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:
Spirituality can increase feelings of hopelessness. This statement is not accurate. In many cases, spirituality can provide comfort, support, and a sense of hope for individuals who are nearing the end of life. Many people turn to their faith and spirituality as a source of strength and consolation during difficult times.
Choice B rationale:
Spirituality can increase the desire to hasten death. This statement is not generally true. Spirituality often has the opposite effect by providing a sense of purpose and meaning in life, which can help individuals find reasons to continue living. While some individuals may grapple with complex feelings related to death, it's not a typical outcome of embracing spirituality.
Choice C rationale:
Spirituality can increase depression. This statement is not accurate. Spirituality can actually serve as a source of emotional support and resilience for individuals facing the end of life. It can help individuals cope with their emotions and provide a sense of peace and comfort.
Choice D rationale:
Spirituality can increase the quality of life. This statement is correct. Spirituality often plays a positive role in the lives of individuals nearing the end of life. It can enhance the quality of life by providing emotional and psychological support, promoting a sense of purpose, and helping individuals find comfort and peace during this challenging time.
Correct Answer is D
Explanation
Choice A rationale:
Holding the tip of the syringe at least 1.3 cm (0.5 in) above the wound while irrigating is not the best practice for wound irrigation. It's crucial to maintain a close distance to the wound to ensure that the irrigation solution effectively cleans the area.
Choice B rationale:
Chilling the irrigant prior to the procedure is not necessary and could be uncomfortable for the patient. Room temperature or slightly warmed sterile saline solution is typically used for wound irrigation to prevent temperature-related discomfort.
Choice C rationale:
Flushing the wound from the most contaminated area to the cleanest area is an incorrect approach for wound irrigation. The wound should be irrigated from the cleanest to the most contaminatedto prevent contamination of previously clean areas and ensures thorough cleaning of the wound.
Choice D rationale:
Irrigating the wound until the solution that is draining is clear is a common practice for wound irrigation. It indicates that the wound is free of contaminants, debris, and infectious material.
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