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
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 B
Explanation
A. A Yankauer suction tip catheter is used for suctioning secretions and does not assess cardiac function or afterload.
B. A blood pressure cuff is essential for measuring blood pressure, which can indicate increased afterload through elevated systemic vascular resistance.
C. An oxygen cannula is used for delivering supplemental oxygen and does not provide information about cardiac afterload.
D. A pulse oximeter measures oxygen saturation, which is not directly related to assessing cardiac afterload.
Correct Answer is D
Explanation
A. The superior vena cava is responsible for returning deoxygenated blood from the upper body to the heart and is not directly involved in myocardial ischemia.
B. The carotid artery supplies blood to the brain and is not the primary focus in the context of myocardial infarction.
C. The pulmonary artery carries deoxygenated blood from the heart to the lungs and is not involved in coronary circulation.
D. The coronary arteries supply blood to the heart muscle itself. Ischemia during a myocardial infarction occurs when these arteries are blocked or narrowed, leading to a lack of blood flow and oxygen to the heart tissue.