A nurse is teaching a client who has urinary incontinence about avoiding foods and beverages that can cause bladder irritation.
Which of the following foods and beverages is a bladder irritant?

Choice A rationale

Chilling the irrigant prior to the procedure is not recommended. Cold irrigant can cause discomfort and potentially lead to vasoconstriction, which can impede the healing process.

Choice B rationale

Irrigating the wound until the solution that is draining is clean is a standard practice in wound care. This helps to ensure that all debris and potential contaminants are removed from the wound.

Choice C rationale

Holding the tip of the syringe at least 13 cm (0.5 in) above the wound while irrigating is not a standard practice. The syringe should be held close to the wound to ensure effective irrigation.

Choice D rationale

Flushing the wound from the most contaminated area to the cleanest area is not a standard practice. The wound should be irrigated from the cleanest to the dirtiest area to prevent the spread of contamination.

Choice A rationale:

Administering oxygen at 2 L/min via nasal cannula is a common intervention for patients experiencing respiratory distress or hypoxia. However, in this scenario, the client’s oxygen saturation is 96%, which is within the normal range. Administering oxygen unnecessarily can lead to complications such as oxygen toxicity, especially in patients with chronic conditions like COPD. The client’s rapid and shallow breathing is likely a response to pain and anxiety rather than a primary respiratory issue. Therefore, addressing the underlying cause of his symptoms, such as pain management and anxiety reduction, would be more appropriate.

Furthermore, the client’s medical history includes hypertension and type 2 diabetes mellitus. These conditions can complicate the administration of oxygen therapy. For instance, patients with hypertension may experience increased blood pressure with supplemental oxygen, and those with diabetes may have altered respiratory responses. It is crucial to consider these factors before initiating oxygen therapy.

In summary, while oxygen therapy is a vital intervention for hypoxia, it is not indicated in this case due to the client’s normal oxygen saturation levels and the need to address pain and anxiety first.

Choice B rationale:

Preparing the client for immediate surgery is a drastic measure that should only be considered if there is a clear indication of a life- threatening injury or condition that requires surgical intervention. In this case, the client has a visible abrasion on his right elbow and complains of pain in his right hip. While these symptoms are concerning, they do not necessarily indicate an immediate need for surgery.

The client’s vital signs, although elevated, do not suggest a life-threatening condition. His temperature is slightly elevated, which could be due to pain or anxiety. His pulse and respirations are elevated, likely due to pain and anxiety as well. His blood pressure is elevated, which is consistent with his history of hypertension. These vital signs do not indicate a need for immediate surgical intervention.

Additionally, the client’s medical history of hypertension, type 2 diabetes mellitus, and osteoarthritis must be considered. These conditions can complicate surgical procedures and increase the risk of complications. Therefore, a thorough assessment and diagnostic imaging, such as X-rays or CT scans, should be performed to determine the extent of the injury before considering surgery.

In summary, immediate surgery is not warranted based on the current assessment. Further evaluation and diagnostic imaging are necessary to determine the appropriate course of action.

Choice C rationale:

Applying a cold pack to the client’s right hip is an appropriate intervention for several reasons. First, the client is experiencing pain in his right hip, which could indicate a soft tissue injury, contusion, or even a fracture. Applying a cold pack can help reduce pain and swelling in the affected area, providing immediate relief.

Cold therapy, also known as cryotherapy, works by constricting blood vessels, which reduces blood flow to the injured area. This helps to decrease inflammation and swelling, which can alleviate pain. Additionally, cold therapy can numb the affected area, providing further pain relief.

The client’s medical history of osteoarthritis is also relevant. Osteoarthritis can cause joint pain and stiffness, and cold therapy is often recommended to manage these symptoms. By applying a cold pack to the right hip, the nurse can help manage the client’s pain and prevent further complications.

In summary, applying a cold pack to the client’s right hip is a safe and effective intervention to manage pain and swelling. It addresses the client’s immediate discomfort and is consistent with best practices for managing soft tissue injuries and osteoarthritis.

Choice D rationale:

Assisting the client to a standing position and assessing his ability to bear weight on the right leg is not appropriate at this stage. The client has reported pain in his right hip, which could indicate a serious injury such as a fracture. Attempting to stand or bear weight on the affected leg could exacerbate the injury and cause further harm.

Before assessing the client’s ability to bear weight, it is essential to conduct a thorough assessment and obtain diagnostic imaging to determine the extent of the injury. This may include X-rays or CT scans to rule out fractures or other serious conditions. Once the extent of the injury is known, a more appropriate plan of care can be developed.

Additionally, the client’s medical history of osteoarthritis should be considered. Osteoarthritis can cause joint pain and stiffness, making it difficult for the client to bear weight on the affected leg. Forcing the client to stand or walk without proper assessment and support could lead to further injury and complications.

In summary, assisting the client to a standing position and assessing his ability to bear weight on the right leg is not appropriate at this stage. A thorough assessment and diagnostic imaging are necessary to determine the extent of the injury and develop a safe and effective plan of care.