Which patients will the nurse determine are in need of perineal ...

[serike]

Which patients will the nurse determine are in need of perineal care? (Select all that apply.)
 
  a. A patient with rectal and genital surgical dressings
  b. A patient with urinary and fecal incontinence
  c. A circumcised male who is ambulatory
  d. A patient who has an indwelling catheter
  e. A bariatric patient

Question 2

The patient is reporting an inability to clear nasal passages. Which action will the nurse take?
 
  a. Use gentle suction to prevent tissue damage.
  b. Instruct patient to blow nose forcefully to clear the passage.
  c. Place a dry washcloth under the nose to absorb secretions.
  d. Insert a cotton-tipped applicator to the back of the nose.

[kaylee05]

Answer to Question 1

ANS: A, B, D, E
Patients most in need of perineal care include those at greatest risk for acquiring an infection (e.g., uncircumcised males, patients who have indwelling urinary catheters, or those who are recovering from rectal or genital surgery or childbirth). A patient with urinary and bowel incontinence needs perineal cleaning with each episode of soiling. Bariatric patients need special attention to body areas such as skin folds and the perineal area. In addition, women who are having a menstrual period require perineal care. Circumcised males are not at high risk for acquiring infection, and ambulatory patients can usually provide perineal self-care.

Answer to Question 2

ANS: A
Excessive nasal secretions can be removed using gentle suctioning. However, patients usually remove secretions from the nose by gentle blowing into a soft tissue. Caution the patient against harsh blowing that creates pressure capable of injuring the eardrum, the nasal mucosa, and even sensitive eye structures. If the patient is unable to remove nasal secretions, assist by using a wet washcloth or a cotton-tipped applicator moistened in water or saline. Never insert the applicator beyond the length of the cotton tip.

[serike]

Excellent

[nathang24]

TYSM