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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Take 3,000 mg of vitamin C daily: High doses of vitamin C are not recommended because excess vitamin C is metabolized into oxalate, which can increase the risk of calcium oxalate stone formation. This practice would worsen rather than prevent recurrence.
B. Eat 12 oz of animal protein daily: Excessive animal protein intake increases calcium and uric acid excretion while lowering urinary citrate, which promotes stone formation. Clients with calcium oxalate stones are advised to limit animal protein, not increase it.
C. Restrict calcium intake to one serving per day: Severe restriction of dietary calcium is not recommended. Adequate calcium intake is necessary because calcium binds oxalate in the gut, preventing absorption. Restricting calcium can increase oxalate absorption and stone risk.
D. Drink 3 L of fluid every day: Increasing fluid intake dilutes urine, reduces urinary supersaturation, and promotes passage of crystals before they aggregate into stones. Maintaining a high fluid intake is the most effective and recommended measure to prevent recurrence of calcium oxalate stones.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"}}
Explanation
- Administering NSAIDs for pain relief is contraindicated because NSAIDs can further impair kidney function by reducing renal perfusion and promoting nephrotoxicity. In a client with elevated BUN and creatinine, these drugs can accelerate kidney injury and worsen fluid retention or hypertension.
- Encouraging a high-protein diet is contraindicated in this scenario. Excess protein intake increases the workload on the kidneys and can exacerbate azotemia in clients with chronic kidney disease, particularly when BUN and creatinine are already elevated.
- Assessing for signs of fluid overload is an anticipated nursing action. The client presents with edema, periorbital swelling, and decreased urine output, indicating fluid retention. Monitoring for increased edema, lung sounds, weight gain, and blood pressure helps prevent complications such as pulmonary edema or worsening hypertension.
- Monitoring blood glucose levels regularly is an anticipated nursing action because diabetes contributes to kidney damage and can complicate the management of chronic kidney disease. Maintaining optimal glucose control reduces further renal injury and helps prevent acute complications such as hyperglycemia-related fluid shifts.
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