The unlicensed assistive personnel (UAP) tells the nurse that an older client has requested powder applied after a tub bath to relieve itchy dry skin. Which instruction should the nurse provide to the UAP?

Cover moist areas of the skin with cornstarch.

Gently apply lotion to the skin after bathing.

Add bath oil directly to the warm bath water.

Switch to using a liquid soap for bar soap.

Answer and Explanation

The Correct Answer is B

A.   Applying cornstarch or other powders to moist skin can exacerbate dryness and irritation, as powders can absorb moisture but also contribute to a dry skin environment. In general, powders are not recommended for use on already dry or irritated skin, especially for older adults, as they can lead to further skin issues or contribute to fungal infections.
B.   Gently applying lotion or moisturizer to the skin after bathing is the most appropriate action. Moisturizers help to rehydrate and lock in moisture, reducing the risk of dry, itchy skin. Applying lotion to damp skin (immediately after bathing) is particularly effective as it helps to seal in the moisture.
C.   Adding bath oil to the bath water can be beneficial for moisturizing the skin, as it helps to create a barrier that prevents moisture loss. However, for the client’s specific request about post-bath relief, adding oil to the bath water does not address the immediate need for skin care after bathing.
D.   Liquid soap can be gentler on the skin compared to bar soap, which can be drying, especially if it contains harsh ingredients. However, switching from bar soap to liquid soap is a preventive measure and does not provide immediate relief for already dry and itchy skin.

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Correct Answer is D

Explanation

A. Using larger bags might help accommodate the gas more comfortably and reduce the need for making pinholes. However, this solution does not address the immediate issue of gas accumulation and may not be practical for all clients.
B. "Burping" the bag is a recognized technique for managing gas in colostomy bags. It involves opening the end of the bag slightly to release gas, which helps to prevent the bag from ballooning and causing discomfort. This method is effective and safe, as it is specifically designed to manage gas without compromising the integrity of the bag.
C. Making pinholes in the colostomy bag is not a recommended practice. Pinholes can lead to leakage and increase the risk of skin irritation or infection. While ensuring the pinholes are at the top might reduce some complications, it does not solve the fundamental issue and poses a risk to the client's health and hygiene.
D. Colostomy bags equipped with built-in gas release valves are designed specifically to manage gas accumulation safely and effectively. Informing the client about these specialized bags provides a practical solution to the problem of gas buildup and avoids the risks associated with making pinholes.

A. Provide a box of tissues for the client to use when coughing. B. Assist the client in changing into a fresh hospital gown. C. Teach the client to cover the mouth with hands when coughing. D. Obtain face masks for staff to wear upon entering the room.

Correct Answer is A

Explanation

A.Providing tissues is a helpful measure for clients to use when they need to cough or sneeze. It promotes good hygiene by allowing the client to dispose of respiratory secretions properly. However, this choice does not address the immediate concern of how the client is currently coughing and the potential for spreading infection.
B.Assisting the client with a gown change may be necessary if their current gown is soiled. However, this action does not directly address the infection control issue or the client’s method of coughing. Changing the gown is secondary to addressing proper coughing techniques and infection control.
C.Teaching clients to cover their mouth with their hands is not ideal, as it can spread germs if the hands are not washed immediately afterward. Instead, clients should be taught to cough into a tissue or their elbow (not the sleeve) to minimize the spread of germs. This is a crucial component of infection control and helps reduce the risk of transmission.
D.Providing face masks for staff is an important measure in infection control, especially if the client has a respiratory illness. However, it does not address the client's current coughing technique or teach the client how to prevent the spread of infection through their own actions.

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The unlicensed assistive personnel (UAP) tells the nurse that an older client has requested powder applied after a tub bath to relieve itchy dry skin. Which instruction should the nurse provide to the UAP?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a colostomy tells the nurse about making small pin holes in the drainage bag to help relieve the gas that collects. Which action should the nurse implement?

Correct Answer is D

Explanation

When entering a client's room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?

Correct Answer is A

Explanation

An older client with colorectal carcinoma receives a colostomy following a bowel resection and the nurse is reviewing written instructions about colostomy care that the client will take home after discharge. Which action should the nurse include when reviewing the instructions with the client?

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

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