A nurse is reinforcing teaching with a client who is 12 hr postpartum and has an episiotomy. Which of the following instructions should the nurse include?

Cleanse the perineal area from back to front.

Wash the perineal area with povidone-iodine twice daily

Change the perineal pad with each void

"Wipe the perineal area with a soft cloth."

Answer and Explanation

The Correct Answer is C

Answer: C. Change the perineal pad with each void.

Rationale:

A) Cleanse the perineal area from back to front: Cleansing from back to front is not recommended as it increases the risk of introducing bacteria from the anal area to the perineal wound, potentially leading to infection. The correct technique is front-to-back cleansing to prevent contamination.

B) Wash the perineal area with povidone-iodine twice daily: Povidone-iodine is not typically recommended for regular perineal care postpartum, as it can disrupt normal flora and potentially irritate the healing tissues. Using warm water and mild soap is safer for cleansing the area.

C) Change the perineal pad with each void: Changing the perineal pad with each void helps maintain cleanliness and reduces moisture in the perineal area, decreasing the risk of infection and promoting comfort during the healing process of an episiotomy.

D) Wipe the perineal area with a soft cloth: Wiping the area can disrupt the stitches and may cause discomfort. Instead, clients are usually advised to gently pat dry or use a squirt bottle to cleanse, which reduces pressure on the healing tissue.

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Correct Answer is A

Explanation

After a patient dies, postmortem care includes preparing them for family viewing . The nurse should place the body in the supine position, with the arms at the sides and the head on a pillow. Then elevate the head of the bed 30 degrees to prevent discoloration from blood setling in the face.

The other options are not correct because:

b) The nurse should cleanse the client's body while wearing appropriate personal protective equipment (PPE) based on indications for isolation precautions, not necessarily sterile gloves.

c) If the patient wore dentures and your facility’s policy permits, gently insert them; then close the mouth.

d) The nurse should close the eyes by gently pressing on the lids with their fingertips. If they don’t stay closed, place moist coton balls on the eyelids for a few minutes, and then try again to close them. Surgical tape is not mentioned as necessary .

A. Oral irrigating device B. Seizure pads C. Sterile gloves D. Tongue blade

Correct Answer is B

Explanation

b. Seizure pads

Explanation:

The nurse should place seizure pads in the client's room when admitting a client with bacterial meningitis. Bacterial meningitis is an infection that aﬀects the meninges, the protective membranes covering the brain and spinal cord. It can cause inﬂammation and swelling of the brain, leading to an increased risk of seizures.

Seizure pads are specifically designed to provide a cushioning and protective barrier between the client's head and the hard surface, reducing the risk of injury during a seizure. They are placed on the bed or matress to help prevent head trauma or other injuries that may occur if a seizure occurs.

Now, let's discuss why the other options are not necessary for the client with bacterial meningitis:

a. Oral irrigating device:

An oral irrigating device is not necessary for a client with bacterial meningitis. Bacterial meningitis primarily aﬀects the central nervous system and does not require oral care interventions. The focus of care for these clients is on managing the infection, monitoring vital signs, and providing supportive care.

c. Sterile gloves:

While sterile gloves are commonly used in healthcare settings, they are not specifically required for the care of a client with bacterial meningitis. Standard precautions, including the use of non-sterile gloves, are sufficient for providing care to these clients. Sterile gloves are typically used for invasive procedures or when there is a need to maintain a sterile field.

d. Tongue blade:

A tongue blade is not necessary for the care of a client with bacterial meningitis. Tongue blades are typically used for oral assessments or when examining the throat, which are not directly related to the management or treatment of bacterial meningitis. The focus of care for these clients is on infection control, monitoring for complications, and providing comfort and support.

In summary, when admitting a client with bacterial meningitis, the nurse should prioritize placing seizure pads in the client's room to ensure their safety during potential seizure activity.

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A nurse is reinforcing teaching with a client who is 12 hr postpartum and has an episiotomy. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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