A nurse is providing skin care for a patient with urinary incontinence. What actions should the nurse take?
Use soap to clean the patient’s skin.
Apply a barrier cream to the patient’s skin.
Avoid applying friction when drying the patient’s skin.
Use warm water to clean the patient’s skin.
Correct Answer : B,C,D
Choice A rationale
Using soap to clean the patient’s skin is not the best practice. Soap can dry out and irritate the skin, especially in patients with urinary incontinence. It can disrupt the skin’s natural pH balance and make it more susceptible to damage.
Choice B rationale
Applying a barrier cream to the patient’s skin is a recommended practice. Barrier creams provide a protective layer on the skin that can help prevent irritation from urine. They can also help to keep the skin moisturized, which is important for maintaining skin integrity.
Choice C rationale
Avoiding friction when drying the patient’s skin is crucial. Friction can cause further damage to the skin, especially in areas that are already irritated or broken down due to incontinence. It’s recommended to gently pat the skin dry rather than rubbing it.
Choice D rationale
Using warm water to clean the patient’s skin is a good practice. Warm water is less irritating to the skin than hot water and can help to cleanse the area without causing additional discomfort or damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Excessive thirst and urination are symptoms of hyperglycemia, not hypoglycemia. Hyperglycemia could occur if the TPN solution was infusing too quickly, but it would not be a result of the infusion pump not working.
Choice B rationale
Shakiness and diaphoresis are manifestations of hypoglycemia. When a sudden interruption in the infusion of TPN occurs, the patient is at risk for hypoglycemia.
Choice C rationale
Fever and chills are symptoms of infection, not a direct result of the TPN infusion stopping.
Choice D rationale
Hypertension and crackles in the lungs are signs of fluid overload, not hypoglycemia. These symptoms would not be expected if the TPN infusion stopped.
Correct Answer is C
Explanation
Choice A rationale
Purulent drainage is thick and opaque. It can have a yellow, tan, green, or brown color and is a sign of infection.
Choice B rationale
Sanguineous drainage is bright red and indicates active bleeding3.
Choice C rationale
Serosanguineous drainage is typically pink-red and thin. It is made up of blood and serous fluid and is typically seen in a normal, non-infected wound3.
Choice D rationale
Serous drainage is clear and thin, like the fluid from a blister3.
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