A client with urinary and fecal incontinence has an increased risk for developing a sacral pressure ulcer. Which information should the practical nurse (PN) give the unlicensed assistive personnel (UAP) who is assisting with the care of the client?

Encourage the client to rest quietly in bed.

Keep the client's skin clean and dry.

Obtain supplies for contact precautions.

Document any changes in skin integrity.

Answer and Explanation

The Correct Answer is B

The correct answer is Choice B.

Choice B rationale:

The practical nurse (PN) should instruct the unlicensed assistive personnel (UAP) to keep the client's skin clean and dry. Proper skin care is essential for a client with urinary and fecal incontinence to prevent the development of pressure ulcers. Keeping the skin clean and dry helps reduce moisture-related skin breakdown.

Choice A rationale:

Encouraging the client to rest quietly in bed is not directly related to preventing pressure ulcers. While adequate rest is essential for overall health, it does not specifically address the risk of pressure ulcers in an incontinent client.

Choice C rationale:

Obtaining supplies for contact precautions is unrelated to the client's risk of developing a sacral pressure ulcer. Contact precautions are used to prevent the spread of infectious diseases and do not address skin integrity.

Choice D rationale:

Documenting any changes in skin integrity is important, but it is the responsibility of the healthcare team, including the PN. However, this response does not provide proactive measures to prevent the pressure ulcer from occurring in the first place, which is the primary concern in this situation.

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Correct Answer is C

Explanation

Choice A rationale:

Urinary output is not directly related to stomatitis, which is inflammation of the mouth and throat. While monitoring urinary output is important in many situations, it is not relevant in this case.

Choice B rationale:

Blood pressure while standing is not directly related to stomatitis either. This assessment is more relevant for conditions such as orthostatic hypotension, which can cause a drop in blood pressure upon standing.

Choice C rationale:

Ability to swallow is crucial in the context of stomatitis. Stomatitis can cause painful sores in the mouth, making it difficult for the client to eat or drink. Assessing the client's ability to swallow will help determine the impact of stomatitis on their nutritional intake and overall well-being.

Choice D rationale:

Frequency of bowel movements is unrelated to stomatitis. This assessment is more relevant for gastrointestinal issues or constipation, not for a condition affecting the mouth and throat.

A. Boiled brown rice, 1/2 cup. B. Canned tomato soup, 1/2 cup. C. Fresh orange slices, 1 small. D. Grilled chicken, 3 ounces. E. Vegetables topped with cheddar cheese.

Correct Answer is ["A","C","D"]

Explanation

The correct answer is choice A, C, and D. Choice A rationale: Boiled brown rice is a good option for a client with renal disease needing to limit salt intake. It is low in sodium and does not contribute to fluid retention. Choice B rationale: Canned tomato soup is typically high in sodium, which can lead to fluid retention and increased blood pressure, making it an unsuitable choice for someone with renal disease who needs to limit salt intake. Choice C rationale: Fresh orange slices are low in sodium and high in vitamin C. They do not contribute to fluid retention and are suitable for a client with renal disease on a low-salt diet. Choice D rationale: Grilled chicken, especially if not seasoned with salt, is a low-sodium protein source that fits within the dietary restrictions for a client with renal disease. Choice E rationale: Vegetables are generally a good choice, but topping them with cheddar cheese increases the sodium content significantly, making it an inappropriate choice for someone on a low-salt diet, as cheese is often high in sodium.

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A client with urinary and fecal incontinence has an increased risk for developing a sacral pressure ulcer. Which information should the practical nurse (PN) give the unlicensed assistive personnel (UAP) who is assisting with the care of the client?

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Naxlex Comprehensive Predictor Exams

The practical nurse (PN) learns that a client who is receiving chemotherapy has developed stomatitis. Which information should the PN obtain from the client during a focused assessment?

Correct Answer is C

Explanation

The practical nurse (PN) is reinforcing dietary instructions with a client who has renal disease regarding the need to limit salt intake. Which selections for a lunch meal indicate to the PN that the client is following the diet plan? (Select all that apply.).

Correct Answer is ["A","C","D"]

Explanation

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