A client has arrived in the inpatient postoperative unit. What action by the inpatient nurse takes priority?

Choice A rationale:
While adequate hydration is important for overall health and urinary function, it does not directly address the priority nursing diagnosis of urinary incontinence. Increased fluid intake without addressing the underlying incontinence can actually exacerbate the problem by increasing urine output.
It's crucial to assess for signs of urinary retention or incomplete bladder emptying, as excessive fluid intake can worsen these conditions.
Individualized fluid intake goals should be established based on the client's overall health status, bladder capacity, and fluid balance.
Choice B rationale:
Satisfaction with incontinence products can improve comfort and quality of life, but it does not necessarily indicate that the underlying issue of incontinence has been resolved.
It's important to evaluate the effectiveness of incontinence products in managing leakage and preventing skin breakdown, but they should not be considered a definitive solution for incontinence.
Explore other interventions to address the root cause of incontinence, such as bladder training, pelvic floor muscle exercises, or medications.
Choice C rationale:
Increased activity and socialization can be positive outcomes of effective incontinence management, but they are not direct measures of the priority nursing diagnosis.
Improved social engagement and activity levels might reflect a reduction in incontinence episodes and increased confidence, but they should not be the sole indicators of success.
Assess for specific changes in incontinence frequency, severity, and impact on daily life to more accurately gauge progress.
Choice D rationale:
Intact, healthy skin in the perineal area is a direct and objective indicator that a priority nursing diagnosis of urinary incontinence has been met.
It demonstrates that the interventions implemented to manage incontinence have been effective in preventing skin breakdown and irritation, which are common complications of incontinence.
This finding aligns with the goal of maintaining skin integrity and preventing infection, which are essential aspects of incontinence care.

Choice A rationale:
Metabolic alkalosis is a condition characterized by an increase in the pH of the blood due to an excess of bicarbonate (HCO3-) in the body. It is not typically caused by severe diarrhea. In fact, diarrhea can often lead to a loss of bicarbonate, which can contribute to metabolic acidosis.
Causes of metabolic alkalosis include: excessive vomiting, use of diuretics, and excessive intake of alkali such as antacids. Clinical manifestations of metabolic alkalosis include: muscle twitching, paresthesias, seizures, confusion, and lethargy.
Choice B rationale:
Respiratory alkalosis is a condition characterized by a decrease in the partial pressure of carbon dioxide (PaCO2) in the blood, leading to an increase in blood pH. It is caused by hyperventilation, which removes excess CO2 from the body. Severe diarrhea does not typically cause hyperventilation.
Causes of respiratory alkalosis include: anxiety, hyperventilation syndrome, high altitude sickness, and pulmonary embolism. Clinical manifestations of respiratory alkalosis include: lightheadedness, dizziness, paresthesias, palpitations, and tetany.
Choice C rationale:
Respiratory acidosis is a condition characterized by an increase in the partial pressure of carbon dioxide (PaCO2) in the blood, leading to a decrease in blood pH. It is caused by hypoventilation, which prevents the body from removing enough CO2. Severe diarrhea does not typically cause hypoventilation.
Causes of respiratory acidosis include: chronic obstructive pulmonary disease (COPD), pneumonia, asthma, and neuromuscular disorders.
Clinical manifestations of respiratory acidosis include: headache, confusion, somnolence, and coma.
Choice D rationale:
Metabolic acidosis is a condition characterized by a decrease in the pH of the blood due to an excess of acid in the body or a loss of bicarbonate. Severe diarrhea can lead to metabolic acidosis through several mechanisms:
Loss of bicarbonate in the stool: Diarrhea often contains a significant amount of bicarbonate, which can be lost from the body in large amounts during severe diarrheal episodes. This loss of bicarbonate can lead to a decrease in the blood's pH, resulting in metabolic acidosis.
Dehydration: Severe diarrhea can also lead to dehydration, which can concentrate acids in the blood and contribute to metabolic acidosis.
Lactic acidosis: In some cases, severe diarrhea can also cause lactic acidosis, a type of metabolic acidosis that occurs when there is a buildup of lactic acid in the body. This can happen due to impaired circulation or tissue hypoxia, which can occur as a complication of severe diarrhea.