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.
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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Related Questions
Correct Answer is C
Explanation
A. Offer three large meals: Small, frequent meals are better tolerated.
B. Administer a bronchodilator after meals: Should be given before meals.
C. Limit fluid intake with meals: Reduces gastric distension and improves calorie intake.
D. Ambulate before meals: May increase fatigue and reduce intake.
Correct Answer is []
Explanation
Potential condition: Deep vein thrombosis
Based on the provided information, the client is most likely experiencing Deep Vein Thrombosis (DVT). This is suggested by the client's history of smoking, lack of exercise, obesity, recent surgery, and the fact that they are not wearing sequential compression devices due to discomfort.
Actions to Take
- Request a prescription for a lower-extremity Doppler flow study: This will help confirm the presence of a blood clot in the deep veins.
- Assess for Homan's sign: This is a clinical test used to check for DVT, although it's not always reliable.
Parameters to Monitor
- Signs of bleeding after anticoagulation initiation: This is crucial because anticoagulants are often used to treat DVT, and monitoring for bleeding is essential.
- PT/INR and platelet count: These parameters help assess the effectiveness and safety of anticoagulation therapy.
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