The nurse caring for a client in an extended care facility should ...

[lak]

The nurse caring for a client in an extended care facility should provide which intervention in a bladder retraining program?
 
  1. Providing negative reinforcement when the client is incontinent
  2. Having the client wear adult diapers as a preventative measure
  3. Putting the client on a q2h toilet schedule during the day
  4. Promoting the intake of caffeine to stimulate voiding

Question 2

Which of the following would indicate that the clinician performing the catheterization of a fe-male client was competent?
 
  1. Keeping both hands sterile throughout the procedure
  2. Reinserting the catheter if it was misplaced initially in the vagina
  3. Inflating the balloon to test it before catheter insertion
  4. Advancing the catheter 7 to 8 inches

[b614102004]

Answer to Question 1

ANS: 3
A bladder retraining program includes initiating a toileting schedule on awakening, at least every 2 hours during the day and evening, before getting into bed, and every 4 hours at night. Negative reinforcement should not be used when the client is incontinent. However, positive reinforcement should be provided when continence is maintained. The client should be offered protective un-dergarments to contain urine and reduce the client's embarrassment (not diapers). Tea, coffee, other caffeine drinks, and alcohol should be minimized.

Answer to Question 2

ANS: 3
Before inserting the indwelling catheter, the balloon should be tested by injecting the fluid from the prefilled syringe into the balloon port. The dominant hand is kept sterile throughout the pro-cedure. The nondominant hand is not kept sterile because it touches the client. If the catheter is misplaced, it should be left in the vagina as a landmark indicating where not to insert, and anoth-er sterile catheter should be inserted into the urethra. The catheter should be advanced 2 to 3 inches in the female client.

[lak]

TYSM

[apple]

Excellent