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 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.

3. What are the key interventions for managing a patient with asthma?

A. Administer bronchodilators and monitor oxygen levels
B. Encourage deep breathing exercises
C. Provide corticosteroids and monitor for respiratory distress
D. Provide antihistamines and monitor blood pressure

Correct answer: A

Rationale: The correct answer is A: Administer bronchodilators and monitor oxygen levels. Asthma management involves using bronchodilators to help open the airways and improve breathing. Monitoring oxygen levels is essential to ensure the patient is getting enough oxygen. Choice B, encouraging deep breathing exercises, can be helpful for some respiratory conditions but is not a key intervention for managing an acute asthma attack. Choice C, providing corticosteroids and monitoring for respiratory distress, is important for long-term asthma management and severe exacerbations but is not the immediate key intervention during an acute attack. Choice D, providing antihistamines and monitoring blood pressure, is not typically indicated for asthma management as asthma is primarily an airway disease, not a histamine-mediated condition.

4. What are the nursing interventions for a patient receiving anticoagulant therapy?

A. Monitor INR levels and check for bleeding
B. Administer antiplatelet therapy
C. Check for signs of DVT and provide anticoagulation
D. Administer aspirin and monitor for bleeding

Correct answer: A

Rationale: The correct nursing intervention for a patient receiving anticoagulant therapy is to monitor INR levels and check for signs of bleeding. Monitoring the INR levels helps assess the effectiveness and safety of anticoagulant therapy, while checking for bleeding is essential due to the increased risk associated with anticoagulants. Choice B is incorrect as antiplatelet therapy is not the standard treatment for patients on anticoagulant therapy. Choice C is incorrect as providing additional anticoagulation is not a direct nursing intervention in this scenario. Choice D is incorrect because administering aspirin, an antiplatelet medication, along with anticoagulants can increase the risk of bleeding and is generally avoided.

5. When providing family education for those who have a relative with Alzheimer's disease about minimizing stress, which of the following suggestions is most relevant?

A. Allow the client to rest four to five times during the day
B. Assess the cognitive functioning of the client regularly
C. Provide reality orientation even if the memory loss is severe
D. Maintain consistency in environment, routine, and caregivers

Correct answer: D

Rationale: The most relevant suggestion for minimizing stress in individuals with Alzheimer's disease is to maintain consistency in the environment, routine, and caregivers. This approach helps create a sense of familiarity and security for the individual, reducing stress and anxiety. Choice A is incorrect as it suggests allowing the client to go to bed multiple times during the day, which may disrupt their routine and lead to confusion. Choice B is incorrect as continuously testing cognitive functioning can be overwhelming and stressful for the individual. Choice C is also incorrect as providing reality orientation in cases of severe memory loss can cause frustration and confusion, ultimately increasing stress levels.