A nurse is observing an assistive personnel (AP) complete perineal care for a female client who has an indwelling urinary catheter. For which of the following actions by the AP should the nurse intervene?
Cleanses in the direction from the perineum to the rectum
Wipes the catheter from the urethral meatus down toward the tubing
Uses separate sections of the washcloth to cleanse each area
Washes the client's labia minora before the labia majora
The Correct Answer is D
A. Cleanses in the direction from the perineum to the rectum:
This is the correct direction (front to back) to prevent fecal contamination of the urinary tract. No intervention needed.
B. Wipes the catheter from the urethral meatus down toward the tubing:
This is correct technique to remove microorganisms away from the urinary meatus. No intervention needed.
C. Uses separate sections of the washcloth to cleanse each area:
This is correct to prevent cross-contamination. No intervention needed.
D. Washes the client's labia minora before the labia majora:
The labia majora should be cleansed before the labia minora to prevent contamination of the inner structures with organisms from the outer structures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Document in the nurses' notes that an incident report was completed:
This is incorrect. The incident report is an internal risk management tool and should not be mentioned in the medical record.
B. Record the facts about the incident in the medical record:
The nurse should document objective facts about the event, assessment, and interventions in the client’s medical record without referencing the incident report.
C. Provide the family with a copy of the incident report:
Incident reports are confidential and not shared with clients or families.
D. Place a copy of the incident report in the medical record:
This is incorrect; incident reports are kept separately from the medical record to avoid legal complications.
Correct Answer is D
Explanation
A. "I can ask your provider to prescribe a different route for the medication.":
This is premature without first exploring the client’s specific concerns.
B. "I will administer the medication when you are feeling less anxious.":
This delays treatment unnecessarily and does not address the client’s anxiety.
C. "Why are you nervous about receiving this medication?":
“Why” questions can sound judgmental and may put the client on the defensive.
D. "You need this medication to feel better.":
This is a direct but supportive statement that reinforces the medication’s purpose; however, the best approach in real practice would combine reassurance with addressing concerns (e.g., explaining the procedure).
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