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.

Answer and Explanation

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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Correct Answer is A

Explanation

Rationale:

A. Performing blood glucose monitoring before breakfast is crucial for timely insulin administration and managing diabetes effectively.

B. Applying a condom catheter is important but can generally be done after more urgent tasks.

C. Delivering a clean urine specimen is important but less time-sensitive compared to blood glucose monitoring.

D. Feeding a client is important but may not be as urgent as tasks directly affecting medical management.

A. An infant who has pertussis and is receiving oxygen via nasal cannula B. An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions C. A school-age child who has diabetes mellitus and requires blood glucose monitoring D. A toddler who has both arms in casts and needs to be fed his breakfast

Correct Answer is A

Explanation

Rationale:

A. An infant who has pertussis and is receiving oxygen via nasal cannula requires immediate assessment to ensure that the oxygen therapy is adequate and to monitor for any signs of respiratory distress or worsening condition.

B. An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions does not require immediate assessment as the client is stable enough for discharge planning.

C. A school-age child who has diabetes mellitus and requires blood glucose monitoring should be assessed, but it is less urgent compared to a client with a respiratory condition.

D. A toddler who has both arms in casts and needs to be fed his breakfast needs attention, but this is less critical compared to monitoring a client with a respiratory condition.

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A nurse is preparing to bathe a client. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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