Which patients will the nurse determine are in most need of regular perineal care? (Select all that apply.)

A patient who has an indwelling catheter

A patient with urinary and fecal incontinence

A patient with rectal and genital surgical dressings

A bariatric patient

A circumcised male who is ambulatory

Answer and Explanation

Correct Answer : A,B,C,D

A. A patient with an indwelling catheter requires regular perineal care to prevent infection due to increased risk from the catheter.
B. Urinary and fecal incontinence increase the risk of skin breakdown and infection, necessitating frequent perineal care.
C. Surgical dressings in the rectal and genital areas require perineal care to maintain hygiene and prevent wound contamination.
D. Bariatric patients often need regular perineal care due to skin folds and increased risk of moisture-related skin breakdown.
E. A circumcised, ambulatory male typically has a lower risk of infection and may not require as frequent perineal care unless other factors are present.

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Correct Answer is A

Explanation

A. Encouraging self-care helps promote independence and functional recovery in stroke patients, supporting rehabilitation and enhancing self-esteem.
B. Bed rest is not recommended as it can contribute to muscle deconditioning and complications associated with immobility.
C. While coordination with therapy is beneficial, gait training is typically handled by physical therapy rather than occupational therapy.
D. Providing a complete bed bath limits the patient’s autonomy; encouraging partial participation supports the patient's involvement in self-care.

A. A patient with hypercapnia wearing an oxygen mask B. A patient with a chest tube ambulating with the chest tube unclamped C. A patient with thick secretions being tracheal suctioned first and then orally D. A patient with a new tracheostomy and tracheostomy obturator at bedside

Correct Answer is B

Explanation

A. A patient with hypercapnia requires monitoring, but wearing an oxygen mask indicates some level of intervention is in place.
B. A patient with a chest tube should never ambulate with the chest tube unclamped, as this can lead to a collapsed lung and respiratory distress; thus, this patient should be prioritized.
C. While a patient with thick secretions may need suctioning, this is not as critical as ensuring the safety of a patient with an unclamped chest tube.
D. A patient with a new tracheostomy requires monitoring, but the presence of the obturator indicates readiness for emergencies; this does not take priority over the safety of the patient with the chest tube.

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Which patients will the nurse determine are in most need of regular perineal care? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for an older-adult patient who has been diagnosed with a stroke. Which intervention will the nurse add to the care plan?

Correct Answer is A

Explanation

A nurse is caring for a group of patients. Which patient should the nurse see first?

Correct Answer is B

Explanation

Which patients will the nurse determine are in most need of regular perineal care? (Select all that apply.)

A nurse is teaching a patient how to meditate. Which behavior presented by the patient indicates effective learning?

A patient requires repositioning every 2 hours. Which task can the nurse delegate to the nursing assistive personnel?

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The nurse has received a report from the emergency department that a patient with tuberculosis will be coming to the unit. Which items will the nurse need to care for this patient? (Select all that apply.)

A terminally ill patient is experiencing constipation secondary to pain medication. Which is the best method for the nurse to improve the patient's constipation problem?

A patient has been diagnosed with heart failure and cardiac output is decreased. Which formula can the nurse use to calculate cardiac output?