. A nurse is implementing a bladder retraining program for a client. Which of the following actions should the nurse take?

Assist the client to the bathroom every 2 hr.

Encourage the client to hold her urine when feeling the urge to urinate.

Restrict oral fluid intake during waking hours.

Provide adult diapers until bladder retraining is successful.

Answer and Explanation

The Correct Answer is B

A. Assisting the client to the bathroom every 2 hours may not support bladder retraining, which aims to increase the time between voids and encourage the client to recognize the need to urinate.

B. Encouraging the client to hold her urine when feeling the urge is a key component of bladder retraining, as it helps to increase bladder capacity and promotes a normal voiding pattern.

C. Restricting oral fluid intake is not recommended, as it can lead to dehydration and may not effectively aid in bladder retraining. Adequate fluid intake is essential for bladder health.

D. Providing adult diapers does not promote bladder retraining; it may enable continued incontinence rather than encouraging the client to regain control over bladder function.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Although the adolescent in a halo brace has some immobility, the greatest risk factors for skin breakdown involve areas where prolonged pressure is applied, and older adults are more vulnerable due to age-related skin changes.

B. A fractured radius and arm cast do not pose a significant risk for skin breakdown because the client can still mobilize and reposition themselves, reducing prolonged pressure.

C. An older adult with a hip fracture in Buck's traction is at greatest risk for skin breakdown due to immobility, pressure from the traction setup, and the reduced skin elasticity and healing capacity that come with age.

D. While skeletal balanced suspension traction poses some risk, a young adult typically has better skin integrity and mobility than an older adult, reducing the risk for skin breakdown.

A. A postoperative client whose blood pressure at 0800 was 138/86 mm Hg and now at 1000 is 90/60 mm Hg B. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 100 mg/dL C. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous D. A client who reports pain as 1 on a scale of 1 to 10 at 0800 now reports pain as 3

Correct Answer is A

Explanation

A. A significant drop in blood pressure from 138/86 mm Hg to 90/60 mm Hg indicates potential hypovolemia or hemorrhage, which requires immediate intervention to prevent shock or other complications. This is the most critical finding among the clients.

B. A client with stable blood glucose levels between 110 mg/dL and 100 mg/dL is not a priority, as these readings are within a normal range and do not indicate immediate danger.

C. The transition of wound drainage from sanguineous to serosanguineous is a normal part of the healing process and is not an urgent concern.

D. A mild increase in pain from 1 to 3 on a 1 to 10 scale is also not an immediate priority, as it remains within a low pain range and can be managed with routine pain control measures.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

. A nurse is implementing a bladder retraining program for a client. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown?

Correct Answer is C

Explanation

A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse's priority?

Correct Answer is A

Explanation

A nurse is teaching a client about maintaining skin integrity to decrease the risk of infection. Which of the following instructions should the nurse include?

A nurse is implementing a bladder retraining program for a client. Which of the following actions should the nurse take?

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances?

A nurse is assessing a client's wound dressing, and observes a clear watery drainage. The nurse should document this drainage as which of the following?

A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply)

A nurse is providing teaching about ileostomy care to a client. Which of the following statements by the client indicates a need for further teaching?

A nurse is providing teaching to a client who has a new colostomy, and had a bowel preparation before surgery. Which of the following information should the nurse include in the teaching?

A nurse is providing care for four clients on a medical-surgical unit. Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)