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 B
Explanation
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. .
Correct Answer is A
Explanation
Choice A rationale:
"Keep your back straight.”. Maintaining correct posture when transferring clients is essential to prevent injuries to both the nurse and the patient. The correct answer, "Keep your back straight," is crucial in ensuring that the nurse avoids straining their back muscles. When transferring patients, it's essential to use proper body mechanics and keep the spine in a neutral position. This minimizes the risk of back injuries and promotes safe patient handling. Bending or twisting the back can lead to musculoskeletal problems, such as back pain or herniated discs.
Choice B rationale:
"Keep your knees straight.”. Keeping your knees straight is not the correct choice for maintaining correct posture when transferring clients. In fact, it's essential to keep your knees slightly bent when lifting or transferring a patient. This position helps to maintain stability and distribute the weight evenly, reducing the risk of injury.
Choice C rationale:
"Tilt your head toward your chest.”. Tilting the head toward the chest is unrelated to maintaining proper posture during patient transfers. It is important to keep the head in a neutral position while transferring patients, focusing on the back and leg positioning.
Choice D rationale:
"Loosen your abdominal muscles.”. Loosening abdominal muscles is not a recommended practice during patient transfers. Maintaining core strength and stability is essential for proper body mechanics. Relaxing the abdominal muscles can lead to poor posture and decreased stability, increasing the risk of injury.
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