A nurse is reinforcing teaching with a client who requires a bladder-training program for urinary incontinence.
Which of the following instructions should the nurse include in the teaching?
“Record your urination times for 24 hours before beginning the program.”
“Drink 4 liters of fluid between 6:00 a.m. and 8:00 p.m.”
“Void every 2 hours while awake.”
“Eliminate caffeine from your diet.”
The Correct Answer is A
This instruction helps the client to establish a baseline of their bladder function and identify their voiding patterns. It also helps the nurse to design an individualized bladder-training program for the client.
Choice B is wrong because drinking 4 liters of fluid between 6:00 a.m. and 8:00 p.m. is excessive and can increase the frequency and urgency of urination. The client should drink enough fluids to prevent dehydration and constipation, but avoid drinking large amounts at one time or before bedtime.
Choice C is wrong because voiding every 2 hours while awake is not a bladder- training technique, but a scheduled toilet trip. Bladder training requires following a fixed voiding schedule and delaying urination after feeling the urge to go. Voiding every 2 hours may not allow the bladder to fill sufficiently and may interfere with the goal of increasing the bladder capacity.
Choice D is wrong because eliminating caffeine from the diet is not a specific instruction for bladder training, but a general lifestyle strategy to ease bladder problems. Caffeine can irritate the bladder and act as a diuretic, which can increase urine production and frequency.
However, eliminating caffeine alone may not be enough to improve urinary incontinence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This statement indicates that the client has orthopnea, which is a sign of worsening heart failure and fluid overload. The nurse should intervene by assessing the client’s vital signs, oxygen saturation, lung sounds, and edema, and notifying the provider for possible diuretic adjustment.
Choice A is wrong because “I’m urinating in larger amounts.” is an expected outcome of taking furosemide, which is a loop diuretic that increases urine output and reduces fluid retention.
Choice C is wrong because “I suck on hard candy for my dry mouth.” is a harmless way to cope with the side effect of dry mouth caused by furosemide.
Choice D is wrong because “I’ve lost 3 pounds in the last week.” is a positive sign that the client is losing excess fluid and improving their heart failure
condition. A weight loss of 2 to 4 pounds per week is acceptable for clients taking diuretics.
Normal ranges for heart failure clients are:
- Blood pressure: less than 140/90 mmHg
- Heart rate: 60 to 100 beats per minute
- Respiratory rate: 12 to 20 breaths per minute
- Oxygen saturation: greater than 95%
- Weight: stable or decreasing within 2 to 4 pounds per week
Correct Answer is D
Explanation
Bleach.
According to the CDC, bleach is an effective disinfectant for environmental surfaces contaminated with blood or body fluids from a person with AIDS or other bloodborne pathogens. Bleach can kill HIV and hepatitis viruses when used in a 1:10 dilution with water.
Choice A is wrong because isopropyl alcohol is not recommended for disinfecting environmental surfaces. It can evaporate quickly and may not have enough contact time to kill the pathogens.
Choice B is wrong because chlorhexidine is an antiseptic, not a disinfectant. It is used for skin cleansing or wound irrigation, but it is not effective against spores or non-enveloped viruses.
Choice C is wrong because hydrogen peroxide is a low-level disinfectant that can be inactivated by organic matter.
It is not suitable for disinfecting surfaces contaminated with blood or body fluids.
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