A nurse is caring for a client who has limited mobility and is experiencing urinary incontinence. Which of the following actions should the nurse take to prevent skin breakdown?

Avoid using moisturizers on the client's skin.

Place the client on a timed voiding schedule.

Place the client in high-Fowler's position while in bed.

Wash urine off the client's skin with hot water and soap.

Answer and Explanation

The Correct Answer is B

A. Avoid using moisturizers on the client's skin. Moisturizers are important for maintaining skin integrity, especially in clients with incontinence, to prevent skin breakdown.
B. Place the client on a timed voiding schedule. This is correct. A timed voiding schedule can help manage incontinence by reducing the frequency of wetness and thereby preventing skin breakdown.
C. Place the client in high-Fowler's position while in bed. High-Fowler’s position is not typically indicated for preventing skin breakdown and can increase pressure on the sacral area.
D. Wash urine off the client's skin with hot water and soap. Washing with hot water and soap can be harsh and irritating to the skin. It is better to use mild soap and lukewarm water.

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

Explanation

A. "I should drink enough fluids throughout the day to have pale yellow urine." Adequate hydration helps flush bacteria out of the urinary tract and dilute urine, which can reduce the risk of infection. Pale yellow urine typically indicates proper hydration.
B. "I should void every 2 to 4 hours during the day." Frequent voiding helps to flush out any bacteria that may be present in the bladder, reducing the risk of infection.
C. "I should use mild soap when cleaning the perineal area." Mild soap is less likely to irritate the urethra and surrounding tissues, which can help prevent UTIs. Harsh soaps can disrupt the natural flora and cause irritation.
D. "I should void immediately after intercourse." Voiding after intercourse helps to flush out any bacteria that may have entered the urethra during sexual activity, reducing the risk of infection.
E. "I should apply a thin layer of talcum powder after each void." Talcum powder is not recommended as it can irritate the urethra and perineal area, and particles can enter the urinary tract, potentially increasing the risk of infection.

A. Offer the client hot chocolate or tea prior to rest periods. B. Encourage the client to ambulate in the hallway before resting. C. Cluster routine care activities to allow rest periods without interruptions. D. Encourage the client to watch television to relax.

Correct Answer is C

Explanation

A. Offer the client hot chocolate or tea prior to rest periods. While warm beverages can be comforting and help some people relax, hot chocolate and many teas contain caffeine, which can interfere with sleep. Even decaffeinated options might not be the best choice close to bedtime due to the fluid content, which could increase the need for nighttime urination, disrupting sleep.
B. Encourage the client to ambulate in the hallway before resting. Light physical activity, such as ambulating, can help promote relaxation and reduce muscle tension, which might aid sleep. However, it is essential to consider the client's postoperative status and ensure that ambulation is safe and appropriate for their condition. Overexertion close to bedtime might have the opposite effect and increase alertness.
C. Cluster routine care activities to allow rest periods without interruptions. This is a highly recommended intervention. By clustering care activities, the nurse can minimize disturbances during rest periods, allowing the client to have longer, uninterrupted sleep. This is crucial in a hospital setting where frequent interruptions can significantly impact the quality of sleep.
D. Encourage the client to watch television to relax. While watching television can be relaxing for some, it can also be stimulating and potentially interfere with sleep due to the light and noise. Blue light emitted from screens can suppress melatonin production, making it harder to fall asleep. Therefore, this is generally not recommended as a sleep aid.

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A nurse is caring for a client who has limited mobility and is experiencing urinary incontinence. Which of the following actions should the nurse take to prevent skin breakdown?

Nursing Test Bank

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