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 A
Explanation
A. A liquid nutritional supplement that contains protein: A full liquid nutritional supplement with added protein is best because protein is critical for skin integrity and tissue repair. Supplements also provide balanced calories, vitamins, and minerals necessary to support overall skin health and prevent breakdown.
B. Beef broth, or chicken broth: While broth provides fluids and some electrolytes, it is very low in calories and protein, making it insufficient alone for preventing impaired skin integrity in a client with reduced oral intake.
C. Fortified lowfat milk: Milk offers some protein and nutrients, but a specialized nutritional supplement is more calorie-dense and protein-rich, providing a more comprehensive solution for a client at risk for skin breakdown.
D. Apple or grapefruit juice: Fruit juices offer hydration and some vitamins but lack significant protein and calories. They are inadequate for maintaining skin integrity, especially when protein intake is a primary concern.
Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"D"},"D":{"answers":"A"}}
Explanation
SBAR Format:
Situation:
I am holding the digoxin because the client's heart rate is too low.
Background:
The client is a 59-year-old male with hypertension and heart failure. He is currently taking furosemide and digoxin.
Assessment:
Heart rate is 48 beats/minute, blood pressure is 109/76 mm Hg.
Recommendation:
Do you want to recheck the digoxin level to see if there is toxicity? I will monitor the client's heart rate, blood pressure, and perfusion with a continuous monitor until his heart rate returns to normal.
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