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?
Wash the penis from the scrotum to the tip using a spiral motion.
Use water with no soap to prevent skin irritation.
Don sterile gloves to prevent infection.
Discard the washcloth after cleansing the urethral meatus.
The Correct Answer is D
The correct answer is choice d.
Choice A rationale:
Washing the penis from scrotum to tip using a spiral motion can trap bacteria under the foreskin and increase risk of infection.
Choice B rationale:
Soap helps remove dirt and bacteria, reducing infection risk. Soapy water is preferred over plain water for perineal care.
Choice C rationale:
While hand hygiene is crucial, sterile gloves are not typically required for routine perineal care in an SCI patient unless there's a break in the skin or a high risk of infection.
Choice D rationale:
Discarding the washcloth after cleansing the urethral meatus is essential to prevent transferring bacteria to other areas.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Recent myocardial infarction is not a contraindication for warfarin administration. Warfarin is often prescribed for patients with a history of myocardial infarction to prevent clot formation and reduce the risk of stroke.
Choice B rationale:
Recent eye surgery is a contraindication for the administration of warfarin. Warfarin can increase the risk of bleeding, which is particularly concerning after eye surgery due to the delicate nature of ocular tissues. Using anticoagulants in this scenario can lead to severe complications, including vision loss.
Choice C rationale:
Thrombophlebitis, inflammation of a vein with clot formation, is not a contraindication for warfarin administration. In fact, anticoagulants like warfarin are commonly prescribed to prevent the extension of clots and reduce the risk of complications associated with thrombophlebitis.
Choice D rationale:
Breast cancer is not a direct contraindication for warfarin administration. However, the decision to use anticoagulants in patients with a history of breast cancer should be made carefully, considering individual factors such as the stage of cancer, ongoing treatment, and overall risk of thromboembolic events.
Correct Answer is C
Explanation
Choice A rationale:
Heart rate 58/min. Clozapine, an atypical antipsychotic medication, can cause bradycardia (slow heart rate) as a side effect. However, the heart rate of 58/min is within the normal range for adults, so it is not a contraindication for clozapine administration.
Choice B rationale:
Fasting blood glucose 100 mg/dL. A fasting blood glucose level of 100 mg/dL is within the normal range (70-99 mg/dL) for adults. It is not a contraindication for clozapine administration.
Choice C rationale:
WBC count 2,900/mm3. Clozapine can cause agranulocytosis, a severe reduction in white blood cell (WBC) count, which can lead to increased susceptibility to infections. A WBC count of 2,900/mm3 is significantly below the normal range (4,000-11,000/mm3) and is a contraindication for clozapine administration due to the risk of severe immunosuppression.
Choice D rationale:
Hgb 14 g/dL. Hemoglobin (Hgb) level of 14 g/dL is within the normal range for adult males (13.8-17.2 g/dL) and females (12.1-15.1 g/dL). It is not a contraindication for clozapine administration.
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