A nurse is performing a bed bath for a client who has a respiratory infection. Which of the following actions should the nurse take?

Apply sterile gloves prior to bathing the client.

Replace the top linens with a bath blanket.

Apply clean linens to the bed before bathing the client.

Fill the basin with hot water.

Answer and Explanation

The Correct Answer is B

A. Apply sterile gloves prior to bathing the client.: Clean, non-sterile gloves are sufficient for personal hygiene unless there is contact with broken skin or body fluids.

B. Replace the top linens with a bath blanket.: A bath blanket provides warmth and maintains the client's privacy/modesty while the top linens are being laundered.

C. Apply clean linens to the bed before bathing the client.: Linens should be changed after the bath to ensure the new linens stay dry and clean.

D. Fill the basin with hot water.: Water should be warm (usually 43°C to 46°C or 110°F to 115°F) to prevent burns and skin irritation.

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Correct Answer is ["B","C"]

Explanation

A. Check for a positive Babinski reflex.: This is used to assess upper motor neuron dysfunction, not balance.

B. Have the client perform heel-to-toe walking.: This (tandem walking) tests cerebellar function and the client's ability to maintain an upright posture while moving.

C. Perform the Romberg test.: The Romberg test assesses balance by having the client stand with feet together and eyes closed; significant swaying indicates a loss of balance.

D. Have the client lie in bed and use his heel to draw a line on the opposite shin.: This (heel-to-shin test) assesses coordination, but since the client is lying down, it does not test balance.

E. Perform Weber's test.: This is a hearing test used to determine if sound is heard equally in both ears.

A. Paralytic ileus B. Distention C. Borborygmi D. Hypoactivity

Correct Answer is C

Explanation

A. Paralytic ileus: This refers to a lack of intestinal peristalsis, which results in absent bowel sounds, not loud growling.

B. Distention: This describes the physical appearance of an abdomen that is swollen or bloated with gas or fluid; it is not a term for an auscultated sound.

C. Borborygmi: This is the clinical term for hyperactive, loud, gurgling, or "growling" stomach sounds caused by the movement of gas through the intestines.

D. Hypoactivity: This refers to infrequent or quiet bowel sounds, usually fewer than 5 per minute.

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A nurse is performing a bed bath for a client who has a respiratory infection. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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