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 A

Explanation

A. 46-year-old with a low neutrophil count: Neutrophils are essential for fighting infection. A low neutrophil count (neutropenia) significantly increases infection risk, making this the highest-priority patient.

B. 59-year-old seven days post abdominal surgery: While postoperative patients are at risk for infection, the greatest risk is within the first few days after surgery. By day seven, the risk decreases if no signs of infection are present.

C. 82-year-old with a history of leukemia ten years ago: While leukemia can affect the immune system, a history of leukemia from ten years ago is less concerning than an active condition causing immunosuppression.

D. 62-year-old on antibiotic therapy: While antibiotics can disrupt normal flora and increase the risk of infections like Clostridioides difficile, this risk is lower than that of a patient with neutropenia.

A. The relationship occurs spontaneously. B. It is based on the needs of the nurse. C. The nurse and client will have a social relationship. D. The nurse is accountable for the outcome.

Correct Answer is D

Explanation

A. The relationship occurs spontaneously: Therapeutic relationships are intentional and structured, unlike spontaneous social interactions.

B. It is based on the needs of the nurse: The relationship is centered on the needs of the client, not the nurse.

C. The nurse and client will have a social relationship: A therapeutic nurse-client relationship is professional, not social. It focuses on supporting the client’s well-being.

D. The nurse is accountable for the outcome: The nurse is responsible for maintaining professional boundaries and ensuring that the relationship supports the client’s health goals.

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

Nursing Test Bank

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