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 D

Explanation

A. A face shield is unnecessary unless there is a risk of splashing.

B. Masks are not needed for C. difficile, as it is not spread through airborne transmission.

C. Alcohol-based hand rubs are ineffective against C. difficile spores; handwashing with soap and water is required.

D. Contact precautions for C. difficile require the nurse to remove the protective gown and gloves inside the client's room to prevent contamination of outside areas.

A. Blood pressure B. Temperature C. Potassium level D. WBC count E. Breath sounds

Correct Answer is ["B","D","E"]

Explanation

A. Blood pressure – The client's blood pressure of 114/56 mm Hg is within an acceptable range and does not indicate hypotension or hypertension.

B. Temperature – A temperature of 38.6°C (101.5°F) is indicative of fever, which is concerning in a client undergoing chemotherapy due to their increased risk of infection (febrile neutropenia). Prompt evaluation and intervention are necessary to prevent sepsis.

C. Potassium level – The client's potassium level of 3.6 mEq/L is within the normal range (3.5 to 5 mEq/L) and does not require immediate intervention.

D. WBC count – The client's WBC count has decreased to 3,800/mm³, which is below the normal range (5,000 to 10,000/mm³), indicating leukopenia. This places the client at a higher risk for infection, requiring close monitoring and potential interventions.

E. Breath sounds – The presence of crackles at the lung bases suggests possible pulmonary complications, such as fluid overload, infection (e.g., pneumonia), or early signs of acute respiratory distress syndrome (ARDS). This finding warrants further assessment and intervention.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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