Which of the following actions can the nurse take to help prevent a health care-associated infection in an incontinent patient?

Avoiding use of a urinary catheter

Applying absorbent briefs

Restricting Fluids

Toileting patient every 4 hours

Answer and Explanation

The Correct Answer is B

A.   Avoiding use of a urinary catheter: While avoiding unnecessary urinary catheterization is important to prevent healthcare-associated urinary tract infections, this action may not be directly applicable to an incontinent patient who requires interventions to manage incontinence.
B.   Applying absorbent briefs: Using absorbent briefs helps contain urine and feces, reducing the risk of skin breakdown and contamination of the environment.
C.   Restricting Fluids: Restricting fluids may lead to dehydration and is not a recommended approach for preventing healthcare-associated infections in incontinent patients.
D.   Toileting patient every 4 hours: Toileting frequency should be individualized based on the patient's needs and not restricted to a specific time interval. Additionally, simply toileting the patient may not be sufficient to prevent healthcare-associated infections if proper hygiene practices are not followed.

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Correct Answer is D

Explanation

A. Pupil size and reaction: Pupil size and reaction are typically assessed to monitor neurological function and are not directly related to tissue integrity.
B. Heart rate and blood pressure: Heart rate and blood pressure are vital signs that provide information about cardiovascular function but do not specifically assess tissue integrity.
C. Respiratory rate and oxygen saturation: Respiratory rate and oxygen saturation are indicators of respiratory function and oxygenation status and are not directly related to tissue integrity.
D. Skin turgor and moisture: Skin turgor, the skin's ability to return to its normal shape after being pinched, and moisture levels are important assessments for monitoring tissue hydration and integrity. Changes in skin turgor and moisture can indicate dehydration, which can impair tissue integrity and wound healing.

A. Administering analgesic medications B. Performing gentle massage on the affected area C. Applying a heating pad to the affected area D. Using topical antibiotics on the affected area

Correct Answer is A

Explanation

A. Administering analgesic medications: Analgesic medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids, can help alleviate pain associated with impaired skin integrity by reducing inflammation and blocking pain signals.
B. Performing gentle massage on the affected area: While massage can sometimes provide relief for certain types of pain, it may not be appropriate for all types of impaired skin integrity and could potentially exacerbate the condition or cause further damage.
C. Applying a heating pad to the affected area: Heat therapy may be contraindicated for certain types of impaired skin integrity, as it can increase inflammation and worsen pain. It is not
typically recommended as a primary intervention for managing pain in this context.
D. Using topical antibiotics on the affected area: Topical antibiotics are used to treat or prevent infections but are not primarily indicated for pain management associated with impaired skin
integrity.

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Which of the following actions can the nurse take to help prevent a health care-associated infection in an incontinent patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following assessments should be performed to monitor for impaired tissue integrity?

Correct Answer is D

Explanation

Which of the following interventions can help manage pain associated with impaired skin integrity?

Correct Answer is A

Explanation

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