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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale

Troponin is a cardiac enzyme which indicates a client has experienced a myocardial infarction. It is not a laboratory test that supports a diagnosis of malnutrition.

Choice B rationale

Albumin is a measure of plasma proteins which reflects the nutritional condition of a client experiencing anorexia and malnutrition over an extended period of time. Therefore, a nurse

should expect altered albumin levels in a client who reports anorexia and is experiencing malnutrition.

Choice C rationale

Total bilirubin is altered in clients who are experiencing hepatobiliary disease. It is not a laboratory test that supports a diagnosis of malnutrition.

Choice D rationale

Creatine kinase is a cardiac enzyme which is useful in the diagnosis of a myocardial infarction. It is not a laboratory test that supports a diagnosis of malnutrition.

A. Vibration of the eardrum is directly transmitted to the eighth cranial nerve, bypassing the inner ear structures. B. Sound waves enter the ear canal and are converted to electrical impulses. C. Vibration of the eardrum transmits through the bony ossicles to the perilymph in the inner ear, stimulating the eighth cranial nerve. D. Sound is transmitted directly from the eardrum to the brain.

Correct Answer is C

Explanation

Choice A rationale

Vibration of the eardrum is not directly transmitted to the eighth cranial nerve, bypassing the inner ear structures. The vibrations from the eardrum are first transmitted through the ossicles (tiny bones in the middle ear) to the cochlea in the inner ear.

Choice B rationale

Sound waves enter the ear canal, but they are not directly converted to electrical impulses. The sound waves cause the eardrum to vibrate, and these vibrations are transmitted through the ossicles to the cochlea, where they are converted into electrical signals that are sent to the brain via the eighth cranial nerve.

Choice C rationale

Vibration of the eardrum transmits through the bony ossicles to the perilymph in the inner ear, stimulating the eighth cranial nerve. This is the correct description of the process of hearing.

Choice D rationale

Sound is not transmitted directly from the eardrum to the brain. The sound-induced vibrations of the eardrum are transmitted through the ossicles to the cochlea, where they are converted into electrical signals that are sent to the brain via the eighth cranial nerve.

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A nurse is providing skin care for a patient with urinary incontinence. What actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered?

Correct Answer is B

Explanation

Which of the following correctly describes the process of hearing?

Correct Answer is C

Explanation

A nurse is evaluating a patient’s sensory function.Which of the following sensory stimuli is primarily associated with the tactile system?

The nurse is preparing to test a patient for postvoid residual with a bladder scan. Which action will the nurse take?

A nurse is assessing a patient’s wound dressing and observes a watery red drainage. How should the nurse document this type of drainage?

A nurse is evaluating a nursing assistive personnel’s (AP) care for a patient with an indwelling catheter. Which action by the AP will cause the nurse to intervene?

A nurse is providing care for a patient in a long-term care facility who is receiving enteral feedings via a nasogastric (NG) tube.What action should the nurse take before administering the tube feeding?

A nurse in a post-anesthesia care unit (PACU) is assessing a patient who has a newly created colostomy. What findings should the nurse report to the provider?

A nurse is caring for a patient who is receiving enteral tube feeding and has a new prescription to dilute the formula. The nurse recognizes this is being done to resolve which of the following conditions?

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?