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 D

Explanation

Choice A reason: Leaving the dressing off is not advisable as it can expose the wound to potential infection and delay healing.

Choice B reason: A transparent dressing may not be the best choice for a stage 3 pressure injury with significant granulation tissue.

Choice C reason: Increasing the frequency of dressing changes without specific orders may not be necessary and could disrupt the healing process.

Choice D reason: A hydrocolloid gel dressing is appropriate for a stage 3 pressure injury as it maintains a moist environment, which is conducive to wound healing and granulation.

A. Describing a client's illness in the breakroom without mentioning a name. B. Discussing health history with the client behind a closed curtain. C. Faxing health records to the client's primary healthcare provider. D. Sharing a client's discharge needs with other treatment team members.

Correct Answer is A

Explanation

Choice A reason: Even without mentioning the client's name, discussing health information in a public area like a breakroom can still lead to a HIPAA violation due to the possibility of revealing identifiable information indirectly.

Choice B reason: Discussing health history with a client behind a closed curtain maintains privacy and confidentiality, adhering to HIPAA regulations.

Choice C reason: Faxing health records to a client's primary healthcare provider is a common practice and is not a HIPAA violation if done securely and with proper consent.

Choice D reason: Sharing a client's discharge needs with other treatment team members is necessary for continuity of care and is not a HIPAA violation as long as it is done within the healthcare team.

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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

The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

Correct Answer is D

Explanation

The nurse is preparing an in-service on the Health Insurance Portability and Accountability Act (HIPAA) violations. Which example should the nurse use to demonstrate a HIPAA violation?

Correct Answer is A

Explanation

A client is in the terminal stage of lung cancer. Outside the room, the client's spouse expresses to the nurse feelings of helplessness and a lack of hope for the future. How should the nurse respond?

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

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