A nurse is creating a plan of care to maintain the skin integrity of a client who experiences frequent diarrhea due to ulcerative colitis. Which of the following interventions should the nurse include in the plan?
Administer a soap-suds enema to cleanse the colon.
Soak in a sitz bath for 20 min after each stool.
Wipe perianal area with warm water and apply a barrier cream.
Cleanse with antimicrobial scrub and vigorously dry.
The Correct Answer is C
A. Soap-suds enemas are not recommended for clients with ulcerative colitis because they can irritate the colon and worsen symptoms. Enemas should be used cautiously, if at all, and only when medically indicated.
B. Soaking in a sitz bath can help soothe perianal discomfort, but it is not the most effective intervention for protecting the skin from diarrhea-related irritation. Barrier creams are a more direct way to protect the skin from further damage.
C. Wiping the perianal area with warm water and applying a barrier cream is an appropriate and effective intervention to protect the skin. The warm water is gentle, and the barrier cream provides a protective layer that helps prevent skin breakdown from frequent contact with stool.
D. Cleansing with an antimicrobial scrub and vigorously drying the perianal area could cause further irritation and damage to already sensitive skin. The focus should be on gentle cleansing and protecting the skin with a barrier cream.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.5"]
Explanation
Number of tablets = Desired dose (mg) / Tablet strength (mg/tablet)
In this case:
Desired dose = 25 mg
Tablet strength = 50 mg/tablet
Plugging the values into the formula:
Number of tablets = 25 mg / 50 mg/tablet = 0.5 tablets
Correct Answer is D
Explanation
A. Parenteral nutrition (PN) should not be left out for extended periods. Generally, unused PN should be discarded after 24 hours, not 12 hours, to prevent contamination and bacterial growth.
B. The flow rate of PN should be monitored and adjusted carefully, but it should not be increased without orders. Rapid adjustments could cause complications such as fluid overload or electrolyte imbalances.
C. PN solution should be removed from the refrigerator 1 to 2 hours before use to allow it to come to room temperature, but 2 hours may be too long. It should be done cautiously to avoid bacterial growth at room temperature.
D. Monitoring daily laboratory values is essential for assessing the client's nutritional status, electrolytes, liver function, and kidney function. These values help guide ongoing care and detect complications of PN, such as electrolyte imbalances or liver dysfunction.
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