An older adult client arrives at the clinic describing a new onset of urinary incontinence. Which intervention should the nurse implement?
Obtain a clean, voided urine specimen for analysis.
Evaluate the client's response to bladder training efforts.
Provide protective undergarments for the client.
Encourage increased fluid intake for 24 hours.
The Correct Answer is A
Choice A reason: Obtaining a urine specimen is essential for analyzing possible infections or other abnormalities that could be causing urinary incontinence.
Choice B reason: While evaluating the client's response to bladder training is important, it is not the first step before diagnosing the cause of new-onset incontinence.
Choice C reason: Providing protective undergarments may help manage symptoms but does not address the underlying cause of the incontinence.
Choice D reason: Encouraging increased fluid intake could potentially exacerbate incontinence symptoms and is not a diagnostic intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["67"]
Explanation
Step 1: Convert the volume of fluid to be infused from mL to mL (since the rate is usually measured in mL/hr):
100 mL = 100 mL (No conversion needed as the volume is already in mL)
Step 2: Convert the time for infusion from hours to hours (since the rate is usually measured in mL/hr):
1.5 hours = 1.5 hours (No conversion needed as the time is already in hours)
Step 3: Calculate the rate (volume ÷ time):
Rate = Volume ÷ Time
Rate = 100 mL ÷ 1.5 hours
Rate = 66.67 mL/hr
So, the nurse should program the infusion pump to deliver at a rate of 67 mL/hr (rounded to the nearest whole number
Correct Answer is A
Explanation
Choice A reason: A headache with blurred vision following alteplase administration could indicate intracranial hemorrhage, which requires immediate intervention.
Choice B reason: Lower extremity edema is not typically an immediate concern post-alteplase administration unless it indicates a deep vein thrombosis.
Choice C reason: Paroxysmal supraventricular tachycardia requires monitoring, but it is not as urgent as a headache with blurred vision, which could signify a life-threatening complication.
Choice D reason: Frequent premature ventricular contractions should be monitored, but they are not as critical as a headache with blurred vision post-alteplase.
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