A nurse is assisting a client who has a spinal cord injury with bathing. Which of the following actions should the nurse take?

Provide the client with a fixed showerhead.

Give the client a long-handled sponge.

Fill the client's bathtub with water at 48° C (118.4° F).

Offer the client bar soap.

Answer and Explanation

The Correct Answer is B

A.   A fixed showerhead may not allow the client to effectively control the water flow or direction, which could limit their independence and ability to bathe safely. A handheld showerhead is generally more suitable as it enables the client to direct the water flow where needed.
B.   A long-handled sponge allows the client to reach different parts of their body without requiring significant movement, making bathing easier and more manageable. It promotes independence and safety, especially for clients with limited mobility.
C.   This temperature is too high and poses a risk of burns or scalding, especially for clients with spinal cord injuries who may have impaired sensation. The water temperature should be lower, typically around 37-40°C (98.6-104°F), to prevent injury.
D.   While bar soap can be used, it may not be the best option for individuals with limited hand function or dexterity. Liquid soap or body wash may be easier to handle and use, promoting independence and reducing frustration.

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Correct Answer is C

Explanation

A. While neurological assessments are important in understanding the extent of injury, they are not the immediate priority when a client is not breathing. The focus should be on ensuring airway patency and resuscitation.
B. Stabilizing the cervical spine is essential if there is a suspected fracture. However, if the client is not breathing, securing the airway is the most urgent need. Placing a collar can come after addressing the airway.
C. The jaw-thrust maneuver is specifically designed to open the airway without flexing the neck, which is crucial in suspected cervical spine injuries. Ensuring that the airway is open is the top priority for an unresponsive client who is not breathing.
D. While evaluating for other injuries is necessary in the context of a motor vehicle accident, this should occur after securing the airway. The primary concern is to address the life-threatening issue of the client not breathing.

A. WBC 2300/mm3 B. Hemoglobin 12 g/dL C. RBC 5 million/mm3 D. Platelets 155.000/mm3

Correct Answer is A

Explanation

A. This value indicates leukopenia, which is a low white blood cell count. It is a common side effect of chemotherapy, as it can suppress bone marrow function and increase the risk of infection. A WBC count below 4000/mm³ is concerning and should be reported to the provider for potential intervention, such as monitoring for infection or adjusting chemotherapy.
B. A hemoglobin level of 12 g/dL is generally within the normal range for adult females (typically 12-16 g/dL). While chemotherapy can cause anemia, this specific level does not indicate a need for immediate reporting unless there are additional symptoms or changes.
C. An RBC count of 5 million/mm³ is also within the normal range for adult females (typically 4.2-5.4 million/mm³). This value does not warrant concern or reporting to the provider.
D. A platelet count of 155,000/mm³ is considered to be on the lower end of the normal range (typically 150,000-450,000/mm³). While it is not critically low, it may indicate the onset of thrombocytopenia, which can occur with chemotherapy. It should be monitored, but this specific value may not need immediate reporting unless there are additional clinical signs or significant drops in platelet counts.

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A nurse is assisting a client who has a spinal cord injury with bathing. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is A

Explanation

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