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 ["A","B","C","D"]
Explanation
A. Asking about travel outside the United States helps identify potential exposure to infections that are more prevalent in certain areas.
B. Assessing handwashing techniques is crucial, as proper hand hygiene is a fundamental way to prevent infections.
C. Understanding the patient's perception of infection risk in their home environment can highlight potential areas for intervention.
D. Knowing the signs and symptoms of infection allows the nurse to evaluate the patient’s awareness and ability to recognize early signs of infection.
E. While mobility can affect overall health, it is not directly related to assessing the risk of infection.
F. Knowing who runs errands may provide context for the patient's support system, but it does not directly assess infection risk.
Correct Answer is B
Explanation
A. Increasing activity level may be unrealistic for a patient on strict bed rest due to a pelvic fracture.
B. Repositioning every 2 hours is a realistic and achievable goal for a patient on bed rest to prevent complications such as pressure ulcers and maintain circulation.
C. Using a walker for ambulation may not be feasible immediately after a pelvic fracture.
D. Transferring with a sliding board may not be safe or appropriate in the early stages post-injury, especially if bed rest is required.