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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E","F"]
Explanation
Capillary refill 4 seconds: A prolonged capillary refill time of more than 2 seconds may indicate poor perfusion, possibly due to dehydration or circulatory compromise. This warrants immediate follow-up to assess for potential dehydration or shock.
Hyperactive bowel sounds: This may indicate gastrointestinal distress, such as diarrhea or irritation.
Diaper area erythema: Diaper rash is common in toddlers, particularly with diarrhea. Extremities cool: Cool extremities can be a sign of poor peripheral circulation, often associated with dehydration or developing hypovolemic shock. Immediate intervention is needed to address potential circulatory issues.
Reports no tears: The absence of tears, especially in a toddler, may suggest significant dehydration. This is a concerning sign and requires immediate follow-up to assess the child's hydration status and consider interventions, such as IV fluids or electrolyte management.
Lethargic: The child's lethargy, especially after vomiting and with decreased responsiveness, raises concern for potential dehydration, electrolyte imbalance, or a worsening condition. Lethargy in a toddler requires prompt evaluation and intervention to prevent further deterioration.
Correct Answer is B
Explanation
A. Keeping the television on at night can cause confusion and disrupt sleep patterns, increasing the risk of injury.
B. Assisting the client to the toilet frequently can prevent falls and reduce the risk of incontinence-related injuries.
C. Raising side rails may increase the risk of injury due to falls or entrapment.
D. Placing the bedside table at the foot of the bed may lead to confusion and increase fall risk.
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