Which of the following are essential in the care for a patient with incontinence-associated dermatitis? (SELECT ALL THAT APPLY)
apply warm compresses to relieve discomfort
check the client's skin for moisture at least q 2 hrs
use a moisture barrier product after cleansing
decrease oral intake in early morning
dry the skin with a vigorous motion to promote circulation
Correct Answer : A,B,C
A. Applying warm compresses can help relieve discomfort
B. Regular monitoring of skin moisture is crucial in managing IAD. Moist skin is more susceptible to breakdown, so frequent checks allow for prompt intervention, such as changing incontinence products or applying protective barriers.
C. Applying a moisture barrier product after cleansing helps protect the skin from moisture and irritants found in urine or feces. These products create a protective barrier that can prevent further damage and promote healing of already affected skin. This is essential in managing IAD.
D There is no clinical
Rationale to decrease oral intake in the early morning specifically for managing IAD. Hydration is important for overall skin health, and reducing oral intake without medical indication could lead to dehydration, which may worsen skin condition.
E. Vigorous drying of the skin is not recommended as it can exacerbate skin irritation and damage. Instead, gentle patting or air drying is preferred to avoid further trauma to the already compromised skin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. This is the part of the IV administration set that pierces the IV bag or bottle to allow fluid to flow into the tubing. The plastic insertion spike must remain sterile because it comes into direct contact with the fluid within the IV container. Contamination of the spike could introduce microorganisms into the IV solution.
B. The catheter adapter or hub is the part of the IV administration set where the IV catheter or cannula connects. It is crucial for this part to remain sterile to prevent introducing pathogens into the bloodstream during catheter insertion or manipulation.
D. The Y-site injection port is a branching point in the IV tubing where additional medications or fluids can be infused into the IV line. It must remain sterile to prevent contamination when administering medications or secondary infusions.
C. The drip chamber is located in the IV tubing, just below the IV bag or bottle. It is designed to visualize and regulate the flow of IV fluid into the patient. It does not directly contact the bloodstream or the IV fluid inside the tubing.
E. Roller clamp to regulate flow (Option E) does not necessarily need to be sterile because it does not come into direct contact with IV fluid or the patient's bloodstream. However, it should be handled with clean hands to maintain general cleanliness and to prevent contamination of other sterile parts of the IV set.
Correct Answer is A
Explanation
A. The JP drain helps prevent excessive accumulation of fluid in the wound by actively draining it away. If fluid were to accumulate excessively, it could impair wound healing and increase the risk of infection.
However, the primary purpose of the JP drain is to remove fluid rather than prevent its collection altogether.
B. The JP drain does not directly assess the degree of healing. Its primary function is to drain fluid from the wound to promote healing by preventing fluid accumulation, which could hinder healing. Assessing the degree of healing typically involves visual inspection of the wound by the healthcare provider rather than relying on the drain.
C. This is not the purpose of the JP drain. Healing generally occurs by the gradual migration of cells and tissues to close the wound, which is an internal process. The JP drain assists in the healing process by preventing complications due to fluid accumulation but does not influence healing from outside to inside.
D. While the JP drain itself does not directly prevent the entrance of microorganisms into the wound, it indirectly contributes to infection prevention by removing excess fluid. Accumulated fluid can provide a medium for bacterial growth, potentially leading to infection. By draining fluid effectively, the JP drain helps maintain a cleaner wound environment, reducing the risk of infection.
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