A nurse is teaching a client about maintaining skin integrity to decrease the risk of infection. Which of the following instructions should the nurse include?
"Use a moisturizer on your skin after cleaning."
"Allow your skin to air dry after bathing."
"Rub your skin firmly when cleaning."
"Wash your skin daily with hot water."
The Correct Answer is A
Rationale:
A. Using a moisturizer after cleaning helps keep the skin hydrated, preventing dryness and cracking, which can increase the risk of infection.
B. Allowing the skin to air dry can lead to excessive dryness, especially in vulnerable areas, potentially compromising the skin’s integrity.
C. Rubbing the skin firmly can cause irritation, damage, and increased risk of skin breakdown, particularly in individuals with fragile skin.
D. Washing the skin daily with hot water can strip the skin of natural oils, leading to dryness and irritation, which increases the risk of infection. Warm water should be used instead.
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Correct Answer is C
Explanation
Rationale:
A. A wet-to-dry dressing is typically used for debridement and is not appropriate for a shallow pressure ulcer without necrotic tissue, as it can damage healthy tissue during dressing changes.
B. Leaving the area without a dressing is not advisable as it exposes the wound to contaminants and increases the risk of infection; a dressing should be used to protect the area.
C. A hydrocolloid dressing is ideal for shallow partial-thickness wounds as it provides a moist environment, promotes healing, and helps to cushion the area while maintaining a barrier against bacteria.
D. Alginate dressings are primarily used for wounds with moderate to heavy exudate and would not be suitable in this case due to the lack of drainage.
Correct Answer is B
Explanation
Rationale:
A. Sanguineous drainage is characterized by bright red blood; it indicates fresh bleeding and does not include watery components.
B. Serosanguineous drainage is a combination of clear, watery fluid and blood, often appearing light pink to red. The description of watery red drainage fits this category, making it the correct choice.
C. Serous drainage is clear, pale yellow fluid without blood, indicating a non-bloody exudate. It does not match the description of watery red drainage.
D. Purulent drainage is thick, opaque, and often yellow, green, or brown due to the presence of pus and infection. It does not apply here as the drainage is described as watery red.