Immediately after completing the total bed bath and linen change for an unconscious client, the practical nurse (PN) observes that the client was incontinent with a large amount of liquid feces. Which action should the PN implement?

Repeat the total bed bath and complete linen change.

Place incontinent pads around the client's buttocks.

Cleanse any soiled skin and change the soiled linens.

Spray a skin protectant around the perineal area.

Answer and Explanation

The Correct Answer is C

A. Repeat the total bed bath and complete linen change: Repeating a full bed bath is not necessary unless the client is extensively soiled. It is more efficient and less disruptive to clean only the areas affected by incontinence while ensuring comfort and hygiene are maintained.
B. Place incontinent pads around the client's buttocks: While using incontinent pads helps manage future incontinence, it does not address the immediate need to clean the client and remove soiled linens, which is crucial to prevent skin breakdown and infection.
C. Cleanse any soiled skin and change the soiled linens: Cleaning the soiled skin and changing the linens is the best immediate response to maintain skin integrity, prevent infection, and promote client comfort. This targeted approach ensures the client remains clean without unnecessary interventions.
D. Spray a skin protectant around the perineal area: Applying a skin protectant is a helpful preventive measure after cleansing, but it should not be the first step. The priority is to remove feces and soiled linens before considering protective applications to the skin.

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Correct Answer is D

Explanation

A. Sacrum: The sacrum is a common site for pressure ulcers in a supine position, but once the client is turned onto the side, pressure shifts away from the sacrum to lateral body surfaces. It is not the most at-risk area in the new position.
B. Ischial tuberosities: The ischial tuberosities bear weight when sitting, not typically when lying in a lateral position. Therefore, they are less likely to be the first site to show erythema when turned onto the side.
C. Lateral malleolus: The lateral malleolus can be at risk when the lower legs rub against the bed, but it is a smaller surface area and would show signs later compared to larger, more pressure-exposed areas like the iliac crest.
D. Iliac crest: The iliac crest on the side the client is turned onto bears significant pressure in the lateral position. It is a major bony prominence directly exposed to force against the mattress, making it the most likely site to show early erythema.

A. Wear a surgical mask during all client contact. B. Use an isolation gown when providing client care. C. Determine if the client's room has negative airflow. D. Place a mask on the client if the client leaves the room.

Correct Answer is D

Explanation

A. Wear a surgical mask during all client contact: While wearing a surgical mask protects the nurse from inhaling respiratory droplets, it is equally important to prevent the client from spreading droplets to others, especially when moving outside the room.
B. Use an isolation gown when providing client care: An isolation gown protects against contact transmission rather than droplet transmission. Influenza spreads primarily through respiratory droplets, so gowns are not the primary measure to prevent its spread.
C. Determine if the client's room has negative airflow: Negative airflow rooms are necessary for airborne infections like tuberculosis, not for droplet-spread infections such as influenza. Standard precautions for influenza focus more on masking and hygiene practices.
D. Place a mask on the client if the client leaves the room: Masking the client when outside their room helps contain respiratory droplets, minimizing the risk of infecting others. This intervention is crucial in controlling the spread of influenza within healthcare settings.

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Immediately after completing the total bed bath and linen change for an unconscious client, the practical nurse (PN) observes that the client was incontinent with a large amount of liquid feces. Which action should the PN implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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