. 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.

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Correct Answer is B

Explanation

A. Sanguineous drainage is characterized by bright red blood; it indicates fresh bleeding and does not include watery components.

B. Serosanguineous drainage is a combination of clear, watery fluid and blood, often appearing light pink to red. The description of watery red drainage fits this category, making it the correct choice.

C. Serous drainage is clear, pale yellow fluid without blood, indicating a non-bloody exudate. It does not match the description of watery red drainage.

D. Purulent drainage is thick, opaque, and often yellow, green, or brown due to the presence of pus and infection. It does not apply here as the drainage is described as watery red.

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.

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

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is B

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

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