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.

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. A goal of maintaining a blood pressure less than 140/80 mm Hg aligns with recommended targets for clients with cardiovascular disease to reduce the risk of complications.
B. While physical activity is beneficial, stating that the nurse will encourage the client to walk is not a measurable client-centered outcome. A better outcome would focus on the client’s actions.
C. Monitoring blood glucose is more relevant for diabetes management rather than a primary outcome for cardiovascular disease.
D. A target of less than 160/90 mm Hg is too high and does not align with standard guidelines for blood pressure control in cardiovascular disease.

A. Have you experienced ankle edema and varicose veins? B. Did you receive treatment for weeping ulcers on lower legs? C. Were your legs ever suddenly swollen, red, warm, and painful? D. Does the calf pain occur when walking short distances?

Correct Answer is D

Explanation

A. Ankle edema and varicose veins are more commonly associated with venous insufficiency rather than peripheral arterial disease. Asking about these symptoms may not provide relevant information about chronic arterial symptoms.
B. Weeping ulcers on the lower legs are more indicative of venous insufficiency rather than peripheral arterial disease. Asking about these ulcers may not provide relevant information about chronic arterial symptoms.
C. Sudden onset of leg swelling, redness, warmth, and pain is suggestive of acute arterial occlusion rather than chronic arterial symptoms. Asking about these symptoms may be important for assessing acute arterial events, but it does not specifically address chronic arterial symptoms.
D. Peripheral arterial disease commonly presents with intermittent claudication, which causes calf pain or discomfort during physical activity, such as walking short distances. Asking about calf pain during walking can help assess for symptoms of peripheral arterial disease and its
impact on mobility and quality of life.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is developing a plan of care for a client who reports chest pain on exertion and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

Correct Answer is A

Explanation

A client arrives for an annual physical exam and reports having calf pain. The client's health history reveals peripheral arterial disease. Which question should the nurse ask the client about expected findings related to chronic arterial symptoms?

Correct Answer is D

Explanation

An older adult client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, what nursing care intervention(s) should the nurse include in the client's plan of care? Select all that apply.

A parent asked the nurse how to care for their 4-year-old child after receiving the Haemophilus influenzae type b (Hib) conjugate vaccine. Which instruction should the nurse provide?

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

The healthcare provider prescribes ear drops to an adult client with an ear infection. Which teaching should the nurse provide?

The nurse is completing an admission assessment on an older adult client with dehydration, failure to thrive, and who is immobile. The nurse reports to the healthcare provider that the client's right calf is red and swollen. The nurse should suspect which probable cause of these findings?

The healthcare provider prescribes a 5% dextrose injection with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?

Patient data Exhibits Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?