A nurse is caring for a male client who has a spinal cord injury. Which of the following techniques should the nurse use when providing perineal care?

Use water with no soap to prevent skin irritation.

Discard the washcloth after cleansing the urethral meatus.

Don sterile gloves to prevent infection.

Wash the penis from the scrotum to the tip using a spiral motion.

Answer and Explanation

The Correct Answer is B

A. While avoiding harsh soap is important, using water alone may not adequately clean the area.

B. After cleaning the urethral meatus, the nurse should discard the washcloth or use a different part of it to prevent the spread of bacteria.

C. Clean gloves are typically sufficient unless the procedure involves a sterile environment.

D. The penis should be cleaned from the tip to the base (proximal to distal) to reduce the risk of introducing bacteria.

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Correct Answer is B

Explanation

A. Sinus tachycardia: Incorrect. Sinus tachycardia shows a regular rhythm with identifiable P waves, not a wavy baseline.

B. Atrial fibrillation: The wavy baseline and absent P waves are characteristic of atrial fibrillation, a common arrhythmia that results from rapid and irregular electrical activity in the atria.

C. Second-degree heart block: Incorrect. Second-degree heart block would show P waves with intermittent conduction of the QRS complex, not a wavy baseline.

D. Ventricular asystole: Incorrect. Ventricular asystole would show no electrical activity, which is different from a wavy baseline.

A. A reddened area measuring 10 mm B. A reddened area measuring 5 mm C. An induration measuring 5 mm D. An induration measuring 10 mm

Correct Answer is D

Explanation

A. A reddened area without induration is not a positive result.

B. A reddened area without induration is not considered positive.

C. An induration of 5 mm is positive only for high-risk groups (e.g., immunocompromised clients).

D. An induration measuring 10 mm is considered positive in most adults, indicating TB exposure.

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A nurse is caring for a male client who has a spinal cord injury. Which of the following techniques should the nurse use when providing perineal care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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