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 B

Explanation

A. Aspiration: While aspiration precautions may be necessary in certain situations, elevated parathyroid hormone levels are not typically associated with an increased risk of aspiration.
B. Falls: Elevated parathyroid hormone levels can lead to hypercalcemia, which may cause weakness, confusion, and increased risk of falls due to muscle weakness and altered mental status.
C. Suicide: While mental health assessment and intervention may be important for overall patient care, elevated parathyroid hormone levels do not directly increase the risk of suicide.
D. Hypothermia: Elevated parathyroid hormone levels are not typically associated with an increased risk of hypothermia. Hypercalcemia may lead to dehydration and electrolyte
imbalances, but hypothermia is not a common complication.

A. Administer an IV analgesic. B. Provide pillow for splinting. C. Assess the IV site for patency. D. Place in a high-Fowler's position.

Correct Answer is A

Explanation

A. Administering an IV analgesic is the most important intervention for managing the client's severe abdominal incisional pain. Prompt pain management is essential for the client's comfort and well-being, and severe pain can lead to increased physiological stress responses, such as
tachycardia and hypertension.
B. Providing a pillow for splinting may help alleviate pain to some extent, but it does not address the underlying cause of the severe abdominal incisional pain. Pain management with analgesics is the priority.
C. Assessing the IV site for patency is important for ensuring the delivery of medications, but it is not the most urgent intervention in this situation where the client is experiencing severe pain.
D. Placing the client in a high-Fowler's position may help alleviate some discomfort, but it is not the most important intervention for managing the client's severe abdominal incisional pain.
Administering analgesics should be prioritized.

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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

The nurse is caring for a client with elevated parathyroid hormone levels. Which safety precaution should the nurse include in the plan of care?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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