A nurse is caring for a client who has limited mobility and is experiencing urinary incontinence. Which of the following actions should the nurse take to prevent skin breakdown?

Avoid using moisturizers on the client's skin.

Place the client on a timed voiding schedule.

Place the client in high-Fowler's position while in bed.

Wash urine off the client's skin with hot water and soap.

Answer and Explanation

The Correct Answer is B

A. Avoid using moisturizers on the client's skin. Moisturizers are important for maintaining skin integrity, especially in clients with incontinence, to prevent skin breakdown.
B. Place the client on a timed voiding schedule. This is correct. A timed voiding schedule can help manage incontinence by reducing the frequency of wetness and thereby preventing skin breakdown.
C. Place the client in high-Fowler's position while in bed. High-Fowler’s position is not typically indicated for preventing skin breakdown and can increase pressure on the sacral area.
D. Wash urine off the client's skin with hot water and soap. Washing with hot water and soap can be harsh and irritating to the skin. It is better to use mild soap and lukewarm water.

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Correct Answer is D

Explanation

A. Keep the client's bed in its highest position with the side rails up. Keeping the bed in its highest position increases the risk of falls, especially for a client with urinary incontinence who may attempt to get up quickly. This does not adhere to safety guidelines.
B. Provide adult diapers for the client to wear while in bed. While providing diapers may be necessary, it is not the primary safety intervention. It is more important to address the client's mobility and ensure they can safely access the bathroom.
C. Store the client's personal possessions in the closet in her room. Keeping the room tidy and ensuring personal items are stored safely can reduce clutter and fall risks but does not directly address incontinence management or safety goals.
D. Ask the client to give a return demonstration of how to use the call light. Ensuring the client knows how to use the call light is crucial for safety. It allows them to call for assistance when needed, reducing the risk of falls when they need to use the bathroom.

A. Instruct the client to use the call light for assistance. B. Document the type of alarm used. C. Test the alarm and battery of the device. D. Apply the sensor pad to the client's bed.

Correct Answer is C

Explanation

A. Instruct the client to use the call light for assistance. This is important but should be done after ensuring the alarm is working correctly.
B. Document the type of alarm used. Documentation is necessary but should follow ensuring the device is functioning.
C. Test the alarm and battery of the device. Ensuring the bed alarm and battery are functioning properly is critical to the safety of the client. The alarm needs to be reliable to alert staff if the client attempts to get out of bed.
D. Apply the sensor pad to the client's bed. This step is necessary but should follow testing the alarm and battery to ensure they are functioning.

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A nurse is caring for a client who has limited mobility and is experiencing urinary incontinence. Which of the following actions should the nurse take to prevent skin breakdown?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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