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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Applies non-skid socks before getting the patient out of bed: Non-skid socks help prevent slipping and are an appropriate fall precaution.
B. Activates the chair alarm when the patient is sitting in the chair: Chair alarms alert staff if the patient attempts to get up unassisted, reducing fall risk.
C. Ensures that the bed is in the lowest position prior to leaving the room: Keeping the bed low reduces the severity of injury in case of a fall.
D. Places the patient on bed rest: Bed rest is not a standard fall precaution unless medically necessary. It can lead to deconditioning and further weakness, increasing fall risk.
Correct Answer is A
Explanation
A. Placing an indwelling urinary catheter: Indwelling urinary catheters are a leading cause of catheter-associated urinary tract infections (CAUTIs), which are common healthcare-associated infections.
B. Administering medications through an NG tube: While NG tubes can introduce bacteria, they are not as high-risk as urinary catheters, which provide a direct route for infection.
C. Changing a sacral wound dressing: While wounds can become infected, proper wound care techniques minimize risk. Urinary catheters pose a greater risk due to prolonged exposure to bacteria.
D. Replacing an ostomy appliance: While maintaining hygiene is important, ostomy appliances are not a major source of healthcare-associated infections compared to urinary catheters.
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