A nurse is preparing to give a bed bath to a client who had a cerebrovascular accident (CVA). Which of the following actions should the nurse plan to take?

Wash in a distal to proximal direction.

Use a circular motion with the washcloth.

Massage legs after completing the bath.

Disconnect the IV tubing prior to performing the bath.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The nurse should wash the client in a distal to proximal direction during a bed bath after a cerebrovascular accident (CVA) to prevent the risk of clot dislodgement. This method ensures that any potential clots or debris are moved away from the central circulation, reducing the risk of harm.

Choice B rationale:

Using a circular motion with the washcloth can increase friction and potentially irritate the skin. Clients with a history of CVA might have reduced sensation or mobility, making them susceptible to skin breakdown. Hence, avoiding circular motions is important to prevent skin damage.

Choice C rationale:

Massaging the legs after completing the bath can also pose a risk of clot dislodgement. It is essential to avoid vigorous massage on areas affected by deep vein thrombosis (DVT) to prevent complications like pulmonary embolism.

Choice D rationale:

There is no need to disconnect the IV tubing before performing the bath unless specifically indicated by the healthcare provider. In general, clients receiving continuous IV infusions can continue the infusion while maintaining proper infection control measures during the bath.

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Correct Answer is D

Explanation

Choice A rationale:
A PaO2 value of 86 mm Hg is within the normal range (80-100 mm Hg) and does not indicate respiratory acidosis. PaO2 measures the partial pressure of oxygen in arterial blood.
Choice B rationale:
A pH of 7.4 is within the normal range (7.35-7.45) and does not indicate respiratory acidosis. The pH reflects the acidity or alkalinity of the blood.
Choice C rationale:
An HCO3 (bicarbonate) level of 16 mEq/L is within the normal range (22-28 mEq/L) and does not indicate respiratory acidosis. HCO3 is a measure of the metabolic component of the body's acid-base balance.
Choice D rationale:
This is the correct choice. A PaCO2 value of 58 mm Hg is elevated and indicates respiratory acidosis. PaCO2 measures the partial pressure of carbon dioxide in arterial blood, and an elevated value suggests the presence of excess carbon dioxide, leading to acidosis.

A. "Bedside water pitchers should be covered after being filled.". B. "Dressings that get wet in the shower should be allowed to dry out.". C. "Used needles should be placed in the sharps container at the nurses' station.". D. "Drainage bottles should be emptied when they become full.".

Correct Answer is A

Explanation

Choice A rationale:

Covering bedside water pitchers after being filled helps reduce the risk of contamination and infection by preventing the entry of airborne pathogens or debris.

Choice B rationale:

Allowing dressings that get wet in the shower to dry out is not an effective infection control strategy. Wet dressings can become a breeding ground for bacteria, and it is important to change wet dressings promptly to minimize the risk of infection.

Choice C rationale:

Used needles should be immediately disposed of in sharps containers, not placed at the nurses' station. Placing used needles in the sharps container promptly helps prevent accidental needlestick injuries and potential transmission of infections.

Choice D rationale:

Drainage bottles should be emptied regularly to prevent overfilling, but they should not be allowed to become full. Regular emptying ensures proper functioning and reduces the risk of spillage or contamination in the client care area.

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A nurse is preparing to give a bed bath to a client who had a cerebrovascular accident (CVA). Which of the following actions should the nurse plan to take?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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