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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. Apply a pain scale to describe intensity.
Choice A rationale:
Asking about elements of the pain experience is important for a comprehensive pain assessment, but it is not the most critical aspect immediately after administering an analgesic. This step is more relevant during the initial assessment to understand the nature and characteristics of the pain.
Choice B rationale:
Questioning the client about precipitating factors can help identify what triggers the pain, which is useful for long-term pain management strategies. However, this is not the primary focus after giving an analgesic, as the immediate goal is to evaluate the effectiveness of the pain relief.
Choice C rationale:
Locating where in the body the pain occurs is essential for diagnosing and understanding the pain’s origin. However, after administering an analgesic, the priority is to assess the change in pain intensity rather than its location.
Choice D rationale:
Applying a pain scale to describe intensity is crucial after giving an analgesic because it provides a quantifiable measure of the pain relief achieved. This helps in determining the effectiveness of the medication and guides further pain management interventions.
By focusing on the pain intensity using a standardized pain scale, the practical nurse can objectively evaluate the patient’s response to the analgesic and make informed decisions about any additional pain management needs.
Correct Answer is C
Explanation
This is the first action that the PN should take because the catheter size and balloon volume are inappropriate for the client. A #18 urinary catheter is too large for a female client who weighs 50 kg, and a 30 mL balloon may cause bladder trauma or discomfort. The PN should consult with the charge nurse and obtain a smaller catheter (such as #14 or #16) with a 10 mL balloon.
A. Obtaining a 30 mL syringe and a vial of sterile water is not the first action because it does not address the issue of the catheter size and balloon volume.
B. Asking the client if she has previously been catheterized is not the first action because it does not address the issue of the catheter size and balloon volume.
D. Positioning the client and observing the urinary meatus is not the first action because it does not address the issue of the catheter size and balloon volume.
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