The 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?
Suggest contacting the healthcare provider for a prescription for catheter insertion.
Recommend a complete bath to cleanse the perineal area more fully.
Evaluate the effectiveness of this measure to stimulate client voiding.
Instruct the PN that this technique promotes infection in elderly females.
The Correct Answer is C
A. Suggest contacting the healthcare provider for a prescription for catheter insertion: Catheter insertion may not be necessary if the client is able to void with this technique. It's important to evaluate less invasive measures first.
B. Recommend a complete bath to cleanse the perineal area more fully: While cleanliness is important, the immediate concern is addressing urinary incontinence and promoting voiding.
C. Evaluate the effectiveness of this measure to stimulate client voiding: Warm water can sometimes stimulate voiding reflexes in clients who have difficulty emptying their bladders. Assessing the client's response to this measure is appropriate.
D. Instruct the PN that this technique promotes infection in elderly females: Pouring warm water over the perineal area does not necessarily promote infection, especially if proper hygiene
measures are followed. It's important to assess the effectiveness of the intervention before assuming it is inappropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Observing body language and movement can provide valuable information about pain, but it doesn't directly assess the quality of the pain. It's more indicative of the client's physical response to pain rather than the pain itself.
B. Identifying effective pain relief measures is important for pain management but doesn't directly assess the quality of the pain. This approach focuses on interventions rather than understanding the nature of the pain.
C. Providing a numeric pain scale can quantify the intensity of pain, but it doesn't necessarily assess the quality of the pain. While useful for tracking pain levels over time, it doesn't provide insights into the characteristics or nature of the pain.
D. Asking the client to describe the pain allows for a subjective assessment of its quality,
intensity, duration, and any associated symptoms. This approach provides valuable information for tailoring pain management strategies and understanding the client's experience.
Correct Answer is C
Explanation
A. Suggest contacting the healthcare provider for a prescription for catheter insertion: Catheter insertion may not be necessary if the client is able to void with this technique. It's important to evaluate less invasive measures first.
B. Recommend a complete bath to cleanse the perineal area more fully: While cleanliness is important, the immediate concern is addressing urinary incontinence and promoting voiding.
C. Evaluate the effectiveness of this measure to stimulate client voiding: Warm water can sometimes stimulate voiding reflexes in clients who have difficulty emptying their bladders. Assessing the client's response to this measure is appropriate.
D. Instruct the PN that this technique promotes infection in elderly females: Pouring warm water over the perineal area does not necessarily promote infection, especially if proper hygiene
measures are followed. It's important to assess the effectiveness of the intervention before assuming it is inappropriate.
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