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.

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Correct Answer is A

Explanation

A. Moving the client to a private room, keeping the door closed, and initiating droplet
precautions are important to prevent potential transmission of COVID-19, especially considering the client's symptoms and recent loss of taste and smell, which are associated with COVID-19.
B. Assisting the client to recall everyone possibly exposed since onset of symptoms is relevant for contact tracing but does not address immediate infection control measures for the suspected case.
C. Placing the nasal swab specimen for COVID-19 directly into a biohazard bag is a correct laboratory procedure but does not address immediate infection control measures for the
suspected case.
D. Teaching the client to wear a mask, hand wash, and social distance to prevent spreading the virus is important for preventing transmission, but in this scenario, immediate isolation
precautions are necessary until a COVID-19 diagnosis is confirmed or ruled out.

A. Hydrocortisone. B. Potassium chloride. C. Regular insulin. D. Broad spectrum antibiotic.

Correct Answer is A

Explanation

A. Hydrocortisone: In Addison's disease, there is adrenal insufficiency leading to decreased cortisol production. During times of stress or illness, such as in this case of an acute viral infection, cortisol replacement therapy (such as hydrocortisone) is crucial to supplement the deficient endogenous cortisol production. This helps to manage the client's weakened state and stabilize their condition.
B. Potassium chloride: While the client's potassium level is elevated, indicating hyperkalemia, administering potassium chloride intravenously would exacerbate the hyperkalemia and potentially lead to further complications, such as cardiac arrhythmias.
C. Regular insulin: Regular insulin is indicated for the treatment of hyperglycemia, but the client's glucose level is low, indicating hypoglycemia. Administering regular insulin in this scenario would further decrease the client's blood glucose level, worsening their condition.
D. Broad spectrum antibiotic: While an acute viral infection may predispose the client to secondary bacterial infections, there is no indication from the client's presentation or laboratory values suggesting a need for broad spectrum antibiotics at this time. The priority is addressing
the adrenal crisis and stabilizing the client's condition with appropriate cortisol replacement therapy.

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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

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?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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