A nurse is caring for a male client who has a spinal cord injury. Which of the following techniques should the nurse use when providing perineal care?

Use water with no soap to prevent skin irritation.

Discard the washcloth after cleansing the urethral meatus.

Don sterile gloves to prevent infection.

Wash the penis from the scrotum to the tip using a spiral motion.

Answer and Explanation

The Correct Answer is B

A. While avoiding harsh soap is important, using water alone may not adequately clean the area.

B. After cleaning the urethral meatus, the nurse should discard the washcloth or use a different part of it to prevent the spread of bacteria.

C. Clean gloves are typically sufficient unless the procedure involves a sterile environment.

D. The penis should be cleaned from the tip to the base (proximal to distal) to reduce the risk of introducing bacteria.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Pain Medication:

Fractures are painful, and pain management is essential for the child’s comfort and to prevent complications related to inadequate pain control.

Limb Immobilization:

Immobilization of the fractured arm (e.g., with a splint or cast) is necessary to promote proper alignment and healing of the nondisplaced fracture of the radius and ulna.

Incorrect Options:

Antibiotics: There is no indication of infection, such as an open fracture or systemic signs of infection, which would require antibiotics.

Surgical Consultation: A nondisplaced fracture typically does not require surgical intervention. Conservative treatment with immobilization is sufficient.

Bed Rest: This is not necessary for an isolated arm fracture, as the child can remain mobile.

A. Monitor vital signs every hour for the first 4 hr. B. Administer medications intramuscularly. C. Provide a diet low in protein. D. Observe for bruising of the skin.

Correct Answer is D

Explanation

A. Monitor vital signs every hour for the first 4 hr: Incorrect. Vital signs should be monitored more frequently, typically every 15 minutes during the first hour after administration, due to the risk of bleeding.

B. Administer medications intramuscularly: Incorrect. Intramuscular injections should be avoided while the client is on alteplase due to the increased risk of bleeding.

C. Provide a diet low in protein: Incorrect. There is no need for a low-protein diet with alteplase therapy. The focus should be on managing bleeding risks and monitoring for complications.

D. Observe for bruising of the skin: Alteplase is a thrombolytic medication, and one of its major side effects is bleeding. The nurse should monitor the client for signs of bruising, bleeding, or hemorrhage.

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A nurse is caring for a male client who has a spinal cord injury. Which of the following techniques should the nurse use when providing perineal care?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a 9-year-old child at a clinic. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The nurse should anticipate a prescription for ____1__ and ­­­ ___2___.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

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Correct Answer is D

Explanation

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