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 B

Explanation

A. Keep daily cholesterol intake between 500 to 750 mg. The recommended daily cholesterol intake is less than 300 mg.
B. Keep daily fat intake between 20% to 35% of total calories. This is the recommended range for fat intake according to dietary guidelines.
C. Keep daily protein intake between 40% to 50% of total calories. The recommended range for protein intake is about 10% to 35% of total calories.
D. Keep daily sodium intake between 2,000 to 2,500 mg. The recommended daily sodium intake is less than 2,300 mg, and ideally less than 1,500 mg for most adults.

A. Log off the computer before he leaves the nurses' station. B. Turn off the monitor so others cannot view the client's data. C. Position the computer's screen so no one else can view it. D. Ask another nurse to complete the documentation.

Correct Answer is A

Explanation

A. Log off the computer before he leaves the nurses' station: This is correct. Logging off ensures that no unauthorized person can access the client's electronic health records, maintaining privacy and security.
B. Turn off the monitor so others cannot view the client's data. This action alone does not provide sufficient security, as the computer might still be logged in.
C. Position the computer's screen so no one else can view it. While this helps with privacy, it does not secure the computer from unauthorized access in the nurse’s absence.
D. Ask another nurse to complete the documentation. This is not appropriate as it may lead to incomplete or inaccurate documentation. Each nurse should document their own care.

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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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Correct Answer is A

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