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"]
Explanation
A. Abdominal circumference: The increase in abdominal circumference by 1 cm (0.4 in) since the prior assessment is concerning and may indicate a complication such as abdominal distension, which could be a sign of necrotizing enterocolitis (NEC) or other gastrointestinal issues. NEC is a serious condition that is common in preterm infants, especially those receiving enteral feedings.
B. Gestational age: Being born at 34 weeks gestation is a significant risk factor. Prematurity increases the risk for complications like respiratory distress syndrome (RDS), infections, and feeding difficulties. Preterm infants are also at risk for problems with thermoregulation, which is why the neonate is on a radiant warmer.
C. Respiratory distress: The presence of substernal retractions, nasal flaring, and an elevated respiratory rate (70/min) indicates respiratory distress. Preterm neonates, especially those born at 34 weeks, are at risk for RDS due to insufficient surfactant production, which can lead to difficulty breathing and hypoxemia.
D. UAC: The umbilical arterial catheter (UAC) is commonly used for monitoring blood pressure and obtaining blood samples in neonates. However, it carries a risk for complications such as infection, thrombosis, and injury to blood vessels. This is an invasive device that could contribute to complications.
E. Feeding method (Continuous breast milk feedings via OG tube): Although feeding via an orogastric tube is a standard method for preterm neonates, it does not pose an immediate risk factor in this case. The method of feeding itself is not a complication risk. However, complications like feeding intolerance or aspiration can arise, which would require further monitoring.
G. 5-minute Apgar score: A 5-minute Apgar score of 7 is considered an acceptable score for a neonate. Although it indicates some initial difficulty, this score does not present a significant risk factor for complications by itself. A lower score would be more concerning, but a score of 7 typically suggests the neonate is transitioning well.
Correct Answer is D
Explanation
A. A 25-gauge needle is too small and inappropriate for accessing a port.
B. An angiocatheter is used for peripheral IV access, not for implanted ports.
C. A butterfly needle is used for venipuncture, not for accessing ports.
D. A noncoring needle (e.g., Huber needle) is specifically designed to access an implanted venous port without causing damage to the septum, preserving the integrity of the port.
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