A nurse is providing skin care for a client who has urinary incontinence. Which of the following actions should the nurse take?
Use soap to clean the client's skin.
Apply friction when drying the client's skin.
Use hot water to clean the client's skin.
Apply a barrier cream to the client's skin.
The Correct Answer is D
Choice A reason: Using soap to clean the client's skin is not a recommended action, as it can dry out and irritate the skin, increasing the risk of skin breakdown and infection.
Choice B reason: Applying friction when drying the client's skin is not a recommended action, as it can damage and abrade the skin, causing pain and inflammation.
Choice C reason: Using hot water to clean the client's skin is not a recommended action, as it can increase the blood flow and inflammation to the skin, as well as remove the natural oils that protect the skin.
Choice D reason: Applying a barrier cream to the client's skin is a recommended action, as it can moisturize and protect the skin from the effects of urine, such as acidity, bacteria, and enzymes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not the correct answer because reassessing the patient is not the next step after completing an assessment. Reassessment is done periodically or when there is a change in the patient's condition, but not immediately after the initial assessment.
Choice B reason: This is not the correct answer because writing nursing interventions is not the next step after completing an assessment. Nursing interventions are the actions that the nurse plans and implements to achieve the desired outcomes for the patient. They are based on the nursing diagnoses, which are derived from the analysis of the assessment data.
Choice C reason: This is the correct answer because analyzing cues is the next step after completing an assessment. Analysis is the process of identifying patterns, relationships, and trends in the assessment data, and comparing them with the normal and expected findings. Analysis helps the nurse to identify the patient's problems, needs, strengths, and risks.
Choice D reason: This is not the correct answer because creating SMART goals is not the next step after completing an assessment. SMART goals are the specific, measurable, achievable, realistic, and time-bound outcomes that the nurse and the patient agree on. They are based on the nursing diagnoses, which are derived from the analysis of the assessment data.
Correct Answer is B
Explanation
Choice A reason: Fluid volume deficit is a condition in which the body loses more fluid than it gains, resulting in dehydration, hypotension, and electrolyte imbalances. It is not a complication of IV fluid therapy, but rather a reason for initiating it.
Choice B reason: Fluid volume excess is a condition in which the body retains more fluid than it needs, resulting in edema, hypertension, and heart failure. It is a potential complication of IV fluid therapy, especially in older adults who have reduced renal function and cardiac output. The nurse's assessment findings of crackles, shortness of breath, and jugular vein distention are indicative of fluid overload and pulmonary congestion.
Choice C reason: Speed shock is a systemic reaction that occurs when a substance is administered too rapidly into the bloodstream, causing adverse effects such as chest pain, dyspnea, hypotension, and cardiac arrest. It is not a complication of IV fluid therapy, but rather a risk associated with IV medication administration.
Choice D reason: Pulmonary embolism is a blockage of one or more pulmonary arteries by a blood clot, fat, or air, causing impaired gas exchange, chest pain, dyspnea, and hemoptysis. It is not a complication of IV fluid therapy, but rather a possible outcome of venous thromboembolism, which can be prevented by using anticoagulants and mechanical devices.
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