what are the steps in providing perineal care to a patient

ATI LPN

ATI PN Comprehensive Predictor 2020

1. What are the steps in providing perineal care to a patient?

A. Clean the perineal area with soap and water
B. Use antiseptic wipes to prevent infection
C. Pat the area dry after cleaning
D. Always use gloves when performing care

Correct answer: A

Rationale: The correct answer is A: Clean the perineal area with soap and water. This step is essential in preventing infection and promoting hygiene. Using antiseptic wipes (choice B) is not a standard practice for perineal care; soap and water are preferred. While patting the area dry after cleaning (choice C) is important, the initial step of cleaning with soap and water is crucial. Using gloves (choice D) is a good practice to prevent the spread of infection, but it is not the initial step in providing perineal care.

2. What is the first step in assessing a patient with suspected stroke?

A. Check for facial droop
B. Assess speech clarity
C. Perform a neurological assessment
D. Call for emergency assistance

Correct answer: D

Rationale: The correct answer is to call for emergency assistance (Option D) when assessing a patient with suspected stroke. Time is crucial in stroke management, and activating emergency services promptly can ensure timely access to specialized care such as stroke units and treatments like thrombolytic therapy. Checking for facial droop (Option A), assessing speech clarity (Option B), and performing a neurological assessment (Option C) are important steps in evaluating a stroke but should follow the immediate action of calling for emergency assistance. These initial assessments can help confirm the suspicion of a stroke and provide valuable information to healthcare providers when they arrive. However, the priority is to ensure the patient receives appropriate care without delay by activating emergency services.

3. A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home?

A. Family members who smoke should be at least 10 ft away from the client when oxygen is in use
B. Nail polish should not be used near a client who is receiving oxygen
C. A 'No Smoking' sign should be placed on the front door
D. Cotton bedding and clothing should be replaced with items made from wool

Correct answer: C

Rationale: The correct answer is C. Placing a 'No Smoking' sign on the front door is crucial for fire safety when using oxygen at home. Choice A is incorrect as family members who smoke should not be around the client when oxygen is in use, not just at a distance. Choice B is not directly related to oxygen safety. Choice D is also irrelevant as the type of bedding and clothing material does not impact oxygen safety.

4. A client is learning to use a cane. What instruction is essential for this client?

A. Advance the cane and the weaker leg at the same time
B. Maintain two points of support on the ground at all times
C. Use the cane on the weaker side for better support
D. Advance the cane 30 to 45 cm with each step

Correct answer: B

Rationale: The correct instruction for a client learning to use a cane is to maintain two points of support on the ground at all times. This ensures better stability and reduces the risk of falls. Choice A is incorrect because advancing the cane and the weaker leg simultaneously may lead to imbalance. Choice C is incorrect because the cane should be used on the stronger side to provide support. Choice D is incorrect because there is no specific measurement for advancing the cane with each step, and the focus should be on maintaining stability.

5. A client with a new prescription for prednisone for the treatment of Addison's disease needs teaching. Which instruction should the nurse include?

A. Take the medication with food
B. Avoid taking aspirin
C. Schedule a bone density test
D. Expect increased appetite

Correct answer: C

Rationale: The correct instruction for the nurse to include is to schedule a bone density test. Prednisone can lead to reduced bone density, making regular monitoring crucial for clients on long-term therapy. Instructing the client to take the medication with food (choice A) or avoid taking aspirin (choice B) are not directly related to prednisone therapy for Addison's disease. While prednisone can cause increased appetite, it is not the priority instruction in this scenario, compared to monitoring bone density (choice D).