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?
“Take your diuretic medication with your evening meal."
"Decrease your intake of cranberry juice."
"Plan to urinate every 3 hours while you are awake"
“Limit your fluid intake to 500 milliliters per day."
The Correct Answer is C
A. “Take your diuretic medication with your evening meal." Taking diuretics in the evening can increase nighttime urination, worsening sleep disruption and incontinence. They should generally be taken in the morning to minimize nocturia.
B. "Decrease your intake of cranberry juice." Cranberry juice is often recommended to promote urinary tract health, though it doesn’t directly worsen urge incontinence. It is not necessary to avoid it unless advised by a provider for another reason.
C. "Plan to urinate every 3 hours while you are awake." Scheduled voiding at regular intervals is a key strategy in bladder retraining. It helps reduce urgency episodes and gradually increases bladder capacity and control over time.
D. “Limit your fluid intake to 500 milliliters per day." Severely limiting fluids can lead to dehydration, concentrated urine, and bladder irritation, potentially worsening incontinence. Adequate fluid intake should be maintained unless otherwise directed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Urinary output 120 mL/4 hr. This is on the lower end of normal but not critical. It should be monitored, especially in clients on opioids, but does not require immediate reporting ahead of more life-threatening findings.
B. Pupil diameter 6 mm. Dilated pupils may suggest other issues such as anxiety, medication effects, or pain, but are not a common concern with morphine, which usually causes miosis (pupil constriction). Still, this is not the most urgent concern.
C. Bowel movement 5 days ago. Constipation is a common side effect of opioids, including morphine, and should be addressed with stool softeners or laxatives. However, it is not an emergency.
D. Blood pressure 80/40 mm Hg. This indicates hypotension, a potentially life-threatening side effect of IV morphine, especially if it results in decreased perfusion or shock. It requires immediate intervention and provider notification.
Correct Answer is A
Explanation
A. Flush the tubing with 30 mL of water every 4 hr. Flushing the tube regularly helps maintain patency, prevent clogging, and ensure that the feeding is delivered effectively. This is a standard practice in managing enteral feeding systems.
B. Check for gastric residual every 12 hr. Gastric residuals should typically be checked every 4 to 6 hours, or per facility protocol, especially in clients at risk for aspiration. Waiting 12 hours is too long and may delay identifying feeding intolerance.
C. Place enough formula in the container to last 18 hr. Open systems should have fresh formula added every 4 hours to reduce the risk of bacterial contamination. Leaving formula in the feeding bag for 18 hours exceeds safety guidelines and increases infection risk.
D. Maintain bed elevation at 20°. The head of the bed should be elevated to at least 30 to 45 degrees to reduce the risk of aspiration. A 20° elevation is insufficient and does not provide adequate protection during feeding.
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