A nurse is planning care for an older adult client who has urinary incontinence. Which of the following interventions should the nurse include in the client's plan of care?
Apply a moisture barrier in a thick layer to the vulnerable skin areas.
Cleanse the skin with antibacterial soap and hot water after each incontinence episode.
Toilet the client every 4 hr while the client is awake.
Reduce the client's daily fluid intake.
The Correct Answer is A
A. Applying a moisture barrier helps protect the skin from irritation and breakdown due to prolonged exposure to moisture.
B. Cleansing the skin with antibacterial soap and hot water may be too harsh and can contribute to skin irritation; gentle cleaning with a mild cleanser is preferable.
C. Toileting the client every 4 hours may not be frequent enough to prevent skin breakdown; a more frequent toileting schedule should be implemented.
D. Reducing the client's daily fluid intake is not a recommended intervention for urinary incontinence, as it may lead to dehydration and other health issues.
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Correct Answer is C
Explanation
A. Raising the index finger is not a typical response for managing gagging during NG tube insertion.
B. Bearing down during insertion is not an appropriate instruction and may increase the risk of complications.
C. Instructing the client to say "stop" if a burning sensation is felt inside the nose allows for communication and prompt action to ensure the client's comfort and safety.
D. Inhaling forcefully during insertion is not a recommended action and may interfere with the procedure.
Correct Answer is C
Explanation
A. Having the guard sign a release of information form may not be appropriate in an emergency situation, and immediate action is needed to address the injury.
B. Telling the guard to submit an inmate inquiry form to the warden may delay necessary medical intervention in an emergency.
C. Completing an incident report is appropriate to document the situation and the care provided It is not necessary to disclose the inmate's HIV status in the report.
D. Instructing the guard to ask the inmate is not a proper approach to handling a medical emergency. The nurse should focus on providing immediate care to the injured inmate.
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