The client has a red, raised skin rash. During the bath, the priority action of the nurse is to:
1. Assess for further inflammatory reactions
2. Discuss the body image problems created by the presence of the rash
3. Wash the skin thoroughly with hot water and soap
4. Moisturize the skin to prevent drying
ANS: 1
The first action the nurse should take is to assess for further inflammatory reactions to determine if it is localized or systemic. Discussing body image problems would not be the priority nursing action. Skin should be washed with warm water, not hot, as it may dry the skin. All soap should be rinsed well so not to leave residue that may cause further irritation. The rash may be caused by moisture; thus moisturizing the skin would not be appropriate. A lotion to help prevent itching may be applied.
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