An older adult client residing in a long-term care facility has become disoriented and suddenly develops 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.

Place a protective undergarment on the client.

Encourage increased fluid intake for 24 hours.

Answer and Explanation

The Correct Answer is A

A.   Urinary incontinence in an older adult can be a symptom of various underlying conditions, such as urinary tract infections, dehydration, or cognitive impairment. Obtaining a urine specimen for analysis can help to identify the underlying cause of the incontinence and guide appropriate treatment.
B.   Bladder training is a technique used to improve bladder control and reduce incontinence. However, it's not appropriate to evaluate the client's response to bladder training efforts when they have suddenly become disoriented and developed incontinence. This suggests a potential underlying medical condition that needs to be addressed first.
C.   While protective undergarments can be helpful in managing incontinence, they do not address the underlying cause of the problem. It's important to identify and treat the underlying condition to improve the client's quality of life and prevent complications.
D.   While dehydration can sometimes contribute to incontinence, it's not appropriate to increase fluid intake in a client who has suddenly become disoriented. This could worsen their condition, especially if they have cognitive impairment or other underlying medical conditions.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. While this breakfast is healthy and nutritious, it does not contain significant amounts of calcium or vitamin D, which are essential for bone health.
B. Bran muffins, mixed fruit, and orange juice are all good sources of calcium and vitamin D, two essential nutrients for bone health. A diet rich in calcium and vitamin D is recommended for individuals with osteoporosis to help strengthen bones and reduce the risk of fractures.
C. While granola bars and grapefruit juice can be healthy, they may not provide enough calcium and vitamin D to meet the nutritional needs of a client with osteoporosis.
D. While skim milk is a good source of calcium, the bagel and jelly do not provide significant amounts of calcium or vitamin D.

A. Report a mismatch of prescribed and available doses. B. Calculate the dose on hand to match the prescribed dose. C. Ask the pharmacist if another dose can be dispensed. D. Withhold the medication until the exact dose is available.

Correct Answer is A

Explanation

A. This is a critical first step when a medication dose discrepancy is identified. Reporting the mismatch alerts the appropriate personnel (such as the pharmacy or healthcare provider) to investigate and resolve the issue. This ensures that the correct dose is administered and helps prevent potential medication errors.
B. While calculating the dose on hand is important to ensure accurate dosing, this action should be secondary to reporting the issue first. Calculating the dose is part of the process to verify and adjust the dose if needed, but the primary concern is to report the discrepancy to get it addressed properly and safely.
C. Asking the pharmacist for a different dose is a valid action, but it should come after reporting the discrepancy. The pharmacist can provide guidance on whether a different dose can be dispensed and help clarify any issues with the medication.
D. Withholding the medication is an appropriate precaution if there is uncertainty about the dose, but it is not the first action to take. This step should follow the initial reporting of the discrepancy to ensure that the medication is correct and safe to administer.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

An older adult client residing in a long-term care facility has become disoriented and suddenly develops urinary incontinence. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis?

Correct Answer is B

Explanation

The electronic medication system alerts the nurse that the medication dose scanned for the client is two times higher than the dose prescribed. Which action should the nurse implement?

Correct Answer is A

Explanation

In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative care nurse is arranging for discharge, the client verbalizes concerns about pain. Which action should the nurse implement?

An older client with colorectal carcinoma receives a colostomy following a bowel resection and the nurse is reviewing written instructions about colostomy care that the client will take home after discharge. Which action should the nurse include when reviewing the instructions with the client?

While turning a client who recently suffered a cerebrovascular accident (CVA), the nurse assesses for pressure areas and skin breakdown. The skin over the sacral area is intact with non- blanchable redness. Which intervention is most important for the nurse to implement for this immobile client?

The nurse is demonstrating three-point gait crutch walking to an older adult man who broke his foot while playing soccer with his grandchildren. Which behavior indicates that the client understands proper crutch walking?

Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?

The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?

The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?