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. Getting up and walking with the physical therapy aide promotes early mobility and is a positive statement.
B. Doing leg exercises every hour while awake helps prevent complications such as deep vein thrombosis (DVT).
C. Leaving antiembolic stockings on during sleep helps prevent DVT, so the client's statement is incorrect.
D. Using a footstool while sitting in a chair promotes proper positioning and comfort.
Correct Answer is D
Explanation
A. Wrapping the finger in a warm cloth helps improve blood flow and can facilitate the blood sample collection.
B. Rubbing the fingertip with an alcohol pad cleans the site before the puncture.
C. Puncturing the side of the fingertip is less painful and avoids the pain receptors.
D. The nurse should intervene if the client elevates the finger above the level of the heart. Holding the finger below the level of the heart in a dependent position will help increase blood flow to the area and ensure an adequate specimen for collection.
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