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 B

Explanation

The nurse should report the possible abuse to adult protective services if an older adult client states that their child took all their money. This is an important nursing intervention to ensure the safety and well-being of the client.

a) Instructing the client to report the theft to the police may be appropriate, but it is not the first action the nurse should take. The nurse has a legal and ethical obligation to report suspected abuse to the appropriate authorities.

c) Asking the client if there is another family member they can call for financial help may be appropriate, but it does not address the issue of possible abuse.

d) Restricting visitation for the client's family until discharge is not appropriate and may violate the client's rights.

A. Soiled linens are placed on the floor. B. Uncapped sharps are put in a puncture-resistant container. C. Dampened cloths are used for dusting the area. D. Waste containers are lined with single bags.

Correct Answer is A

Explanation

Immunocompromised individuals have a weakened immune system, which makes them more susceptible to infections. Soiled linens, when placed on the floor, can potentially harbor pathogens and become a source of contamination. It is essential to handle soiled linens properly by placing them in designated containers or bags to prevent the spread of infectious agents.

Uncapped sharps put in a puncture-resistant container: This is the correct practice for disposing of sharps, such as needles or lancets. Uncapped sharps should always be placed in puncture-resistant containers to prevent accidental injuries and potential transmission of infections.

Dampened cloths used for dusting the area: Dampened cloths for dusting can help minimize the dispersal of dust and allergens, but it does not necessarily pose a significant risk of infection.

However, it is important to ensure that the dampened cloths are properly cleaned and sanitized to prevent the growth and spread of microorganisms.

Waste containers lined with single bags: Waste containers lined with single bags are a common practice for proper waste management and disposal. While it is important to maintain good waste management practices to prevent the spread of infections, the use of single bags alone does not significantly affect the risk of infection for immunocompromised clients.

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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 B

Explanation

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Correct Answer is A

Explanation

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