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.

Answer and Explanation

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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Correct Answer is C

Explanation

When collecting data from a child with pertussis (whooping cough), the nurse should expect the following manifestations:

Paroxysmal cough: The hallmark symptom of pertussis is a severe, uncontrollable cough that often occurs in bursts (paroxysms) followed by a characteristic "whooping" sound as the child inhales.
Posttussive vomiting: The coughing spells can be so severe that they may lead to vomiting.
Inspiratory whoop: As mentioned earlier, during the inhalation phase after a coughing episode, the child may make a distinctive whooping sound.
Cyanosis: The prolonged coughing episodes can sometimes cause the child's face to turn blue (cyanosis) due to inadequate oxygen intake.
Fatigue and exhaustion: The frequent and intense coughing episodes can be exhausting for the child, leading to fatigue and sleep disturbances.

Other possible manifestations of pertussis can include a mild fever, runny nose, and sneezing. However, these symptoms are less specific to pertussis and can be seen in other respiratory infections as well.

The manifestations listed in the question (beefy, red tongue; facial erythema; peeling of the hands and feet) are not typically associated with pertussis and may be indicative of other conditions or diseases. It is important to consult a healthcare provider for a proper evaluation and diagnosis.

A. Verify the dosage with another nurse. B. Inject 15 units of air into the regular insulin vial. C. Withdraw 10 units of NPH insulin. D. Place the cap over the needle.

Correct Answer is B

No explanation

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?

Correct Answer is C

Explanation

A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?

Correct Answer is B

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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?