A man with urinary incontinence tells the registered nurse he wears adult incontinence briefs for protection. What potential risks should the registered nurse discuss with this client?
Recurring skin breakdown and urinary tract infections.
Recurring foul odor and leakage of briefs.
Recurring inability to control urine output.
Recurring public embarrassment.
The Correct Answer is A
Skin breakdown:
Prolonged exposure to urine, especially in the presence of incontinence briefs, can irritate and macerate the skin, leading to breakdown.
Factors contributing to skin breakdown:
Moisture from urine:
Creates a warm, moist environment ideal for bacterial growth.
Disrupts the skin's natural barrier function, making it more susceptible to damage.
Friction from incontinence briefs:
Can rub against the skin, causing irritation and further damage.
Chemical irritants in urine:
Ammonia and other substances in urine can further irritate and damage the skin.
Signs of skin breakdown:
Redness, warmth, tenderness, or swelling of the skin.
Blisters, erosions, or ulcers.
Pain or discomfort.
Prevention of skin breakdown:
Frequent changing of incontinence briefs (as soon as they become wet or soiled).
Thorough cleansing of the skin with mild soap and water after each change.
Application of a skin barrier cream or ointment to protect the skin.
Use of breathable incontinence briefs that allow air to circulate.
Monitoring of the skin for signs of breakdown and seeking prompt medical attention if any occur. Urinary tract infections (UTIs):
Bacteria from the skin can enter the urinary tract through the urethra, leading to infection.
Factors increasing UTI risk in those with incontinence:
Incomplete bladder emptying:
Residual urine in the bladder provides a breeding ground for bacteria.
Use of incontinence briefs:
Can trap moisture and bacteria near the urethra.
Difficulty with personal hygiene:
May lead to the spread of bacteria from the skin to the urinary tract.
Signs of a UTI:
Frequent urination.
Pain or burning during urination.
Urgency to urinate.
Blood in the urine.
Cloudy or foul-smelling urine.
Prevention of UTIs:
Maintaining good personal hygiene.
Drinking plenty of fluids to help flush bacteria from the urinary tract.
Promptly emptying the bladder when the urge to urinate is felt.
Seeking medical attention if any signs of a UTI occur.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["65"]
Explanation
Here are the steps to calculate the flow rate in gtt/min:
Step 1: Calculate the total volume of fluid to be infused.
The order is for 1.5 grams of Ampicillin added to 100 mL of Normal Saline, so the total volume is 100 mL. Step 2: Calculate the number of vials of Ampicillin needed.
Each vial contains 500 mg of Ampicillin, and the order is for 1.5 grams (which is 1500 mg). Therefore, you will need 3 vials of Ampicillin (1500 mg ÷ 500 mg/vial = 3 vials). Step 3: Calculate the total volume of Ampicillin solution.
Each vial contains 10 mL of Ampicillin solution, and you need 3 vials.
Therefore, the total volume of Ampicillin solution is 30 mL (3 vials × 10 mL/vial = 30 mL). Step 4: Calculate the total volume to be infused, including the Ampicillin solution. The total volume is 100 mL of Normal Saline + 30 mL of Ampicillin solution = 130 mL. Step 5: Calculate the infusion time in minutes.
The order is to infuse over 120 minutes.
Step 6: Calculate the flow rate in gtt/min.
Use the formula: Flow rate (gtt/min) = Total volume (mL) × Drop factor (gtt/mL) ÷ Infusion time (min) Plug in the values: Flow rate = 130 mL × 60 gtt/mL ÷ 120 min
Simplify: Flow rate = 7800 ÷ 120
Flow rate = 65 gtt/min
Therefore, the flow rate in gtt/min in which the IV fluid is to flow is 65 gtt/min.
Correct Answer is A
Explanation
Choice A rationale:
Tertiary health promotion and illness prevention focus on managing existing health conditions and preventing complications. Administering a nebulized bronchodilator to a client who is short of breath directly addresses an existing respiratory problem, aiming to relieve symptoms and prevent further respiratory distress. This intervention falls under tertiary prevention because it targets a client already experiencing respiratory symptoms.
Key points:
Bronchodilators open constricted airways, easing airflow and breathing.
Nebulizers deliver medication directly to the lungs, providing rapid relief.
Shortness of breath is a common symptom of respiratory conditions like asthma and COPD.
Prompt treatment of respiratory symptoms can prevent worsening of the condition and potential complications.
Choice B rationale:
Teaching a client about the risks of light cigarettes is an example of primary prevention. It aims to prevent lung disease before it develops by educating individuals about the harms of smoking.
Choice C rationale:
Advocating for more explicit warning labels on cigarette packages is a form of secondary prevention. It targets at-risk populations (smokers) to encourage behavior change and reduce smoking rates, ultimately lowering the incidence of lung disease.
Choice D rationale:
Assisting with lung function testing is a diagnostic procedure, not a tertiary prevention intervention. It helps to identify respiratory problems but doesn't directly manage or prevent them.
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