Questions: A nurse finds that a patient who has urinary incontinence scores 11 on the Braden Scale. Which nursing action is most appropriate to prevent this patient from developing pressure injuries? Managing shear Managing moisture Providing nutrition intervention Providing foam wedges for positioning

A nurse finds that a patient who has urinary incontinence scores 11 on the Braden Scale. Which nursing action is most appropriate to prevent this patient from developing pressure injuries? Managing shear Managing moisture Providing nutrition intervention Providing foam wedges for positioning
Transcript text: A nurse finds that a patient who has urinary incontinence scores 11 on the Braden Scale. Which nursing action is most appropriate to prevent this patient from developing pressure injuries? Managing shear Managing moisture Providing nutrition intervention Providing foam wedges for positioning
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Solution

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The answer is: Managing moisture.

Explanation for each option:

  1. Managing shear: While managing shear is important in preventing pressure injuries, it is not the most directly relevant action for a patient with urinary incontinence. Shear refers to the force that causes layers of tissue to slide against each other, which can contribute to pressure injuries, but it is not directly related to moisture management.

  2. Managing moisture: This is the most appropriate action for a patient with urinary incontinence. Moisture from incontinence can lead to skin maceration and increase the risk of pressure injuries. Therefore, managing moisture by keeping the skin clean and dry, using barrier creams, and changing incontinence products frequently is crucial.

  3. Providing nutrition intervention: Nutrition is important for overall skin health and healing, but it is not the most immediate concern for a patient with urinary incontinence in the context of preventing pressure injuries.

  4. Providing foam wedges for positioning: Foam wedges can help with positioning to reduce pressure on certain areas, but they do not address the specific issue of moisture management related to urinary incontinence.

Summary: For a patient with urinary incontinence who scores 11 on the Braden Scale, the most appropriate nursing action to prevent pressure injuries is managing moisture. This involves keeping the skin clean and dry, using barrier creams, and changing incontinence products frequently.

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