A nurse is providing teaching to a client who has stress incontinence. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
"Attempt to void every 2 hours."
"Perform Kegel exercises several times daily."
"Maintain a daily fluid intake of 1,000 to 1,200 mL/day."
"Take prescribed diuretics no later than 2000."
"Maintain optimal body weight for height."
Correct Answer : A,B,E
Rationale:
A. "Attempt to void every 2 hours.": Scheduled voiding helps reduce the likelihood of bladder overfilling and decreases episodes of leakage, especially in stress incontinence where physical pressure causes urine loss.
B. "Perform Kegel exercises several times daily.": Kegel exercises strengthen the pelvic floor muscles, which support the bladder and urethra. Regular practice improves muscle tone and helps control urine leakage during activities like coughing or sneezing.
C. "Maintain a daily fluid intake of 1,000 to 1,200 mL/day.": Limiting fluids excessively can lead to concentrated urine and bladder irritation, increasing urgency and risk of infection. A moderate, well-balanced intake closer to 1,500–2,000 mL/day is generally recommended.
D. "Take prescribed diuretics no later than 2000.": While relevant for fluid management, it's not a direct or primary instruction specifically for treating or managing stress incontinence itself. Diuretics increase urine production, which could potentially worsen incontinence.
E. "Maintain optimal body weight for height.": Excess weight increases abdominal pressure on the bladder, worsening stress incontinence. Achieving and maintaining a healthy weight can reduce symptoms and support pelvic muscle strength.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Rationale:
A. Assess the client's lung sounds prior to the infusion: Pre-transfusion assessment of lung sounds is essential to detect any baseline abnormalities and to monitor for fluid overload or transfusion-related lung complications such as transfusion-associated circulatory overload.
B. Infuse the blood over 4 hr: Older adults are at increased risk for fluid overload, so transfusing packed RBCs slowly over 4 hours is appropriate and safer, as long as the blood is completely administered within the maximum 4-hour window from removal from refrigeration.
C. Verify with another nurse that the unit of blood is compatible with the client's blood type: A dual verification process is mandatory to ensure safe administration. The nurse must check the client’s ID, blood type, unit number, and expiration date with another licensed professional before initiating the transfusion.
D. Prime the infusion tubing with 0.45% sodium chloride: Only 0.9% sodium chloride (normal saline) should be used to prime and flush blood transfusion tubing. Hypotonic solutions like 0.45% sodium chloride can cause hemolysis and should never be used with blood products.
E. Don sterile gloves to prepare the blood administration setup: Sterile gloves are not necessary for setting up a blood transfusion. Clean gloves are sufficient for handling equipment and initiating IV therapy, following standard precautions.
Correct Answer is B
Explanation
Rationale:
A. Autonomy: Autonomy involves respecting a client’s right to make their own healthcare decisions. While important, this scenario concerns unequal treatment rather than limiting the clients’ decision-making rights.
B. Justice: Justice refers to fairness and equity in the distribution of healthcare resources. Providing supplies to one client based on insurance status while denying them to another reflects unequal and unethical treatment, violating the principle of justice.
C. Beneficence: Beneficence means acting in the best interest of the client by promoting well-being. Although the insured client is benefitting, failing to support the uninsured client equally undermines the overall intent to do good for all clients.
D. Nonmaleficence: Nonmaleficence is the obligation to do no harm. While denying supplies could lead to harm, the primary ethical breach in this situation lies in the unfair distribution of care, which relates more directly to justice.
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