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.
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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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
Choice A reason: Measuring body temperature is a standard procedure but not directly related to monitoring for adverse effects of prasugrel, which primarily include bleeding complications.
Choice B reason: Assessing skin turgor is generally used to evaluate hydration status and is not specific to prasugrel's adverse effects.
Choice C reason: Checking for pedal edema can indicate heart failure or vascular problems but is not a direct indicator of prasugrel's adverse effects.
Choice D reason: Observing the color of urine is important as prasugrel can cause significant and sometimes fatal bleeding. Dark or bloody urine may be an early indicator of such bleeding.
Correct Answer is A
Explanation
Choice A reason: Understanding the reason for taking aspirin is crucial because it could be for a chronic condition that requires antiplatelet action, which ibuprofen does not provide. Aspirin is often prescribed for its antiplatelet effect to prevent blood clots, while ibuprofen is primarily used for pain and inflammation.
Choice B reason: While the dosage of ibuprofen is important, it is secondary to understanding the purpose of the aspirin therapy. Overdosing on ibuprofen can lead to serious side effects, but the immediate risk of stopping aspirin without a suitable substitute could be more critical.
Choice C reason: Assessing the amount of pain control is important to evaluate the effectiveness of ibuprofen as a substitute for aspirin. However, this does not address the potential risks associated with the cessation of aspirin, especially if it was prescribed for cardiovascular reasons.
Choice D reason: The presence of gastric pain could indicate an adverse reaction to ibuprofen, which is known to cause gastrointestinal issues. However, this information is not as immediately necessary as understanding the reason for aspirin therapy, which could have significant implications for the client's health.
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