A nurse is planning care to prevent skin breakdown for a client who is immobile and has urinary incontinence. Which of the following actions should the nurse include in the plan of care?

Request a prescription for an indwelling urinary catheter.

Arrange for an alternating pressure mattress.

Apply cornstarch to the client's skin.

Reposition the client every 4 hours.

Answer and Explanation

The Correct Answer is B

An alternating pressure mattress can help prevent skin breakdown in a client who is immobile by redistributing pressure and reducing the risk of pressure ulcers. This is an appropriate action for the nurse to include in the plan of care for a client who is immobile and has urinary incontinence.

a. An indwelling urinary catheter can increase the risk of infection and should only be used when other methods of managing urinary incontinence are not eﬀective.

c. Cornstarch can absorb moisture and help keep the skin dry, but it is not recommended for use on broken skin or in areas where there is a risk of fungal infection.

d. Repositioning the client every 4 hours may not be frequent enough to prevent skin breakdown. The client should be repositioned at least every 2 hours to reduce the risk of pressure ulcers.

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Correct Answer is C

Explanation

If a client reports pain and informs the nurse that pain medications are not an option for managing their pain, the nurse can oﬀer non-pharmacological interventions such as a back massage to help relieve the client's pain. This is an appropriate response by the nurse.

a. Telling the client that the pain medication will work if they just give it a chance is not an appropriate response as it dismisses the client's concerns and preferences.

b. The nurse should not recommend that the client take any herbal remedies without first consulting with the healthcare provider.

d. Asking the client why they think pain medication is not going to help them may be appropriate in some situations, but it is not necessarily the best initial response. The nurse should first oﬀer non- pharmacological interventions to help relieve the client's pain.

A. Decreased judgment B. Decreased activity C. Increased reﬂexes D. Increased auditory alertness

Correct Answer is A

Explanation

Decreased judgment is a common sign of sleep deprivation. When a person is sleep deprived, their cognitive function can be impaired, leading to difficulty making decisions and exercising good judgment.

Options b, c, and d are not necessarily indicative of sleep deprivation. Decreased activity can be a sign of many diﬀerent conditions, including fatigue or depression. Increased reﬂexes and increased auditory alertness are not commonly associated with sleep deprivation.

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A nurse is planning care to prevent skin breakdown for a client who is immobile and has urinary incontinence. Which of the following actions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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A nurse is planning care to prevent skin breakdown for a client who is immobile and has urinary incontinence. Which of the following actions should the nurse include in the plan of care?