The nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?

Suggest contacting the healthcare provider for a prescription for catheter insertion.

Recommend a complete bath to cleanse the perineal area more fully.

Evaluate the effectiveness of this measure to stimulate client voiding.

Instruct the PN that this technique promotes infection in elderly females.

Answer and Explanation

The Correct Answer is C

A.   Suggest contacting the healthcare provider for a prescription for catheter insertion: Catheter insertion may not be necessary if the client is able to void with this technique. It's important to evaluate less invasive measures first.
B.   Recommend a complete bath to cleanse the perineal area more fully: While cleanliness is important, the immediate concern is addressing urinary incontinence and promoting voiding.
C.   Evaluate the effectiveness of this measure to stimulate client voiding: Warm water can sometimes stimulate voiding reflexes in clients who have difficulty emptying their bladders. Assessing the client's response to this measure is appropriate.
D.   Instruct the PN that this technique promotes infection in elderly females: Pouring warm water over the perineal area does not necessarily promote infection, especially if proper hygiene
measures are followed. It's important to assess the effectiveness of the intervention before assuming it is inappropriate.

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Correct Answer is B

Explanation

A. Monitoring for changes in stool color is important because itraconazole can rarely cause liver toxicity, which may manifest as changes in stool color (e.g., clay-colored stools). This statement demonstrates the client's understanding of the need for monitoring for potential adverse effects.
B. Taking itraconazole with antacids is incorrect because antacids can reduce the absorption of itraconazole. This statement requires correction by the nurse as it could potentially decrease the effectiveness of the medication.
C. Drinking grapefruit juice can increase the effects of itraconazole by inhibiting its metabolism, leading to higher blood levels of the medication. Therefore, this statement is incorrect and requires correction.
D. Reporting any difficulty with breathing is important as itraconazole can rarely cause severe allergic reactions or respiratory side effects. This statement demonstrates the client's
understanding of the need to report any concerning symptoms.

A. Institute an exercise plan. B. Regulate food portions. C. Obtain satisfaction with appearance. D. Achieve a steady weight loss.

Correct Answer is B

Explanation

A. Instituting an exercise plan is important for overall health and may be part of the client's
treatment plan. However, the primary focus initially should be on addressing disordered eating behaviors and achieving a balanced diet.
B. Regulating food portions is a crucial goal for individuals with binge eating disorder to help establish healthier eating habits and prevent episodes of overeating.
C. Obtaining satisfaction with appearance may be a long-term goal for some individuals with binge eating disorder, but it is not typically the first goal addressed in treatment.
D. Achieving a steady weight loss may not be appropriate for all individuals with binge eating disorder, as the focus should be on promoting a healthy relationship with food rather than solely on weight loss.

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The nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for itraconazole. Which statement made by the client requires additional instruction by the nurse?

Correct Answer is B

Explanation

The nurse is caring for a client with a binge eating disorder. Which goal should the nurse first establish with the client?

Correct Answer is B

Explanation

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. Which action should the nurse take first?

The nurse is completing an admission assessment on an older adult client with dehydration, failure to thrive, and who is immobile. The nurse reports to the healthcare provider that the client's right calf is red and swollen. The nurse should suspect which probable cause of these findings?

The nurse notes that a client is receiving a heparin infusion labeled, Heparin Sodium 25,000 Units in 5% Dextrose Injection, 500 mL at a rate of 50 mL/hour. What dose of heparin is the client receiving per hour? (Enter the numerical value only.)

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A client with bladder cancer had surgical placement of a ureteroileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?

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