A nurse is preparing to bathe a client. Which of the following actions should the nurse plan to take?
Fill the bath basin with tap water that is 39° C (102.2° F).
Pull the curtain around the client's bed.
Wash the client's arms and hands first.
Use a washcloth to wipe the client's eyes from the outer canthus to the inner canthus.
The Correct Answer is B
Rationale:
A. Fill the bath basin with tap water that is 39° C (102.2° F) is too warm for bathing; the recommended water temperature is typically around 37°C (98.6°F) to prevent burns or discomfort.
B. Pull the curtain around the client's bed ensures privacy for the client during the bath, which is important for maintaining dignity and confidentiality.
C. Wash the client's arms and hands first is not necessarily the first step; typically, washing the face and then moving to the rest of the body is preferred.
D. Use a washcloth to wipe the client's eyes from the outer canthus to the inner canthus is incorrect as it should be done from the inner canthus to the outer canthus to avoid spreading any discharge across the eye.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Capillary refill time of 4 seconds is concerning but less urgent compared to immediate post-catheter removal issues.
B. Fruity breath odor in late-stage cirrhosis could indicate a metabolic issue but is less immediate than issues related to urinary output.
C. Green gastric aspirate with a pH of 5.3 is within normal range for NG tube decompression.
D. A client who has not voided 5 hours after catheter removal is at risk for urinary retention or other complications and should be assessed immediately.
Correct Answer is B
Explanation
Rationale:
A. Reinforcing discharge teaching is less critical during a disaster and should be secondary to addressing immediate needs.
B. Focusing on life-threatening emergencies aligns with the priorities in a disaster situation, where resources are limited.
C. Stocking additional supplies should be managed based on current needs and priorities but is not as urgent as immediate patient care.
D. Focusing on ADLs is important but not the priority when dealing with life-threatening situations.
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