A nurse is caring for a client who is postoperative and reports frequent leakage of small amounts of urine. The nurse notes that the client’s bladder is palpable upon examination. The nurse should identify these findings as which of the following forms of incontinence?

Stress

Urge

Functional

Overflow

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Stress incontinence occurs when urine leaks due to pressure on the bladder from activities such as coughing, sneezing, laughing, or exercising. It is typically associated with weakened pelvic floor muscles or urethral sphincter deficiency. However, it does not usually involve a palpable bladder or frequent leakage of small amounts of urine.

Choice B Reason:

Urge incontinence, also known as overactive bladder, is characterized by a sudden, intense urge to urinate followed by involuntary loss of urine. This condition is often caused by involuntary bladder contractions. While it involves frequent urination, it does not typically present with a palpable bladder.

Choice C Reason:

Functional incontinence occurs when a person is unable to reach the toilet in time due to physical or mental impairments, such as severe arthritis or dementia. This type of incontinence is not related to bladder function itself and does not involve a palpable bladder.

Choice D Reason:

Overflow incontinence is characterized by the frequent leakage of small amounts of urine due to an overfilled bladder that cannot empty completely. This condition often results in a palpable bladder upon examination, as the bladder remains distended with urine. It is commonly seen in postoperative clients or those with conditions that obstruct urine flow or impair bladder emptying.

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Correct Answer is B

Explanation

Choice A Reason

“Lie on your left side.” This statement is incorrect. After a liver biopsy, the client should lie on their right side to apply pressure to the biopsy site and help prevent bleeding.

Choice B Reason

“Lie on your right side.” This is the correct instruction. Lying on the right side helps compress the liver biopsy site, reducing the risk of bleeding and promoting clot formation.

Choice C Reason

“Increase your fluid intake.” This statement is not specifically related to post-liver biopsy care. While staying hydrated is generally good advice, it is not a primary instruction for post-biopsy care.

Choice D Reason

“Decrease your fluid intake.” This statement is incorrect. There is no need to decrease fluid intake after a liver biopsy. Proper hydration is important for overall health and recovery.

A. Request a prescription for an antibiotic. B. Educate the client on pursed-lip breathing. C. Place the client on airborne precautions. D. Initiate oxygen therapy for SpO₂ of 92%.

Correct Answer is B

Explanation

Choice A Reason

Request a prescription for an antibiotic. This intervention is not typically included in the standard care plan for all COPD patients. Antibiotics are generally reserved for cases of acute exacerbations of COPD (AECOPD) with signs of bacterial infection, such as increased dyspnea, increased sputum purulence, and increased sputum volume. Routine use of antibiotics without these signs is not recommended.

Choice B Reason

Educate the client on pursed-lip breathing. This is the correct intervention. Pursed-lip breathing is a technique that helps improve ventilation, release trapped air in the lungs, and reduce the work of breathing. It is particularly beneficial for patients with COPD as it helps them manage shortness of breath and improve their breathing efficiency.

Choice C Reason

Place the client on airborne precautions. This intervention is incorrect. COPD is not an infectious disease that requires airborne precautions. Airborne precautions are used for diseases that are transmitted through the air, such as tuberculosis. COPD management focuses on improving lung function and preventing exacerbations.

Choice D Reason

Initiate oxygen therapy for SpO₂ of 92%. This intervention is partially correct but needs clarification. Oxygen therapy is typically initiated for COPD patients with chronic hypoxemia, usually when SpO₂ is less than 88-90%. An SpO₂ of 92% may not necessarily require oxygen therapy unless the patient is experiencing significant symptoms or has other comorbid conditions.

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A nurse is caring for a client who is postoperative and reports frequent leakage of small amounts of urine. The nurse notes that the client’s bladder is palpable upon examination. The nurse should identify these findings as which of the following forms of incontinence?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?

Correct Answer is B

Explanation

A nurse is initiating a plan of care for a client who has COPD. Which of the following interventions should the nurse include?

Correct Answer is B

Explanation

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