A nurse is teaching a female client about personal hygiene. Which of the following client actions indicates an understanding of teaching?
The client brushes her teeth twice daily.
The client wipes back to front when toileting.
The client washes her perineum first when bathing.
The client takes a hot bubble bath every day.
The Correct Answer is A
Rationale:
A. The client brushes her teeth twice daily: Brushing teeth at least twice a day is recommended to reduce plaque buildup, prevent tooth decay, and maintain oral health. This practice is consistent with standard personal hygiene guidelines.
B. The client wipes back to front when toileting: Wiping from back to front increases the risk of transferring bacteria from the anal area to the urethra, which can lead to urinary tract infections. The correct method is front to back.
C. The client washes her perineum first when bathing: The perineal area should be washed last to avoid transferring bacteria from this region to other parts of the body, especially the face. Washing it first increases the risk of cross-contamination.
D. The client takes a hot bubble bath every day: Daily hot bubble baths can dry out the skin and disrupt normal skin flora, potentially leading to irritation or infection. Mild, less frequent bathing with warm (not hot) water is healthier for skin integrity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Document the client's level of understanding about potential adverse effects: Documentation is important but should occur after assessing the client’s knowledge and providing teaching.
B. Determine the client's knowledge about diaphragm use: Assessment is the first step in the nursing process. Understanding the client’s baseline knowledge allows the nurse to tailor teaching and identify misconceptions before providing instruction.
C. Supervise return demonstration of diaphragm use: Return demonstration evaluates learning but is only appropriate after teaching and assessment have been completed.
D. Teach the client how to insert the diaphragm: Teaching is essential but should follow assessment of the client’s current understanding to ensure the instruction is effective and appropriate.
Correct Answer is A
Explanation
Rationale:
A. Serum potassium: Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. Monitoring serum potassium is essential to detect elevated levels early and prevent cardiac complications.
B. Platelet count: Spironolactone does not significantly affect platelet production or function, so routine monitoring of platelets is not indicated for this medication.
C. Urine ketones: Ketone monitoring is relevant for clients with uncontrolled diabetes or ketosis, but it is not related to spironolactone therapy.
D. Total bilirubin: Bilirubin levels are used to assess liver function, which is not directly affected by spironolactone in most clients, so routine monitoring is not necessary unless the client has underlying hepatic disease.
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