A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse take?
Apply corn-starch to the client’s skin.
Allow the client’s skin to air-dry after cleaning.
Clean the client’s skin with a pH-balanced cleanser.
Use hot water to clean the client’s skin.
The Correct Answer is C
Urinary incontinence can lead to skin irritation and breakdown if the skin is not properly cleaned 1. Using a pH-balanced cleanser can help maintain the skin’s natural acidity and prevent irritation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Answer: D. The client grimaces when they move.
Rationale:
A) The client rates their pain as an 8 on a scale of 0 to 10:
Pain ratings provided by the client are subjective and reflect their personal experience and perception of pain. While important for assessing pain severity, this rating is based on the client's personal report rather than observable evidence.
B) The client states the pain is located on their abdomen:
The location of pain, as reported by the client, is subjective information. It is based on the client's personal experience and cannot be objectively measured or observed by the nurse.
C) The client reports a burning sensation:
Describing the sensation of pain, such as a burning feeling, is a subjective experience. This description provides valuable information about the nature of the pain but does not serve as an objective indicator.
D) The client grimaces when they move:
Observing a grimace is an objective indicator of pain. It is a visible, physical response that the nurse can see and document, indicating that the client is experiencing discomfort or pain. Objective indicators are observable signs that can be noted by healthcare providers.
Correct Answer is B
Explanation
An oxygen saturation of 88% is below the normal range of 95-100%, indicating that the client may be experiencing hypoxia. Encouraging the client to take deep breaths can help increase their oxygen saturation level.
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