. The client should maintain an upright position.
B. Shaking the inhaler before use is correct to ensure proper dispersion of the medication.
C. Rinsing the mouth out before using the inhaler is not necessary for proper technique.
D. Waiting 10 seconds between puffs allows for optimal delivery of the medication to the airways.

A. Two-point B. Four-point C. Swing-through D. Three-point

Correct Answer is D

Explanation

A. The two-point gait requires partial weight-bearing on both legs, making it unsuitable for a client who can only bear weight on one leg.
B. The four-point gait also requires weight-bearing on both legs and provides maximum stability, but it is not appropriate for a client who can bear weight on only one leg.
C. The swing-through gait is generally used by clients with paralysis of the legs or for those who need to use both legs minimally while moving with crutches. It is not the most suitable option for a client with weight-bearing restrictions on one leg.
D. The three-point gait is the correct technique for a client who can bear weight on only one leg. In this gait, both crutches and the affected leg are moved forward together, followed by the weight-bearing leg. This method allows the client to ambulate safely while maintaining the non-weight-bearing leg off the ground.

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

Nursing Test Bank

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