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 D

Explanation

A. Adequate nutrition actually promotes wound healing. Poor nutrition, especially a lack of protein and vitamins, delays healing and increases the risk of infection.

B. Chronic wounds heal better in a moist environment rather than a dry one. Moist wound healing promotes cell migration and prevents scab formation, improving healing.

C. Fat tissue does not heal more rapidly. In fact, it heals more slowly due to decreased vascularization, which impairs oxygen delivery and nutrient supply to the tissue.

D. Long-term steroid use diminishes the body’s inflammatory response, reducing the body's ability to initiate the healing process. This delay in inflammation can lead to slower wound healing and a higher risk of infection.

A. A 5-year-old female who is a quadriplegic. B. A 5-year-old with a Braden Scale score of 7. C. A 5-year-old female who has controlled diabetes and is ambulating three times a day. D. A 35-year-old male with a BMI of 13.6 that is incontinent of stool and has a right leg splint.

Correct Answer is ["A","B","D"]

Explanation

A. A quadriplegic client is at high risk for pressure injuries due to immobility and lack of sensation, which can lead to prolonged pressure on skin and tissues.

B. A Braden Scale score of 7 indicates severe risk for pressure injuries. The lower the Braden score, the higher the risk, with scores less than 9 signifying very high risk.

C. A client with controlled diabetes who is ambulating frequently is not at high risk for pressure injuries because mobility reduces the risk of sustained pressure.

D. A BMI of 13.6 indicates severe underweight status, and incontinence of stool increases moisture, both of which elevate the risk of pressure injuries. Additionally, the splint on the leg may create pressure points.

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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

The nurse is providing health teaching to a client with a wound. Which of the following should be included in the teaching?

Correct Answer is D

Explanation

You're working on a medical surgical floor. You have the following patients below. Select all the patients below that are at risk for a pressure injury: (Select All that Apply.)

Correct Answer is ["A","B","D"]

Explanation

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