Which assessment finding is most important when planning to provide a complete bed bath to a bedfast client?

2+ pitting edema of the feet.

Pallor.

Orthopnea.

Right-sided paralysis.

Answer and Explanation

The Correct Answer is C

A.   2+ pitting edema of the feet. While edema requires monitoring and may necessitate some adjustments in care, it does not directly impact the ability to provide a bed bath.
B.   Pallor. Pallor indicates potential anemia or poor circulation but does not directly impact the provision of a bed bath.

C.   Orthopnea. Orthopnea, difficulty breathing when lying flat, is critical to consider when planning a bed bath. The client may need to be positioned with the head elevated to facilitate breathing and ensure comfort during the bath.
D.   Right-sided paralysis. Paralysis requires careful handling to prevent injury, but it is not as

immediately critical to the bathing process as orthopnea, which directly affects the client's ability to breathe comfortably.

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Correct Answer is A

Explanation

A. Administer oxygen via face mask. The decrease in fetal heart rate after contractions indicates possible fetal distress. Administering oxygen to the mother can increase oxygen delivery to the fetus, potentially improving fetal oxygenation and alleviating distress.
B. Apply an Internal fetal heart monitor. While continuous monitoring is important, the first priority is to address the immediate fetal distress. Monitoring alone will not address the issue.
C. Notify the healthcare provider. Notifying the provider is important, but addressing the immediate fetal distress takes priority.
D. Use a vibroacoustic stimulator. Vibroacoustic stimulation can be used to assess fetal well- being, but it does not address the underlying fetal distress, which is the priority.

A. Clamp the chest tube immediately with a plastic clamp. B. Apply an occlusive dressing over the chest tube site. C. Ensure the chest tubing is not kinked or hanging low. D. Reinforce the chest tube connection to the container with tape.

Correct Answer is C

Explanation

A. Clamp the chest tube immediately with a plastic clamp. Clamping the chest tube can lead to tension pneumothorax, which is a life-threatening complication. It should never be done unless specifically instructed by a healthcare provider.
B. Apply an occlusive dressing over the chest tube site. This action is not indicated in this situation and could interfere with drainage.
C. Ensure the chest tubing is not kinked or hanging low. This is the correct intervention as a kinked or dependent chest tube can impede drainage, leading to respiratory distress.
D. Reinforce the chest tube connection to the container with tape. While ensuring the chest tube connection is secure is important, it is not the priority in this situation where the client is experiencing sudden shortness of breath.

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Which assessment finding is most important when planning to provide a complete bed bath to a bedfast client?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A client with a right hemopneumothorax has a chest tube connected to suction. While turning to the left side, the client becomes suddenly short of breath and anxious. Which intervention should the nurse implement?

Correct Answer is C

Explanation

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