A nurse is planning care to prevent skin breakdown for a client who is immobile and has urinary incontinence. Which of the following actions should the nurse include in the plan of care?
Request a prescription for an indwelling urinary catheter.
Arrange for an alternating pressure mattress.
Apply cornstarch to the client's skin.
Reposition the client every 4 hours.
The Correct Answer is B
An alternating pressure mattress can help prevent skin breakdown in a client who is immobile by redistributing pressure and reducing the risk of pressure ulcers. This is an appropriate action for the nurse to include in the plan of care for a client who is immobile and has urinary incontinence.
a. An indwelling urinary catheter can increase the risk of infection and should only be used when other methods of managing urinary incontinence are not effective.
c. Cornstarch can absorb moisture and help keep the skin dry, but it is not recommended for use on broken skin or in areas where there is a risk of fungal infection.
d. Repositioning the client every 4 hours may not be frequent enough to prevent skin breakdown. The client should be repositioned at least every 2 hours to reduce the risk of pressure ulcers.
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Related Questions
Correct Answer is C
Explanation
The nurse should assist the client with a bowel cleansing before an intravenous pyelogram. This helps to ensure that the bowel is empty and that the images obtained during the procedure are clear. The other
a. Oral contrast is not typically used for an intravenous pyelogram.
b. Pain in the suprapubic region is not a common side effect of an intravenous pyelogram.
d. Removing metal objects is important for procedures that use magnetic resonance imaging (MRI), but it is not necessary for an intravenous pyelogram.
Correct Answer is D
Explanation
When a nurse receives a new prescription over the telephone from a client's provider, the first action the nurse should take is to write down the complete prescription. This ensures that the nurse has an accurate record of the prescription and can refer to it when administering medication or providing care.
Option a is incorrect because documenting the prescription as a telephone prescription in the medical record is important but not the first action.
Option b is incorrect because reading back the prescription to the provider is important but not the first action.
Option c is incorrect because ensuring that the provider signs the prescription is important but not the first action.
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