A nurse provides a back massage as palliative care to an unconscious client who is grimacing and restless. Which of the following indicates a therapeutic response? (Select all that apply.)

The client draws his legs up into a fetal position.

The facial muscles relax.

The respiratory rate increases.

The shoulders droop.

The pulse is within the expected range

Answer and Explanation

Correct Answer : B,D,E

A.   Drawing legs up into a fetal position may indicate discomfort or agitation.
B.   Facial muscle relaxation is indicative of a therapeutic response to the massage.
C.   An increased respiratory rate may suggest distress or discomfort.
D.   Drooping shoulders suggest relaxation and a positive response to the massage.
E.   Maintaining an expected pulse rate indicates that the massage is not causing undue stress or discomfort.

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Correct Answer is A

Explanation

A. This is because using the same sponge repeatedly can introduce bacteria and other contaminants to the surgical site, increasing the risk of infection.
B. Cleansing the surgical site with a povidone-iodine solution is not recommended because it can cause skin irritation and allergic reactions. The nurse should use a chlorhexidine-based antiseptic solution instead, which is more effective and less toxic.
C. Shaving the client's hair near the surgical site is generally avoided, as it can increase the risk of infection. Hair removal, if needed, is often done with clippers.
D. The surgical site should be scrubbed starting at the center and moving outwards in a circular motion.

A. Instruct client to use an incentive spirometer every 4 hr. B. Place the client in a room with negative-pressure airflow. C. Serve cooked fruit with meals. D. Report temperatures greater than 39.5 C (102.3 F lasting more than 4 hr.)

Correct Answer is D

Explanation

A. The use of an incentive spirometer is more relevant for preventing respiratory complications, not related to the client's low WBC count.
B. Negative-pressure airflow rooms are typically used for clients with airborne infections, not those with low WBC counts.
C. Cooked fruits may be advisable to reduce the risk of bacterial contamination in immunosuppressed clients, but it does not directly address the low WBC count.
D. Reporting temperatures greater than 39.5°C (102.3°F) lasting more than 4 hours is crucial as it may indicate an infection, and prompt intervention is needed in immunosuppressed clients.

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A nurse provides a back massage as palliative care to an unconscious client who is grimacing and restless. Which of the following indicates a therapeutic response? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with performing a skin preparation for a client who is scheduled for surgery. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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