A nurse is caring for a client who is incontinent.
Which of the following actions should the nurse take?
Clean the client's skin with hot water.
Dry between folds in the client's skin.
Apply baby powder to the client's skin.
Restrict the client's fluid intake.
The Correct Answer is B
Choice A rationale:
Clean the client's skin with hot water. Using hot water to clean a client's skin who is incontinent can be harmful. Hot water can damage the skin and exacerbate any existing skin issues. It is essential to use lukewarm water and gentle, pH-balanced cleansers to prevent skin irritation.
Choice B rationale:
Dry between folds in the client's skin. This is the correct answer. When caring for a client who is incontinent, it is crucial to ensure that the skin is kept clean and dry. Moisture between skin folds can lead to skin breakdown and the development of pressure ulcers. Drying the skin thoroughly helps prevent these issues.
Choice C rationale:
Apply baby powder to the client's skin. Applying baby powder is not recommended, as it can create a moist environment that may promote the growth of fungi and bacteria. It can also potentially lead to respiratory issues if the client inhales the powder. It's better to focus on keeping the skin clean and dry without using powder.
Choice D rationale:
Restrict the client's fluid intake. Restricting the client's fluid intake is not a suitable approach. Adequate hydration is essential for overall health and well-being. Dehydration can lead to various complications and negatively impact the client's overall health. Instead, focus on managing incontinence through appropriate hygiene and the use of incontinence products. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Tightening abdominal muscles is not the first action the nurse should take when repositioning a client. Repositioning a client requires proper body mechanics and coordination. Tightening abdominal muscles may not be as effective or safe as other actions in ensuring the client's safety during repositioning.
Choice B rationale:
Raising the height of the client's bed is not the first action the nurse should take when repositioning a client. Adjusting the bed height is a secondary consideration and can be done after ensuring proper body mechanics and patient safety during the repositioning process.
Choice C rationale:
Pivoting the feet in the direction of the move is a crucial step when repositioning a client. This action allows the nurse to maintain balance and control during the transfer. It also reduces the risk of injury to the nurse and the client. However, it is not the first action to be taken.
Choice D rationale:
Placing the feet in line with the shoulders is the first action the nurse should take when repositioning a client. This wide base of support provides stability and balance. It allows the nurse to maintain control during the repositioning process, reducing the risk of injury to both the nurse and the client. After achieving this stable stance, pivoting the feet in the direction of the move is the next step to facilitate the repositioning.
Correct Answer is C
Explanation
Choice A rationale:
Dysphagia is a difficulty or discomfort with swallowing and is not a complication of diverticulitis. Diverticulitis typically involves inflammation or infection of diverticula in the colon and may present with symptoms such as abdominal pain, fever, and changes in bowel habits, but dysphagia is not a characteristic feature.
Choice B rationale:
Ulcerative colitis is a distinct inflammatory bowel disease and is not a complication of diverticulitis. These conditions have different causes and affect different parts of the digestive tract. While both conditions can cause abdominal discomfort, they are not directly related.
Choice C rationale:
Peritonitis is a potential complication of diverticulitis. When diverticula become infected and rupture, they can spill their contents into the abdominal cavity, leading to peritonitis, which is an inflammation of the peritoneum (the lining of the abdominal cavity). This condition can be life-threatening and requires prompt medical intervention.
Choice D rationale:
Crohn's disease is a separate inflammatory bowel disease and is not a complication of diverticulitis. Crohn's disease can affect any part of the digestive tract, whereas diverticulitis typically occurs in the colon. They have distinct clinical features and treatment approaches. .
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