An older adult client arrives at the clinic describing a new onset of urinary incontinence. Which intervention should the nurse implement?

Obtain a clean, voided urine specimen for analysis.

Evaluate the client's response to bladder training efforts.

Provide protective undergarments for the client.

Encourage increased fluid intake for 24 hours.

Answer and Explanation

The Correct Answer is A

Choice A reason: Obtaining a urine specimen is essential for analyzing possible infections or other abnormalities that could be causing urinary incontinence.

Choice B reason: While evaluating the client's response to bladder training is important, it is not the first step before diagnosing the cause of new-onset incontinence.

Choice C reason: Providing protective undergarments may help manage symptoms but does not address the underlying cause of the incontinence.

Choice D reason: Encouraging increased fluid intake could potentially exacerbate incontinence symptoms and is not a diagnostic intervention.

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Correct Answer is D

Explanation

Choice A reason: Reviewing the medical record for the date of insertion is important but does not address the immediate concern of pain or potential complications at the IV site.

Choice B reason: Applying ice and then a warm compress may be used for phlebitis or infiltration, but if the client is experiencing pain, the priority is to address the potential for complications.

Choice C reason: Documentation is a necessary step, but it should not be the first action taken when a client reports pain at the IV site.

Choice D reason: If the IV site is painful, it may be indicative of infiltration, phlebitis, or another complication. The nurse should discontinue the painful IV and insert a new one at a different site to prevent further discomfort and potential harm to the client.

A. Offer supplemental formula feedings. B. Teach about the use of a breast pump. C. Recommend using a breast shield. D. Encourage the use of ice on the areola.

Correct Answer is C

Explanation

Choice A reason: Offering supplemental formula feedings is not the first-line action for inverted nipples as it does not address the issue and may lead to nipple confusion, potentially complicating future breastfeeding attempts.

Choice B reason: Teaching about the use of a breast pump is beneficial for milk expression but does not directly assist with the immediate concern of latching issues due to inverted nipples.

Choice C reason: Using a breast shield can be helpful for mothers with inverted nipples. It can temporarily draw out the nipple, allowing the baby to latch on more easily. This tool acts as a bridge between the breast and the baby's mouth, facilitating breastfeeding while the mother works on long-term solutions for her inverted nipples.

Choice D reason: Encouraging the use of ice on the areola may temporarily stiffen the nipple, but it is not a recommended practice for addressing inverted nipples as it can cause discomfort and may not be effective in promoting a successful latch.

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An older adult client arrives at the clinic describing a new onset of urinary incontinence. Which intervention should the nurse implement?

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Naxlex Comprehensive Predictor Exams

While the nurse is preparing a scheduled IV medication, the client states that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement?

Correct Answer is D

Explanation

A client who is one day postpartum reports to the nurse that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?

Correct Answer is C

Explanation

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