A nurse is preparing a client for discharge home who is confused and incontinent after a stroke. Which instructions regarding bladder training will the nurse include in the teaching plan for the client's family?

"Oﬀer the client the commode or urinal every 2 hours."

"Decrease the client's oral ﬂuid intake to 1 L/day."

"Instruct the client to hold urine as long as possible to restore bladder tone."

"Use a Foley catheter at night to prevent accidents."

Answer and Explanation

The Correct Answer is A

The nurse will include the instruction "Oﬀer the client the commode or urinal every 2 hours" in the teaching plan for the client's family. This approach is known as timed voiding and can help the client re-establish a regular pattern of urination. Option "a" promotes frequent voiding, which helps

prevent accidents and promotes bladder health. Option "b" is not a recommended approach and can lead to dehydration, urinary tract infections, and other complications. Option "c" is also not recommended since holding urine for extended periods can lead to bladder distention and increase the risk of urinary tract infections. Option "d" is also not recommended since catheterization should only be considered in specific cases where other options have failed or are not feasible.

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Correct Answer is B

Explanation

Furosemide is a loop diuretic that works by blocking the reabsorption of sodium and chloride in the ascending loop of Henle in the kidney, leading to increased urine output. However, this medication can also cause potassium loss through increased urinary excretion, which can lead to hypokalemia (low potassium level). Hypokalemia can cause confusion, weakness, and other neurological symptoms.

The normal range for serum potassium is 3.5 to 5.0 mEq/L. A potassium level of 2.9 mEq/L is below the normal range and is considered hypokalemic. Therefore, the nurse should correlate the client's confusion with the low potassium level and notify the healthcare provider to adjust the medication or provide potassium supplements if indicated.

A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic alkalosis D. Metabolic acidosis

Correct Answer is B

Explanation

Based on the given documentation, the nurse suspects that the client has respiratory alkalosis. The client's ABG results show a pH of 7.52, which indicates alkalosis and the PaO2 level is slightly low, suggesting respiratory involvement. Rapid breathing (RR44) and wheezing also support the possibility of respiratory alkalosis.

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A nurse is preparing a client for discharge home who is confused and incontinent after a stroke. Which instructions regarding bladder training will the nurse include in the teaching plan for the client's family?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is taking furosemide (Lasix), a diuretic. and becomes confused. Which potassium level does the nurse correlate with this condition?

Correct Answer is B

Explanation

A client comes to the emergency department with Asthma. Based on the documentation noted below, the nurse suspects that the client has what abnormality? 10/1/2022 at 18:30 Client wheezing, RR44, BP 140/90, HR 104, T 98.4 F, ABG results show pH 7.52 mmHg, HCO3-26, PaO2 90 mmHg C. Wynn RN

Correct Answer is B

Explanation

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