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 C

Explanation

A. Using a belt restraint is generally not recommended unless specifically ordered for safety reasons, as it may not be appropriate or necessary in all cases. Restraints should only be used when absolutely needed and when all other methods of ensuring safety have been considered.
B. Emptying the urinary drainage bag before moving the client is important to prevent overflows and ensure that the bag does not become a source of discomfort or potential infection. However, this step might not always be immediately necessary unless the bag is full or the client’s comfort and hygiene are at risk.
C. Repositioning the urinary drainage bag is crucial for ensuring that the bag remains below the level of the bladder and is not subject to kinks or obstructions. This helps prevent backflow and potential infections. Proper positioning also contributes to the client’s comfort and dignity, making this a priority before moving the client.
D. Elevating the client’s feet on the footrests is important for their comfort and to prevent swelling or pressure sores, especially if the client has limited mobility or circulatory issues. Proper positioning can prevent discomfort and promote better circulation, which is essential for maintaining the client’s well- being during transport.

A. Decrease the rate of the feeding by half. B. Observe for an allergic reaction to the formula. C. Hang a new bag of the enteral formula. D. Stop the tube feeding and assess the client.

Correct Answer is D

Explanation

A. Decreasing the rate of the feeding might be a consideration if the feeding was too rapid, but it is not the immediate priority if aspiration is suspected.
B. While it is important to monitor for allergic reactions to enteral formulas, this is not the immediate concern if aspiration is suspected. Allergic reactions would typically present with symptoms such as rash, itching, or gastrointestinal distress, and not immediately after aspiration.
C. Hanging a new bag of enteral formula is not an appropriate action if aspiration is suspected. The
priority is to ensure the client’s safety and address any complications that may arise from the aspiration, such as aspiration pneumonia.
D. Stopping the tube feeding and assessing the client is the most appropriate initial action if aspiration is suspected. Immediate assessment is necessary to determine if the client is experiencing signs of aspiration, such as coughing, wheezing, difficulty breathing, or changes in consciousness.

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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?

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Correct Answer is C

Explanation

A client with a gastrostomy tube is receiving a continuous feeding, and the nurse suspects that the client has aspirated some of the feeding. Which action should the nurse take?

Correct Answer is D

Explanation

The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

A male client tells the nurse that he is taking large doses of a fish oil supplement to lower his triglyceride level. Which action should the nurse take?

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?

A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?

A client started a 24-hour urine collection several hours ago. The client tells the nurse that the last voiding was accidentally flushed instead of saved in the container. Which intervention should the nurse initiate?

At 2000, the unlicensed assistive personnel (UAP) reports several client problems to the nurse who is working on a medical unit. Which client needs the most immediate follow-up by the nurse?