A nurse is assisting a client who requests to take a tub bath. Which of the following actions should the nurse take?

Check on the client every 10 min during the bath

Add bath oil to the water after the client gets into the tub

Drain the tub water before the client gets out

Allow the client to remain in the bath for 30 min

Answer and Explanation

The Correct Answer is C

A. If the client is independent, give them privacy to bathe, if they prefer. If leaving a client unattended, check on them every 5 minutes or more frequently as needed. Ensure the client knows how to use safety items such as shower chairs and grab bars.

B. Adding bath oil to the water after the client is in the tub can create a slippery surface, increasing the risk of falls. Bath oil should be added before the client enters the tub or avoided if there is a risk of slipping.

C. Draining the tub water before the client gets out helps prevent slips and falls that can occur if the client attempts to exit the tub while the water is still present. This practice enhances safety by reducing the risk of accidents.

D. Tub baths or very warm showers can lead to a person feeling faint, nauseous, or tired. Baths should not last longer than 20 minutes and should be discontinued at the first sign of patient discomfort, weakness, or complaints of feeling faint.

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Correct Answer is ["C"]

Explanation

A: The tubing should not be coiled on the bed, especially not above the collection bag, as this can interfere with the drainage of urine and increase the risk of infection.

B: The drainage bag should always be kept below the level of the bladder during ambulation to prevent backflow and reduce the risk of infection.

C: Securing the catheter tubing to the lower abdomen (for male clients) or thigh (for female clients) helps to reduce the risk of catheter displacement and trauma. Proper securing also prevents unnecessary tension on the tubing, which can cause urethral irritation.

D:A sterile specimen should be collected from the sampling port of the catheter tubing, not directly from the drainage bag, which could lead to contamination.

A. Beefy, red tongue B. Facial erythema C. Fever D. Peeling of the hands and feet

Correct Answer is C

Explanation

When collecting data from a child with pertussis (whooping cough), the nurse should expect the following manifestations:

Paroxysmal cough: The hallmark symptom of pertussis is a severe, uncontrollable cough that often occurs in bursts (paroxysms) followed by a characteristic "whooping" sound as the child inhales.
Posttussive vomiting: The coughing spells can be so severe that they may lead to vomiting.
Inspiratory whoop: As mentioned earlier, during the inhalation phase after a coughing episode, the child may make a distinctive whooping sound.
Cyanosis: The prolonged coughing episodes can sometimes cause the child's face to turn blue (cyanosis) due to inadequate oxygen intake.
Fatigue and exhaustion: The frequent and intense coughing episodes can be exhausting for the child, leading to fatigue and sleep disturbances.

Other possible manifestations of pertussis can include a mild fever, runny nose, and sneezing. However, these symptoms are less specific to pertussis and can be seen in other respiratory infections as well.

The manifestations listed in the question (beefy, red tongue; facial erythema; peeling of the hands and feet) are not typically associated with pertussis and may be indicative of other conditions or diseases. It is important to consult a healthcare provider for a proper evaluation and diagnosis.

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A nurse is assisting a client who requests to take a tub bath. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?

Correct Answer is ["C"]

Explanation

A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?

Correct Answer is C

Explanation

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