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 ["A","B","D"]

Explanation

Choice A rationale:

The nurse should administer oxygen to the client experiencing a sickle cell crisis. Sickle cell crisis can cause vaso-occlusion, leading to tissue hypoxia and pain. Administering oxygen helps to improve tissue oxygenation and relieve symptoms.

Choice B rationale:

Administering opioids is appropriate for managing the severe pain associated with a sickle cell crisis. Opioids are effective analgesics that can help alleviate the acute pain experienced by the client.

Choice C rationale:

Administering whole blood is not typically indicated for a sickle cell crisis. Whole blood transfusion is reserved for specific indications, such as severe anemia or acute blood loss, but it is not a standard treatment for sickle cell crisis pain.

Choice D rationale:

Elevating the head of the bed to 30° can improve oxygenation and reduce the workload on the respiratory system, which is beneficial for clients experiencing a sickle cell crisis. It helps to optimize lung expansion and alleviate hypoxia.

Choice E rationale:

Keeping the client NPO (nothing by mouth) is not necessary in a sickle cell crisis. There is no indication that the client cannot tolerate oral intake, so allowing them to eat and drink as usual is appropriate.

A. High lipase. B. High creatine kinase-MB (CK-MB). C. Low hemoglobin. D. Low urine specific gravity.

Correct Answer is D

Explanation

Choice A rationale:
High lipase is not a typical laboratory finding related to overusing prescribed diuretics and a sodium level of 127 mEq/L. Lipase is an enzyme involved in lipid digestion and is more relevant in assessing pancreatic function.
Choice B rationale:
High creatine kinase-MB (CK-MB) is not associated with overusing prescribed diuretics or hyponatremia (low sodium level). CK-MB is a specific marker for myocardial damage and is usually elevated in conditions like myocardial infarction.
Choice C rationale:
Low hemoglobin is not directly related to overusing prescribed diuretics and a sodium level of 127 mEq/L. Low hemoglobin may indicate anemia or other hematological issues but this is not a typical finding in this scenario.
Choice D rationale:
The correct answer is low urine specific gravity. Overusing diuretics can lead to excessive urination, causing the urine to become more dilute with lower specific gravity. A low urine specific gravity indicates decreased urine concentration and can be a sign of fluid and electrolyte imbalances, including hyponatremia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a client who is in a sickle cell crisis. Which of the following actions should the nurse take?(Select all that apply.).

Correct Answer is ["A","B","D"]

Explanation

A nurse in an emergency department is assessing a client who is overusing prescribed diuretics and has a sodium level of 127 mEq/L. Which of the following laboratory findings should the nurse expect?

Correct Answer is D

Explanation

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