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?

Wash the penis from the scrotum to the tip using a spiral motion.

Use water with no soap to prevent skin irritation.

Don sterile gloves to prevent infection.

Discard the washcloth after cleansing the urethral meatus.

Answer and Explanation

The Correct Answer is D

The correct answer is choice d.

Choice A rationale:

Washing the penis from scrotum to tip using a spiral motion can trap bacteria under the foreskin and increase risk of infection.

Choice B rationale:

Soap helps remove dirt and bacteria, reducing infection risk. Soapy water is preferred over plain water for perineal care.

Choice C rationale:

While hand hygiene is crucial, sterile gloves are not typically required for routine perineal care in an SCI patient unless there's a break in the skin or a high risk of infection.

Choice D rationale:

Discarding the washcloth after cleansing the urethral meatus is essential to prevent transferring bacteria to other areas.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A) "My child has some swelling around her eyelids and mouth."

In this scenario, the parent reporting swelling around the toddler's eyelids and mouth after receiving immunizations is the nurse's priority concern. Swelling around the eyes and mouth can be indicative of a possible allergic reaction, such as angioedema or anaphylaxis, which can be a serious and life-threatening condition. Immediate assessment and intervention are needed to address this potential allergic reaction.

The other findings, while important, are not as immediately concerning:

B) A temperature of 100.7 degrees Fahrenheit is a mild fever, which can be expected as a side effect of some vaccines. It may not be the nurse's immediate priority, but it should still be monitored.

C) A toddler's decreased feeding of 2 ounces during her last feeding may be related to her discomfort or fever after immunizations. It's essential to monitor this but not an immediate priority.

D) Crying when touched at the injection site is a common response to immunizations and, while uncomfortable for the child, is not typically a cause for immediate concern. However, it should still be addressed with comfort measures.

A. Avoid preparing medications for more than two clients at one time. B. Inform clients about the action of each medication prior to administration. C. Read medication labels at least two times prior to administration. D. Complete an incident report if a client vomits after taking a medication.

Correct Answer is B

Explanation

The correct answer is B.

Choice A reason: Avoid preparing medications for more than two clients at one time is a guideline aimed at reducing the risk of medication errors. However, it is not an absolute rule and may vary depending on the setting and resources available.

Choice B reason: Inform clients about the action of each medication prior to administration. This practice is essential for patient education, ensuring that patients are informed about what medications they are taking and why, which can improve adherence and outcomes.

Choice C reason: Reading medication labels at least two times prior to administration is a good practice to avoid errors, but it is not always specified as a standard requirement in medication administration guidelines.

Choice D reason: Completing an incident report if a client vomits after taking a medication is necessary only if the vomiting is related to an adverse drug reaction or a medication error, not for routine vomiting.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse in a clinic is speaking with a parent of a 1-year-old toddler who received her scheduled immunizations 1 hr ago. Which of the following findings reported by the parent is the nurse's priority?

Correct Answer is A

Explanation

A charge nurse is teaching a newly licensed nurse about medication administration. Which of the following information should the charge nurse include?

Correct Answer is B

Explanation

A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?

A nurse is collecting data from a client who is 18 hr postpartum. The nurse notes that the client is in the "taking-in phase of maternal adjustment. Which of the following manifestations should the nurse expect?

A nurse is caring for a client who has a placenta previa.Which of the following findings should the nurse expect?

A nurse is teaching a group of school-age children about healthy snack options.Which of the following snacks should the nurse include?

A nurse is planning care for a client who is receiving continuous enteral tube feedings through an open system. Which of the following interventions should the nurse include in the plan of care?

A nurse is planning to conduct a support group for adolescents who have cancer.Which of the following actions should the nurse include during the orientation phase?

A nurse is performing a neurological examination on a client as part of a complete physical assessment.The nurse should identify that cranial nerve XI is intact when the client performs which of the following actions?

A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?

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?