A nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?

Evaluate the effectiveness of this measure to stimulate client voiding.

Recommend a complete bath to cleanse the perineal area more fully.

Suggest contacting the healthcare provider for a prescription for catheter insertion.

Instruct the PN that this technique promotes infection in elderly females.

Answer and Explanation

The Correct Answer is A

Choice A reason: Pouring warm water over the perineal area can stimulate the micturition reflex, which may help the client void. It is a non-invasive, first-line intervention to promote natural voiding in clients with urinary incontinence. The nurse should evaluate its effectiveness as it can be a simple yet effective method to assist the client.

Choice B reason: While recommending a complete bath may help maintain hygiene, it does not directly address the immediate need to stimulate voiding. The nurse's priority is to manage the incontinence issue effectively and a bath can be considered after addressing the client's immediate needs.

Choice C reason: Suggesting catheter insertion may be premature without first attempting less invasive measures. Catheterization carries risks such as infection and should be considered only when other interventions are ineffective or not feasible.

Choice D reason: There is no evidence to suggest that pouring warm water over the perineal area promotes infection in elderly females. In fact, proper perineal care is essential in preventing infections, especially in clients with incontinence.

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Correct Answer is B

Explanation

Choice A reason: Washing hands for a total of 20 seconds is recommended by the CDC as part of proper hand hygiene to prevent the spread of germs.

Choice B reason: Turning the water off using bare hands after washing can re-contaminate the hands. The CDC recommends using a paper towel to turn off the tap to avoid re-contamination.

Choice C reason: Keeping hands below elbows when rinsing is the correct procedure to prevent water from running down the arms onto the cleaned hands.

Choice D reason: Lathering using a circular movement is a recommended technique to ensure all surfaces of the hands are cleaned thoroughly.

A. Initiate teaching for client care after discharge. B. Evaluate and update plans of care for clients. C. Begin initial sterile wound care for surgical clients. D. Validate prescribed intravenous flow rates.

Correct Answer is D

Explanation

Choice A reason: Teaching for client care after discharge often involves patient education and planning, which are complex tasks typically reserved for registered nurses due to their scope of practice.

Choice B reason: Evaluating and updating plans of care are responsibilities that involve clinical judgment and are usually performed by registered nurses.

Choice C reason: Initial sterile wound care may require assessment and decision-making that are within the registered nurse's scope of practice.

Choice D reason: Validating prescribed intravenous flow rates is a task that can be delegated to a practical nurse, as it involves monitoring and ensuring that the flow rates are set according to the prescribed orders, which is within the practical nurse's scope of practice.

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A nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes an unlicensed assistive personnel (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

Correct Answer is B

Explanation

After receiving a change of shift report for clients on a medical-surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

Correct Answer is D

Explanation

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