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:
Chlorine bleach is correct. Chlorine bleach is an effective disinfectant against bloodborne pathogens. It's recommended for cleaning surfaces contaminated with blood spills because it can destroy various microorganisms, including bacteria and viruses. However, it's essential to follow proper dilution guidelines and safety precautions when using bleach.
Choice B Reason:
Chlorhexidine gluconate is incorrect. While chlorhexidine gluconate is an antiseptic commonly used for skin disinfection before medical procedures or as a surgical scrub, it's not typically used for cleaning blood spills on surfaces. Its primary application is for skin disinfection, not environmental surface cleaning.
Choice C Reason:
Hydrogen peroxide is incorrect. Hydrogen peroxide is a mild antiseptic that can disinfect wounds or clean certain surfaces. However, it might not be as effective as chlorine bleach in dealing with blood spills. It's generally used more for superficial wound cleaning rather than for disinfecting large contaminated surfaces.
Choice D Reason:
Isopropyl alcohol is incorrect. Isopropyl alcohol is a commonly used disinfectant for surfaces, but when it comes to blood spills, it might not be as effective as chlorine bleach. While it can kill some pathogens, its efficacy against certain bloodborne pathogens may be limited compared to bleach.
Correct Answer is D
Explanation
Choice A Reason:
Urinating after the specimen collection is incorrect. While it's important to ensure urine doesn't contaminate the stool specimen during collection, the instruction to urinate after the collection doesn't directly impact the collection process itself. The primary focus is on avoiding contamination of the stool sample with urine or toilet tissue during collection.
Choice B Reason:
Placing 1.3 cm (0.5 in) of formed stool into a culture tube is incorrect. The amount of stool needed for a specimen can vary based on the specific test requirements or laboratory instructions. A fixed measurement, like 1.3 cm of formed stool, might not accurately represent the necessary quantity for all types of stool tests. Specific instructions from the healthcare provider or laboratory should be followed for proper collection.
Choice C Reason:
Keeping the specimen in a warm area is incorrect. Stool specimens are typically collected and stored at room temperature unless otherwise specified by specific test instructions. Placing the specimen in a warm area could alter the characteristics of the sample or promote bacterial growth, potentially affecting test accuracy. The specimen should be handled according to the specific requirements outlined for the particular test.
Choice D Reason:
Avoid placing toilet tissue in the bedpan after defecation is correct. Placing toilet tissue in the bedpan after defecation can contaminate the stool specimen, affecting the accuracy of test results. It's important to collect the stool sample without any contamination from toilet tissue or urine.
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