A nurse is contributing to the plan of care for a client who has urinary incontinence.
Which of the following interventions should the nurse include in the plan?
Keep the head of the client's bed elevated to 45".
Limit periods of sitting in a chair to 4 hr.
Use a no-rinse perineal cleanser after incontinence.
Avoid the use of draw sheets for repositioning.
The Correct Answer is C
Urinary incontinence is the involuntary loss of urine, and it can have various causes and contributing factors. When developing a plan of care for a client with urinary incontinence, it is important to address interventions that promote comfort, hygiene, and prevention of complications.
using a no-rinse perineal cleanser after incontinence, is an appropriate intervention for maintaining skin hygiene and preventing skin breakdown. Cleansing the perineal area after episodes of urinary incontinence helps to remove any urine residue and reduce the risk of skin irritation or infection. No-rinse cleansers are often preferred as they are gentle on the skin and do not require rinsing, which can be more convenient for the client.
keeping the head of the client's bed elevated to 45 degrees in (option A) is incorrect because it, is not directly related to managing urinary incontinence. This intervention is typically used for clients at risk for aspiration or to improve respiratory function.
limiting periods of sitting in a chair to 4 hours in (option B) is incorrect because it, may be beneficial to prevent prolonged pressure on the pelvic floor muscles and promote circulation. However, it does not specifically address managing urinary incontinence.
avoiding the use of draw sheets for repositioning in (option D) is incorrect because it, is not directly related to managing urinary incontinence. Draw sheets are commonly used to assist with repositioning and transferring clients.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Nitroglycerin is a common medication used to relieve chest pain associated with angina. However, if the client is experiencing ongoing chest pain, it is important to follow the prescribed instructions for nitroglycerin administration, which may involve taking additional doses if needed, as instructed by the healthcare provider. Calling the provider after taking one dose may not address ongoing chest pain adequately.
This action, known as the Valsalva maneuver, is not recommended for managing chest pain associated with stable angina. The Valsalva maneuver involves forcibly exhaling while keeping the mouth and nose closed, which can temporarily decrease blood flow to the heart and may exacerbate chest pain.
Aspirin can be beneficial during angina episodes. However, the recommended dose is usually 162 to 325 milligrams (one tablet). Taking two tablets at once may not be necessary unless specifically advised by a healthcare provider..
I will stop what I am doing and lie down.” Correct: This statement demonstrates an understanding of appropriate action. When experiencing angina, the client should stop any physical activity, sit down, or lie down. Resting helps reduce the heart’s workload and allows blood flow to stabilize.
Correct Answer is D
Explanation
Fidelity, also known as loyalty or faithfulness, refers to the nurse's commitment to keeping promises and fulfilling their responsibilities to the client. By promising to walk with the client in the outdoor courtyard each day, the nurse is demonstrating fidelity by maintaining their commitment to the client's well-being and providing the support needed to alleviate anxiety.
Autonomy refers to the client's right to make decisions about their own care and treatment. While the nurse's promise supports the client's autonomy by accommodating their preference for exercising in the courtyard, it is not the principle being demonstrated by the nurse.
Justice refers to fairness and equality in healthcare, ensuring equitable treatment and distribution of resources. While justice is an important ethical principle, it is not directly applicable in this situation.
Nonmaleficence is the principle of doing no harm and taking action to prevent harm to the client. While the nurse's promise of walking with the client aligns with the goal of reducing anxiety, it is not specifically related to preventing harm.
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