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 B
Explanation
A. Notify the charge nurse: Notifying the charge nurse would be appropriate if the discrepancy persists after troubleshooting. However, first steps should involve checking the equipment to rule out technical errors before escalating the concern.
B. Reposition the oximeter clip: A discrepancy between the manual pulse and the pulse oximeter reading often indicates a technical issue, such as poor sensor placement or poor perfusion. Repositioning the oximeter clip ensures accurate data collection before proceeding with further interventions.
C. Document the conflicting data: Documentation is important, but before recording inconsistent or potentially inaccurate findings, the nurse should first validate the data by ensuring correct technique and equipment function.
D. Measure the blood pressure: Measuring blood pressure is part of a full vital signs assessment but does not address the immediate concern of conflicting pulse readings. Equipment issues must be corrected first to ensure all vital signs are accurate.
Correct Answer is B
Explanation
A. Limit ROM assessment to the lower extremities only: Focusing only on the lower extremities does not fully address the concern. Any physical exertion could further strain the respiratory system when the client is already tachypneic and in distress.
B. Defer ROM assessment because of the respiratory rate: A respiratory rate of 30 breaths per minute indicates respiratory distress. Physical exertion, even mild, could worsen oxygenation issues. Protecting respiratory function is the priority, so the ROM assessment should be deferred until the client's condition stabilizes.
C. Ask client to perform flexion and extension of arms 5 times: Even minimal arm movements could increase oxygen demand and fatigue in a client already experiencing respiratory compromise, making this unsafe at the moment.
D. Observe the client performing lateral flexion of the waist: Lateral flexion involves significant muscular effort and could further tax respiratory function. It is not appropriate when the client is tachypneic and needs respiratory support.
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