The nurse administers an opioid analgesic to an older adult postoperative client in the surgical unit. Which is the most important intervention for the nurse to implement before leaving the client’s room?

Choice A reason: Functional incontinence refers to a situation in which the lower urinary tract is intact, but the individual is unable to reach the toilet because of environmental barriers, physical limitations, or severe cognitive impairment. This is the most likely type of incontinence for an older female adult with severe cognitive impairments, as she may not be aware of her bladder sensations, forget where the bathroom is, or have difficulty communicating her needs.

Choice B reason: Stress incontinence is when urine leaks when you exert pressure on your bladder by coughing, sneezing, laughing, exercising or lifting something heavy. This is not the most likely type of incontinence for an older female adult with severe cognitive impairments, as it is not related to her cognitive status, but rather to the weakening of the pelvic floor muscles and the urethral sphincter.

Choice C reason: Postvoid residual is when the bladder does not empty completely after urination, causing frequent or constant dribbling of urine. This is not the most likely type of incontinence for an older female adult with severe cognitive impairments, as it is not related to her cognitive status, but rather to the obstruction of the bladder outlet, the underactivity of the bladder muscle, or the dysfunction of the bladder nerves.

Choice D reason: Urge incontinence is when you have a sudden, intense urge to urinate followed by an involuntary loss of urine. This is not the most likely type of incontinence for an older female adult with severe cognitive impairments, as it is not related to her cognitive status, but rather to the overactivity of the bladder muscle, the irritation of the bladder lining, or the infection of the urinary tract.

Choice E reason: None of the above is not the correct answer, as there is one choice that is the most likely type of incontinence for an older female adult with severe cognitive impairments.

Choice A reason: Call for someone to bring the sign is not the most important intervention, as it does not address the immediate safety needs of the client. The sign is only a visual reminder of the fall risk, but it does not prevent the client from getting out of bed without assistance.

Choice B reason: Ensure he can reach his personal items is not the most important intervention, as it does not address the potential reasons for the client to get out of bed. The personal items may not include the items that the client needs, such as a phone, a book, or a snack.

Choice C reason: Instruct the client to use the call bell for help is the most important intervention, as it can prevent the client from falling and injuring themselves. The call bell is a device that allows the client to communicate with the nurse and request for help when needed. The nurse should educate the client about the importance of using the call bell and the risks of getting out of bed without assistance.

Choice D reason: Provide a urinal and drinking water is not the most important intervention, as it does not address the possible causes of the client's fall. The client may not need to use the urinal or drink water at the moment, or they may have other needs that are not met by these items.

Choice E reason: None of the above is not the correct answer, as there is one choice that is the most important intervention for the nurse to implement to prevent this event.