A client is receiving oxygen at 2 L/min via a nasal cannula. What oxygen concentration is the client receiving?

Choice A rationale
Requesting a prescription for the insertion of an indwelling urinary catheter is not the best option to prevent skin breakdown in a client with urinary incontinence. Catheters can increase the risk of urinary tract infections and should be used as a last resort.
Choice B rationale

Applying a moisture barrier ointment to the skin can help protect the skin from the damaging effects of urine. This can help prevent skin breakdown and is a common practice in the care of clients with urinary incontinence.
Choice C rationale
Cleaning the skin and perineum with hot water after each episode of incontinence is not recommended. Hot water can dry out the skin and cause irritation. It’s better to use warm water and a gentle cleanser.
Choice D rationale
Checking the client’s skin every 8 hours for signs of breakdown is important, but it’s not the only action the nurse should take. The nurse should also take proactive measures to protect the skin, such as applying a moisture barrier ointment.

Choice A rationale
Antimicrobial dressings are typically used for wounds that are infected or at high risk of infection. A stage I pressure ulcer, which involves intact skin with non-blanchable redness, would not typically require an antimicrobial dressing.
Choice B rationale
Wet-to-dry dressings are used for mechanical debridement of wounds with necrotic tissue. A stage I pressure ulcer does not involve necrotic tissue, so this type of dressing would not be appropriate.
Choice C rationale
Transparent dressings are often used for stage I pressure ulcers. They provide a protective layer over the wound, promoting a moist environment and facilitating the healing process.
Choice D rationale

Dry, sterile dressings are typically used for wounds that need to be kept dry. A stage I pressure ulcer benefits from a moist healing environment, which can be provided by a transparent dressing.