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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Applying a water-soluble lubricant to the catheter is not recommended during tracheostomy suctioning as it may introduce contaminants.
Choice B reason: Instilling sodium chloride before suctioning is not a standard practice and can lead to complications such as edema.
Choice C reason: Wearing protective goggles is important to protect the nurse from potential splashes of bodily fluids during the suctioning process.
Choice D reason: Instructing the client to cough as the suction tip is removed is not recommended as it can cause discomfort and potential harm to the tracheal lining.
Correct Answer is C
Explanation
Choice A reason: A thick, dry, and dark area on bilateral heels may indicate the beginning stages of a pressure ulcer, but it is not the earliest sign. The earliest indication is usually a non-blanchable redness over a bony prominence.
Choice B reason: Broken skin without evidence of undermining could be a sign of a pressure ulcer, but it is not the earliest indication. The earliest sign is persistent redness over an area of pressure.
Choice C reason: A defined area of persistent redness over bone, especially if it does not blanch when pressed, is the earliest indication of a pressure ulcer. This stage is known as a Stage 1 pressure injury.
Choice D reason: A superficial sacral ulcer with defined margins indicates that a pressure ulcer has already developed and is not the earliest sign of its development.
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