The nurse is caring for a patient who refuses to bathe in the morning. When asked why, the patient says, "I always bathe in the evening." Which action by the nurse is best?

Explain the importance of maintaining morning hygiene practices.

Tell the patient that daily morning baths are the "normal" routine.

Cancel hygiene for the day and attempt again in the morning.

Defer the bath until evening and pass on the information to the next shift.

Answer and Explanation

The Correct Answer is D

A. Explaining the importance of morning hygiene may overlook the patient's established routine and could create resistance.
B. Stating that morning baths are the "normal" routine does not acknowledge the patient's preferences, potentially causing the patient to feel invalidated.
C. Canceling hygiene for the day disregards the patient's needs and preferred routine.
D. Deferring the bath until evening respects the patient’s routine and preference, promoting patient-centered care and improving comfort and compliance with hygiene practices.

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Correct Answer is A,C,D,E

Explanation

A. Communication signs for airborne precautions are necessary to inform staff and visitors about the required precautions for TB, which is spread via airborne transmission.

B. A surgical mask is not adequate for TB; instead, an N95 respirator is required to filter out the airborne particles effectively.

C. The N95 respirator, gown, gloves, and eyewear are essential personal protective equipment for caring for a patient with tuberculosis. The N95 respirator specifically protects against inhaling infectious particles.

D. Negative-pressure airflow in the room is critical for tuberculosis patients to prevent airborne contaminants from spreading to other areas of the facility.

E. A private room is required to isolate the patient and reduce the risk of transmission to other patients and staff.

F. A communication sign for droplet precautions is not applicable as tuberculosis is primarily transmitted via airborne routes, not droplet transmission.

A. Elevated blood pressure B. Increased pulse rate C. Cyanosis D. Restlessness

Correct Answer is C

Explanation

A. Elevated blood pressure may occur with various conditions but is not a specific late sign of hypoxia.
B. An increased pulse rate can be an early compensatory response to hypoxia rather than a late sign.
C. Cyanosis, which is a bluish discoloration of the skin and mucous membranes, is a classic late sign of hypoxia, indicating severe oxygen deprivation.
D. Restlessness may indicate early signs of hypoxia or anxiety rather than a late sign and can occur before cyanosis develops.

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The nurse is caring for a patient who refuses to bathe in the morning. When asked why, the patient says, "I always bathe in the evening." Which action by the nurse is best?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has received a report from the emergency department that a patient with tuberculosis will be coming to the unit. Which items will the nurse need to care for this patient? (Select all that apply.)

Correct Answer is A,C,D,E

Explanation

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Correct Answer is C

Explanation

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