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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should expect the provider to discontinue phenelzine 2 weeks before starting fluoxetine treatment. Phenelzine is a monoamine oxidase inhibitor (MAOI) and should not be taken with fluoxetine, which is a selective serotonin reuptake inhibitor (SSRI). Taking these two medications together can cause a dangerous drug interaction known as serotonin syndrome.
a) Levothyroxine is a thyroid hormone replacement medication and does not interact with fluoxetine.
b) Acetaminophen is a pain reliever and does not interact with fluoxetine.
c) Simvastatin is a cholesterol- lowering medication and does not interact with fluoxetine.
Correct Answer is D
Explanation
As individuals age, there is a natural decline in kidney function. This can result in a reduced ability to filter and excrete medications and their metabolites from the body. The decreased kidney function can lead to a longer half-life of medications, increased drug accumulation, and an increased risk of adverse drug reactions. It is important for the nurse to adjust medication dosages and frequencies based on the individual's renal function to prevent drug toxicity.
Increased liver function: Aging is associated with a gradual decline in liver function. While there may be some individual variations, in general, liver function decreases rather than increases with age. However, changes in liver function can affect the metabolism and elimination of medications. Some medications may require dosage adjustments based on liver function, but it is not a common physiological change in older adults.
Increased metabolism: Aging is generally associated with a decrease in metabolism rather than an increase. The metabolic rate tends to slow down with age, which can affect the pharmacokinetics of medications. Slower metabolism can result in medications taking longer to be metabolized and cleared from the body, potentially leading to prolonged drug effects.
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