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The nurse is caring for a client who is able to move Independently, but has been placed on bedrest with bathroom priviledges only due to their current treatment. The client has experienced two episodes of functional urinary incontinence. Which intervention(s) should the nurse include in the care plan? (SELECT ALL THAT APPLY)

Apply moisture barrier cream to perineal skin

Consult with the wound care nurse about use of a specialty mattress

Instruct client to shift their weight at least every 15 minutes

Keep head of bed raised at 45 degrees at all times

Massage over bony prominences every hour while awake

Answer and Explanation

Correct Answer : A,B,C

A. Applying moisture barrier cream helps protect the skin from irritation and breakdown due to urinary incontinence.

B. Consulting with the wound care nurse about the use of a specialty mattress is crucial to minimize pressure ulcers.

C. Instructing the client to shift their weight at least every 15 minutes helps reduce pressure and prevent pressure ulcers.

D. Keeping the head of the bed raised at 45 degrees at all times is not necessary and may not address the underlying issue of functional urinary incontinence.

E. Massaging over bony prominences is important for preventing pressure ulcers but does not directly address urinary incontinence.

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Correct Answer is C

Explanation

Explanation:

A. Penrose drains do not rely on negative pressure; they rely on gravity for drainage.

B. Allowing the drain reservoir to fill completely before emptying it may lead to leakage and increased risk of infection.

C. Changing the soiled dressing carefully helps prevent contamination of the wound and promotes healing.

D. Pinning the drain to the dressing is not necessary and may cause discomfort or injury to the client.

A. Apply moisture barrier cream to perineal skin B. Consult with the wound care nurse about use of a specialty mattress C. Instruct client to shift their weight at least every 15 minutes D. Keep head of bed raised at 45 degrees at all times E. Massage over bony prominences every hour while awake

Correct Answer is ["A","B","C"]

Explanation

A. Applying moisture barrier cream helps protect the skin from irritation and breakdown due to urinary incontinence.

B. Consulting with the wound care nurse about the use of a specialty mattress is crucial to minimize pressure ulcers.

C. Instructing the client to shift their weight at least every 15 minutes helps reduce pressure and prevent pressure ulcers.

D. Keeping the head of the bed raised at 45 degrees at all times is not necessary and may not address the underlying issue of functional urinary incontinence.

E. Massaging over bony prominences is important for preventing pressure ulcers but does not directly address urinary incontinence.

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Naxlex Comprehensive Predictor Exams

A postoperative client has an abdominal incision and a Penrose drain. Both are covered with an abdominal dressing. Which is an important nursing action associated with caring for a client with a Penrose drain?

Correct Answer is C

Explanation

Correct Answer is ["A","B","C"]

Explanation

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