A nurse is creating a plan of care to maintain the skin integrity of a client who experiences frequent diarrhea due to ulcerative colitis. Which of the following interventions should the nurse include in the plan?
Administer a soap-suds enema to cleanse the colon.
Soak in a sitz bath for 20 min after each stool.
Wipe perianal area with warm water and apply a barrier cream.
Cleanse with antimicrobial scrub and vigorously dry.
The Correct Answer is C
A. Soap-suds enemas are not recommended for clients with ulcerative colitis because they can irritate the colon and worsen symptoms. Enemas should be used cautiously, if at all, and only when medically indicated.
B. Soaking in a sitz bath can help soothe perianal discomfort, but it is not the most effective intervention for protecting the skin from diarrhea-related irritation. Barrier creams are a more direct way to protect the skin from further damage.
C. Wiping the perianal area with warm water and applying a barrier cream is an appropriate and effective intervention to protect the skin. The warm water is gentle, and the barrier cream provides a protective layer that helps prevent skin breakdown from frequent contact with stool.
D. Cleansing with an antimicrobial scrub and vigorously drying the perianal area could cause further irritation and damage to already sensitive skin. The focus should be on gentle cleansing and protecting the skin with a barrier cream.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Encouraging coughing and deep breathing is important for promoting the clearance of respiratory secretions. However, while it aids in mobilizing secretions, it does not directly thin the mucus.
B. Frequent ambulation helps to improve overall lung function and prevent complications like pneumonia, but it does not specifically thin respiratory secretions.
C. Increasing fluid intake helps thin the respiratory secretions by providing hydration, making it easier for the body to expel mucus through coughing. Hydration is critical for reducing the viscosity of sputum, thus promoting its removal.
D. Regular use of the incentive spirometer helps prevent atelectasis and improve lung expansion but does not directly affect the thinning of respiratory secretions.
Correct Answer is C
Explanation
A. Green tea, while it contains some caffeine, is generally not considered a significant risk factor for the development of peptic ulcers. It may have protective effects due to its antioxidant properties, unlike substances that directly irritate the stomach lining.
B. Moderate alcohol consumption, such as a glass of wine, may irritate the stomach lining but is not a primary risk factor for peptic ulcers unless excessive drinking occurs. This would not be the most significant factor for ulcer development.
C. NSAID use is a well-established risk factor for peptic ulcers. NSAIDs inhibit the production of prostaglandins, which protect the stomach lining from acid damage. Chronic use of NSAIDs can lead to ulcer formation due to this inhibition.
D. Bulimia can lead to acid reflux or esophageal irritation, but it is not a direct risk factor for the formation of peptic ulcers. The primary risk factors for peptic ulcers include H. pylori infection and the use of NSAIDs.
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