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 A

Explanation

A. Positioning the client for secretion drainage by gravity is a key component of postural drainage to facilitate the removal of respiratory secretions.
B. Postural drainage is typically done before meals to avoid potential nausea during the procedure.
C. Bronchodilators are often administered before postural drainage to open the airways and improve the effectiveness of the procedure.
D. Encouraging fluid intake is important to help thin respiratory secretions and promote their removal during postural drainage. Fluid restrictions are not typically indicated in this context.

A. Choose a vein that is soft on palpation. B. Select a vein in the client's dominant arm. C. Select a site distal to previous venipuncture attempts. D. Choose the most proximal vein in the extremity.

Correct Answer is C

Explanation

A. Choosing a vein that is soft on palpation may indicate it's not suitable for IV insertion. A vein with a slight bounce or resilience is preferable.
B. Selecting a vein in the client's dominant arm is not a primary consideration. Both arms are

usually suitable, and the choice depends on factors such as accessibility and patient preference.

C. Selecting a site distal to previous venipuncture attempts reduces the risk of complications such as infiltration or infection and allows for optimal vein preservation.
D. Choosing the most proximal vein in the extremity is not typically recommended for peripheral IV insertion. Veins more distal to the body are often preferred for initial attempts, with
consideration for vein integrity and accessibility.

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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

Naxlex Comprehensive Predictor Exams

A nurse is performing postural drainage for a client. Which of the following is an appropriate intervention?

Correct Answer is A

Explanation

A nurse is caring for a client who requires a peripheral IV insertion. When choosing the site, which of the following is an appropriate action for the nurse to take?

Correct Answer is C

Explanation

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