1. A patient who had surgery yesterday has the initial dressing covering the surgical site. What is the nurse's responsibility in assessing this patient's
... [Show More] wound?
A. Remove the dressing, inspect the wound, and reapply a new dressing.
B. Inspect the wound and reapply the surgical dressing every 2 hours.
C. Inspect the wound, and keep the dressing off until the health care provider arrives.
D. Wait until the health care provider orders the removal of the surgical dressing.
D. Wait until the healthcare provider orders the removal of the surgical dressing
Which wound would be allowed to heal by secondary intention?
A. Cleft lip repair
B. Infected hysterectomy incision
C. Exploratory laparoscopy incision
D. Facial laceration caused by a pocket knife
B. Infected hysterectomy incision
00:02
01:33
Before performing a wound assessment, which nursing action would reduce the patient's risk for infection?
A. Taking the patient's temperature
B. Applying clean gloves
C. Assessing the wound for drainage
D. Assessing the dressing for drainage
B. Applying clean gloves
Which intervention can the nurse delegate to nursing assistive personnel (NAP) in caring for a patient with a wound?
A. Assessing the site for signs of redness or swelling
B. Reporting the presence of wound odor
C. Removing a soiled outer dressing
D. Opening sterile dressings during the dressing change
B. Reporting the presence of wound odor
The nurse notes that a patient's surgical wound is healing slowly. Which health problem would contribute to slow wound healing?
A. Osteoarthritis
B. Glaucoma
C. Deafness
D. Diabetes mellitus
Diabetes Mellitus
. The nurse is delegating to nursing assistive personnel (NAP) the perineal care of a female patient who is totally dependent and confined to bed. Which statement by the NAP requires the nurse's follow-up?
A. "I'll ask for assistance if I need help positioning her."
B. "I'll see if she's up to the care right now."
C. "I'll let you know if I notice any signs of redness or discharge."
D. "I'll be sure to use hot, soapy water, since she has been incontinent."
D. "I'll be sure to use hot, soapy water, since she has been incontinent."
The nurse is preparing to provide perineal care for a female patient who is on bed rest. Which patient position should the nurse use for this care?
A. Supine
B. Prone
C. Side-lying
D. Dorsal recumbent
D. Dorsal Recumbent
As the nurse is preparing to provide perineal care to a female patient with limited mobility, the patient says, "I can do that myself." Which action would be the priority?
A. Provide all the necessary supplies and linen for this task.
B. Assess the patient's ability to perform proper perineal care.
C. Ensure that the patient has privacy while performing perineal care.
D. Document any complaints of irritation or pain in the perineal area
B. Assess the patient's ability to perform proper perineal care
How can the nurse promote infection control while providing perineal care for a female patient who has a catheter?
A. By avoiding the application of tension on the catheter.
B. By patting, not rubbing, the skin dry after thoroughly rinsing it.
C. By cleansing the patient's labia from the pubic area toward the rectum.
D. By using warm water to cleanse the patient's entire perineal area.
C. By cleansing the patient's labia from the pubic area toward the rectum
The nurse is delegating a female patient's perineal care to nursing assistive personnel (NAP). Which instruction would the nurse give to ensure the NAP's safety while performing this care?
A. Wear sterile gloves.
B. Wear clean gloves.
C. Wear an isolation gown.
D. Use hot water.
B. Wear clean gloves
Which of the following interventions directly related to patient safety must the nurse consider when providing perineal care to an elderly male patient with a catheter?
A. Wear clean gloves during care.
B. Assess the patient's ability to provide self-care.
C. Encourage the patient to report any pain originating from the catheter.
D. Monitor the amount of urine in the drainage bag to prevent overflow.
A. Wear clean gloves during care
The nurse observes the nursing assistive personnel (NAP) providing perineal care to a male patient. Which observation of care requires the nurse's follow-up?
A. Assisting the patient into the supine position in bed.
B. Cleansing the tip of the penis with a circular motion, starting at the meatus.
C. Reserving the cleansing of the tip of the penis as the final step in perineal care.
D. Using a gloved hand to grasp the shaft of the penis in order to retract the foreskin.
C. Reserving the cleansing of the tip of the penis as the final step in perineal care
00:00
01:33
A male patient receiving perineal care tells the nurse "It has started to hurt a little down there." What is the nurse's best response?
A. "When did you start experiencing the pain?"
B. "Rate the pain on a scale of 1 to 10."
C. "I'll assess your perineal area for the possible cause of the pain."
D. "Would you like some pain medication before I continue with your care?"
A. "When did you start experiencing the pain?"
The nurse has delegated a male patient's perineal care to the nursing assistive personnel (NAP). Which statement made by the NAP requires the nurse's follow-up?
A. "I will check to see if he cleans himself well."
B. "I will let you know if I see any redness or drainage."
C. "I will ask him if he is experiencing any pain in that area."
D. "I will be sure to use hot, soapy water to be sure he's clean."
D. "I will be sure to use hot, soapy water to be sure he's clean."
What is the primary reason for performing perineal care on a male patient with incontinence?
A. To provide comfort and a relaxed, refreshed feeling
B. To promote personal hygiene while minimizing perineal odor
C. To remove all microorganisms from the patient's perineal area
D. To reduce the risk of skin breakdown in the patient's genital and perineal area
D. To reduce the risk of skin breakdown in the patient's genital and perineal area
Which instruction would the nurse give when asking nursing assistive personnel (NAP) to give a complete bed bath to a patient?
A. Do not massage any reddened areas on the patient's skin.
B. Be sure to wash the patient's face with soap.
C. Disconnect the intravenous tubing when changing the gown.
D. Wear gloves if necessary.
A. Do not massage any reddened areas on the patient's skin [Show Less]