A patient is incontinent on the first day after surgery. This is a risk factor for the development of skin breakdown and infection primarily because:
The moisture creates an environment suitable for the growth of microorganisms in a wound.
Greater pressure is exerted by a wet bed.
Shearing is more likely from wet sheets.
The patient has to be repositioned for the bed to be changed.
The Correct Answer is A
Choice A rationale
Moisture from incontinence can compromise skin integrity and create a favorable environment for bacterial growth, increasing the risk of infection and skin breakdown.
Choice B rationale
While a wet bed may be uncomfortable, it does not exert greater pressure that would lead to skin breakdown or infection.
Choice C rationale
Shearing can occur from moving a patient on any surface; however, wet sheets do not inherently increase the likelihood of shearing.
Choice D rationale
Repositioning the patient is necessary for comfort and to prevent pressure ulcers, but it is not a direct cause of skin breakdown or infection due to incontinence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Elastic adhesive tape is not the best option for a patient experiencing skin irritation from tape removal because it may cause further irritation when removed.
Choice B rationale
Karaya paste is primarily used as a skin barrier and adhesive for ostomy appliances, not for securing dressings, especially in cases of skin irritation.
Choice C rationale
Montgomery straps are designed for situations where frequent dressing changes are needed. They allow the dressing to be changed without removing the adhesive straps each time, minimizing skin irritation.
Choice D rationale
Paper tape is less irritating to the skin than elastic adhesive tape, but it still requires removal with each dressing change, which can irritate sensitive skin.
Correct Answer is D
Explanation
Choice A rationale
Pointing the device away while opening it is a safe practice to prevent contamination and accidental exposure to bodily fluids.
Choice B rationale
Not touching the drainage spout with the hand is correct as it prevents contamination of the spout, which could lead to infection.
Choice C rationale
Compressing the device before closing it is part of the proper procedure to re-establish the vacuum within the drain, which is necessary for it to function correctly.
Choice D rationale
Using one alcohol wipe to clean both the spout and the plug is incorrect because each should be cleaned with a separate sterile wipe to prevent cross-contamination and maintain sterility.
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