A nurse is implementing a bladder-training program for a patient.
Which of the following actions by the assistive personnel (AP) assisting with the patient’s care should the nurse intervene?
The AP assists the patient to the bathroom every 2 hours.
The AP offers the patient the opportunity to urinate 15 minutes before bathing.
The AP instructs the patient to urinate whenever they feel the urge.
The Correct Answer is A
The correct answer is choice A.
Choice A rationale: Assisting the patient to the bathroom every 2 hours is a fixed schedule that doesn't allow for individual variations in bladder function. A bladder-training program should encourage the patient to recognize and respond to their own urge to urinate, promoting self-reliance and bladder control.
Choice B rationale: Offering the opportunity to urinate before bathing is a good practice to prevent accidents and promote comfort. It also helps to reduce the risk of urinary tract infections.
Choice C rationale: Encouraging the patient to urinate when they feel the urge is a key component of bladder training. It helps the patient to develop bladder control and reduce the frequency of accidents.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Wheezing Wheezing is typically associated with respiratory conditions such as asthma or chronic obstructive pulmonary disease (COPD), rather than being a symptom of hyperkalemia.
Choice B rationale:
Cerebral edema Cerebral edema, or swelling in the brain, is not typically a symptom of hyperkalemia. It’s more commonly associated with traumatic brain injury, stroke, or brain tumors.
Choice C rationale:
Decreased deep tendon reflexes Decreased deep tendon reflexes can be a symptom of hyperkalemia. Hyperkalemia is a condition in which the potassium levels in your blood get too high. Potassium helps nerves send signals between your brain and the rest of your body. High levels of potassium can affect nerve function, leading to symptoms such as muscle weakness or decreased reflexes. Choice D rationale:
Hypoactive bowel sounds Hypoactive bowel sounds, or decreased or absent bowel sounds, are typically associated with conditions affecting the gastrointestinal system, such as ileus or bowel obstruction. They are not typically a symptom of hyperkalemia.
Correct Answer is A
Explanation
The correct answer is Choice A: Don sterile gloves before inserting the indwelling urinary catheter.
Choice A rationale:
Donning sterile gloves is crucial to prevent infection during the insertion of an indwelling urinary catheter. Maintaining aseptic technique is essential to avoid introducing pathogens into the urinary tract.
Choice B rationale:
Applying an oil-based lubricant to the catheter is not recommended as it can interfere with the sterility of the procedure and potentially cause irritation or infection.
Choice C rationale:
Testing the balloon before insertion is important, but it is not the first step in the process. The priority is to ensure that the nurse is using sterile gloves to maintain aseptic technique.
Choice D rationale:
Using one cotton swab to clean the patient’s urinary meatus is not sufficient for proper aseptic technique. The area should be cleaned thoroughly with appropriate antiseptic solutions and sterile supplies.
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