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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
When providing teaching about health promotion guidelines to a group of young adult male clients, the nurse should include the recommendation to have a dental examination every 6 months. Regular dental examinations can help prevent dental problems and maintain good oral health.
b) A testicular examination is recommended annually, not every 2 years.
c) A tetanus booster is recommended every 10 years, not every 5 years.
d) A herpes zoster immunization is recommended for adults age 60 and older, not age 50.
Correct Answer is ["480"]
Explanation
480 mL.
The client's total oral intake over the 4-hour period is 3 ounces of milk + 2 ounces of orange juice + 3 ounces of tea + 4 ounces of water = 12 ounces. Since there are approximately 30 mL in 1 ounce, the client's oral intake in mL is 12 ounces * 30 mL/ounce = 360 mL.
The client is also receiving dextrose 5% in 0.45% sodium chloride at a rate of 30 mL/hr by continuous IV infusion. Over a 4-hour period, the client will receive a total of 30 mL/hr * 4 hours = 120 mL from the IV infusion.
Therefore, the client's total intake for that 4-hour period is 360 mL (oral intake. + 120 mL (IV infusion) = 480 mL.
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