A nurse is caring for an older adult client who has fecal incontinence. Which of the following actions should the nurse take?
Turn the client every 4 hr.
Cleanse the perineal area with povidone-iodine solution.
Apply cornstarch powder to the perineal area.
Place a moisture barrier ointment over the perineal area.
The Correct Answer is D
Choice A Reason:
Turn the client every 4 hr. is incorrect. While repositioning is crucial for preventing pressure ulcers in immobile patients, turning the client every 4 hours might not directly address the issue of fecal incontinence or skin protection in the perineal area.
Choice B Reason:
Cleanse the perineal area with povidone-iodine solution is incorrect. Povidone-iodine solution might be too harsh for routine perineal care and can potentially irritate the skin. A gentler cleansing solution is typically recommended to avoid further skin irritation.
Choice C Reason:
Apply cornstarch powder to the perineal area is incorrect. Cornstarch powder might exacerbate moisture-related skin issues in the perineal area by creating a damp environment, potentially leading to skin maceration and worsening skin problems. It's not typically recommended for use in managing fecal incontinence.
Choice D Reason:
Place a moisture barrier ointment over the perineal area is correct. Using a moisture barrier ointment can help protect the skin from irritation and breakdown caused by prolonged exposure to fecal matter, reducing the risk of skin breakdown and discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
This is the correct action. A filter needle should be used when drawing medication from an ampule to prevent glass particles from being aspirated into the syringe and subsequently administered to the patient.
Choice B Reason:
Adding 0.5 ml of diluent to the medication is incorrect. Adding diluent to medication from an ampule is not a standard practice. Ampules usually contain pre-measured doses of medication and are designed for direct withdrawal without dilution. Adding diluent could alter the concentration and effectiveness of the medication.
Choice C Reason:
This is not necessary. Once the ampule is opened, it should be handled with care to avoid contamination, but cleansing the tip with an alcohol swab is not a standard practice since it does not effectively remove glass particles.
Choice D Reason:
This is incorrect. Ampules are not pressurized containers, and injecting air into an ampule is unnecessary and could cause the medication to spill out or create bubbles that interfere with accurate dosing.
Correct Answer is C
Explanation
Choice A Reason:
"The sides of the sling are for the client to hold on to." Is inaccurate. The sides of the sling in a mechanical lift are typically designed for the lift's attachment points, not for the client to hold on to. Clients usually need to remain relaxed and may not be able to hold on during the transfer.
Choice B Reason:
"The lower end of the sling goes below the client's calves." Is inaccurate. While it's important to position the sling correctly, stating that the lower end goes below the client's calves might not be universally accurate. The placement of the sling would depend on the type of lift and the specific needs of the client. It's crucial to follow manufacturer instructions and individualized care plans for sling placement.
Choice C Reason:
"This type of device is used for a client who cannot assist." Is accurate. This statement correctly identifies the primary purpose of a mechanical lift, which is to assist individuals who are unable to bear weight or assist with movement due to physical limitations. The mechanical lift helps transfer individuals safely without relying on their own strength or ability to assist in the movement.
Choice D Reason:
"The device requires the client to use upper body strength." Is inaccurate. This statement is incorrect. The purpose of a mechanical lift is to assist clients who cannot use their own strength, especially those who cannot bear weight or assist with movement. It is the machine that aids in lifting and transferring the individual, not the client's strength.
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