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 B
Explanation
Choice A reason: Skin turgor is a method to assess hydration status, but it is not the most accurate indicator of fluid balance in a patient with fluid volume overload.
Choice B reason: Monitoring weight is the most accurate method to assess fluid balance. A sudden increase or decrease in weight is indicative of fluid changes.
Choice C reason: Blood pressure can be affected by fluid volume changes, but it does not provide a direct measure of fluid balance.
Choice D reason: Lung sounds can indicate fluid overload in the lungs but do not give a complete picture of overall fluid balance.
Correct Answer is B
Explanation
Choice A reason: While medication shortages can occur, this is not the typical reason for delivering a partial supply of medication for home health care.
Choice B reason: Daptomycin is an antibiotic that has a limited shelf life after it is mixed or reconstituted. This is why pharmacies often deliver only a portion of the doses to ensure the medication remains effective.
Choice C reason: Notifying the healthcare provider is necessary if there is a discrepancy in medication delivery that cannot be explained by standard pharmacy practices.
Choice D reason: Although instructions for medication administration may change, this is not the usual reason for a pharmacy to deliver a partial supply of medication.
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