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 B
Explanation
The most concerning finding in the assessment of a client's right leg after a femoropopliteal bypass graft would be if the client's pedal pulse in the right foot is not palpable. This could indicate a problem with blood flow to the limb.
The other options are also concerning and should be reported to the healthcare provider.
a) A cooler footmay indicate decreased blood flow to the limb.
c) A capillary refill time of 5 secondsmay also indicate decreased blood flow.
d) A pain level of 8 on a scale from 0 to 10should also be reported and addressed.
Correct Answer is D
Explanation
d. Observe the client for 1 hr after meals.
Explanation:
The correct answer is d. Observe the client for 1 hr after meals.
For a client with bulimia nervosa, it is important to closely monitor their behavior after meals to prevent purging behaviors and ensure their safety. Observing the client for 1 hour after meals allows the nurse to provide support, encourage healthy coping strategies, and intervene if necessary to prevent purging episodes.
Option a, administering bupropion 1 hour before meals, is not an appropriate intervention for bulimia nervosa. Bupropion is an antidepressant medication that may be used for certain mood disorders, but it is not the primary treatment for bulimia nervosa.
Option b, allowing the client access to food throughout the day, is not a recommended intervention for a client with bulimia nervosa. Clients with bulimia nervosa often struggle with impulse control and binge eating behaviors. Allowing unrestricted access to food may exacerbate their symptoms and increase the risk of binge-purge cycles.
Option c, weighing the client once weekly, is not the most appropriate intervention for managing bulimia nervosa. While weight monitoring may be a component of treatment, it should not be the sole focus. The treatment for bulimia nervosa involves addressing the underlying psychological and behavioral factors contributing to the disorder.
By recommending the observation of the client for 1 hour after meals, the nurse can provide necessary support, monitor the client for potential purging behaviors, and promote a safe and therapeutic environment for their recovery from bulimia nervosa.
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