Which nursing action is the priority intervention for a client diagnosed with total urinary incontinence?

Toileting routine.

Kegel exercises.

Surgery.

Anticholinergic drug therapy.

Answer and Explanation

The Correct Answer is A

A toileting routine is the priority intervention for a client diagnosed with total urinary incontinence because it helps to prevent skin breakdown, infection, and odor. It also promotes dignity and comfort for the client.

Choice B. Kegel exercises are wrong because they are not effective for total urinary incontinence, which is the complete loss of bladder control. Kegel exercises are more useful for stress or urge urinary incontinence, which are caused by weak pelvic floor muscles.

Choice C. Surgery is wrong because it is not a priority intervention for total urinary incontinence.

Surgery may be considered a last resort option if other conservative measures fail to improve the condition. Surgery may also have risks and complications that need to be weighed against the benefits.

Choice D. Anticholinergic drug therapy is wrong because it is not a priority intervention for total urinary incontinence.

Anticholinergic drugs are used to treat overactive bladder or urge urinary incontinence, which are caused by involuntary bladder contractions. Anticholinergic drugs may have side effects such as dry mouth, constipation, blurred vision, and confusion.

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Correct Answer is B

Explanation

This is the priority nursing diagnosis for a client who has had vomiting and diarrhea for the past three days because it poses the greatest threat to the client’s health and well-

being. Fluid loss can lead to hypovolemia, hypotension, shock, electrolyte imbalance, and renal failure.

Choice A is wrong because fatigue is a subjective symptom that may or may not be related to fluid loss.

It is not a priority over fluid volume deficit.

Choice C is wrong because impaired skin integrity is a potential problem that may occur due to irritation from vomiting and diarrhea, but it is not a priority over fluid volume deficit.

Choice D is wrong because imbalanced nutrition is a potential problem that may occur due to vomiting, but it is not a priority over fluid volume deficit.

A. “The client status is deteriorating. I feel you should come now.”. B. “The client has hypoxemia after 10 minutes on a rebreather mask.”. C. “The PaO2 is 55, PaCO2 is 90, HCO3 is 26.”. D. “The client has a history of chronic obstructive pulmonary disease and was admitted with pneumonia.”.

Correct Answer is B

Explanation

The nurse should make the statement “The client has hypoxemia after 10 minutes on a rebreather mask.” first. This is because SBAR (Situation- Background-Assessment-Recommendation) is a communication tool that helps provide essential, concise information, usually during crucial situations. The first component of SBAR is Situation, which is a concise statement of the problem.

The nurse should state the most urgent and relevant problem first, which is the client’s hypoxemia.

Choice A is wrong because it is not a clear statement of the situation.

It is vague and does not provide specific information about the client’s condition or vital signs.

It also expresses the nurse’s feeling rather than an objective assessment.

Choice C is wrong because it is part of the Assessment component of SBAR, not the Situation.

It provides numerical data about the client’s blood gas analysis, but it does not state the problem or the reason for calling the healthcare provider.

Choice D is wrong because it is part of the Background component of SBAR, not the Situation.

It provides pertinent and brief information related to the situation, such as the client’s medical history and diagnosis, but it does not state the current problem or concern.

Normal ranges for blood gas analysis are:

PaO2: 80-100 mmHg
PaCO2: 35-45 mmHg
HCO3: 22-26 mEq/L

Hypoxemia is defined as a low level of oxygen in the blood, usually below 60 mmHg.

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Which nursing action is the priority intervention for a client diagnosed with total urinary incontinence?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing diagnosis is priority for a client who has had vomiting and diarrhea for the past three days?

Correct Answer is B

Explanation

The nurse calls the healthcare provider using SBAR Communication. Which statement should the nurse make first?

Correct Answer is B

Explanation

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