A nurse is implementing a bladder training program for a client who had a stroke. Which of the following interventions should the nurse take first?

Determine the client's pattern for voiding

Discourage intake of carbonated beverages.

Assist the client with relaxation techniques.

Offer toileting opportunities every 1 to 2 hr.

Answer and Explanation

The Correct Answer is A

Explanation: The first step in bladder training is to assess the client's baseline bladder function and identify factors that may affect it, such as fluid intake, medications, or mobility issues. The other interventions are part of bladder training but should be implemented after assessment.

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Correct Answer is D

Explanation

A.Taping the tube to the child's cheek is not a recommended practice. It can cause skin irritation, discomfort, or even accidental removal of the tube. Proper securing of the tube to the abdomen using appropriate devices is the preferred method to prevent dislodgement.

B.Applying water-soluble lubricant to the gastrostomy site routinely is not recommended because it can trap moisture, leading to maceration or infection.

C.Some gastrostomy tubes require an extension set for feeding, especially low-profile devices (e.g., button-type gastrostomy tubes). This extension makes it easier to administer feeds or medications and can be removed afterward. However, this is not typically part of routine site care.

D.Securing the tubing to the child's abdomen helps prevent accidental dislodgement or pulling of the gastrostomy tube. This can be done using appropriate securing devices, such as adhesive dressings or commercially available tube holders, as recommended by the healthcare provider.

A. I will disinfect contaminated hard surfaces with a mixture of one part peroxide to 10 parts water. B. I will place used sharp items in an empty cereal box for disposal. C. I will put soiled dressings in a tied plastic bag before placing them in the trash. D. I will use animal-skin condoms when having sex.

Correct Answer is C

Explanation

The correct answer is C. Putting soiled dressings in a tied plastic bag before placing them in the trash reduces the risk of exposure to blood-borne pathogens for anyone who handles the trash.

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A nurse is implementing a bladder training program for a client who had a stroke. Which of the following interventions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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