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: B

Rationale: When assessing a client with an autoimmune disorder, the nurse should look for signs such as hives or rashes. Autoimmune disorders can manifest with various skin manifestations, including hives or rashes, which may be indicative of an autoimmune response. These skin manifestations may occur due to the immune system mistakenly attacking the body's own tissues. Observing and monitoring these skin changes can help in assessing and managing the autoimmune disorder in the client. Additionally, localized inflammation may also be present in autoimmune disorders, but hives or rashes are more commonly associated with these conditions.

Correct Answer: C

Rationale: Before drawing blood from a central venous catheter like a Hickman type, it is essential to ensure that the catheter is patent and free of any clots. Flushing the catheter with a heparinized solution (to prevent clot formation) before withdrawing blood helps clear the catheter and ensures accurate blood sample collection. Removing clots or obstructions from the catheter is crucial to prevent complications and maintain the catheter's function. Therefore, it is important to first flush the catheter with a heparinized solution before drawing blood from it.

Correct Answer: A

Rationale: Caput succedaneum is the vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery. It is often caused by pressure from the vaginal wall during labor. This condition does not involve the calvarial bone and typically resolves on its own within a few days after birth. Hydrocephalus refers to the abnormal accumulation of cerebrospinal fluid within the brain, which can result in an enlarged head circumference. Cephalhematoma is a collection of blood between the periosteum and the skull bone, usually occurring after birth trauma. Subdural hematoma is bleeding between the dura mater and the arachnoid mater surrounding the brain and is typically seen in traumatic head injuries.

Correct Answer: A

Rationale: Weight increment varies and is generally less than 7-8 kg/yr.