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 B

Explanation

Choice A reason: Praising the UAP for using standard precautions is not appropriate in this situation as using the same gloves for multiple clients breaches infection control protocols.

Choice B reason: The nurse should instruct the UAP to change gloves immediately to prevent cross-contamination between clients.

Choice C reason: While scheduling an in-service program on asepsis is beneficial for long-term education, it does not address the immediate risk of infection.

Choice D reason: Submitting an adverse occurrence report may be necessary if there is a pattern of non-compliance, but the first action should be to correct the behavior and ensure client safety.

A. Uses normal saline to irrigate the wound. B. Cleans from less soiled to more soiled areas. C. Opens a sterile package towards the body. D. Places soiled dressing in a plastic bag.

Correct Answer is C

Explanation

Choice A reason: Using normal saline to irrigate the wound is a correct practice and does not indicate a need for additional teaching. Normal saline is isotonic and is commonly used for wound irrigation because it does not interfere with the natural healing process.

Choice B reason: Cleaning from less soiled to more soiled areas is also a correct technique to prevent contamination of cleaner areas. This method helps to reduce the risk of infection and is a standard practice in wound care.

Choice C reason: Opening a sterile package towards the body is incorrect and indicates that additional teaching is needed. When opening a sterile package, it should be opened away from the body to maintain the sterility of the contents and prevent contamination.

Choice D reason: Placing soiled dressing in a plastic bag is a proper disposal method and does not indicate a need for additional teaching. It is important to properly dispose of soiled dressings to prevent the spread of infection.

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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 observes an unlicensed assistive personnel (UAP) providing care for two clients using the same gloves. Which action should the nurse take first?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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