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

Counting sponges, needles, and surgical instruments is an intraoperative activity that is specific to the circulating function of the perioperative nurse. The nurse is responsible for maintaining an accurate count of all surgical items to prevent leaving any foreign objects inside the patient after the surgery. This is a crucial task to ensure patient safety and prevent any potential complications that may arise from such errors.

Option a. admitting, identifying, and assessing the patient, is a preoperative function that is usually performed by the preoperative nurse.

Option c. passing instruments to the surgeon and assistants, is a scrub nurse function that requires knowledge of the surgical procedure and a sterile technique.

Option d. preparing the instrument table and sterile equipment is also a scrub nurse function that requires expertise in sterile technique, knowledge of surgical procedures, and the ability to maintain a sterile environment.

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

Correct Answer is B

Explanation

The pH value is less than the normal range of 7.35-7.45, indicating acidosis. The PaCO2 value is elevated above the normal range of 35-45 mmHg, indicating respiratory acidosis. The PaO2 value is lower than normal, but not significantly low enough to indicate hypoxemia. The HCO3- level is within the normal range, but not significantly high enough to indicate metabolic compensation for respiratory acidosis.

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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

One of the intraoperative activities that are performed by the perioperative nurse and are specific to the circulating function is:

Correct Answer is B

Explanation

A nurse is admitting a client who has status asthmaticus. The client's ABG results are Ph:7.31, Pa02:74mm Hg, PaC02: 56 mmHg and HCO-3: 26mEq/L The nurse should interpret these laboratory values as which of the following imbalances?

Correct Answer is B

Explanation

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