A nurse is contributing to the plan of care for a client who has frequent diarrheal stools. Which of the following interventions should the nurse include in the plan?

Allow the perineal area to air dry after each stool.

Administer a soap-suds enema to cleanse the colon.

Provide the client with a high fiber diet.

Apply a zinc-oxide barrier to the perineal area after each stool.

Answer and Explanation

The Correct Answer is D

A. Allow the perineal area to air dry after each stool. While drying is important, leaving the skin unprotected can lead to skin breakdown and irritation from continued exposure to stool.

B. Administer a soap-suds enema to cleanse the colon. Soap-suds enemas are contraindicated in diarrhea because they can cause further irritation and electrolyte imbalances.

C. Provide the client with a high-fiber diet. A high-fiber diet is recommended for constipation, not diarrhea, as fiber can increase stool frequency.

D. Apply a zinc-oxide barrier to the perineal area after each stool. Zinc-oxide protects the skin from moisture and irritation, helping prevent dermatitis and skin breakdown.

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Correct Answer is C

Explanation

A. Assess fluid balance. While assessment is important, treatment of dehydration (rehydration) is the priority in severe diarrhea.

B. Introduce a regular diet. Introducing a regular diet should come after rehydration, as severe diarrhea can lead to fluid and electrolyte imbalance that must be corrected first.

C. Rehydrate. The immediate priority is fluid replacement (oral or IV) to prevent hypovolemia, electrolyte imbalances, and shock.

D. Maintain fluid therapy. Maintaining fluid therapy is important after rehydration has begun, but initial rehydration is the priority intervention.

A. Relief of urinary retention B. Convenience for the nursing staff or the client's family C. Routine acquisition of a urine specimen D. Measurement of residual urine after urination E. Presence of an open perineal wound

Correct Answer is ["A","D","E"]

Explanation

A. Relief of urinary retention. Urinary catheterization is indicated for clients who cannot void effectively, which can lead to bladder distension and complications.

B. Convenience for the nursing staff or the client's family. Catheterization should never be done for staff convenience due to the high risk of infection (CAUTI - catheter-associated urinary tract infection).

C. Routine acquisition of a urine specimen. Routine urine specimens should be obtained through clean-catch or midstream methods, unless a sterile sample is required for culture and sensitivity testing.

D. Measurement of residual urine after urination. Catheterization may be needed to measure post-void residual volume in cases of urinary retention.

E. Presence of an open perineal wound. A catheter can help prevent urine contamination of an open wound in the perineal area, reducing the risk of infection.

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A nurse is contributing to the plan of care for a client who has frequent diarrheal stools. Which of the following interventions should the nurse include in the plan?

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