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Which patients will the nurse determine are in most need of regular perineal care? (Select all that apply.)

A.

A patient who has an indwelling catheter

B.

A patient with urinary and fecal incontinence

C.

A patient with rectal and genital surgical dressings

D.

A bariatric patient

E.

A circumcised male who is ambulatory

Question Solution

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 C

Explanation

A. Continuing with the injection after seeing blood return increases the risk of injecting into a blood vessel, which is not safe for IM injections.

B. Administering at a slower rate does not address the issue of possible intravascular injection.

C. If blood is aspirated, the correct procedure is to withdraw the needle, dispose of the medication, and prepare a new dose to prevent intravascular administration, as IM injections are meant to be given into muscle tissue, not into a vein.

D. Pulling the needle back slightly is not recommended because it does not ensure that the needle is completely out of the blood vessel.

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.

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