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 A

Explanation

The correct answer is choicea. Teach the client to use a straw when taking the medication to reduce further tooth staining.

Choice A rationale:

Using a straw when taking liquid iron preparations helps minimize contact with the teeth, thereby reducing the risk of staining.

Choice B rationale:

While tooth discoloration can indicate that the iron is being absorbed, it is not a desired effect and should be managed to prevent cosmetic concerns.

Choice C rationale:

Assessing for mouth or gum pain and difficulty swallowing is important but not directly related to the issue of tooth staining.

Choice D rationale:

Advising the client to withhold doses without consulting a healthcare provider could lead to non-compliance and inadequate treatment of iron deficiency.

A. The solution should approximate the client's body temperature (98°F or 36°C). B. The temperature of the enema is unrelated to the enema's effectiveness. C. The solution temperature should be determined by the client's comfort level. D. The temperature should be higher (110°F or 43°C) than the client's body temperature.

Correct Answer is A

Explanation

The correct answer is Choice A:

The solution should approximate the client's body temperature (98°F or 36°C). Choice A rationale:

The ideal temperature for administering an oil retention enema is to approximate the client's body temperature. Using a solution at the client's body temperature helps to prevent discomfort and potential injury to the rectal mucosa. The temperature of 98°F (36°C) is considered safe and comfortable for the client.

Choice B rationale:

This option is incorrect because the temperature of the enema solution does matter. Administering an enema that is too cold or too hot can cause discomfort, cramping, and potential damage to the rectal tissue.

Choice C rationale:

This option is not the best choice because relying solely on the client's comfort level may not ensure the optimal temperature for the enema solution. The client's perception of comfort can vary, and it may not necessarily reflect the ideal temperature for administration.

Choice D rationale:

This option is incorrect because using a temperature higher than the client's body temperature, such as 110°F (43°C), can be harmful and increase the risk of burns or injury to the rectal lining.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A female client taking a liquid iron preparation expresses concern that her tooth color has darkened since starting the medication. Which action should the practical nurse (PN) implement?

Correct Answer is A

Explanation

An oil retention enema is prescribed for a hospitalized client. The practical nurse (PN) should administer the enema solution at which temperature?

Correct Answer is A

Explanation

During a clinic visit, a mother tells the practical nurse (PN) that she keeps her 2-year-old child in a playpen so he will not get dirty. Which rationale should the PN use in responding to this parent?

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The practical nurse (PN) is caring for a client who has darkened membranes of the mouth and a smoky breath. Which priority nursing problem should the PN include in the plan of care?

The unlicensed assistive personnel (UAP) tells the practical nurse (PN) that a male client is angry because the night shift took over 2 hours to bring him the pain medication he had to request three times. Which action should the PN implement first?

A client with obstructive sleep apnea is preparing for sleep. Which action should the practical nurse (PN) implement?

The practical nurse (PN) observes an unlicensed assistive personnel (UAP) performing oral hygiene on an unconscious client who is lying in a flat side-lying position with an emesis basin on a towel under the chin. Which action should the PN take?

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. What question is most important for the practical nurse (PN) to include in the assessment of this client?

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