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.

Answer and Explanation

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. Controlled substances typically require a licensed nurse or provider to witness the wasting, not assistive personnel.
B. Wasted medication should be disposed of according to facility policies but not necessarily in a sharps container unless it is a sharp object.
C. Recording the amount of medication wasted on the controlled substance inventory record is a crucial step to maintain accurate documentation.
D. Returning the unused portion of a controlled substance to the pharmacy is not an appropriate action and goes against medication safety protocols. Controlled substances should be wasted and documented properly.

A. "I am trying to understand why this had to happen to me." B. "I dread going to therapy, but I am getting comfortable with my prosthesis." C. "My leg looks a little red, but my doctor says it's healing well." D. "I may be ready to talk about my leg in a week or so."

Correct Answer is B

Explanation

A. Expressing a desire to understand why the amputation happened suggests the client is still grappling with acceptance.
B. Expressing discomfort with therapy but being comfortable with the prosthesis indicates an acknowledgment of the loss and adaptation to the situation.
C. Noting the leg's appearance and healing is an observation but does not necessarily indicate acceptance.
D. Indicating a readiness to talk about the leg in a week or so suggests the client is not currently ready to discuss or fully accept the loss.

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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?

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