A nurse is implementing a bladder-training program for a client. For which of the following actions by the assistive personnel (AP) who is helping with the client's care should the nurse intervene?

Encourages oral fluid intake during waking hours

Assists the client to the bathroom every 2 hr

Offers the opportunity to urinate 15 min prior to bathing

Instructs the client to urinate whenever the urge occurs

Answer and Explanation

The Correct Answer is D

Choice A reason: Encourages oral fluid intake during waking hours is not an action that the nurse should intervene. Encouraging oral fluid intake during waking hours is a part of a bladder-training program, as it helps to maintain adequate hydration and prevent urinary tract infections. The nurse should instruct the AP to limit the client's fluid intake before bedtime, as it may cause nocturia and disrupt the bladder-training schedule.

Choice B reason: Assists the client to the bathroom every 2 hr is not an action that the nurse should intervene. Assisting the client to the bathroom every 2 hr is a part of a bladder-training program, as it helps to establish a regular pattern of voiding and reduce the risk of incontinence. The nurse should instruct the AP to gradually increase the interval between bathroom visits, as the client's bladder capacity and control improve.

Choice C reason: Offers the opportunity to urinate 15 min prior to bathing is not an action that the nurse should intervene. Offering the opportunity to urinate 15 min prior to bathing is a part of a bladder-training program, as it helps to prevent the stimulation of the micturition reflex by warm water and reduce the risk of accidental voiding. The nurse should instruct the AP to avoid giving the client diuretics, caffeine, or alcohol, as they may increase the urine output and frequency.

Choice D reason: Instructs the client to urinate whenever the urge occurs is an action that the nurse should intervene. Instructing the client to urinate whenever the urge occurs is not a part of a bladder-training program, as it does not help to improve the bladder function and may worsen the urge incontinence. The nurse should instruct the AP to teach the client some techniques to suppress the urge, such as pelvic floor exercises, deep breathing, or distraction.

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Correct Answer is A

Explanation

The correct answer is: A. Place the client on continuous cardiac monitoring.

Choice A reason:

Placing the client on continuous cardiac monitoring is crucial because metabolic alkalosis can lead to life-threatening arrhythmias due to electrolyte imbalances, particularly hypokalemia. Continuous monitoring allows for the early detection and management of these arrhythmias, ensuring patient safety.

Choice B reason:

Obtaining a prescription for insulin is not relevant for treating metabolic alkalosis. Insulin is typically used for managing hyperglycemia and diabetic ketoacidosis, not for correcting alkalosis.

Choice C reason:

Planning to administer sodium bicarbonate is incorrect because sodium bicarbonate is used to treat metabolic acidosis, not alkalosis. Administering it in this context could worsen the alkalosis.

Choice D reason:

Having the client breathe into a paper bag is a technique used for respiratory alkalosis to increase CO2 levels. It is not appropriate for metabolic alkalosis, which requires different management strategies.

A. The nurse applies the sterile drape prior to cleansing the perineal area. B. The nurse coats the indwelling urinary catheter with lubricant. C. The nurse separates the client's labia with her dominant hand. D. The nurse provides perineal care prior to inserting the urinary catheter.

Correct Answer is C

Explanation

Choice A reason: The nurse applies the sterile drape prior to cleansing the perineal area. This is a correct action by the nurse, as it helps to prevent contamination of the catheter insertion site and maintain a sterile field.

Choice B reason: The nurse coats the indwelling urinary catheter with lubricant. This is a correct action by the nurse, as it helps to ease the insertion of the catheter and reduce the risk of trauma or infection.

Choice C reason: The nurse separates the client's labia with her dominant hand. This is an incorrect action by the nurse, as it violates the principle of sterile technique. The nurse should use her non-dominant hand to separate the labia and expose the urethral meatus, and use her dominant hand to hold the catheter. The non-dominant hand should not touch anything else after separating the labia, as it is considered contaminated.

Choice D reason: The nurse provides perineal care prior to inserting the urinary catheter. This is a correct action by the nurse, as it helps to reduce the bacterial load and prevent infection. The nurse should use soap and water to cleanse the perineal area from front to back, and use a new washcloth for each stroke.

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A nurse is implementing a bladder-training program for a client. For which of the following actions by the assistive personnel (AP) who is helping with the client's care should the nurse intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has metabolic alkalosis. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A charge nurse in a long-term care facility is observing another nurse who is inserting an indwelling urinary catheter into a female client. Which of the following actions by the nurse should prompt the charge nurse to intervene?

Correct Answer is C

Explanation

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