The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?

Dizziness can occur during cleansing.

The pubic area should be kept shaved.

The foreskin should not be retracted.

An erection may occur while providing care.

Answer and Explanation

The Correct Answer is D

Choice A reason: Dizziness is not typically associated with perineal care and is not relevant to the instructions.

Choice B reason: Advising to keep the pubic area shaved is not a standard part of perineal care instructions and is a personal choice.

Choice C reason: The statement about not retracting the foreskin is incorrect; the foreskin should be retracted gently for cleaning and then returned to its normal position to prevent infection.

Choice D reason: It is important to inform the caregiver that an erection may occur as a natural reflex during perineal care, and it does not indicate any sexual intent. This helps prepare the caregiver to handle the situation professionally.

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Correct Answer is A

Explanation

Choice A reason: If the oxygen saturation remains stable during the procedure, it indicates that the suctioning is not adversely affecting the client's oxygenation, and the nurse can safely continue.

Choice B reason: Applying an oxygen mask is not necessary if the oxygen saturation is stable and within a safe range.

Choice C reason: Repositioning the pulse oximeter clip is only necessary if there is a concern about the accuracy of the reading, not when the reading is stable.

Choice D reason: There is no need to stop suctioning if the oxygen saturation is stable at 94%, as this is within the acceptable range for most clients.

A. Reduce the amount of pressure being applied on the top of the foot. B. Document in the nurse's notes that the dorsalis pedis pulse is not palpable. C. Obtain a Doppler stethoscope to auscultate the pulse at the same site. D. Palpate the site on the inner side of the ankle below the medial malleolus.

Correct Answer is A

Explanation

Choice A rationale: Excessive pressure can occlude arterial flow, preventing detection of the dorsalis pedis pulse. Reducing pressure allows blood flow to be felt, improving accuracy of pulse assessment.

Choice B rationale: Documentation without rechecking risks inaccurate reporting. Pulses may be present but obscured by technique, so confirming with proper palpation or alternative methods is necessary before recording findings.

Choice C rationale: Doppler stethoscope is useful but should be considered after correcting palpation technique. Initial step is adjusting pressure, as improper technique commonly explains absent pulse detection.

Choice D rationale: Palpating posterior tibial pulse assesses a different artery. While useful for circulation evaluation, it does not address the immediate issue of dorsalis pedis pulse palpation technique.

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The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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