A nurse prepares to bathe a client with a spinal cord injury. Which of the following is the best first action?

A Unscrew the pins from the cervical tongs

B Ask the client to sit on the edge of the bed

C Gather supplies and at least 3 other people

D Remove the straps from the halo vest

Answer and Explanation

The Correct Answer is C

Choice A Rationale: Unscrewing the pins from the cervical tongs is not the best first action for bathing a client with a spinal cord injury.

Choice B Rationale: Asking the client to sit on the edge of the bed may not be appropriate or safe without proper assistance and equipment.

Choice C Rationale: The best first action is to gather supplies and at least 3 other people. Bathing a client with a spinal cord injury can be complex and may require additional assistance for safety and comfort.

Choice D Rationale: Removing the straps from the halo vest is not the first step in the bathing process and may not be necessary.

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Correct Answer is A

Explanation

Choice A Rationale: The client receiving an influenza vaccine 4 weeks ago is relevant because Guillain-Barre syndrome can sometimes be triggered by infections or vaccinations, including influenza vaccines.

Choice B Rationale: The client's hobby of golfing is not directly related to the described symptoms.

Choice C Rationale: Canning jams and preserves is not directly related to the described symptoms.

Choice D Rationale: A history of diabetes, while important for the client's overall health, may not be directly related to the current manifestations.

A. notify the nurse administrator B. clean up the spill C. Ask the client to remain still D. document the incident

Correct Answer is C

Explanation

Choice A Rationale: Notifying the nurse administrator should not be the first action when a client is experiencing pain or injury.

Choice B Rationale: Cleaning up the spill is important to prevent further accidents but does not address the client's immediate pain and discomfort.

Choice C Rationale: Asking the client to remain still is the best first action to ensure the client's safety and assess the extent of the injury or pain.

Choice D Rationale: Documenting the incident is important but should follow

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A nurse prepares to bathe a client with a spinal cord injury. Which of the following is the best first action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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