Which statement, if made by an older client diagnosed with urinary incontinence, indicates a need for further teaching?
“I will take my water pill in the morning so I don’t have to go to the bathroom so much at night.”.
“I will limit how much I drink to reduce my chance of having an accident.”.
“I plan to use the commode next to my bed instead of trying to make it to the bathroom.”.
“I want to use the commode in my room instead of wearing adult briefs.”.
The Correct Answer is B
Limiting fluid intake can lead to dehydration and concentrated urine, which can irritate the bladder and increase the risk of infection. Older adults should drink about 2 liters of fluid per day unless they have a medical condition that requires fluid restriction.
Choice A is correct because taking diuretics in the morning can reduce nocturia and improve sleep quality.
Choice C is correct because using a commode next to the bed can prevent falls and injuries that may occur when trying to reach the bathroom in a hurry.
Choice D is correct because using a commode in the room can preserve dignity and comfort, and reduce skin breakdown and odor that may result from wearing adult briefs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because the first priority for assessing an elderly client who has become confused since admission is to rule out hypoxia, which can cause or worsen delirium. Hypoxia can result from various conditions, such as pneumonia, pulmonary embolism, or heart failure.
Oxygen saturation measurement is a quick and non-invasive way to assess the oxygen level in the blood and identify hypoxia.
Choice B. Review of current medications is wrong because although medications can cause or contribute to confusion and delirium in older adults, they are not the most urgent assessment to perform.
Medications should be reviewed after ensuring adequate oxygenation and addressing other possible causes of confusion.
Choice C. Intake and output last 24 hours is wrong because although dehydration and electrolyte imbalance can cause or worsen confusion and delirium in older adults, they are not the most urgent assessment to perform.
Intake and output should be monitored after ensuring adequate oxygenation and addressing other possible causes of confusion.
Choice D. Use of hearing aids or glasses is wrong because although sensory impairment can cause or worsen confusion and delirium in older adults, it is not the most urgent assessment to perform.
The use of hearing aids or glasses should be ensured after ensuring adequate oxygenation and addressing other possible causes of confusion.
Normal ranges for oxygen saturation are 95% to 100% for healthy adults. Lower levels may indicate hypoxia or other respiratory or cardiac problems.
Correct Answer is D
Explanation
Emptying the urine drainage bags at least once per shift is a task that can be delegated to unlicensed assistive personnel (UAP) assigned to a cardiac surgery unit.
This task does not require assessment, teaching, or evaluation skills that are beyond the scope of practice of UAP.
Choice A is wrong because teaching a client how to use a pillow to support an incision when coughing requires education and evaluation skills that are only within the scope of practice of licensed nurses.
Choice B is wrong because checking the pedal pulses of bed-bound clients requires assessment skills that are only within the scope of practice of licensed nurses.
Pedal pulses are important indicators of peripheral circulation and vascular status.
Choice C is wrong because ambulating the first-day postoperative clients requires assessment and evaluation skills that are only within the scope of practice of licensed nurses.
First-day postoperative clients may have complications such as bleeding, infection, or hypotension that need to be monitored by a nurse.
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