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 B

Explanation

The correct answer is B. Diminished pulses on the affected extremity indicate impaired circulation, which can lead to tissue ischemia, necrosis, and compartment syndrome if not corrected promptly. This is a life-threatening complication that requires immediate intervention such as loosening or cutting off the cast, elevating the limb, or administering vasodilators. The other findings are not as urgent, although they may indicate other problems such as hematoma, infection, or nerve injury that need further assessment and treatment.

A. Call the supervisor to ask for another nurse. B. Remove the nurse from the client care area. C. Assign clients to the remaining staff. D. Document objective findings about the situation.

Correct Answer is B

Explanation

Explanation: The first action that the charge nurse should take is to remove the nurse from the client care area, as this will protect the clients from potential harm and prevent further impairment of the nurse. The charge nurse should then call the supervisor, assign clients to other staff members, and document objective findings about the situation.

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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?

Nursing Test Bank

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