The nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?

Suggest contacting the healthcare provider for a prescription for catheter insertion.

Recommend a complete bath to cleanse the perineal area more fully.

Evaluate the effectiveness of this measure to stimulate client voiding.

Instruct the PN that this technique promotes infection in elderly females.

Answer and Explanation

The Correct Answer is C

A.   Suggest contacting the healthcare provider for a prescription for catheter insertion: Catheter insertion may not be necessary if the client is able to void with this technique. It's important to evaluate less invasive measures first.
B.   Recommend a complete bath to cleanse the perineal area more fully: While cleanliness is important, the immediate concern is addressing urinary incontinence and promoting voiding.
C.   Evaluate the effectiveness of this measure to stimulate client voiding: Warm water can sometimes stimulate voiding reflexes in clients who have difficulty emptying their bladders. Assessing the client's response to this measure is appropriate.
D.   Instruct the PN that this technique promotes infection in elderly females: Pouring warm water over the perineal area does not necessarily promote infection, especially if proper hygiene
measures are followed. It's important to assess the effectiveness of the intervention before assuming it is inappropriate.

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Correct Answer is C

Explanation

A. While monitoring the client’s cardiac status is important due to the risk of arrhythmias with hyperkalemia, obtaining a daily ECG is not the most immediate or frequent evaluation required. Continuous cardiac monitoring is typically preferred in such cases.

B. Monitor and document strict intake and output: While important for overall fluid balance, this option does not specifically address the potential cardiac complications associated with hyperkalemia and insulin administration.
C. The prescribed treatment involves insulin, which facilitates the movement of potassium into cells, thereby reducing serum potassium levels. Monitoring potassium frequently is essential to evaluate the treatment’s effectiveness and to prevent hypokalemia, which can lead to complications such as arrhythmias or muscle weakness.

D. Evaluate glucose levels before and after meals: Monitoring glucose levels is important for diabetes management but does not address the immediate cardiac risks associated with
hyperkalemia and insulin administration.

A. Advise the UAP to resume positioning the client on schedule. B. Assume total care of the client to monitor neurologic function. C. Encourage the UAP to provide comfort care measures only. D. Assign a practical nurse to assist the UAP in turning the client.

Correct Answer is A

Explanation

Even though the client has a "Do Not Resuscitate" (DNR) order, routine care such as turning the client to prevent complications (e.g., pressure ulcers) remains important. The nurse should ensure the UAP understands the need to continue positioning the client according to the care plan, as this is a preventive measure for comfort and overall care, not a resuscitative measure.

B. Assume total care of the client to monitor neurologic function: Assuming total care may not be necessary, but providing guidance on comfort care measures is appropriate.
C.

Comfort care measures are important, but preventing complications such as pressure ulcers by turning the client is also part of providing comfort and care. Ceasing turning the client prematurely could lead to additional complications, which is not in the best interest of the patient.

D. Assign a practical nurse to assist the UAP in turning the client: While additional assistance may be helpful, ensuring that comfort care measures are provided is the priority.

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The nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes a 5% dextrose injection with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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The nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?

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