A nurse is reinforcing teaching with a client who is 12 hr postpartum and has an episiotomy.
Which of the following instructions should the nurse include?
Cleanse the perineal area from back to front.
Wash the perineal area with povidone-iodine twice daily.
Change the perineal pad with each void.
Wipe the perineal area with a soft towel.
Wipe the perineal area with a soft towel.
The Correct Answer is C
A. Cleansing the perineal area from back to front can introduce bacteria from the rectum to the urinary tract, increasing the risk of infection. Front to back is the recommended direction for cleansing.
B. Washing the perineal area with povidone-iodine twice daily may be too frequent and could potentially irritate the area. Gentle cleansing with warm water is typically recommended.
C. Changing the perineal pad with each void helps to maintain cleanliness and prevent infection by reducing the buildup of moisture and bacteria.
D. Wiping the perineal area with a soft towel is appropriate for gentle cleansing but does not address the importance of changing the perineal pad regularly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Methadone is commonly used to manage opioid withdrawal symptoms in newborns due to its long half-life and ability to stabilize opioid receptors, thereby reducing withdrawal symptoms.
B. Incorrect. Meperidine is not typically used for opioid withdrawal in newborns and is associated with a higher risk of toxicity and withdrawal symptoms.
C. Incorrect. Hydromorphone is not typically used for opioid withdrawal in newborns and may not be suitable due to its potency and potential side effects.
D. Incorrect. Fentanyl is not typically used for opioid withdrawal in newborns and is more commonly used for pain management in the perioperative or critical care settings.
Correct Answer is B
Explanation
A. Depersonalization is a feeling of detachment from oneself or feeling like one's thoughts, feelings, and actions are not their own. It does not involve perceptual disturbances such as hearing voices.
B. Hallucination is a sensory perception that occurs in the absence of external stimuli. Auditory hallucinations involve hearing voices or sounds that others do not hear, as described by the client in this scenario.
C. Illusion is a misinterpretation of a sensory stimulus that is actually present in the environment. It involves a distortion or misperception of sensory information, not the perception of something that is not there, as in the case of hallucinations.
D. Derealization is a feeling of unreality or detachment from one's surroundings. It involves a distortion in the perception of the external world rather than sensory experiences such as hearing voices.
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