A nurse is caring for a patient who has a diagnosis of bullous pemphigoid and who is being treated on the medical unit. When providing hygiene for this patient, the nurse should perform which of the following actions?
A) After washing, wipe lesions with sterile gauze to remove cellular debris.
B) Apply antibiotic ointment to lesions after washing.
C) Apply cornstarch to the patient's skin after bathing to facilitate mobility.
D) Avoid using water to cleanse the patient's skin in order to maintain skin integrity.
Ans: C
Feedback:
After the patient's skin is bathed, it is dried carefully and dusted liberally with nonirritating powder (e.g., cornstarch), which enables the patient to move about freely in bed. Open blisters should not normally be wiped and antibiotics are not applied to wound beds in the absence of a secondary infection. Water can safely be used to provide hygiene.
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