A client with fecal incontinence has inflamed skin around the rectal area. Following an episode of incontinence, how should the practical nurse (PN) care for this area?
Spray the area with a mild periwash solution.
Gently massage around the outside of the reddened area.
Rinse the inflamed area with dilute hydrogen peroxide.
Apply a thick coating of antibiotic ointment.
The Correct Answer is A
A. Spray the area with a mild periwash solution: Using a mild periwash solution gently cleanses the skin without causing additional irritation. It removes fecal material effectively while preserving skin integrity, which is crucial for preventing further breakdown in areas already inflamed.
B. Gently massage around the outside of the reddened area: Massaging near inflamed or reddened skin can worsen irritation, increase discomfort, and potentially lead to further tissue damage. Handling should be as gentle and non-traumatic as possible to promote healing.
C. Rinse the inflamed area with dilute hydrogen peroxide: Hydrogen peroxide can be too harsh for already inflamed skin and may delay healing by damaging healthy tissue. It is generally avoided for routine cleansing of delicate perineal areas.
D. Apply a thick coating of antibiotic ointment: Antibiotic ointment is not routinely indicated unless there is evidence of infection. Overuse can alter normal skin flora and may promote resistance; protecting the skin barrier with gentle cleansing and moisture barriers is preferred.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Quickly complete tasks and leave client's room: Leaving the room quickly can make the client feel abandoned and isolated at a time when emotional support is crucial. Presence and attentive listening are important components of compassionate end-of-life care.
B. Request the chaplain to talk with client: While involving spiritual support services can be valuable, immediately referring the client to someone else may delay emotional comfort. The PN should first offer direct support before suggesting additional resources.
C. Ask the client if praying together would help: Offering prayer without knowing the client’s spiritual preferences might be inappropriate or uncomfortable for some individuals. It's better initially to offer silent presence and allow the client to express their needs if they wish.
D. Remain quietly in the client's room for a while: Staying quietly with the client conveys empathy, presence, and support. Nonverbal comfort allows the client space to process emotions and invites communication if they are ready, building trust and emotional security during a difficult moment.
Correct Answer is C
Explanation
A. Healthcare provider notified, client refuses to have blood glucose taken: While this option indicates that the healthcare provider was informed and that the client refused, it does not fully capture the client’s expressed reason for refusal. Complete and precise documentation includes the client’s statement in their own words.
B. Blood glucose not obtained because client no longer wants to have finger stick: This phrasing is too casual and lacks the specificity needed for legal and clinical documentation. It does not reflect the client’s exact words or demonstrate that the healthcare provider was informed about the situation.
C. Refused finger stick and states, "My finger is sore and test useless." Healthcare provider notified: This option best meets documentation standards by including the client's direct quote, ensuring accurate and objective recording of the refusal, and noting that the healthcare provider was informed. It provides a clear, detailed account suitable for medical and legal purposes.
D. Healthcare provider notified that client is uncooperative and irritable, glucose level not assessed: Describing the client as uncooperative and irritable is subjective and could be considered judgmental. Proper documentation should remain objective, focusing on the client’s stated concerns rather than labeling their behavior.
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