The nurse recognizes that the Rationale(s) for giving a client a bath is (are) to: (SELECT ALL THAT APPLY)

develop a nurse-client relationship.

enhance well-being.

assess skin integrity.

stimulate circulation.

moisturize the skin.

Answer and Explanation

Correct Answer : A,B,C,D,E

A. Bathing can indeed foster a nurse-client relationship. It provides an opportunity for interaction and communication between the nurse and the client, promoting trust and rapport.

B Bathing can contribute to the client's overall sense of well-being. It promotes comfort, relaxation, and a feeling of cleanliness, which are important aspects of holistic care.

C. Bathing allows the nurse to visually assess the client's skin integrity. During the process, the nurse can identify any changes in skin color, presence of lesions, wounds, or other abnormalities that may require further assessment or intervention.

D. Bathing, particularly when accompanied by gentle massage or movement of limbs, can stimulate circulation. This helps improve blood flow to tissues, aiding in wound healing and reducing the risk of complications such as pressure ulcers.

E. Depending on the type of bath products used (e.g., moisturizing soap or bath oils), bathing can help moisturize the skin. This is especially beneficial for clients with dry skin or conditions that predispose them to skin dryness.

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Correct Answer is D

Explanation

D. Counting the radial pulse for 30 seconds and then multiplying the count by two gives an estimate of the client's heart rate per minute (bpm). This method is efficient and commonly used in clinical practice, especially if the client's pulse is regular.

A. Counting the radial pulse for two minutes is unnecessarily long and not standard practice. Typically, the radial pulse is counted for either 30 seconds or 60 seconds (one minute) to determine the client's heart rate. Multiplying the count by two for a 30-second count or directly using the count for a 60- second count provides the client's beats per minute (bpm).

B. The radial pulse is assessed by palpating the radial artery on the thumb side (or lateral side) of the client's wrist. The nurse places the index and middle fingers gently over the radial artery and applies light pressure to feel the pulse rhythm and rate.

C. Using the thumb to count the pulse is not recommended because the thumb has its own pulse, which could interfere with accurately assessing the client's radial pulse.

A. Administering oxygen during provision of care B. Assessing response to activity C. Providing rest periods every ten minutes D. Maintaining the bed in high-Fowler's position

Correct Answer is B

Explanation

B. Before, during, and after providing hygiene care, the nurse should continually assess the client's response to activity. Signs such as increased heart rate, shortness of breath, fatigue, or discomfort should be monitored closely. Assessing the client's response allows the nurse to adjust care activities as needed to prevent exacerbation of symptoms or complications.

A. Administering oxygen may be necessary if the client has respiratory compromise or if oxygen saturation levels are low during activities. However, this intervention should be based on the client's specific needs as assessed by the nurse and should not necessarily be a routine intervention

C Providing regular rest periods is an important intervention for clients with activity intolerance. However, the assessment will guide how and when these interventions should be implemented.

D. Fowler's position are also important, but the assessment will guide how and when these interventions should be implemented.

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The nurse recognizes that the Rationale(s) for giving a client a bath is (are) to: (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse prepares to assess the client's radial pulse. Which statement made by the nurse reflects a correct understanding of the procedure? "I will:

Correct Answer is D

Explanation

The nurse is providing for the hygiene needs of a client with an activity intolerance. Which is the priority nursing intervention?

Correct Answer is B

Explanation

The inexperienced nurse is reassigned to another unit to care for a critically ill client whose care is beyond her capability. What action should the nurse take first?

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