A nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?

Evaluate the effectiveness of this measure to stimulate client voiding.

Recommend a complete bath to cleanse the perineal area more fully.

Suggest contacting the healthcare provider for a prescription for catheter insertion.

Instruct the PN that this technique promotes infection in elderly females.

Answer and Explanation

The Correct Answer is A

Choice A reason: Pouring warm water over the perineal area can stimulate the micturition reflex, which may help the client void. It is a non-invasive, first-line intervention to promote natural voiding in clients with urinary incontinence. The nurse should evaluate its effectiveness as it can be a simple yet effective method to assist the client.

Choice B reason: While recommending a complete bath may help maintain hygiene, it does not directly address the immediate need to stimulate voiding. The nurse's priority is to manage the incontinence issue effectively and a bath can be considered after addressing the client's immediate needs.

Choice C reason: Suggesting catheter insertion may be premature without first attempting less invasive measures. Catheterization carries risks such as infection and should be considered only when other interventions are ineffective or not feasible.

Choice D reason: There is no evidence to suggest that pouring warm water over the perineal area promotes infection in elderly females. In fact, proper perineal care is essential in preventing infections, especially in clients with incontinence.

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Correct Answer is C

Explanation

Choice A reason: Offering supplemental formula feedings is not the first-line action for inverted nipples as it does not address the issue and may lead to nipple confusion, potentially complicating future breastfeeding attempts.

Choice B reason: Teaching about the use of a breast pump is beneficial for milk expression but does not directly assist with the immediate concern of latching issues due to inverted nipples.

Choice C reason: Using a breast shield can be helpful for mothers with inverted nipples. It can temporarily draw out the nipple, allowing the baby to latch on more easily. This tool acts as a bridge between the breast and the baby's mouth, facilitating breastfeeding while the mother works on long-term solutions for her inverted nipples.

Choice D reason: Encouraging the use of ice on the areola may temporarily stiffen the nipple, but it is not a recommended practice for addressing inverted nipples as it can cause discomfort and may not be effective in promoting a successful latch.

A. Assess for discomfort when the procedure is completed. B. Instruct the client to keep hands under the sterile field. C. Pour cleansing solution onto the sterile cloth field. D. Verify that the client has given informed consent.

Correct Answer is D

Explanation

Choice A reason: Assessing for discomfort is important, but it is not a safety intervention that should be implemented during the creation of a sterile field.

Choice B reason: Instructing the client to keep hands under the sterile field is not practical or safe, especially since the client is mildly confused and may not be able to follow such instructions.

Choice C reason: Pouring cleansing solution onto the sterile cloth field is part of the debridement process but does not directly relate to client safety.

Choice D reason: Verifying informed consent is crucial for client safety to ensure that the client understands the procedure and agrees to it, especially when the client is confused.

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A nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is one day postpartum reports to the nurse that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?

Correct Answer is C

Explanation

The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created. Which nursing intervention should the nurse implement for client safety?

Correct Answer is D

Explanation

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