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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The pulmonary artery is the large blood vessel that carries deoxygenated blood from the right ventricle to the lungs for gas exchange. It is the only artery that carries deoxygenated blood in the body.
Choice B reason: The pulmonary veins are the blood vessels that carry oxygenated blood from the lungs to the left atrium. They are the only veins that carry oxygenated blood in the body.
Choice C reason: The left ventricle is the chamber of the heart that pumps oxygenated blood to the rest of the body through the aorta. It does not directly connect to the lungs.
Choice D reason: The left atrium is the chamber of the heart that receives oxygenated blood from the pulmonary veins. It does not directly connect to the right ventricle.
Correct Answer is B
Explanation
Choice A reason: The pulse oximeter might not be accurate during times of excessive movement is a correct statement, as movement can interfere with the detection of the pulse and the oxygen saturation. The parents should try to keep the infant still and calm while using the pulse oximeter.
Choice B reason: We will notify the doctor if the pulse oximeter consistently reads 100% is an incorrect statement, as it indicates a misunderstanding of the normal range of oxygen saturation. The parents should not be alarmed if the pulse oximeter reads 100%, as it means that the infant's blood is fully saturated with oxygen. The normal range of oxygen saturation for infants is 95% to 100%.
Choice C reason: The probe of the pulse oximeter can be applied to a finger or a toe is a correct statement, as these are suitable sites for measuring the oxygen saturation in infants. The parents should make sure that the probe fits snugly and securely on the infant's finger or toe.
Choice D reason: We will rotate the probe of the pulse oximeter every 24 hours is a correct statement, as it helps to prevent skin irritation, pressure ulcers, or infection from prolonged contact with the probe. The parents should also check the infant's skin regularly for any signs of redness, swelling, or pain.
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