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The nurse is caring for a client who is able to move Independently, but has been placed on bedrest with bathroom priviledges only due to their current treatment. The client has experienced two episodes of functional urinary incontinence. Which intervention(s) should the nurse include in the care plan? (SELECT ALL THAT APPLY)

Apply moisture barrier cream to perineal skin

Consult with the wound care nurse about use of a specialty mattress

Instruct client to shift their weight at least every 15 minutes

Keep head of bed raised at 45 degrees at all times

Massage over bony prominences every hour while awake

Answer and Explanation

Correct Answer : A,B,C

A. Applying moisture barrier cream helps protect the skin from irritation and breakdown due to urinary incontinence.

B. Consulting with the wound care nurse about the use of a specialty mattress is crucial to minimize pressure ulcers.

C. Instructing the client to shift their weight at least every 15 minutes helps reduce pressure and prevent pressure ulcers.

D. Keeping the head of the bed raised at 45 degrees at all times is not necessary and may not address the underlying issue of functional urinary incontinence.

E. Massaging over bony prominences is important for preventing pressure ulcers but does not directly address urinary incontinence.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. While the client may indeed have activity intolerance due to pain and shallow breathing, the priority problem indicated by the data is related to breathing patterns.

B. Shallow respirations and reluctance to cough and deep breathe indicate an ineffective breathing pattern, which is the priority problem to address to prevent respiratory complications.

C. Ineffective airway clearance may be a concern if the client is not effectively coughing, but the primary issue lies in the breathing pattern.

D. Ineffective gas exchange may occur if breathing patterns are compromised, but the immediate concern is addressing the breathing pattern itself.

A. Selecting a 1 ml syringe with a 5/8 inch needle to be used for giving 0.5 ml of heparin subcutaneously. B. Instructing a client to place a buccal medication under the client's tongue and allowing it to absorb. C. Injecting one mL of air into a vial before withdrawing 20 mg furosemide from a vial labeled 20 mg/mL D. Pouring the ordered medication "Robitussin 2 tsp. now" to the 10 ml mark on a medication cup.

Correct Answer is B

Explanation

A. Using a 1 ml syringe with a 5/8 inch needle for administering 0.5 ml of heparin subcutaneously is appropriate.

B. The instructor should intervene if the student is instructing a client to place a buccal medication under the tongue, as buccal medications should be placed in the cheek pouch, not under the tongue, which is the correct method for sublingual medications.

C. Injecting air into a vial before withdrawing medication is a standard practice to equalize pressure and facilitate withdrawal.

D. Pouring the ordered medication "Robitussin 2 tsp. now" to the 10 ml mark on a medication cup is correct since 1 tsp. is approximately 5mls.

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Naxlex Comprehensive Predictor Exams

A one-day post-operative client complains of severe abdominal pain and has shallow respirations at 22/minute. The client is reluctant to perform coughing and deep breathing. Based on the data, the priority problem that the nurse could assign to this patient is:

Correct Answer is B

Explanation

A nursing Instructor is observing a nursing student prepare and administer medications to adult clients. Which action by the nursing student requires intervention by the instructor?

Correct Answer is B

Explanation

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