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

The correct answer is that the client can apply lotion to their feet if they avoid the area between their toes. Moisturizing the feet can help prevent dry skin and cracking, which are common problems for people with diabetes. However, it is important to avoid applying lotion between the toes, as this can create a moist environment that promotes the growth of fungus and bacteria¹.

Options a, b and d are not correct statements by the client that indicate an understanding of proper foot care for diabetes. Using a pumice stone to soften calluses on the feet, going barefoot just in the house and using a heating pad when feet are cold are not recommended practices for people with diabetes.

A. Erythema along the path of the vein B. Coolness of the client's left forearm C. Pallor of the client's left forearm D. Pitting edema at the insertion site

Correct Answer is A

Explanation

The development of erythema (redness) along the path of the vein indicates phlebitis at the IV site. Phlebitis refers to inﬂammation of the vein, often caused by irritation or infection. When phlebitis occurs, the vein becomes inﬂamed and can appear red, warm, and tender to touch. Erythema is a characteristic sign of phlebitis and suggests that the client's IV site has become irritated or infected.

Let's now discuss why the other

Options are not the correct answers:

Coolness of the client's left forearm: Coolness of the forearm is not typically associated with phlebitis. Instead, it may suggest compromised blood ﬂow to the area, such as arterial insufficiency, rather than inﬂammation of the vein.
Pallor of the client's left forearm: Pallor, or paleness, of the forearm is not a typical finding in phlebitis. It usually indicates reduced blood ﬂow or decreased oxygenation to the area, which can be caused by factors other than inﬂammation of the vein.
Pitting edema at the insertion site: Pitting edema refers to the indentation that remains when pressure is applied to an area of swelling and then release. While edema can occur at the insertion site of an IV, it is not a specific indicator of phlebitis. Edema can result from multiple causes, such as ﬂuid overload or localized inﬂammation, and its presence does not necessarily confirm the presence of phlebitis.

In summary, the presence of erythema along the path of the vein is the finding that indicates the development of phlebitis at the IV site. This redness suggests inﬂammation of the vein, which can be caused by various factors including irritation or infection. The other

Options, such as coolness of the forearm, pallor of the forearm, or pitting edema at the insertion site, are not specific indicators of phlebitis and may be associated with diﬀerent underlying conditions or factors.

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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

A nurse is providing instruction to a client who has diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is monitoring a client who is receiving continuous IV ﬂuid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phlebitis at the IV site?

Correct Answer is A

Explanation

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