The 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?
Suggest contacting the healthcare provider for a prescription for catheter insertion.
Recommend a complete bath to cleanse the perineal area more fully.
Evaluate the effectiveness of this measure to stimulate client voiding.
Instruct the PN that this technique promotes infection in elderly females.
The Correct Answer is C
A. Suggest contacting the healthcare provider for a prescription for catheter insertion: Catheter insertion may not be necessary if the client is able to void with this technique. It's important to evaluate less invasive measures first.
B. Recommend a complete bath to cleanse the perineal area more fully: While cleanliness is important, the immediate concern is addressing urinary incontinence and promoting voiding.
C. Evaluate the effectiveness of this measure to stimulate client voiding: Warm water can sometimes stimulate voiding reflexes in clients who have difficulty emptying their bladders. Assessing the client's response to this measure is appropriate.
D. Instruct the PN that this technique promotes infection in elderly females: Pouring warm water over the perineal area does not necessarily promote infection, especially if proper hygiene
measures are followed. It's important to assess the effectiveness of the intervention before assuming it is inappropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Maintaining the bed flat while sleeping is not specifically related to self-care instructions for chronic venous insufficiency caused by deep vein thrombosis. In fact, elevating the legs while sleeping may be beneficial.
B. Continuing to wear compression stockings is important for managing chronic venous insufficiency and preventing complications such as edema and venous stasis ulcers.
C. Avoiding prolonged standing or sitting helps prevent venous pooling and exacerbation of symptoms associated with chronic venous insufficiency.
D. Using a recliner for long periods of sitting can help reduce venous stasis and swelling by elevating the legs and improving venous return.
E. Crossing legs at the knee can impede blood flow and exacerbate symptoms of chronic venous insufficiency. The correct instruction would be to avoid crossing legs at both the knee and ankle.
Correct Answer is ["A","B","C","D","E"]
Explanation
The client has rested well throughout the night with a continuous positive airway pressure (CPAP) device in place. Sequential devices are in place for venous thromboembolism prevention. The client ambulated 100 yards (91 meters) last night and 200 yards (183 meters) this morning. She reports pain rating of 2 on 0 to 10 scale, located in the abdomen, described as aching. She has tolerated fluids throughout the night with no nausea or vomiting.
Assessment
Neurological Alert and oriented times 4.
Cardiovascular WNL
Respiratory WNL
Gastrointestinal/Genitourinary Voided twice throughout night
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