A nurse is assessing a patient who has had diarrhea for several days. Which of the following findings should the nurse expect?

Dehydration

Decreased bowel sounds

Rigid abdomen

Hypothermia

Answer and Explanation

The Correct Answer is A

Choice A rationale

Dehydration is a common finding in a patient who has had diarrhea for several days. Symptoms of dehydration can include dark-colored urine, excessive thirst, fatigue, dizziness, or light-headedness.

Choice B rationale

Diarrhea does not typically cause decreased bowel sounds.

Choice C rationale

A rigid abdomen is not a typical finding in a patient who has had diarrhea for several days.

Choice D rationale

Hypothermia is not a typical finding in a patient who has had diarrhea for several days.

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Correct Answer is ["B","C","D"]

Explanation

Choice A rationale

Using soap to clean the patient’s skin is not the best practice. Soap can dry out and irritate the skin, especially in patients with urinary incontinence. It can disrupt the skin’s natural pH balance and make it more susceptible to damage.

Choice B rationale

Applying a barrier cream to the patient’s skin is a recommended practice. Barrier creams provide a protective layer on the skin that can help prevent irritation from urine. They can also help to keep the skin moisturized, which is important for maintaining skin integrity.

Choice C rationale

Avoiding friction when drying the patient’s skin is crucial. Friction can cause further damage to the skin, especially in areas that are already irritated or broken down due to incontinence. It’s recommended to gently pat the skin dry rather than rubbing it.

Choice D rationale

Using warm water to clean the patient’s skin is a good practice. Warm water is less irritating to the skin than hot water and can help to cleanse the area without causing additional discomfort or damage.

A. Don sterile gloves before inserting the indwelling urinary catheter. B. Apply an oil-based lubricant to the indwelling urinary catheter. C. Use one cotton swab to clean the client’s genitalia. D. Test the balloon on the indwelling urinary catheter before insertion.

Correct Answer is A

Explanation

Choice A rationale

Donning sterile gloves before inserting the indwelling urinary catheter is a critical step to prevent infection. The urinary tract is normally sterile, and using sterile gloves helps maintain this sterility during the procedure.

Choice B rationale

Applying an oil-based lubricant to the indwelling urinary catheter is not recommended. Oil- based lubricants can damage latex catheters and increase the risk of infection. A water-soluble lubricant is typically used.

Choice C rationale

Using one cotton swab to clean the client’s genitalia is not sufficient. Proper cleaning and disinfection of the area are crucial to prevent introducing bacteria into the urinary tract during catheter insertion.

Choice D rationale

Testing the balloon on the indwelling urinary catheter before insertion is not typically done. The balloon is usually inflated with sterile water once the catheter is in place to ensure that it remains in the bladder.

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A nurse is assessing a patient who has had diarrhea for several days. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing skin care for a patient with urinary incontinence. What actions should the nurse take?

Correct Answer is ["B","C","D"]

Explanation

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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