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. A nurse is collecting data from a male client who is scheduled for a left inguinal herniorrhaphy. Which of the following findings is the priority for the nurse to report to the provider?

A. High blood pressure
B. Decreased bowel sounds
C. Constipation
D. Difficulty urinating

Correct answer: D

Rationale: The correct answer is 'Difficulty urinating.' This finding is crucial to report promptly as it can indicate a complication, such as urinary retention or injury to the urinary tract, which are significant concerns post-hernia surgery. High blood pressure (Choice A) may require monitoring but is not as urgent as difficulty urinating. Decreased bowel sounds (Choice B) and constipation (Choice C) are common after surgery and may resolve with appropriate interventions but are not as critical as addressing difficulty urinating.

3. When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate?

A. Cancer of any type
B. Impaired hearing
C. Prescription drug intoxication
D. Heart failure

Correct answer: C

Rationale: When caring for a client diagnosed with delirium, the most important condition for the nurse to investigate is prescription drug intoxication. Delirium in older adults is commonly caused by medication side effects or interactions. Investigating prescription drug intoxication is crucial as it can be a reversible cause of delirium. While cancer, impaired hearing, and heart failure are important considerations in overall care, prescription drug intoxication takes precedence in cases of delirium.

4. What advice should be given to a client experiencing constipation?

A. Encourage the client to drink water frequently
B. Increase dietary fiber to relieve constipation
C. Administer a laxative to relieve discomfort
D. Encourage the client to increase physical activity

Correct answer: B

Rationale: The correct advice to give to a client experiencing constipation is to increase dietary fiber. Dietary fiber helps relieve constipation by promoting regular bowel movements. Encouraging the client to drink water frequently (Choice A) is also important for overall bowel health, but increasing dietary fiber is more directly related to relieving constipation. Administering a laxative (Choice C) should not be the first-line recommendation and should only be considered if dietary and lifestyle changes do not work. Encouraging the client to increase physical activity (Choice D) can be beneficial for overall health but may not directly address the issue of constipation.

5. A nurse is caring for a client following an acute myocardial infarction who is concerned about fatigue. What is the best strategy to promote independence in self-care?

A. Instruct the client to remain in bed until the fatigue resolves
B. Encourage the client to gradually resume self-care tasks with frequent rest periods
C. Assign assistive personnel to perform all self-care tasks for the client
D. Ask the client's family to assist with self-care

Correct answer: B

Rationale: Encouraging the client to gradually resume self-care tasks with frequent rest periods is the best strategy to promote independence while managing fatigue. This approach allows the client to regain confidence in their abilities and fosters independence. Option A is incorrect as prolonged bed rest can lead to deconditioning and worsen fatigue. Option C is not promoting independence as it involves delegating all self-care tasks to others. Option D involves family assistance, which may be helpful but does not directly promote the client's independence in self-care.