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 D
Explanation
A. Require family members and visitors to wear a mask and gown when visiting the client: Masks and gowns are needed in healthcare settings to prevent cross-contamination, but at home, strict use of personal protective equipment (PPE) is not typically necessary for a draining wound unless there is high-risk exposure. Basic hygiene is usually sufficient.
B. Have the client stay in a room separate from the family with the door closed: Isolation at home is generally not necessary unless the infection is highly contagious through casual contact. Emphasis should instead be placed on good wound care and proper hygiene practices.
C. Use paper plates and disposable utensils for the client's meals and snacks: There is no need to use disposable eating utensils. Normal dishwashing practices are adequate to prevent the spread of infection in a home environment, as long as proper cleaning is maintained.
D. Place soiled dressings in a plastic bag that can be tightly secured for disposal: Proper disposal of contaminated dressings in a sealed plastic bag prevents leakage and minimizes exposure to infectious materials. This practice protects household members from accidental contact with wound drainage.
Correct Answer is B
Explanation
A. Circular or spiral: Circular or spiral turns are useful for covering areas of uniform thickness like the forearm or lower leg. However, they do not provide the necessary flexibility and joint support needed for an area like the wrist that requires frequent movement.
B. Figure-eight turns: Figure-eight bandaging is ideal for joints such as the wrist because it provides secure stabilization while allowing some range of motion. It supports the bandage placement over the wound and accommodates natural joint movement without slipping or tightening.
C. Arm sling: An arm sling supports the entire arm, typically used for fractures or shoulder injuries. It does not address localized wound care needs on the palm or help secure a dressing at the wrist specifically.
D. Glove or sock: A glove or sock dressing covers an entire hand or foot but would not adequately stabilize a dressing over a specific wound on the palm while allowing wrist mobility. It also may not keep the dressing in firm contact with the wound.
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