Which of the ff. nursing actions is most appropriate when doing perineal care on an uncircumcised male patient?

Correct Answer: C

Rationale: When performing perineal care on an uncircumcised male patient, it is important to replace the foreskin over the head of the penis after washing. The foreskin should not be left retracted or pulled back forcibly as it can cause irritation and discomfort to the patient. Leaving the foreskin retracted can also lead to potential complications such as paraphimosis, where the foreskin becomes trapped behind the head of the penis. Proper hygiene involves gently retracting the foreskin to clean underneath it and then returning it to its natural position to protect the sensitive glans penis. Using gentle, warm water with mild soap is typically sufficient for cleaning, and alcohol should be avoided as it can cause irritation and dryness to the sensitive genital area.

Correct Answer: D

Rationale: Too rapid infusion of hyperalimentation solutions can lead to circulatory overload due to the rapid volume expansion, which can strain the heart and lead to fluid overload. This can manifest as symptoms such as shortness of breath, crackles in the lungs, and edema. Additionally, a rapid infusion rate can cause a sudden surge in glucose levels, potentially leading to hypoglycemia due to increased insulin release in response to the elevated glucose levels. It is important for the nurse to maintain a careful and appropriate infusion rate to prevent these complications and ensure patient safety.

Correct Answer: C

Rationale: When suctioning a patient, it is important to limit the suctioning time to avoid hypoxia and tissue trauma. The maximum recommended time for suctioning an adult patient is usually around 10-15 seconds. However, in some cases, such as when dealing with thick or excessive secretions, the maximum time can be extended up to 30 seconds. In this particular case, where James is likely experiencing respiratory distress due to his symptoms, it would be appropriate for Wilma to suction him for a maximum of 30 seconds to effectively clear his airways while minimizing the risk of complications.

Correct Answer: D

Rationale: A potassium level of 6.3 mEq/L indicates hyperkalemia, which can have significant effects on the heart. The heart is one of the most sensitive organs to changes in potassium levels. In hyperkalemia, elevated serum potassium levels can lead to various cardiac manifestations, including dysrhythmias, conduction abnormalities, and eventually cardiac arrest. Monitoring and managing potassium levels are crucial in preventing life-threatening cardiac complications in patients with hyperkalemia. While the kidneys and other organs can also be affected by high potassium levels, the heart is the most critical organ to consider in this scenario.

Correct Answer: C

Rationale: When evaluating the effectiveness of nursing interventions for sinusitis discomfort, assessing the amount and color of sinus drainage is crucial. Changes in these aspects can provide valuable information about the progression of the sinusitis and the effectiveness of the interventions being implemented. Increased or purulent sinus drainage can indicate infection or inflammation, while clearer drainage may suggest improvement. Monitoring these parameters helps the nurse make informed decisions about continuing, modifying, or discontinuing interventions to manage the patient's sinusitis discomfort effectively. Evaluating WBC count, capillary refill, and comfort level are also important assessments in certain situations, but assessing the amount and color of sinus drainage is most directly related to sinusitis symptoms.