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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. High school: Beginning screening at the high school level is too late for early intervention. By adolescence, many obesity-related habits and risk factors are already established, making prevention efforts less effective compared to earlier childhood interventions.
B. Elementary school: Screening during elementary school years is best because it allows early identification of unhealthy weight patterns. Early detection helps in promoting healthy lifestyle habits before adolescence, improving long-term outcomes and reducing the risk of chronic diseases.
C. Onset of puberty: While puberty brings significant physical changes, waiting until this stage may miss earlier opportunities for preventive education and intervention. Early habits formed in childhood often persist into adolescence and adulthood.
D. Kindergarten: Although health education can start early, formal obesity screening at kindergarten may be premature since normal variations in growth patterns are common at that age. Targeting elementary-aged children provides a better balance between early intervention and developmental appropriateness.
Correct Answer is D
Explanation
A. Quickly complete tasks and leave client's room: Leaving the room quickly can make the client feel abandoned and isolated at a time when emotional support is crucial. Presence and attentive listening are important components of compassionate end-of-life care.
B. Request the chaplain to talk with client: While involving spiritual support services can be valuable, immediately referring the client to someone else may delay emotional comfort. The PN should first offer direct support before suggesting additional resources.
C. Ask the client if praying together would help: Offering prayer without knowing the client’s spiritual preferences might be inappropriate or uncomfortable for some individuals. It's better initially to offer silent presence and allow the client to express their needs if they wish.
D. Remain quietly in the client's room for a while: Staying quietly with the client conveys empathy, presence, and support. Nonverbal comfort allows the client space to process emotions and invites communication if they are ready, building trust and emotional security during a difficult moment.
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