The nurse is preparing to provide a bed bath to a client in a long-term care facility. The client states to the nurse, "I don't want a bath; I am going anywhere, so it doesn't matter.". Which of the following would be most appropriate for the nurse to do:

Realize this is his right, tell him it is fine, and document

Insist that he needs a bed bath for hygiene and health reasons, and start the bed bath

Ask open ended questions regarding bathing

Notify the doctor and suggest a psych consult for depression

Answer and Explanation

The Correct Answer is C

A. Realize this is his right, tell him it is fine, and document: Respecting autonomy is important, but immediately accepting refusal without exploring reasons misses an opportunity to assess mood, cognition, or barriers.

B. Insist that he needs a bed bath for hygiene and health reasons, and start the bed bath: Forcing care undermines patient autonomy and can damage trust; the nurse should seek to understand and negotiate.

C. Ask open-ended questions regarding bathing: Using open-ended questions (e.g., "Can you tell me why you don't want a bath today?") explores reasons, assesses for depression, pain, or cultural preferences, and respects the client's autonomy while allowing tailored care.

D. Notify the doctor and suggest a psych consult for depression: Notifying the physician might be appropriate if depression or cognitive decline is suspected, but it is premature before the nurse first assesses and asks the client about the refusal.

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Correct Answer is C

Explanation

A. Stridor: Stridor is a harsh, high-pitched inspiratory sound from upper-airway obstruction, often audible without a stethoscope and focused on inspiration.

B. Crackles: Crackles (rales) are intermittent, popping sounds usually from fluid in the alveoli and are not described as continuous high-pitched squeaks on exhalation.

C. Wheezes: Wheezes are continuous, musical, high-pitched sounds heard primarily on exhalation (though they can occur on both phases) and are typical in asthma due to narrowed airways.

D. Rhonchi: Rhonchi are low-pitched, snoring or gurgling sounds caused by larger-airway secretions and are not the high-pitched squeaks described.

A. Prevention of wound infection B. Promote circulation of venous blood C. Improve mobility D. Encourage lung expansion

Correct Answer is B

Explanation

A. Prevention of wound infection: Pneumatic compression devices do not actively prevent surgical wound infection; infection prevention relies on aseptic technique, antibiotics as indicated, and wound care.

B. Promote circulation of venous blood: These devices intermittently compress the limbs to enhance venous return, reduce venous stasis, and lower the risk of deep vein thrombosis (DVT).

C. Improve mobility: While used when mobility is limited, the devices themselves do not restore or improve the patient’s ability to ambulate.

D. Encourage lung expansion: Lung expansion is promoted by deep-breathing exercises, incentive spirometry, and positioning; pneumatic compression devices target limb circulation rather than pulmonary mechanics.

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The nurse is preparing to provide a bed bath to a client in a long-term care facility. The client states to the nurse, "I don't want a bath; I am going anywhere, so it doesn't matter.". Which of the following would be most appropriate for the nurse to do:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious lung sounds?

Correct Answer is C

Explanation

The client inquires about the purpose of having pneumatic compression devices applied. The nurse understands that the purpose of these devices is to do which of the following:

Correct Answer is B

Explanation

A nurse caring for an 88-year-old client understands that the body temperature of older adults is prone to lower body temperature. The nurse understands this is most likely due to which of the following reasons:

A nurse notes a client's intercostal muscles are pulling inwards and reports difficulty breathing. The nurse would document which of the following to describe this type of abnormal breathing pattern:

The physician prescribes Gabapentin 20 mg PO QID. The pharmacy has available Gabapentin syrup 10 mg/5 ml. The client should receive ml per day?

A client presents to the emergency department following an extended period outside in colder temperatures. The client's rectal temperature is 92 degrees F. Based on this finding, what clinical manifestations would the nurse anticipate? Select all that apply:

The nurse understands, when performing an abdominal assessment, which order is correct:

Using a small adult-sized cuff, the nurse takes a client's blood pressure with a larger upper arm. What results will the nurse likely obtain:

Upon assessment of a client's lungs, the nurse notes intermittent, high-pitched popping sounds heard, more notably on inspiration. This refers to which adventitious lung sound:

While performing sterile wound care, the nurse accidentally brushes a sterile glove against the client's gown. What is the nurse's next action?