A bedfast female client awakens during the night, reporting to the nurse that she is "uncomfortable." What action should the nurse implement first?

Engage the client in relaxation exercises.

Offer to sit with the client until she relaxes.

Administer a prescribed PRN analgesic.

Assist the client to a different position.

Answer and Explanation

The Correct Answer is D

A. Engaging the client in relaxation exercises may be helpful but should be considered after addressing potential physical causes of discomfort, such as positioning.
B. Offering to sit with the client is supportive, but the primary issue of physical discomfort should be addressed first.
C. Administering a PRN analgesic may be necessary if the discomfort persists, but repositioning the client is a less invasive intervention to try first.
D. Assisting the client to a different position is the first action the nurse should take. A change in position can often alleviate discomfort for bedfast clients and is a simple, non-invasive intervention.

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Correct Answer is C

Explanation

A. Dizziness is not typically associated with routine perineal care, so it is not a common concern for the caregiver to monitor during cleansing. Normal care does not usually affect blood pressure or circulation enough to cause dizziness.

B. The foreskin should be gently retracted in male clients who are uncircumcised to clean beneath it, as failing to do so can lead to buildup of secretions and increase the risk of infection. Proper retraction is important for hygiene and to prevent conditions like balanitis.

C. An erection may occur as a reflex response during perineal care, especially in males with intact neurologic function. Caregivers should be aware of this possibility and continue care calmly and professionally without assuming it is sexual in nature.

D. The pubic area does not need to be shaved for routine hygiene, and shaving can cause microabrasions that increase the risk of infection. Proper cleansing with soap and water is sufficient to maintain perineal hygiene.

A. Ask an unlicensed assistive personnel to stay with the client. B. Place the bedpan within the reach of the client. C. Obtain a bedside commode for the client to use. D. Notify the healthcare provider of the client's concerns.

Correct Answer is C

Explanation

A. Asking an unlicensed assistive personnel (UAP) to stay with the client does not directly address the client's concern about being unable to make it to the bathroom.
B. Placing the bedpan within the client’s reach may help, but it is less comfortable and dignified than using a commode, which is a better option for an ambulatory client.
C. Obtaining a bedside commode for the client to use is the best intervention as it provides a practical solution that allows the client to relieve herself without the anxiety of having to walk a distance, thus preventing any accidents.
D. Notifying the healthcare provider of the client’s concerns is unnecessary as this situation can be effectively managed by nursing intervention.

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A bedfast female client awakens during the night, reporting to the nurse that she is "uncomfortable." What action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?

Correct Answer is C

Explanation

Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?

Correct Answer is C

Explanation

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