A nurse is providing skin care for a patient with urinary incontinence. What actions should the nurse take?
Use soap to clean the patient’s skin.
Apply a barrier cream to the patient’s skin.
Avoid applying friction when drying the patient’s skin.
Use warm water to clean the patient’s skin.
Correct Answer : B,C,D
Choice A rationale
Using soap to clean the patient’s skin is not the best practice. Soap can dry out and irritate the skin, especially in patients with urinary incontinence. It can disrupt the skin’s natural pH balance and make it more susceptible to damage.
Choice B rationale
Applying a barrier cream to the patient’s skin is a recommended practice. Barrier creams provide a protective layer on the skin that can help prevent irritation from urine. They can also help to keep the skin moisturized, which is important for maintaining skin integrity.
Choice C rationale
Avoiding friction when drying the patient’s skin is crucial. Friction can cause further damage to the skin, especially in areas that are already irritated or broken down due to incontinence. It’s recommended to gently pat the skin dry rather than rubbing it.
Choice D rationale
Using warm water to clean the patient’s skin is a good practice. Warm water is less irritating to the skin than hot water and can help to cleanse the area without causing additional discomfort or damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Granulation tissue forming at the bottom of the wound bed is a characteristic of secondary intention healing, not primary intention. In secondary intention, the wound is left open and fills with granulation tissue.
Choice B rationale
A wound that was contaminated at the time of injury would likely require secondary intention healing to allow for cleaning and observation of the wound. This is not typical of primary intention healing.
Choice C rationale
Prolonged healing of the wound is not a characteristic of primary intention healing. In primary intention, the wound edges are brought together (approximated), which allows for rapid healing.
Choice D rationale
In primary intention healing, the skin edges of the wound are sutured closed. This is the most distinctive feature of primary intention healing, as it allows for minimal scar formation and quick healing.
Correct Answer is ["35"]
Explanation
Step 1 is: To find out how many mL/hr the nurse should set the infusion pump to deliver, we need to divide the total volume of enteral nutrition (840 mL) by the total time (24 hours).
So, the calculation is: 840 mL ÷ 24 hours = 35 mL/hr Therefore, the nurse should set the infusion pump to deliver 35 mL/hr.
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