The unlicensed assistive personnel (UAP) tells the nurse that an older client has requested powder applied after a tub bath to relieve itchy dry skin. Which instruction should the nurse provide to the UAP?

Cover moist areas of the skin with cornstarch.

Gently apply lotion to the skin after bathing.

Add bath oil directly to the warm bath water.

Switch to using a liquid soap for bar soap.

Answer and Explanation

The Correct Answer is B

A.   Applying cornstarch or other powders to moist skin can exacerbate dryness and irritation, as powders can absorb moisture but also contribute to a dry skin environment. In general, powders are not recommended for use on already dry or irritated skin, especially for older adults, as they can lead to further skin issues or contribute to fungal infections.
B.   Gently applying lotion or moisturizer to the skin after bathing is the most appropriate action. Moisturizers help to rehydrate and lock in moisture, reducing the risk of dry, itchy skin. Applying lotion to damp skin (immediately after bathing) is particularly effective as it helps to seal in the moisture.
C.   Adding bath oil to the bath water can be beneficial for moisturizing the skin, as it helps to create a barrier that prevents moisture loss. However, for the client’s specific request about post-bath relief, adding oil to the bath water does not address the immediate need for skin care after bathing.
D.   Liquid soap can be gentler on the skin compared to bar soap, which can be drying, especially if it contains harsh ingredients. However, switching from bar soap to liquid soap is a preventive measure and does not provide immediate relief for already dry and itchy skin.

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Correct Answer is D

Explanation

A. Dehiscence refers to the separation or opening of a wound’s edges, usually occurring after surgical closure. This can be due to several factors including infection, mechanical stress, or inadequate wound healing. If the incision shows signs of separation or gaping, this term would be appropriate. However, without a visual description or image, it’s unclear if the incision exhibits these characteristics.
B. This term implies that the incision is progressing towards recovery with no significant issues such as infection or dehiscence. This documentation is used when the wound appears clean, dry, and without signs of complications.
C. An infected incision typically shows signs such as increased redness, warmth, swelling, purulent drainage, or an unpleasant odor. If the incision displays these signs, it would be appropriate to document it as infected.
D. This term indicates that the edges of the incision are closely aligned, which is often used to describe an incision that is healing by primary intention. The edges are expected to come together neatly without separation.

A. Imbalanced nutrition: less than body requirements. B. Impaired physical mobility. C. Relocation stress syndrome. D. Body image disturbance.

Correct Answer is A

Explanation

A. After a myocardial infarction, it is important to monitor the client’s blood pressure before they start ambulating to assess their hemodynamic stability. Changes in blood pressure during or after ambulation could indicate problems such as orthostatic hypotension or cardiovascular instability.
B. While monitoring urinary output is important for assessing renal function and fluid balance, it is not the most immediate concern when preparing the client to ambulate post-MI. The priority is to ensure cardiovascular stability and safety during ambulation, so other interventions take precedence in this situation.
C. Dietary teaching about a cardiac diet is important for long-term management and recovery after an MI. However, it is not the immediate concern when the client is preparing to ambulate for the first time. The priority at this moment is to ensure the client’s safety and stability during the initial physical activity.
D. Vital signs should certainly be monitored, but the more immediate concern when the client is preparing to ambulate is ensuring cardiovascular stability and assessing any potential risk factors that could arise during the activity.

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The unlicensed assistive personnel (UAP) tells the nurse that an older client has requested powder applied after a tub bath to relieve itchy dry skin. Which instruction should the nurse provide to the UAP?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While cleansing a client's surgical incision, the nurse observes the incision as seen in the picture. How should the nurse document the appearance of the incision?

Correct Answer is D

Explanation

The nurse is assessing an older female client who was admitted to a long-term facility two days ago. The resident refuses to go to the dining room for meals and calls for help with all activities of daily living. Which nursing problem is best to include in this client's plan of care?

Correct Answer is A

Explanation

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