A nurse plans care for a client with overflow incontinence. Which ...

[Yi-Chen]

A nurse plans care for a client with overflow incontinence. Which intervention should the nurse include in this client's plan of care to assist with elimination?
 
  a. Stroke the medial aspect of the thigh.
  b. Use intermittent catheterization.
  c. Provide digital anal stimulation.
  d. Use the Valsalva maneuver.

Question 2

A nurse reviews the laboratory findings of a client with a urinary tract infection. The laboratory report notes a shift to the left in a client's white blood cell count. Which action should the nurse take?
 
  a. Request that the laboratory perform a differential analysis on the white blood cells.
  b. Notify the provider and start an intravenous line for parenteral antibiotics.
  c. Collaborate with the unlicensed assistive personnel (UAP) to strain the client's urine for renal calculi.
  d. Assess the client for a potential allergic reaction and anaphylactic shock.

[Harbringer]

Answer to Question 1

ANS: D
In clients with overflow incontinence, the voiding reflex arc is not intact. Mechanical pressure, such as that achieved through the Valsalva maneuver (holding the breath and bearing down as if to defecate), can initiate voiding. Stroking the medial aspect of the thigh or providing digital anal stimulation requires the reflex arc to be intact to initiate elimination. Due to the high risk for infection, intermittent catheterization should only be implemented when other interventions are not successful.

Answer to Question 2

ANS: B
An increase in band cells creates a shift to the left. A left shift most commonly occurs with urosepsis and is seen rarely with uncomplicated urinary tract infections. The nurse will be administering antibiotics, most likely via IV, so he or she should notify the provider and prepare to give the antibiotics. The shift to the left is part of a differential white blood cell count. The nurse would not need to strain urine for stones. Allergic reactions are associated with elevated eosinophil cells, not band cells.

[Yi-Chen]

Gracias!

[momolu]

TYSM