The nurse enters the room of an older adult client and observes the client positioned in a wheelchair as seen in the picture. The unlicensed assistive personnel (UAP) is preparing to push the client's wheelchair in the hallway. Which instruction should the nurse provide the UAP before the client is moved into the hallway?

Use a belt restraint to secure the client in the chair.

Empty the client's urinary drainage bag.

Reposition the client's urinary drainage bag.

Elevate the client's feet higher on the foot rests.

Answer and Explanation

The Correct Answer is C

A.   Using a belt restraint is generally not recommended unless specifically ordered for safety reasons, as it may not be appropriate or necessary in all cases. Restraints should only be used when absolutely needed and when all other methods of ensuring safety have been considered.
B.   Emptying the urinary drainage bag before moving the client is important to prevent overflows and ensure that the bag does not become a source of discomfort or potential infection. However, this step might not always be immediately necessary unless the bag is full or the client’s comfort and hygiene are at risk.
C.   Repositioning the urinary drainage bag is crucial for ensuring that the bag remains below the level of the bladder and is not subject to kinks or obstructions. This helps prevent backflow and potential infections. Proper positioning also contributes to the client’s comfort and dignity, making this a priority before moving the client.
D.   Elevating the client’s feet on the footrests is important for their comfort and to prevent swelling or pressure sores, especially if the client has limited mobility or circulatory issues. Proper positioning can prevent discomfort and promote better circulation, which is essential for maintaining the client’s well- being during transport.

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Correct Answer is B

Explanation

A. Infection in the lower leg could cause localized redness, swelling, warmth, and possibly pain. However, the presence of these symptoms alone is not as specific to infection, especially without additional symptoms like fever or purulent discharge.
B. Deep vein thrombosis is a condition where a blood clot forms in a deep vein, commonly in the legs. The symptoms of DVT include swelling (edema), redness (erythema), warmth, and sometimes pain in the affected leg. Given that the client has paresis on one side and is likely less mobile, the risk of DVT increases.
C. A pulmonary embolism occurs when a blood clot (often from the legs) travels to the lungs and causes a blockage. While a pulmonary embolism is a serious complication of DVT, the findings of localized edema and erythema in the leg are more directly associated with DVT itself rather than the secondary complication of a pulmonary embolism.
D. Fat emboli typically occur after fractures or trauma and lead to fat droplets entering the bloodstream and causing blockages in the lungs, brain, or skin. The classic symptoms include respiratory distress, neurological symptoms, and petechial rash.

A. Obtain a clean, voided urine specimen for analysis. B. Evaluate the client's response to bladder training efforts. C. Place a protective undergarment on the client. D. Encourage increased fluid intake for 24 hours.

Correct Answer is A

Explanation

A. Urinary incontinence in an older adult can be a symptom of various underlying conditions, such as urinary tract infections, dehydration, or cognitive impairment. Obtaining a urine specimen for analysis can help to identify the underlying cause of the incontinence and guide appropriate treatment.
B. Bladder training is a technique used to improve bladder control and reduce incontinence. However, it's not appropriate to evaluate the client's response to bladder training efforts when they have suddenly become disoriented and developed incontinence. This suggests a potential underlying medical condition that needs to be addressed first.
C. While protective undergarments can be helpful in managing incontinence, they do not address the underlying cause of the problem. It's important to identify and treat the underlying condition to improve the client's quality of life and prevent complications.
D. While dehydration can sometimes contribute to incontinence, it's not appropriate to increase fluid intake in a client who has suddenly become disoriented. This could worsen their condition, especially if they have cognitive impairment or other underlying medical conditions.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older client is hospitalized following an embolic stroke resulting in right-sided paresis. Three days after admission, the nurse notes edema and erythema to the right lower leg. These findings should alert the nurse to which possible condition?

Correct Answer is B

Explanation

An older adult client residing in a long-term care facility has become disoriented and suddenly develops urinary incontinence. Which intervention should the nurse implement?

Correct Answer is A

Explanation

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