A nurse is caring for a client who is incontinent of bowel and bladder. Which of the following actions should the nurse take?

Clean the client’s skin with hot water.

Wait until the patient has a bowel movement before performing perineal hygiene.

Dry between folds in the client’s skin.

Apply baby powder to the client’s skin.

Answer and Explanation

The Correct Answer is C

Choice A reason: Hot water can scald or irritate sensitive skin, especially in incontinent patients prone to breakdown. Warm water with mild soap is recommended to clean without causing thermal injury or exacerbating skin irritation.

Choice B reason: Waiting for a bowel movement before hygiene increases the risk of skin breakdown and infection, as urine and feces can irritate skin. Regular cleaning after each incontinent episode is essential to maintain skin integrity.

Choice C reason: Drying between skin folds prevents moisture accumulation, which fosters bacterial and fungal growth, leading to infections or dermatitis. Thorough drying after cleaning is critical for incontinent patients to protect skin and prevent complications.

Choice D reason: Baby powder can clump in moist areas, creating an environment for bacterial growth and skin irritation. It is not recommended for incontinent patients, as it may worsen skin conditions rather than protect the skin.

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Correct Answer is D

Explanation

Choice A reason: Green liquid stool in a colostomy pouch is often benign, resulting from diet (e.g., green vegetables) or medications. In an 80-year-old, this is not immediately concerning unless accompanied by systemic symptoms like fever or pain.

Choice B reason: Slight bleeding when wiping a colostomy is common, especially in an 18-year-old with a new stoma, due to fragile tissue. It warrants monitoring but is not as concerning as signs of poor stoma viability.

Choice C reason: A red, moist colostomy in a 45-year-old indicates a healthy, well-perfused stoma, which is normal post-placement. This is an expected finding and does not raise immediate concern compared to abnormal stoma appearance.

Choice D reason: A pale pink/purple colostomy suggests poor perfusion or ischemia, especially in a 55-year-old. This abnormal color, even with moisture, indicates potential stoma necrosis, requiring urgent assessment to prevent complications like tissue death or infection.

A. I will wipe from the back to front with the cleansing cloth. B. I should not collect a urine sample when I am menstruating. C. I should let the urine cool to room temperature before sending it to the lab. D. I need to urinate a small amount in the toilet before collecting the sample.

Correct Answer is D

Explanation

Choice A reason: Wiping from back to front risks introducing perianal bacteria into the urethra, contaminating the sample. Proper technique involves wiping front to back to minimize contamination, making this statement incorrect and indicative of misunderstanding.

Choice B reason: While menstruation may complicate urine collection, it is not an absolute contraindication. With proper technique (e.g., using a tampon), samples can be collected. This statement reflects a misconception and does not confirm understanding of midstream collection.

Choice C reason: Urine should be sent to the lab promptly or refrigerated to prevent bacterial growth or analyte degradation. Allowing it to cool to room temperature risks inaccurate results, so this statement demonstrates a lack of understanding of proper handling.

Choice D reason: Urinating a small amount into the toilet first flushes out urethral contaminants, ensuring a cleaner midstream sample. This technique is critical for accurate urinalysis or culture, confirming the client’s understanding of the taught procedure.

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A nurse is caring for a client who is incontinent of bowel and bladder. Which of the following actions should the nurse take?

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