An older resident of an extended care facility has recurrent urinary tract infections. The nursing care plan includes the goal, "Increase daily intake of fluids." Which nursing intervention is most useful in assisting the resident to meet this goal?

Record the client's intake and output every shift.

Offer a glass of fluid every hour while awake.

Increase fluids provided with the client's meals.

Maintain a full pitcher of water at the bedside.

Answer and Explanation

The Correct Answer is B

A.   Record the client's intake and output every shift: While important for monitoring fluid balance, this intervention does not directly facilitate increased fluid intake.
B.   Offer a glass of fluid every hour while awake: This intervention ensures regular and frequent opportunities for the resident to consume fluids, which can help increase overall intake.
C.   Increase fluids provided with the client's meals: While this may help increase fluid intake, relying solely on meals may not be sufficient, especially if the resident does not finish their meals.
D.   Maintain a full pitcher of water at the bedside: While having water readily available is important, relying solely on this may not ensure regular intake throughout the day.

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Correct Answer is D

Explanation

A. Ankle edema and varicose veins are more commonly associated with venous insufficiency rather than peripheral arterial disease. Asking about these symptoms may not provide relevant information about chronic arterial symptoms.
B. Weeping ulcers on the lower legs are more indicative of venous insufficiency rather than peripheral arterial disease. Asking about these ulcers may not provide relevant information about chronic arterial symptoms.
C. Sudden onset of leg swelling, redness, warmth, and pain is suggestive of acute arterial occlusion rather than chronic arterial symptoms. Asking about these symptoms may be important for assessing acute arterial events, but it does not specifically address chronic arterial symptoms.
D. Peripheral arterial disease commonly presents with intermittent claudication, which causes calf pain or discomfort during physical activity, such as walking short distances. Asking about calf pain during walking can help assess for symptoms of peripheral arterial disease and its
impact on mobility and quality of life.

A. The client's daily blood pressure will be less than 140/80 mm Hg this month. B. The nurse will encourage the client to walk thirty minutes every day. C. The client will monitor blood glucose and blood pressure after each meal. D. The client's blood pressure readings will be less than 160/90 mm Hg.

Correct Answer is A

Explanation

A. A goal of maintaining a blood pressure less than 140/80 mm Hg aligns with recommended targets for clients with cardiovascular disease to reduce the risk of complications.
B. While physical activity is beneficial, stating that the nurse will encourage the client to walk is not a measurable client-centered outcome. A better outcome would focus on the client’s actions.
C. Monitoring blood glucose is more relevant for diabetes management rather than a primary outcome for cardiovascular disease.
D. A target of less than 160/90 mm Hg is too high and does not align with standard guidelines for blood pressure control in cardiovascular disease.

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An older resident of an extended care facility has recurrent urinary tract infections. The nursing care plan includes the goal, "Increase daily intake of fluids." Which nursing intervention is most useful in assisting the resident to meet this goal?

Nursing Test Bank

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