A nurse is initiating bladder retraining for a client who has urge urinary incontinence. Which of the following instructions should the nurse give the client?

"Decrease your intake of cranberry juice."

"Limit your fluid intake to 500 milliliters per day."

"Plan to urinate every 3 hours while you are awake."

"Take your diuretic medication with your evening meal."

Answer and Explanation

The Correct Answer is C

Rationale:

A. "Decrease your intake of cranberry juice.": Cranberry juice is not known to worsen urge incontinence. It is more commonly used for urinary tract health. There is no need to reduce it unless the client finds it personally irritating.

B. "Limit your fluid intake to 500 milliliters per day.": Severely restricting fluids can lead to dehydration and concentrated urine, which may irritate the bladder and worsen incontinence. Adequate hydration is essential for bladder health.

C. "Plan to urinate every 3 hours while you are awake.": Scheduled voiding helps retrain the bladder by establishing regular emptying times and reducing urgency. Over time, this improves bladder control and reduces incontinence episodes.

D. "Take your diuretic medication with your evening meal.": Diuretics should be taken in the morning to avoid nocturia and sleep disturbances. Evening dosing increases the risk of nighttime incontinence due to increased urine production during sleep.

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Correct Answer is D

Explanation

Rationale:

A. "Client in room 303 is requesting snacks between meals.": While client preferences are important, this information is non-urgent and can be communicated through care plans or written notes. It does not directly impact immediate nursing care during a shift change.

B. "Client in room 304 has a laptop that they use for relaxation.": This is personal, non-clinical information and is not essential for safe and effective handoff communication. Shift reports should focus on medical status, treatment plans, or immediate needs.

C. "Client in room 302 has multiple visitors.": Visitor status is not a priority item in a shift report unless it directly affects client care, safety, or monitoring. Including such information can distract from more clinically significant updates.

D. "Client in room 301 is in the cardiac catheterization lab.": This is critical information because it reflects a current procedure, potential risks, and possible post-procedure care needs. Reporting this ensures continuity of monitoring and prioritization.

A. A client who has an open compound fracture of the humerus B. A client who has multiple facial lacerations C. A client who has a puncture wound in the right lower lung D. A client who has full-thickness burns over the lower extremities

Correct Answer is B

Explanation

Rationale:

A. A client who has an open compound fracture of the humerus: This injury requires surgical intervention and has a moderate to high risk of complications. It is typically classified as yellow, indicating delayed care is acceptable but not minor.

B. A client who has multiple facial lacerations: These are superficial injuries that can be treated with simple wound care and suturing. The client is likely stable and ambulatory, fitting the criteria for a green tag, which denotes minor injuries requiring minimal care.

C. A client who has a puncture wound in the right lower lung: This suggests potential internal injury and respiratory compromise. Such a case is urgent and unstable, requiring immediate intervention, and would be tagged red for immediate treatment.

D. A client who has full-thickness burns over the lower extremities: Full-thickness burns covering a large area are life-threatening and resource-intensive to manage. Depending on the extent, this may fall under red or black, depending on survivability and available resources.

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A nurse is initiating bladder retraining for a client who has urge urinary incontinence. Which of the following instructions should the nurse give the client?

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Naxlex Comprehensive Predictor Exams

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