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

Avoid bathing this patient until they are stable.

Only bathe the perineal area.

Perform the bath in a semi-Fowler's position.

Delegate the task to the assistive personnel.

Answer and Explanation

The Correct Answer is C

A. Avoid bathing this patient until they are stable: Hygiene is essential for preventing infection and promoting comfort. Bathing should not be entirely avoided unless the patient is critically unstable.

B. Only bathe the perineal area: While perineal care is important, other areas also require cleaning, and modifications can be made to prevent excessive exertion.

C. Perform the bath in a semi-Fowler's position: Semi-Fowler's position (30–45°) promotes lung expansion and reduces dyspnea, making it the best position for bathing a patient with breathing difficulty.

D. Delegate the task to the assistive personnel: While an assistive personnel (AP) can assist, the nurse should assess the patient first and be involved in care for clients with respiratory distress.

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Correct Answer is C

Explanation

A. "Tell me about your support system at home." This is an open-ended, therapeutic question that encourages the patient to discuss their support network.

B. "What treatment options has your doctor spoken with you about?" This is an appropriate way to assess the patient's understanding of their diagnosis and plan of care.

C. “I am sure you are scared. Everything will be okay." This statement is nontherapeutic because it offers false reassurance and dismisses the patient’s emotions rather than acknowledging their concerns.

D. "This must be a hard time for you. How are you coping?" This is an empathetic statement that acknowledges the patient's feelings and invites them to express their emotions.

A. Output assessment B. General Status C. Stoma assessment D. Laboratory data

Correct Answer is B

Explanation

A. Output assessment: Liquid stool and gas output are expected findings for an ileostomy.

B. General status: The patient’s avoidance of looking at the ileostomy suggests poor adaptation and possible psychological distress, which may require intervention.

C. Stoma assessment: A red, moist, and protruding stoma is a normal finding.

D. Laboratory data: The patient’s potassium level is on the lower end but still within normal limits. There are no critical abnormalities.

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Stoma Assessment	Stoma is protruding 2cm, is red and moist. Peristomal area is clean and intact.
Output	Liquid stool that is malodorous. Gas present in the appliance.
General Status	Patient is avoiding looking at the ileostomy during care.
Laboratory Data	Potassium 3.6 mEq/L (normal 3.5 to 5 mEq/L) Sodium 137 mEq/L (normal 135 to 145 mEq/L) Creatinine 0.9 mg/dL (normal 0.6 to 1.2 mg/dL)

Laboratory Test	Reference Range	Patient Results
White Blood Cells	5,000- 10,000/mm3	9,500/mm3
Neutrophil Count	2.500-8,000/mm3	5,200/mm3
HIV	Negative	Positive

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

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Naxlex Comprehensive Predictor Exams

The student nurse is conducting a health history for a patient recently diagnosed with cancer. What statement made by the student would require remediation by the clinical faculty?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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