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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

A. Surgical debridement may be necessary for nonviable tissue, but white skin around wound edges may indicate wound healing, not necessarily nonviable tissue.

B. Turning and positioning every two hours is important for preventing pressure ulcers but is not directly related to the presence of white skin around wound edges.

C. White skin around the edges of a wound is often indicative of maceration, which occurs when skin has been in contact with moisture for an extended period. This condition can make the skin appear lighter and feel softer, wetter, or soggier than usual. Maceration can slow down the healing process and make the skin more susceptible to infection. Therefore, it is crucial to address the excessive moisture to prevent further complications.

D. White skin around the edges of a wound is often indicative of maceration, which occurs when skin has been in contact with moisture for an extended period.

A. skin irritation. B. loss of the patch. C. Interactions with other medications D. drug overdose.

Correct Answer is D

Explanation

A. Skin irritation is a possible side effect of nitroglycerin patches but is not a reason to remove the patch before starting an intravenous infusion.

B. Loss of the patch is not a primary concern when transitioning from a nitroglycerin patch to an intravenous infusion.

C. While interactions with other medications are possible, they are not the primary reason to remove the nitroglycerin patch.

D. Removing the old nitroglycerin patch before starting the intravenous infusion is essential to avoid the risk of drug overdose, as the patch continues to release medication even after removal.

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Naxlex Comprehensive Predictor Exams

The nurse is performing a dressing change for a patient and notices white skin around the wound edges. The nurse is aware that:

Correct Answer is C

Explanation

The nurse is caring for a client who has been wearing a nitroglycerin patch and receives an order to start a nitroglycerin intravenous infusion. The old patch must be removed from the client's body in order to avoid:

Correct Answer is D

Explanation

In order to minimize discomfort when giving an injection to a client, the nurse should:

A client has a serum magnesium level of 0.9 mEq/L. The nurse would monitor this client for which sign or symptom?

The best way for the nurse to assess a client's level of dyspnea is to:

The nurse explains to a client that the benefits of using a spacer with Inhaled medication is/are to: (SELECT ALL THAT APPLY)

It is most critical for the nurse to use a filtered needle when preparing a parenteral medication that:

At which site on the diagram would the nurse give an Intramuscular injection into the vastus lateralis?

When doing the client's skin assessment, the nurse notes a 3 cm area of partial thickness skin loss that looks like a blister on the client's sacral area. The nurse consults the wound care nurse, who stages the wound as a stage pressure ulcer.

The nurse recognizes that the five "rights" associated with delegation in nursing Include the right: (SELECT ALL THAT APPLY)