A nurse is caring for a client with urinary incontinence.
What action should the nurse take to prevent skin breakdown?

Request a prescription for the insertion of an indwelling urinary catheter.

Apply a moisture barrier ointment to the skin.

Clean the skin and perineum with hot water after each episode of incontinence.

Check the client’s skin every 8 hours for signs of breakdown.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Requesting a prescription for the insertion of an indwelling urinary catheter is not the best option to prevent skin breakdown in a client with urinary incontinence. Catheters can increase the risk of urinary tract infections and should be used as a last resort.
Choice B rationale

Applying a moisture barrier ointment to the skin can help protect the skin from the damaging effects of urine. This can help prevent skin breakdown and is a common practice in the care of clients with urinary incontinence.
Choice C rationale
Cleaning the skin and perineum with hot water after each episode of incontinence is not recommended. Hot water can dry out the skin and cause irritation. It’s better to use warm water and a gentle cleanser.
Choice D rationale
Checking the client’s skin every 8 hours for signs of breakdown is important, but it’s not the only action the nurse should take. The nurse should also take proactive measures to protect the skin, such as applying a moisture barrier ointment.

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Correct Answer is C

Explanation

Choice A rationale

Mycoplasmal pneumonia, also known as walking pneumonia, is typically not an airborne disease. Standard precautions, including the use of a surgical mask, are usually sufficient when caring for these patients.
Choice B rationale
Scarlet fever is caused by group A Streptococcus bacteria, which are spread through respiratory droplets. Standard precautions, including the use of a surgical mask, are usually sufficient when caring for these patients.
Choice C rationale
Tuberculosis is an airborne disease. Healthcare providers should wear an N95 respirator when caring for a client with tuberculosis to protect themselves from inhaling the bacteria.
Therefore, Choice C is the correct answer.
Choice D rationale
Scabies is caused by a mite and is spread through direct skin-to-skin contact. It is not an airborne disease, so an N95 respirator is not necessary when caring for a client with scabies.

A. Wait for 30 minutes and then measure the client’s oral temperature. B. Proceed to measure the client’s oral temperature immediately. C. Document the inability to obtain an accurate reading of the client’s oral temperature. D. Provide the client a sip of warm water and wait 5 minutes before measuring his oral temperature.

Correct Answer is A

Explanation

Choice A rationale
The nurse should wait for 30 minutes and then measure the client’s oral temperature. Consuming cold substances like ice chips can temporarily lower the oral temperature, leading to inaccurate readings. Therefore, it’s recommended to wait for a period of time to allow the oral temperature to return to its normal state.
Choice B rationale
Proceeding to measure the client’s oral temperature immediately after consuming ice chips would likely result in an inaccurately low reading. The cold from the ice chips can temporarily lower the temperature in the mouth.
Choice C rationale
Documenting the inability to obtain an accurate reading of the client’s oral temperature is not the best action in this situation. While it’s important to document any factors that might affect the accuracy of a temperature reading, in this case, the nurse can simply wait a period of time after the client has consumed the ice chips before taking the oral temperature.
Choice D rationale
Providing the client a sip of warm water and waiting 5 minutes before measuring his oral temperature may not be sufficient to ensure an accurate temperature reading. The mouth needs adequate time to return to its normal temperature after consuming something cold.

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A nurse is caring for a client with urinary incontinence. What action should the nurse take to prevent skin breakdown?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients on an infectious disease unit. When should the nurse wear an N95 respirator mask?

Correct Answer is C

Explanation

A nurse is about to take a client’s oral temperature, but the client has just consumed some ice chips. What should the nurse do next?

Correct Answer is A

Explanation

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A nurse is caring for a client with urinary incontinence.
What action should the nurse take to prevent skin breakdown?