Which patients will the nurse determine are in most need of regular perineal care? (Select all that apply.)

A patient who has an indwelling catheter

A patient with urinary and fecal incontinence

A patient with rectal and genital surgical dressings

A bariatric patient

A circumcised male who is ambulatory

Answer and Explanation

Correct Answer : A,B,C,D

A. A patient with an indwelling catheter requires regular perineal care to prevent infection due to increased risk from the catheter.
B. Urinary and fecal incontinence increase the risk of skin breakdown and infection, necessitating frequent perineal care.
C. Surgical dressings in the rectal and genital areas require perineal care to maintain hygiene and prevent wound contamination.
D. Bariatric patients often need regular perineal care due to skin folds and increased risk of moisture-related skin breakdown.
E. A circumcised, ambulatory male typically has a lower risk of infection and may not require as frequent perineal care unless other factors are present.

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Correct Answer is B

Explanation

A. Increasing activity level may be unrealistic for a patient on strict bed rest due to a pelvic fracture.
B. Repositioning every 2 hours is a realistic and achievable goal for a patient on bed rest to prevent complications such as pressure ulcers and maintain circulation.
C. Using a walker for ambulation may not be feasible immediately after a pelvic fracture.
D. Transferring with a sliding board may not be safe or appropriate in the early stages post-injury, especially if bed rest is required.

A. 15 degree B. 90 degree C. 30 degree D. 45 degree

Correct Answer is A

Explanation

A. The tuberculin test is administered intradermally, and the needle should be inserted at a 15-degree angle to ensure the medication is delivered just under the surface of the skin.
B. A 90-degree angle is used for intramuscular injections, not for intradermal tests like the tuberculin test.
C. A 30-degree angle is commonly used for subcutaneous injections and is too deep for an intradermal injection.
D. A 45-degree angle is also used for subcutaneous injections but is not suitable for intradermal injections.

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Which patients will the nurse determine are in most need of regular perineal care? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a care plan for a patient prescribed bed rest as a result of a pelvic fracture. Which goal statement is realistic for the nurse to assign to this patient?

Correct Answer is B

Explanation

The nurse is planning to administer a tuberculin test with a 27-gauge, 5/8-inch needle. At which angle will the nurse insert the needle?

Correct Answer is A

Explanation

The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?

A patient requires repositioning every 2 hours. Which task can the nurse delegate to the nursing assistive personnel?

The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia?

A patient's heart rate increased from 94 to 164 beats/min. What will the nurse expect as a result?

A 17-year-old patient, dying of heart failure, wants to have organs removed for transplantation after death. Which action by the nurse is correct?

Which sociocultural finding in the history of a patient will alert the nurse to a possible developmental problem?

A nurse is helping parents who have a child diagnosed with attention-deficit/hyperactivity disorder. Which strategy will the nurse share with the parents to reduce stress regarding homework assignments?

Which determination is the nurse trying to achieve by monitoring a patient's cardiac output?