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 B

Explanation

Choice A reason: Having the client sign a new surgical permit is not necessary unless the surgeon agrees to the addition of the procedure after being informed.

Choice B reason: The nurse should inform the surgeon about the client's request to include the removal of the second lipoma. The surgeon will decide if it is feasible and safe to add the procedure to the current surgical plan.

Choice C reason: The nurse cannot unilaterally add procedures to a surgical permit; this must be done by the surgeon after evaluating the client's condition and the risks involved.

Choice D reason: Notifying the surgical staff of the client's confusion does not address the client's request and may not lead to a resolution of the issue.

A. Document the site where the medication was given. B. Notify the healthcare provider of the allergic response. C. Elevate the area and apply light pressure over the site. D. Apply a cold pack to the area for twenty minutes.

Correct Answer is A

Explanation

Choice A reason: The appearance of a small, round raised area, known as a wheal, is a normal reaction to an intradermal injection and should be documented.

Choice B reason: This is not an allergic response but a normal reaction to an intradermal injection, so there is no need to notify the healthcare provider.

Choice C reason: There is no need to elevate the area or apply pressure as the raised area is a normal reaction to the medication being correctly placed in the dermis.

Choice D reason: Applying a cold pack is not necessary for a normal reaction to an intradermal injection.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing the signed operative consent with a client who is admitted for the removal of a lipoma on the left leg. The client reports the permit should include another lipoma on the right leg. Which action should the nurse implement?

Correct Answer is B

Explanation

A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?

Correct Answer is A

Explanation

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