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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.8"]
Explanation
Amount (mg) ÷ Concentration (mg/mL) = Volume (mL)
Step 1: The amount of hydromorphone the patient needs is 3 mg. Step 2: The concentration of the hydromorphone solution is 4 mg/mL. Step 3: Substitute the values into the formula: 3 mg ÷ 4 mg/mL.
Step 4: Calculate the volume: 3 ÷ 4 = 0.75 mL. 0.8 rounded to the nearest tenth
Correct Answer is D
Explanation
Choice A reason: Recording the client's pulse rate and rhythm is part of the assessment, but it is not the first action to take when assessing for orthostatic hypotension.
Choice B reason: Assisting the client to stand is part of the assessment process, but it should be done after the initial blood pressure and pulse have been measured while the client is supine.
Choice C reason: Applying the blood pressure cuff securely is necessary for an accurate reading, but it is not the first step in the process of assessing for orthostatic hypotension.
Choice D reason: The first action is to position the client supine for a few minutes before taking the initial blood pressure and pulse measurements, as this provides a baseline for comparison when the client stands.

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