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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Instruct the client to use the hallway grab bars when walking. This is correct. Using hallway grab bars provides support and stability, helping to prevent falls in clients with osteoporosis.
B. Assist the client to the bathroom every 4 hr. Assisting the client to the bathroom regularly is important, but every 4 hours might not be frequent enough and doesn't directly address fall prevention throughout all activities.
C. Administer an antianxiety medication at bedtime. Antianxiety medications can cause sedation and increase the risk of falls, especially in older adults.
D. Monitor the client's activity every 2 hr. Monitoring the client’s activity is important, but this does not provide specific fall prevention strategies or interventions.
Correct Answer is D
Explanation
A. "Report a firm ridge below the breasts to the provider." A firm ridge along the bottom curve of the breast can be normal. It’s important to distinguish between normal breast tissue and abnormal lumps. Encouraging clients to report any changes or new lumps to the provider is more appropriate.
B. "Keep your arm relaxed at your side on the side you are examining." The correct technique involves raising the arm on the side being examined to help spread out the breast tissue, making it easier to palpate for lumps and abnormalities.
C. "Use your thumb and forefinger to palpate each breast for lumps." The correct technique involves using the pads of the fingers (not the thumb and forefinger) to palpate the breast in a systematic pattern, such as circular motions or vertical strips, to thoroughly check all areas of the breast.
D. "Use firm pressure to palpate near the area of the ribs and chest wall." Using firm pressure is appropriate for palpating deeper tissues closer to the ribs and chest wall, as this helps detect lumps that may not be superficial.
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