A client with urinary and fecal incontinence has an increased risk for developing a sacral pressure ulcer. Which information should the practical nurse (PN) give the unlicensed assistive personnel (UAP) who is assisting with the care of the client?
Encourage the client to rest quietly in bed.
Keep the client's skin clean and dry.
Obtain supplies for contact precautions.
Document any changes in skin integrity.
The Correct Answer is B
The correct answer is Choice B.
Choice B rationale:
The practical nurse (PN) should instruct the unlicensed assistive personnel (UAP) to keep the client's skin clean and dry. Proper skin care is essential for a client with urinary and fecal incontinence to prevent the development of pressure ulcers. Keeping the skin clean and dry helps reduce moisture-related skin breakdown.
Choice A rationale:
Encouraging the client to rest quietly in bed is not directly related to preventing pressure ulcers. While adequate rest is essential for overall health, it does not specifically address the risk of pressure ulcers in an incontinent client.
Choice C rationale:
Obtaining supplies for contact precautions is unrelated to the client's risk of developing a sacral pressure ulcer. Contact precautions are used to prevent the spread of infectious diseases and do not address skin integrity.
Choice D rationale:
Documenting any changes in skin integrity is important, but it is the responsibility of the healthcare team, including the PN. However, this response does not provide proactive measures to prevent the pressure ulcer from occurring in the first place, which is the primary concern in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Coffee-ground secretions draining via nasogastric tube suction.
Choice A rationale:
Oral ice chips eaten 30 minutes after vomiting postoperatively could be considered normal in some cases. However, this finding may not require immediate reporting to the RN unless
other concerning symptoms are present. Choice B rationale:
The inability to void 4 hours after discontinuing an indwelling catheter is not an immediate concern. It's not uncommon for some clients to experience difficulty urinating initially after catheter removal. The client should be closely monitored, and the RN should be informed if the situation persists or worsens.
Choice C rationale:
This is the correct answer because coffee-ground secretions draining via nasogastric tube suction can indicate bleeding in the gastrointestinal tract, potentially from the stomach or esophagus. This finding requires immediate attention as it could be a sign of a serious condition and may require urgent intervention.
Choice D rationale:
Ineffective pain management reported while using morphine PCA is a concern but may not be as critical as the coffee-ground secretions. The PN should still report this finding to the RN for appropriate assessment and possible adjustment of pain management, but it may not warrant immediate reporting.
Correct Answer is B
Explanation
The correct answer is choice B: Thinning of the skin with loss of elasticity.
Choice A rationale:
While a decreased ability to communicate can be a significant challenge in elderly clients, it is not the primary physical characteristic of aging that contributes to the risk of pressure ulcers. Pressure ulcers develop due to prolonged pressure on specific areas of the skin, leading to reduced blood flow and tissue damage.
Choice B rationale:
Thinning of the skin with loss of elasticity is a critical physical characteristic of aging that contributes to the risk of pressure ulcers. As the skin becomes thinner and less elastic with age, it becomes more susceptible to injury from pressure and shear forces, increasing the likelihood of developing pressure ulcers.
Choice C rationale:
A 16 percent increase in overall body fat does not directly contribute to the risk of pressure ulcers. While changes in body composition occur with aging, the primary risk factors for pressure ulcers are related to skin integrity and mobility, not body fat percentage.
Choice D rationale:
Calcium loss in the bones (osteoporosis) is not the main contributing factor to pressure ulcers. Osteoporosis primarily affects bone density and strength but does not directly influence the development of pressure ulcers.
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