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","C","D","F","G","H"]

Explanation

Frequent episodes of apnea, responds to tactile stimuli: Apnea in a neonate, especially one born preterm (at 34 weeks gestation), is not uncommon but should be carefully monitored. However, frequent apnea episodes may indicate an underlying respiratory issue, such as respiratory distress syndrome (RDS) or an infection. Apnea that requires tactile stimuli to resolve should be followed up with further assessment and possibly intervention.

Substernal retractions and nasal flaring: These are signs of respiratory distress. Substernal retractions and nasal flaring indicate the neonate is working harder to breathe, which may point to respiratory distress syndrome (RDS) or other respiratory compromise. Close monitoring and follow-up are necessary to assess the neonate's respiratory status and oxygenation.

Respiratory rate of 70/min: This is on the higher end for a neonate and may indicate respiratory distress or compensation for oxygenation issues. Close monitoring is required.

Temperature of 36.3 °C (97.3 °F): While this temperature is within the normal range for a neonate, it is on the lower end of the spectrum. Neonates, especially preterm ones, are at risk for hypothermia. The neonate is on a radiant warmer, which suggests that there may still be concerns regarding temperature regulation. This needs to be monitored closely to ensure proper thermal regulation.

Increased abdominal circumference by 1 cm (0.4 in): An increase in abdominal circumference can be a sign of feeding intolerance, such as necrotizing enterocolitis (NEC), or other gastrointestinal issues. It is important to continue monitoring for other signs of NEC or abdominal distension, which can indicate the need for intervention.

A. The client takes furosemide twice daily. B. The client has a history of asthma. C. The client takes vitamin C daily. D. The client has a history of alcohol use disorder.

Correct Answer is B

Explanation

A. The client takes furosemide twice daily: There is no direct contraindication between furosemide and lavender oil.

B. Lavender oil, especially in aromatherapy, can trigger respiratory issues in some individuals, particularly those with asthma. Essential oils can act as irritants and exacerbate bronchospasms, potentially leading to wheezing, coughing, or an asthma attack. Therefore, the nurse should advise caution when using lavender oil in clients with a history of asthma.

C. The client takes vitamin C daily: There is no significant interaction between lavender oil and vitamin C.

D. While lavender has mild sedative properties, it is not a direct contraindication for clients with a history of alcohol use disorder. However, excessive use of lavender could enhance CNS depression when combined with alcohol, so it should be used with caution.

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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

Correct Answer is ["B","C","D","F","G","H"]

Explanation

A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication for using lavender?

Correct Answer is B

Explanation

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