A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The client is incontinent of stool and urine. Which of the following actions should the nurse take to prevent skin breakdown?
Explanation & Rationale
A. "Clean the client's skin with soap and hot water" is incorrect. Soap and hot water can be harsh on the skin and can cause irritation, especially in clients who are at risk for skin breakdown. The nurse should use lukewarm water and a gentle cleanser to clean the skin. B. "Limit the client's fluid intake" is incorrect. Limiting fluid intake is not a recommended approach for preventing skin breakdown. Proper hydration helps maintain skin elasticity and prevent dryness. C. "Use a moisture barrier on the client's skin" is correct. A moisture barrier is crucial for protecting the skin from prolonged exposure to moisture from incontinence, which can lead to skin breakdown. The barrier helps prevent irritation and allows the skin to stay intact. D. "Massage the area around the client's coccyx" is incorrect. Massaging over bony prominences, such as the coccyx, is not recommended, as it can damage tissue and increase the risk of pressure ulcers. The nurse should avoid massaging these areas.