A nurse is providing teaching to an older adult client about factors that increase the risk of urinary tract infection. Which of the following information should the nurse include?
Bladder capacity decreases in older adults.
The urethral sphincter functions less efficiently.
Decreased bladder tone can cause urinary retention.
The ability to concentrate urine decreases.
The Correct Answer is C
A. "Bladder capacity decreases in older adults." While bladder capacity does decrease with age, this alone does not directly increase UTI risk.
B. "The urethral sphincter functions less efficiently." Although sphincter function may decline, this typically leads to incontinence rather than urinary retention, which is the main UTI risk factor.
C. "Decreased bladder tone can cause urinary retention." Urinary retention leads to stasis of urine, promoting bacterial growth and increasing UTI risk.
D. "The ability to concentrate urine decreases." Decreased ability to concentrate urine does not directly cause UTIs, though it may lead to dehydration, which could contribute to UTI risk indirectly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"E"}
Explanation
The client is most at risk of developing atelectasis and paralytic ileus.
Rationale:
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Atelectasis – The client has shallow breathing and received IV morphine, which can suppress respiratory effort. Postoperative clients, especially those with abdominal surgery, are at higher risk for atelectasis due to pain-related splinting and immobility.
- Paralytic Ileus – The client has hypoactive bowel sounds at both assessments, indicating delayed return of bowel function postoperatively. This is common after abdominal surgery, especially with opioid use, and can lead to paralytic ileus.
- Urinary tract infection (UTI) – The client has voided 350 mL of clear yellow urine, indicating normal urinary function post-catheter removal.
- Delayed wound healing – There is no sign of wound complications (dressing remains dry and intact).
- Deep vein thrombosis (DVT) – No signs of unilateral swelling, redness, or pain, and the client is wearing sequential compression devices to prevent DVT.
Correct Answer is C
Explanation
A. Report the incident to the pharmacy. While the pharmacy may need to be informed, client safety is the priority. The immediate concern is monitoring the client for opioid overdose effects.
B. Notify the client's provider. The provider should be notified, but assessing the client's condition comes first so that the nurse can provide accurate information about any potential adverse effects.
C. Measure the client's respiratory rate. The priority action is to assess the client for signs of opioid toxicity, especially respiratory depression. Morphine can cause decreased respiratory rate, sedation, and hypotension. If the respiratory rate is dangerously low (e.g., below 12 breaths per minute), interventions such as administering naloxone (Narcan) may be necessary.
D. Complete an incident report. An incident report should be completed, but client safety and assessment take priority before documentation.
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