A nurse is contributing to the plan of care for a client who is experiencing a herpes simplex outbreak. Which of the following interventions should the nurse recommend?

Avoid over-the-counter topical ointments.

Cleanse skin eruptions with povidone-iodine.

Administer an antibiotic medication.

Place disposable thermometers in the client's room.

Answer and Explanation

The Correct Answer is B

A.   Incorrect. Over-the-counter topical ointments may worsen herpes simplex outbreaks.
B.   Correct. Cleaning skin eruptions with povidone-iodine helps prevent secondary infection.
C.   Incorrect. Antiviral medications, not antibiotics, are used to treat herpes simplex outbreaks.
D.   Incorrect. Disposable thermometers are not directly related to herpes simplex outbreak management.

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Correct Answer is B

Explanation

A. Incorrect. The bedside table should be within easy reach of the bed to prevent the client from attempting to reach for items and potentially falling.
B. Correct. Moving the client's bed to the main floor of the house reduces the need for using stairs, which can be a fall risk for clients at risk for falls.
C. Incorrect. Keeping the lighting dim increases the risk of falls. Adequate lighting is important to prevent falls.
D. Incorrect. Area rugs on slick floor surfaces can be hazardous and increase the risk of falls.
They should be removed or secured properly.

A. Empty the client's ostomy pouch before removing the skin barrier. B. Change the client's ostomy appliance 1 hr after breakfast. C. Use a moisturizing soap to clean the skin around the client's stoma. D. Create an opening on the skin barrier that is 1.27 cm (0.5 in.) larger than the client's stoma.

Correct Answer is A

Explanation

A.Emptying the ostomy pouch before removing the skin barrier reduces the risk of spillage and makes the procedure less messy. It is also more comfortable for the client and helps prevent leakage of stool onto the skin, which can cause irritation.

B. It’s generally recommended to change an ostomy appliance when the bowel is least active, such as before meals or several hours after eating. Changing it one hour after breakfast may coincide with increased bowel activity, which can increase the risk of leakage and make the change more challenging.

C.Moisturizing soaps should be avoided when cleaning the skin around the stoma because they can leave a residue that interferes with the adhesion of the skin barrier, potentially leading to leakage. The nurse should use a mild, non-moisturizing soap or just water to clean the area to ensure proper adhesion of the appliance.

D.The opening on the skin barrier should closely match the size of the stoma, with a slight gap of about 1/8 inch (0.3 cm) around it to avoid pressure on the stoma while also protecting the surrounding skin. Creating an opening that is 0.5 inches (1.27 cm) larger than the stoma would leave too much skin exposed, increasing the risk of irritation and infection.

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A nurse is contributing to the plan of care for a client who is experiencing a herpes simplex outbreak. Which of the following interventions should the nurse recommend?

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Naxlex Comprehensive Predictor Exams

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