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:

Removing 45 mL of urine from the catheter with a syringe is correct. To obtain a sterile urine specimen from an indwelling urinary catheter, the nurse should use a sterile syringe to aspirate a specific volume of urine from the catheter tubing. This method ensures minimal contamination and an accurate representation of the urine in the bladder at that moment.

Choice B Reason:

Clamping the catheter tubing for 60 min is incorrect.

Clamping the catheter tubing can lead to potential complications such as urinary retention, backflow of urine, or discomfort for the client. It's not a standard practice and could compromise the client's care.

Choice C Reason:

Clamping the catheter tubing below the needleless port is incorrect.

Clamping the catheter tubing can disrupt the urinary drainage and potentially cause issues like urinary stasis or increase the risk of infection. It's not an appropriate method for collecting a sterile urine specimen.

Choice D Reason:

Place the specimen in a clean specimen cup is incorrect. While placing the specimen in a clean cup is necessary, the method of collecting a urine sample from an indwelling catheter involves using a sterile syringe to aspirate a specific volume of urine directly from the catheter tubing, rather than pouring it into a cup from the collection bag.

A. Discontinue supplements containing vitamin C 24 hr. before the test B. Refrain from consuming pork 7 days before the test. C. Place a thick layer of stool on the specimen card. D. Urinate prior to collecting the stool specimen

Correct Answer is D

Explanation

Choice A Reason:

Discontinuing supplements containing vitamin C 24 hr. before the test is incorrect. While high doses of vitamin C might interfere with the accuracy of some laboratory tests, it typically doesn't impact fecal occult blood testing. However, it's always best to follow specific instructions provided by the healthcare provider or laboratory.

Choice B Reason:

Refraining from consuming pork 7 days before the test. There isn't typically a requirement to avoid specific foods, such as pork, before a fecal occult blood test. The test is designed to detect blood in the stool, regardless of the diet. However, some dietary restrictions might be advised based on specific instructions or conditions, but these are not universally applicable.

Choice C Reason:

Placing a thick layer of stool on the specimen card is incorrect. When collecting a sample for a fecal occult blood test, it's important to follow the specific instructions provided by the healthcare provider or laboratory. Generally, a small portion of stool is applied to the designated area on the specimen card as instructed, rather than applying a thick layer. Applying too much stool can affect the accuracy of the test.

Choice D Reason:

Urinating prior to collecting the stool specimen is correct. This instruction ensures that the urine doesn't contaminate the stool sample, which could potentially affect the accuracy of the test results.

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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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Explanation

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Correct Answer is D

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