The nurse most effectively addresses the protection of a terminally il

The nurse most effectively addresses the protection of a terminally ill, incontinent client’s skin from irritation and breakdown by:

1. Using adult diapers and changing them as soon as they become wet or otherwise soiled
2. Assessing the client’s bed frequently for wetness and assuring clean, dry linens and clothing
3. Securing an order for an indwelling catheter and keeping the perineal area free of fecal matter
4. Offering the client frequent opportunities to toilet and responding promptly to requests to toilet

ANSWER

ANS: 2
Progressive disease and decreased level of consciousness can result in both urinary and fecal in-continence. The most effective means of protect skin from irritation or breakdown is by main-taining dry linens and clothing. The remaining options are not inappropriate, but a client may not be able to respond to the need to urinate or defecate. While adult diapers and an indwelling catheter are viable interventions, the client must still be provided with care that ensures that skin will be clean and dry.