Author Question: An older adult's perineal skin is dry and thin with mild excoriation. When providing hygiene care ... (Read 35 times)

bobbysung · **on:** Jul 22, 2018

An older adult's perineal skin is dry and thin with mild excoriation. When providing hygiene care after episodes of diarrhea, what should the nurse do?

a. Thoroughly scrub the skin with a washcloth and hypoallergenic soap.
b. Tape an occlusive moisture barrier pad to the patient's skin.
c. Apply a skin protective ointment after perineal care.
d. Massage the skin with light kneading pressure.

Question 2

Which action will the nurse take to reduce the risk of excoriation to the mucosal lining of the patient's nose from a nasogastric tube?

a. Instill Xylocaine into the nares once a shift.
b. Tape tube securely with light pressure on nare.
c. Lubricate the nares with water-soluble lubricant.
d. Apply a small ice bag to the nose for 5 minutes every 4 hours.

dyrone · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: C
Cleansing with a no-rinse cleanser and application of a barrier ointment should be done after each episode of diarrhea. Tape and occlusive dressings can damage skin. Excessive pressure and massage are inappropriate and may cause skin breakdown.

Answer to Question 2

ANS: C
The tube constantly irritates the nasal mucosa, increasing the risk of excoriation. Frequent lubrication with a water-soluble lubricant decreases the likelihood of excoriation and is less toxic than oil-based if aspirated. Xylocaine is used to treat sore throat, not nasal mucosal excoriation. While the tape should be secure, pressure will increase excoriation. Ice is not applied to the nose.