A nurse is caring for a client who is incontinent of urine. Which of the following actions should the nurse take?
Rinse the client's skin with hot water.
Keep the clients skin area moist.
Apply barrier cream to the client's cleansed skin.
Apply a thin layer of cornstarch to the client's skin.
The Correct Answer is C
A. Rinse the client's skin with hot water: Hot water can damage the skin’s protective barrier, causing irritation and increasing the risk of breakdown. Using lukewarm water is safer and helps maintain skin integrity while cleansing the area.
B. Keep the client’s skin area moist: Excess moisture from urine or feces contributes to maceration and increases the risk of skin breakdown. The skin should be kept clean and dry, not intentionally moist, to prevent irritation and pressure injury.
C. Apply barrier cream to the client's cleansed skin: Barrier creams protect the skin from prolonged exposure to urine and stool, helping to prevent incontinence-associated dermatitis. Applying the cream after cleansing creates a protective layer, maintaining skin integrity and reducing irritation.
D. Apply a thin layer of cornstarch to the client's skin: Cornstarch can clump when in contact with moisture and may promote fungal growth. It is not recommended for protecting skin from incontinence-related irritation and may worsen skin breakdown.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The client has state-sponsored health insurance: Information about insurance coverage is important for discharge planning but is not typically the focus of an interprofessional team meeting. This detail is usually managed by case management or social services rather than guiding immediate clinical decision-making.
B. The client's vital signs are checked every 8 hr: The frequency of routine vital sign monitoring is a standard nursing task and does not provide meaningful insight into the client’s current functional or clinical status. Interprofessional discussions focus more on changes or problems rather than routine care schedules.
C. The client's next dressing change is scheduled in 4 hr: While wound care timing is important for nursing care, it does not require interprofessional input unless complications or barriers exist. This information is task-oriented rather than problem-focused and is better documented in the nursing plan of care.
D. The client has developed difficulty ambulating: New difficulty with ambulation represents a change in functional status that impacts safety, mobility, and discharge planning. This information is highly relevant to the interprofessional team, including physical therapy, occupational therapy, and providers. Sharing this promotes coordinated interventions and appropriate referrals.
Correct Answer is C
Explanation
A. Gross motor skills: Rolling from abdomen to back, playing with feet, smiling responsively, and turning toward sounds are expected developmental milestones at 6 months of age. These findings indicate appropriate gross motor, social, and sensory development.
B. Temperature: A temperature of 37.4° C (99.3° F) is within the normal range for an infant. This finding does not suggest infection or illness and does not require provider notification.
C. Weight: At 6 months of age, an infant is expected to have approximately doubled their birth weight. This infant weighed 3.6 kg at birth and currently weighs 5.9 kg, which suggests inadequate weight gain and should be reported for further evaluation.
D. Feeding habits: Breastfeeding combined with small amounts of cereal and fruit three times daily is appropriate for a 6-month-old infant. There is no indication from the feeding history alone that intake is inappropriate.
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