A 68-yr-old patient admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action should be included in the plan of care?

Apply absorbent adult incontinence diapers and pads over the bed linens.

Assist the patient to the bathroom every 2 hours during the day

Restrict fluids between meals and after the evening meal

Insert an indwelling catheter until the symptoms have resolved.

Answer and Explanation

The Correct Answer is B

A. Apply absorbent adult incontinence diapers and pads over the bed linens: Absorbent products may help keep the skin dry, but it does not address the patient’s continence needs or promote independence. Prolonged use also increases risk of skin breakdown and infection.

B. Assist the patient to the bathroom every 2 hours during the day: Scheduled toileting supports continence, reduces the risk of falls, and promotes dignity. It also helps prevent skin complications from incontinence and reduces the likelihood of urinary tract infections.

C. Restrict fluids between meals and after the evening meal: Fluid restriction is not appropriate in dehydration, as the patient needs fluid replacement to restore balance. Limiting fluids could worsen confusion, impair perfusion, and further elevate the risk of complications

D. Insert an indwelling catheter until the symptoms have resolved: Indwelling catheters increase the risk of urinary tract infections, especially in older adults. Catheterization should be avoided unless absolutely necessary for close monitoring of urine output or in cases of urinary obstruction.

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Correct Answer is ["A","B","E"]

Explanation

A. Raisins: Raisins are dried fruits that contain high amounts of potassium. In clients with chronic kidney disease, the kidneys are less able to excrete potassium, increasing the risk of hyperkalemia. Limiting intake of raisins helps maintain safer serum potassium levels.

B. Tomatoes: Tomatoes are naturally high in potassium, and consuming them in large amounts can contribute to elevated potassium levels in clients with kidney impairment. Avoiding or limiting tomato-based foods is important for dietary potassium management.

C. Green Beans: Green beans are relatively low in potassium compared with other vegetables and are generally safe for clients with chronic kidney disease when consumed in moderation. They do not pose a significant risk for hyperkalemia.

D. Asparagus: Asparagus contains moderate amounts of potassium but is lower than high-potassium foods such as bananas or tomatoes. It can usually be included in a kidney-friendly diet in controlled portions.

E. Bananas: Bananas are very high in potassium and are considered a high-risk food for clients with chronic kidney disease. Restricting bananas is essential to prevent dangerous increases in serum potassium levels.

A. Breast cancer survivor for 8 years B. Alcohol use disorder C. 65-years of age D. Pacemaker

Correct Answer is B

Explanation

A. Breast cancer survivor for 8 years: A history of cancer may be a concern, but most transplant programs require 2–5 years of remission before eligibility. Being cancer-free for 8 years would not be a contraindication.

B. Alcohol use disorder: Active substance abuse is a contraindication because it increases the risk of poor medication adherence, post-transplant complications, and graft failure. Patients must demonstrate sobriety before being considered.

C. 65-years of age: Older age alone is not a contraindication. Many transplant centers accept patients in their 60s and even 70s, as long as they are otherwise healthy and suitable candidates for surgery.

D. Pacemaker: The presence of a pacemaker is not a contraindication to transplantation. It is compatible with surgery and long-term management, provided cardiac function is stable.

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A 68-yr-old patient admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action should be included in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","E"]

Explanation

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Correct Answer is B

Explanation

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