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 B

Explanation

A. Granulex is a topical medication used for wound care, but it may not be the first choice for a stage II pressure ulcer.
B. Hydrocolloid dressings are appropriate for stage II pressure ulcers, providing a moist environment to support healing and protecting the wound from contamination.
C. Proteolytic enzymes are used for debridement of necrotic tissue and may not be the primary choice for a stage II pressure ulcer.

D. Cortisone cream is a topical steroid that may be used for certain skin conditions but is not typically the first-line treatment for pressure ulcers.

A. Frequency of previous vital sign measurement B. Effectiveness of the last dose of pain medication C. Number of family members who have visited D. Time of the client's last bath

Correct Answer is B

Explanation

A. The frequency of previous vital sign measurements may be important but is not the most critical information to communicate during a transfer.
B. The effectiveness of the last dose of pain medication is crucial information for the receiving facility to manage the client's pain appropriately.
C. The number of family members who have visited is important for emotional support but may not be the priority for the receiving facility.
D. The time of the client's last bath is relevant but may not be as critical as information related to pain management during the hand-off report.

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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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