Which of the following are essential in the care for a patient with incontinence-associated dermatitis? (SELECT ALL THAT APPLY)

apply warm compresses to relieve discomfort

check the client's skin for moisture at least q 2 hrs

use a moisture barrier product after cleansing

decrease oral intake in early morning

dry the skin with a vigorous motion to promote circulation

Answer and Explanation

Correct Answer : A,B,C

A. Applying warm compresses can help relieve discomfort

B. Regular monitoring of skin moisture is crucial in managing IAD. Moist skin is more susceptible to breakdown, so frequent checks allow for prompt intervention, such as changing incontinence products or applying protective barriers.

C. Applying a moisture barrier product after cleansing helps protect the skin from moisture and irritants found in urine or feces. These products create a protective barrier that can prevent further damage and promote healing of already affected skin. This is essential in managing IAD.

D There is no clinical

Rationale to decrease oral intake in the early morning specifically for managing IAD. Hydration is important for overall skin health, and reducing oral intake without medical indication could lead to dehydration, which may worsen skin condition.

E. Vigorous drying of the skin is not recommended as it can exacerbate skin irritation and damage. Instead, gentle patting or air drying is preferred to avoid further trauma to the already compromised skin.

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Correct Answer is D

Explanation

D. Assessing the client is the nurse's first responsibility when a medication error is suspected. The nurse should promptly assess the client's condition to determine if any harm has occurred as a result of the error. This assessment includes vital signs, physical assessment, and evaluation of any signs or symptoms related to the medication error.

A. Documenting the medication error is important for accurate record-keeping and subsequent investigation. However, it should not be the nurse's first action. The priority should be to assess and address any potential harm to the client.

B. Calling the physician may be necessary depending on the severity of the error and the client's condition. However, it is not the first responsibility of the nurse in response to a suspected medication error. The nurse's primary concern should be the immediate assessment and management of the client's condition.

C. Notifying the supervisor or charge nurse is an important step to report the incident and seek guidance on next steps. Supervisors can assist in managing the situation, implementing corrective measures, and ensuring appropriate documentation and reporting procedures are followed. This is typically one of the first actions after ensuring the client's safety.

A. Keep the environment free of obstacles B. Raise the bed for client ease upon exiting C. Avoid bright lighting D. Keep linens away from nursing uniform

Correct Answer is A

Explanation

A. This is essential to prevent falls, which are a common and serious risk for the elderly. A clutter-free environment allows for safe and easy mobility.

B. Raising the bed, can actually increase the risk of falls if the bed is too high for safe exit.

C. Bright lighting can cause glare and visual discomfort for elderly individuals, especially those with age- related eye conditions such as cataracts or macular degeneration. However, adequate lighting is crucial for safety. The key is to provide sufficient lighting that is evenly distributed and free of glare or harsh shadows, which can help prevent falls.

D. While keeping linens away from the nursing uniform is good practice for infection control, it does not directly relate to the immediate physical safety of the client in the same way that a clear environment does.

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Which of the following are essential in the care for a patient with incontinence-associated dermatitis? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is A

Explanation

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