A nurse is providing skin care for a client who has urinary incontinence. Which of the following actions should the nurse take?
Use soap to clean the client's skin.
Apply friction when drying the client's skin.
Use hot water to clean the client's skin.
Apply a barrier cream to the client's skin.
The Correct Answer is D
Choice A reason: Using soap to clean the client's skin is not a recommended action, as it can dry out and irritate the skin, increasing the risk of skin breakdown and infection.
Choice B reason: Applying friction when drying the client's skin is not a recommended action, as it can damage and abrade the skin, causing pain and inflammation.
Choice C reason: Using hot water to clean the client's skin is not a recommended action, as it can increase the blood flow and inflammation to the skin, as well as remove the natural oils that protect the skin.
Choice D reason: Applying a barrier cream to the client's skin is a recommended action, as it can moisturize and protect the skin from the effects of urine, such as acidity, bacteria, and enzymes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not the correct answer because reassessing the patient is not the next step after completing an assessment. Reassessment is done periodically or when there is a change in the patient's condition, but not immediately after the initial assessment.
Choice B reason: This is not the correct answer because writing nursing interventions is not the next step after completing an assessment. Nursing interventions are the actions that the nurse plans and implements to achieve the desired outcomes for the patient. They are based on the nursing diagnoses, which are derived from the analysis of the assessment data.
Choice C reason: This is the correct answer because analyzing cues is the next step after completing an assessment. Analysis is the process of identifying patterns, relationships, and trends in the assessment data, and comparing them with the normal and expected findings. Analysis helps the nurse to identify the patient's problems, needs, strengths, and risks.
Choice D reason: This is not the correct answer because creating SMART goals is not the next step after completing an assessment. SMART goals are the specific, measurable, achievable, realistic, and time-bound outcomes that the nurse and the patient agree on. They are based on the nursing diagnoses, which are derived from the analysis of the assessment data.
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because safety is the second level of Maslow's hierarchy of needs, and it includes the needs for security, stability, protection, and freedom from fear and anxiety. The couple who just lost their house in a fire are likely experiencing a threat to their safety needs, as they have lost their shelter, possessions, and sense of security. The nurse should identify and address their safety needs as a priority, and help them find alternative housing, financial assistance, and emotional support.
Choice B reason: This is not the correct answer because self-actualization is the highest level of Maslow's hierarchy of needs, and it includes the needs for personal growth, fulfillment, and realization of one's potential. The couple who just lost their house in a fire are unlikely to be concerned with their self-actualization needs at this time, as they have more pressing and basic needs to meet. The nurse should focus on their lower-level needs first, before helping them achieve their higher-level needs.
Choice C reason: This is not the correct answer because esteem is the fourth level of Maslow's hierarchy of needs, and it includes the needs for self-respect, confidence, recognition, and appreciation. The couple who just lost their house in a fire may experience a loss of esteem, as they may feel ashamed, helpless, or worthless. However, their esteem needs are not the most urgent or important at this time, as they have more fundamental needs to satisfy. The nurse should support their esteem needs by showing empathy, respect, and encouragement, but not neglect their lower-level needs.
Choice D reason: This is not the correct answer because love and belonging is the third level of Maslow's hierarchy of needs, and it includes the needs for affection, intimacy, friendship, and social acceptance. The couple who just lost their house in a fire may benefit from their love and belonging needs, as they may seek comfort, support, and connection from others. However, their love and belonging needs are not the primary or essential at this time, as they have more basic and vital needs to fulfill. The nurse should facilitate their love and belonging needs by providing a caring and compassionate environment, but not overlook their lower-level needs.
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