A nurse is preparing to provide a complete bed bath for a client. Which of the following actions should the nurse take?

Offer the client a bedpan once the bath is complete.

Don sterile gloves prior to providing perineal care for the client.

Remove the client's top sheet after placing a bath blanket over it.

Ask the client's partner to leave the room until the bath is complete.

Answer and Explanation

The Correct Answer is C

A. Offer the client a bedpan once the bath is complete.
The client should be offered the bedpan before the bath to ensure comfort.

B. Don sterile gloves prior to providing perineal care for the client.
Clean gloves are appropriate for bed baths and perineal care unless the client has open wounds.

C. Remove the client's top sheet after placing a bath blanket over it.
Maintains client privacy and warmth during the bath.

D. Ask the client's partner to leave the room until the bath is complete.
The client should be consulted first-respect autonomy and preferences before asking visitors to leave.

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Correct Answer is D

Explanation

A. Encourage the client to rest in bed during the day.
Promotes isolation and worsens depression. Activity should be encouraged.

B. Request a prescription for antidiarrheal medication.
Constipation, not diarrhea, is a more common vegetative symptom.

C. Provide low-calorie snacks throughout the day.
High-calorie, nutrient-dense foods are better for clients with poor appetite.

D. Offer the client high-protein fluids frequently.
Vegetative symptoms include poor appetite-offering high-protein fluids helps maintain nutrition and hydration.

A. A client who is 4 days postpartum and has lochia serosa B. A client who is 3 days postpartum and has not had a bowel movement since prior to admission C. A client who is 1 day postpartum and has not voided in 8 hr D. A client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus

Correct Answer is C

Explanation

A. A client who is 4 days postpartum and has lochia serosa
This is an expected finding in the healing process.

B. A client who is 3 days postpartum and has not had a bowel movement
Common postpartum; not urgent unless severe discomfort or obstruction is present.

C. A client who is 1 day postpartum and has not voided in 8 hr
Urinary retention increases the risk of uterine atony and postpartum hemorrhage-must be addressed urgently.

D. A client whose fundus is 2–4 cm below the umbilicus on day 2
Normal involution of the uterus; not concerning.

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