A nurse is beginning a complete bed bath for a client. After preparing the client by removing the client's gown and placing a bath blanket over him, which of the following areas should the nurse wash first?
Chest
Perineal area
Face
Feet
The Correct Answer is C
The correct answer is choice C, face. When beginning a complete bed bath, the nurse should first wash the client's face, followed by the arms, chest, abdomen, legs, perineal area, back, and then feet. Washing the face first is important to promote client comfort and hygiene, and also sets a positive tone for the rest of the bath. Additionally, washing the face before the perineal area helps to prevent cross-contamination of bacteria from the perineal area to the face.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Apply restraints to the hands or wrists to keep the patient in bed:Restraints should only be used when absolutely necessary and as a last resort, and the client in this scenario is oriented and can follow instructions. Restraints can also increase the risk of injury, agitation, and further falls.
B. Place a belt restraint on the client when they are sitting in a chair:Belt restraints restrict movement and should only be used when other measures are insufficient to protect the client. Since the client is oriented and can follow directions, this intervention is not warranted and could cause harm.
C. Keep the bed in the lowest position with all four side rails up:
Incorrect. Raising all four side rails is considered a form of restraint and can increase the risk of injury. Clients may attempt to climb over the side rails, leading to falls. Keeping the bed in a low position is appropriate, but using all four side rails is not.
D. Educate the patient on using the call light and make sure the call light is within reach.This is the most appropriate action as the client is oriented and can follow directions. Educating the patient on how to use the call light and ensuring it is easily accessible encourages them to ask for assistance when needed, reducing the risk of falls.
Correct Answer is ["A","B","C","E"]
Explanation
A.Observe for signs and symptoms of respiratory distress.
B.Auscultate anterior and posterior lung fields.
C. Inspect the skin for pallor and cyanosis.
E. Observe rate, rhythm, and depth of respirations.
When assessing a client's oxygenation status, a nurse should observe for signs and symptoms of respiratory distress, such as dyspnea, wheezing, and use of accessory muscles. Auscultation of the anterior and posterior lung fields is important to identify any adventitious breath sounds such as crackles, wheezes or rhonchi that may indicate airway obstruction, fluid accumulation, or other respiratory abnormalities. Inspection of the skin is also important to detect pallor or cyanosis, which may indicate reduced oxygen levels in the blood. Lastly, observing the rate, rhythm, and depth of respirations can provide information on the adequacy of oxygen exchange in the lungs.
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