A nurse is providing care for a patient with excessive diaphoresis. Which intervention is most appropriate to prevent skin breakdown?
Apply alcohol-based products to dry the skin.
Use moisture-wicking linens and change them frequently.
Apply talcum powder to absorb moisture.
Decrease fluid intake to reduce sweating.
The Correct Answer is B
A. Apply alcohol-based products to dry the skin: Alcohol is extremely drying and irritating; it strips the skin of its natural oils, leading to further skin damage.
B. Use moisture-wicking linens and change them frequently: Moisture-wicking materials (linens and clothing) draw moisture away from the skin, and frequent changes prevent the skin from remaining in prolonged contact with sweat, thereby protecting the skin barrier from maceration.
C. Apply talcum powder to absorb moisture: Talcum powder can clump when mixed with sweat, creating an abrasive paste that increases friction and irritation, leading to skin breakdown.
D. Decrease fluid intake to reduce sweating: Decreasing fluid intake can lead to dehydration, which is detrimental to overall health and wound healing, and is an inappropriate and dangerous method for managing diaphoresis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Focus on vitamin C supplements exclusively: While Vitamin C is essential for collagen synthesis, an exclusive focus neglects other critical nutrients.
B. Reduce fat intake to prevent weight gain: Appropriate fat intake is necessary for cell membrane integrity and the absorption of fat-soluble vitamins (A, D, E, K), which support skin health.
C. Ensure adequate protein intake to promote healing:Protein (specifically amino acids) is the building block for new tissue, collagen, and immune cells. Without adequate protein, the body cannot repair damaged tissue or mount an effective inflammatory response, which critically impairs skin integrity and wound healing.
D. Increase carbohydrate intake to provide energy: This is necessary, as energy is required for healing, but protein is the structural material, making it the highest priority for tissue promotion.
Correct Answer is C
Explanation
A. Normal healing process: Normal healing involves serous or serosanguineous drainage. Purulent drainage signifies a complication (infection).
B. Eschar formation: Eschar is hard, black, necrotic tissue; it is not a type of drainage.
C. Presence of infection: Purulent drainage (pus)-which is thick, opaque, and often yellow, green, or brown-is composed of dead white blood cells, bacteria, and tissue debris, indicating a localized bacterial infection.
D. Granulation tissue: Granulation tissue is bright red, moist, and bumpy tissue, which is a sign of the proliferative phase of normal healing, not the fluid component.
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