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 C
Explanation
A. Soft-serve ice cream:
Cold dairy products can exacerbate nausea and cause mucus thickening; they are not the best choice during chemotherapy-induced nausea.
B. String cheese:
Cheese is high in fat and can delay gastric emptying, potentially worsening nausea.
C. Raisin toast:
Light, dry, low-fat foods such as toast, crackers, or pretzels are often well tolerated during nausea because they are easy to digest and bland.
D. Hot tea:
Hot beverages can increase stomach activity and worsen nausea; cool or room-temperature fluids are generally better tolerated.
Correct Answer is B
Explanation
A. "Respite care provides social support through others who are experiencing similar situations.":
This describes a support group, not respite care.
B. "Respite care provides time away from caregiving responsibilities for brief periods of time.":
Respite care gives temporary relief to primary caregivers by providing short-term professional or volunteer care for the client.
C. "Respite care reduces the need for nursing visits from the home health care agency.":
Respite care is for caregiver relief, not to replace skilled nursing visits.
D. "Respite care provides delivery of meals and supplies to your home.":
This describes a home-delivered meal program, not respite care.
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