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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
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.
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.
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