The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?

Dizziness can occur during cleansing.

The pubic area should be kept shaved.

The foreskin should not be retracted.

An erection may occur while providing care.

Answer and Explanation

The Correct Answer is D

Choice A reason: Dizziness is not typically associated with perineal care and is not relevant to the instructions.

Choice B reason: Advising to keep the pubic area shaved is not a standard part of perineal care instructions and is a personal choice.

Choice C reason: The statement about not retracting the foreskin is incorrect; the foreskin should be retracted gently for cleaning and then returned to its normal position to prevent infection.

Choice D reason: It is important to inform the caregiver that an erection may occur as a natural reflex during perineal care, and it does not indicate any sexual intent. This helps prepare the caregiver to handle the situation professionally.

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Correct Answer is C

Explanation

Choice A reason: While a medication reference guide is useful, it does not replace the need for clarification from the prescribing healthcare provider regarding dosage discrepancies.

Choice B reason: The nursing unit charge nurse can be a resource, but the prescriber should be the first contact for medication orders.

Choice C reason: The healthcare provider who prescribed the medication is the most appropriate resource to clarify and potentially correct the dosage of the oral antibiotic.

Choice D reason: The hospital pharmacist is a valuable resource for medication information and can be consulted, but the prescriber should first be contacted to address the discrepancy in dosages.

A. Confer with the physical therapist for correct crutch size. B. Ask the client to sit down while the crutch length is adjusted. C. Assess the client for signs of diminished circulation in the hands. D. Proceed with teaching the client how to walk with the crutches.

Correct Answer is D

Explanation

The correct answer is choiced. Proceed with teaching the client how to walk with the crutches.

Choice A rationale:

Confer with the physical therapist for correct crutch size. This is unnecessary because the crutches are already correctly fitted.A space of three finger widths between the top of the crutch and the client’s axilla is appropriate to prevent pressure on the axilla and potential nerve damage.

Choice B rationale:

Ask the client to sit down while the crutch length is adjusted. This action is not needed since the crutches are already properly adjusted.Adjusting the crutch length further could lead to improper fitting, which might cause discomfort or injury.

Choice C rationale:

Assess the client for signs of diminished circulation in the hands. While assessing circulation is important, it is not directly related to the fitting of the crutches.Proper crutch fitting focuses on ensuring there is no pressure on the axilla and that the client can use the crutches comfortably.

Choice D rationale:

Proceed with teaching the client how to walk with the crutches. This is the correct action because the crutches are already properly fitted.The nurse should now focus on educating the client on the correct use of the crutches to ensure safe and effective mobility.

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The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?

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Correct Answer is C

Explanation

A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger widths between the top of the crutch and the client's axilla. Which action should the nurse take?

Correct Answer is D

Explanation

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