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 A

Explanation

A. Using a moisturizer after cleaning helps keep the skin hydrated, preventing dryness and cracking, which can increase the risk of infection.

B. Allowing the skin to air dry can lead to excessive dryness, especially in vulnerable areas, potentially compromising the skin’s integrity.

C. Rubbing the skin firmly can cause irritation, damage, and increased risk of skin breakdown, particularly in individuals with fragile skin.

D. Washing the skin daily with hot water can strip the skin of natural oils, leading to dryness and irritation, which increases the risk of infection. Warm water should be used instead.

A. Unable to state the phase B. Inflammatory C. Proliferative D. Maturation

Correct Answer is B

Explanation

A. Stating that the phase cannot be determined is incorrect because the wound presents clear signs indicative of a healing phase.

B. The inflammatory phase of healing typically lasts for 3 to 5 days post-injury and is characterized by redness, swelling, warmth, and pain due to the body’s response to injury. The lack of slough or drainage, along with surrounding tissue swelling and pain, aligns with the inflammatory phase.

C. The proliferative phase follows the inflammatory phase and involves the formation of new tissue and the development of granulation tissue, which is not yet apparent in Mr. Jones's wound.

D. The maturation phase occurs after the proliferative phase, focusing on the strengthening and reorganization of collagen, which is not relevant as the wound is still in the inflammatory stage.

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

Correct Answer is A

Explanation

Mr. Jones injured his left shin 4 days ago. Upon removal of the dressing, the wound is noted to be red, no slough or drainage. Surrounding tissue is swollen and is painful to the touch. The wound measures 3cm by 5 cm. What phase of healing is the wound in?

Correct Answer is B

Explanation

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