A nurse is caring for an older adult client who has fecal incontinence. Which of the following actions should the nurse take?

Turn the client every 4 hr.

Cleanse the perineal area with povidone-iodine solution.

Apply cornstarch powder to the perineal area.

Place a moisture barrier ointment over the perineal area.

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Turn the client every 4 hr. is incorrect. While repositioning is crucial for preventing pressure ulcers in immobile patients, turning the client every 4 hours might not directly address the issue of fecal incontinence or skin protection in the perineal area.

Choice B Reason:

Cleanse the perineal area with povidone-iodine solution is incorrect. Povidone-iodine solution might be too harsh for routine perineal care and can potentially irritate the skin. A gentler cleansing solution is typically recommended to avoid further skin irritation.

Choice C Reason:

Apply cornstarch powder to the perineal area is incorrect. Cornstarch powder might exacerbate moisture-related skin issues in the perineal area by creating a damp environment, potentially leading to skin maceration and worsening skin problems. It's not typically recommended for use in managing fecal incontinence.

Choice D Reason:

Place a moisture barrier ointment over the perineal area is correct. Using a moisture barrier ointment can help protect the skin from irritation and breakdown caused by prolonged exposure to fecal matter, reducing the risk of skin breakdown and discomfort.

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Correct Answer is A

Explanation

Choice A Reason:

Type 1 diabetes mellitus is correct. individuals with diabetes, especially Type 1 diabetes mellitus, are at an increased risk of developing cardiovascular disease. Diabetes can contribute to atherosclerosis, increasing the risk of heart disease, stroke, and other cardiovascular complications.

Choice B Reason:

Orthostatic hypotension is not correct. It refers to a drop-in blood pressure when moving from a lying to a standing position and is more related to blood pressure regulation than a direct risk factor for cardiovascular disease.

Choice C Reason:

A BMI of 24 is incorrect because it is within the normal range is not typically considered a significant risk factor for cardiovascular disease. However, higher BMIs, especially in the overweight or obese categories, can increase the risk.

Choice D Reason:

A family history of osteoporosis is incorrect because it is related to bone health and susceptibility to osteoporosis, a condition characterized by weak and brittle bones. While it's an important health consideration, it's not directly linked to cardiovascular disease risk.

A. "He appears anxious about the transfer." B. "He is allergic to sulfa." C. "His partner has been visiting." D. "He is voiding adequately."

Correct Answer is B

Explanation

Choice A Reason:

"He appears anxious about the transfer."While this might be relevant in certain contexts, it is subjective and less critical compared to other clinical information. The transfer report should prioritize objective data that directly impacts the client’s care.

Choice B Reason:

"He is allergic to sulfa." Allergies are crucial information that must be communicated during any transfer. This ensures that the receiving healthcare team is aware and can avoid administering medications that could cause an allergic reaction. This is important information to include in the transfer report.

Choice C Reason:

"His partner has been visiting." While it may be helpful to know about the client’s support system, this information is not as critical as details about the client's health status, medications, or allergies.

Choice D Reason:

"He is voiding adequately." Voiding patterns can be relevant, particularly if there have been recent issues with urinary function or if the client is being monitored for urinary output. However, unless there is a specific reason this is critical to ongoing care, it may not be the most essential information to include.

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A nurse is caring for an older adult client who has fecal incontinence. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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