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 B

Explanation

A. Assessing whether the expected outcomes were realistic involves evaluating if the goals set in the plan of care were achievable given the client’s condition, resources, and constraints. While this is an important consideration, it is not the immediate next step after reviewing the expected outcomes.
B. After reviewing the expected outcomes, the next critical step is to gather and analyze current client data. This includes assessing the client’s current condition, symptoms, and responses to interventions. By comparing this data with the expected outcomes, the nurse can determine if the goals are being met, if they need adjustment, or if different interventions are required.
C. Reviewing professional standards of care involves understanding the accepted norms and guidelines for nursing practice. While important, this action typically precedes the direct evaluation of care and is part of ensuring that the care plan was developed and implemented according to professional guidelines.
D. Modifying nursing interventions is an action that might be required if the evaluation shows that the expected outcomes are not being met. However, this action is taken after evaluating the effectiveness of the current interventions by comparing client data with expected outcomes.

A. Document the presence of orthopnea. B. Elevate the head of the bed. C. Obtain a pulse oximeter. D. Assess the client's vital signs.

Correct Answer is B

Explanation

A. Orthopnea is a condition where a person has difficulty breathing when lying flat and may require sitting or standing to breathe more easily. While documenting orthopnea is important for the medical record and understanding the client’s condition, it is not the immediate priority in addressing acute breathing difficulty.
B. Elevating the head of the bed is an immediate and effective action to help alleviate breathing difficulty. This position helps improve respiratory mechanics by allowing the diaphragm to move more freely and reducing pressure on the lungs.
C. Using a pulse oximeter to measure oxygen saturation is important for assessing the client’s oxygen levels and determining the need for supplemental oxygen. However, this action is secondary to immediately addressing the position that is causing difficulty.
D. Assessing vital signs is important for a comprehensive evaluation of the client’s overall condition and to identify any critical changes in health status. However, in the case of immediate breathing difficulty, it is more urgent to take actions that directly address the breathing issue before performing a thorough assessment.

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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

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?

Correct Answer is B

Explanation

A client is having trouble breathing while lying in a dorsal recumbent position. Which action should the nurse implement first?

Correct Answer is B

Explanation

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