A nurse is caring for a client with urinary incontinence.
What action should the nurse take to prevent skin breakdown?
Request a prescription for the insertion of an indwelling urinary catheter.
Apply a moisture barrier ointment to the skin.
Clean the skin and perineum with hot water after each episode of incontinence.
Check the client’s skin every 8 hours for signs of breakdown.
Check the client’s skin every 8 hours for signs of breakdown.
The Correct Answer is B
Choice A rationale
Requesting a prescription for the insertion of an indwelling urinary catheter is not the best option to prevent skin breakdown in a client with urinary incontinence. Catheters can increase the risk of urinary tract infections and should be used as a last resort.
Choice B rationale
Applying a moisture barrier ointment to the skin can help protect the skin from the damaging effects of urine. This can help prevent skin breakdown and is a common practice in the care of clients with urinary incontinence.
Choice C rationale
Cleaning the skin and perineum with hot water after each episode of incontinence is not recommended. Hot water can dry out the skin and cause irritation. It’s better to use warm water and a gentle cleanser.
Choice D rationale
Checking the client’s skin every 8 hours for signs of breakdown is important, but it’s not the only action the nurse should take. The nurse should also take proactive measures to protect the skin, such as applying a moisture barrier ointment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Mycoplasmal pneumonia, also known as walking pneumonia, is typically not an airborne disease. Standard precautions, including the use of a surgical mask, are usually sufficient when caring for these patients.
Choice B rationale
Scarlet fever is caused by group A Streptococcus bacteria, which are spread through respiratory droplets. Standard precautions, including the use of a surgical mask, are usually sufficient when caring for these patients.
Choice C rationale
Tuberculosis is an airborne disease. Healthcare providers should wear an N95 respirator when caring for a client with tuberculosis to protect themselves from inhaling the bacteria.
Therefore, Choice C is the correct answer.
Choice D rationale
Scabies is caused by a mite and is spread through direct skin-to-skin contact. It is not an airborne disease, so an N95 respirator is not necessary when caring for a client with scabies.
Correct Answer is B
Explanation
Choice A rationale
It is a good practice to change the batteries in smoke detectors annually to ensure they are working properly. This statement does not indicate a need for further instruction.
Choice B rationale
Using a walker when going upstairs can be dangerous due to the risk of falls. It is recommended that individuals use handrails or assistance when navigating stairs, not a walker. This statement indicates that the client needs further instruction.
Choice C rationale
Leaving a night light on can help prevent falls by providing visibility during the night. This statement does not indicate a need for further instruction.
Choice D rationale
Installing grab bars in the bathroom, especially near the toilet and in the shower, can provide support and prevent falls. This statement does not indicate a need for further instruction.
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