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 are the signs and symptoms of fluid overload?

A. Edema, shortness of breath, weight gain
B. High blood pressure and jugular venous distention
C. Low blood pressure and cyanosis
D. Tachycardia and dizziness

Correct answer: A

Rationale: The correct signs and symptoms of fluid overload include edema, shortness of breath, and weight gain. Edema is the abnormal accumulation of fluid causing swelling, shortness of breath can occur due to fluid accumulating in the lungs, and weight gain is often seen as a result of excess fluid retention. Choices B, C, and D are incorrect because high blood pressure and jugular venous distention are more indicative of conditions like heart failure, while low blood pressure and cyanosis are seen in conditions like shock or poor perfusion. Tachycardia and dizziness are not typical signs of fluid overload.

3. A nurse is reinforcing teaching with a client about the client's recent diagnosis of multiple sclerosis. The client states, 'I am very upset and I want to be alone for a little while.' Which of the following responses should the nurse make?

A. I see that you are feeling overwhelmed. I will come back when you are ready
B. This is normal, and I will check on you later
C. You are feeling frustrated. Let's talk about your concerns.
D. You will feel better soon. Let me get you some water.

Correct answer: A

Rationale: Acknowledging the client's feelings and allowing them space demonstrates understanding and respect for their emotions.

4. How should a healthcare provider assess a patient with potential diabetic ketoacidosis (DKA)?

A. Monitor blood glucose and check for ketones in urine
B. Administer insulin and provide fluids
C. Administer potassium and check for electrolyte imbalance
D. Administer sodium bicarbonate and monitor urine output

Correct answer: A

Rationale: Correct answer: To assess a patient with potential diabetic ketoacidosis (DKA), healthcare providers should monitor blood glucose and check for ketones in the urine. Elevated blood glucose levels and the presence of ketones in urine are indicative of DKA. Choice B is incorrect because administering insulin and providing fluids are treatments for DKA rather than assessment measures. Choice C is incorrect as administering potassium and checking for electrolyte imbalance are interventions related to managing DKA complications, not initial assessment. Choice D is incorrect because administering sodium bicarbonate and monitoring urine output are not primary assessment actions for DKA.

5. A nurse is caring for a client who has been experiencing chronic pain. Which of the following interventions should the nurse implement?

A. Provide the client with distractions such as television
B. Administer pain medication around the clock
C. Teach the client relaxation techniques
D. Perform massage therapy on the client

Correct answer: C

Rationale: The correct intervention for a client experiencing chronic pain is to teach relaxation techniques. This helps the client manage pain more effectively by reducing stress and anxiety, which can contribute to the perception of pain. Providing distractions like television (Choice A) may offer temporary relief but does not address the underlying issue of chronic pain. Administering pain medication around the clock (Choice B) may lead to dependency and not promote holistic pain management. Massage therapy (Choice D) can be beneficial but may not be as effective as teaching relaxation techniques in the long term for managing chronic pain.