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 A

Explanation

A nurse caring for a school-age child who has appendicitis should monitor for several manifestations of a perforated appendix and report to the provider. According to my sources, one of the major complications of appendicitis is the perforation of the appendix, which can lead to peritonitis, abscess formation, or portal pylephlebitis. Perforation generally occurs 24 hours after the onset of pain. Symptoms include a fever of 37.7⁰C or greater, a toxic appearance, and continued abdominal pain or tenderness.

B- Lethargy is not mentioned as a manifestation of a perforated appendix.

C- Decreased abdominal girth is not mentioned as a manifestation of a perforated appendix.

D- Bradycardia, which refers to a slower than normal heart rate, is also not mentioned as a manifestation of a perforated appendix.

A. Reduced fat in the stools B. Improved respiratory function C. Improved absorption of vitamins B and C D. Decreased sodium excretion

Correct Answer is A

Explanation

Reduced fat in the stools

Pancrelipase is an enzyme replacement therapy used in the treatment of cystic fibrosis, a condition that affects the exocrine glands, including the pancreas. Cystic fibrosis impairs the production and secretion of digestive enzymes, leading to malabsorption of nutrients, particularly fats.

Pancrelipase contains enzymes (lipase, amylase, and protease) that help in the digestion of fats, carbohydrates, and proteins, respectively. By administering pancrelipase, the nurse aims to improve the digestion and absorption of nutrients, especially fats. As a result, one of the therapeutic effects of pancrelipase in a child with cystic fibrosis is a reduction in fat in the stools, as the enzymes help break down dietary fats properly, preventing their excretion undigested.

Improved respiratory function in (option B) is not correct because while cystic fibrosis primarily affects the respiratory system, the administration of pancrelipase does not directly improve respiratory function. Other treatments and interventions are used to manage respiratory symptoms in cystic fibrosis.

Improved absorption of vitamins B and C in (option C) is not correct because Pancrelipase primarily aids in the digestion and absorption of fats, carbohydrates, and proteins. Although the absorption of vitamins can be indirectly affected by improved digestion, the main therapeutic effect of pancrelipase is related to fat digestion.

Decreased sodium excretion in (option D) is not correct because Pancrelipase does not have a direct effect on sodium excretion. Sodium balance is primarily regulated by the kidneys, and interventions targeting sodium excretion would involve dietary changes or medications targeting renal function.

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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 caring for a school-age child who has appendicitis. For which of the following findings should the nurse monitor as a manifestation of a perforated appendix and report to the provider?

Correct Answer is A

Explanation

A nurse is administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?

Correct Answer is A

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?