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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Clients who incurred disease complications promptly received rehabilitation: This outcome suggests that the focus is on secondary prevention rather than primary prevention.
B. More than half of at-risk clients were diagnosed early in their disease process: While early diagnosis is important, it is not a direct measure of the effectiveness of a primary prevention program.
C. Average client scores improved on specific risk factor knowledge tests: This outcome indicates that clients are better informed about risk factors for sexually transmitted diseases, suggesting that the primary prevention program has been effective in increasing awareness and knowledge.
D. New screening protocols were developed, validated, and implemented: While developing new screening protocols may be beneficial, it does not directly measure the effectiveness of the
primary prevention program.

A. Initiate neurological monitoring every 2 hours. B. Assess bilateral breath sounds. C. Review client's daily medications. D. Palpate suprapubic region for urinary retention. E. None F. None

Correct Answer is C

Explanation

A. Initiating neurological monitoring every 2 hours is critical for a client with a TIA. This allows for early detection of any changes in neurological status, which could indicate worsening conditions or the onset of a stroke. Monitoring helps ensure prompt intervention if symptoms escalate.

B. While assessing bilateral breath sounds is important for overall respiratory function, it is not the most urgent priority in managing a TIA. Neurological assessments take precedence in this situation.

C. Reviewing the client's daily medications is important for understanding potential risk factors and management, but it is a secondary intervention. Neurological monitoring takes priority in the acute phase of care for a TIA.

D. Palpating the suprapubic region for urinary retention is more relevant in clients at risk for retention due to neurological or urological issues but is not a primary concern in managing a TIA. The focus should be on neurological function.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse implements a primary prevention program for sexually transmitted diseases in a nurse managed health center. Which outcome indicates that the program was effective?

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