Which of the following actions can the nurse take to help prevent a health care-associated infection in an incontinent patient?

Avoiding use of a urinary catheter

Applying absorbent briefs

Restricting Fluids

Toileting patient every 4 hours

Answer and Explanation

The Correct Answer is B

A.   Avoiding use of a urinary catheter: While avoiding unnecessary urinary catheterization is important to prevent healthcare-associated urinary tract infections, this action may not be directly applicable to an incontinent patient who requires interventions to manage incontinence.
B.   Applying absorbent briefs: Using absorbent briefs helps contain urine and feces, reducing the risk of skin breakdown and contamination of the environment.
C.   Restricting Fluids: Restricting fluids may lead to dehydration and is not a recommended approach for preventing healthcare-associated infections in incontinent patients.
D.   Toileting patient every 4 hours: Toileting frequency should be individualized based on the patient's needs and not restricted to a specific time interval. Additionally, simply toileting the patient may not be sufficient to prevent healthcare-associated infections if proper hygiene practices are not followed.

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Correct Answer is B

Explanation

A. Thickening of the epidermis: The epidermis tends to thin rather than thicken with aging.
Thinning of the epidermis can lead to increased vulnerability to injury and slower wound healing.
B. Thinning of the epidermis: Thinning of the epidermis is a common age-related change in the skin. This thinning can result in a decreased barrier function, making the skin more susceptible to damage and infection.
C. Oiliness of the skin: Older adults often experience a decrease in oil production, leading to drier skin rather than oilier skin.
D. Increased elasticity of the skin: With aging, the skin tends to lose elasticity, resulting in sagging and wrinkles rather than increased elasticity.

A. Pupil size and reaction B. Heart rate and blood pressure C. Respiratory rate and oxygen saturation D. Skin turgor and moisture

Correct Answer is D

Explanation

A. Pupil size and reaction: Pupil size and reaction are typically assessed to monitor neurological function and are not directly related to tissue integrity.
B. Heart rate and blood pressure: Heart rate and blood pressure are vital signs that provide information about cardiovascular function but do not specifically assess tissue integrity.
C. Respiratory rate and oxygen saturation: Respiratory rate and oxygen saturation are indicators of respiratory function and oxygenation status and are not directly related to tissue integrity.
D. Skin turgor and moisture: Skin turgor, the skin's ability to return to its normal shape after being pinched, and moisture levels are important assessments for monitoring tissue hydration and integrity. Changes in skin turgor and moisture can indicate dehydration, which can impair tissue integrity and wound healing.

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Which of the following actions can the nurse take to help prevent a health care-associated infection in an incontinent patient?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for an older client and educating the student nurse on assessing the skin. The student nurse knows that an older client's skin is most likely to experience which of the following changes with aging?

Correct Answer is B

Explanation

Which of the following assessments should be performed to monitor for impaired tissue integrity?

Correct Answer is D

Explanation

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