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    Ati med surg proctored exam

    A 68-yr-old patient admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action should be included in the plan of care?

    Explanation & Rationale

    A. Apply absorbent adult incontinence diapers and pads over the bed linens: Absorbent products may help keep the skin dry, but it does not address the patient’s continence needs or promote independence. Prolonged use also increases risk of skin breakdown and infection. B. Assist the patient to the bathroom every 2 hours during the day: Scheduled toileting supports continence, reduces the risk of falls, and promotes dignity. It also helps prevent skin complications from incontinence and reduces the likelihood of urinary tract infections. C. Restrict fluids between meals and after the evening meal: Fluid restriction is not appropriate in dehydration, as the patient needs fluid replacement to restore balance. Limiting fluids could worsen confusion, impair perfusion, and further elevate the risk of complications D. Insert an indwelling catheter until the symptoms have resolved: Indwelling catheters increase the risk of urinary tract infections, especially in older adults. Catheterization should be avoided unless absolutely necessary for close monitoring of urine output or in cases of urinary obstruction.

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