A nurse assisting a client who requests to take a tub bath. Which of the following actions should the nurse take?
Drain the tub water before the client gets out
Check on the client every 10 min during the bath.
Add bath oil to the water after the client gets into the tub
Allow the client to remain in the bath for 30 min.
The Correct Answer is A
A) Drain the tub water before the client gets out: Draining the water before the client gets out of the tub is the safest option. This helps prevent the risk of slipping or falling, as the water level will lower once the client begins to stand. Additionally, it ensures that the client can safely exit the tub without the danger of being unbalanced or disoriented by the water.
B) Check on the client every 10 min during the bath: While monitoring the client during the bath is important, checking every 10 minutes may not be frequent enough to ensure their safety, especially for clients who have mobility or cognitive issues. Ideally, the nurse should stay with or observe the client more closely or provide assistance if needed. Continuous supervision is preferred, particularly if the client is at risk for falls or other complications.
C) Add bath oil to the water after the client gets into the tub: Bath oils can create a slippery surface, which could increase the risk of falls or accidents. It's generally better to avoid adding oils to the bath water, as they can make the tub and the client’s skin slick, posing safety hazards. If oil is necessary for skin care, it should be applied to the skin after the bath, not in the water.
D) Allow the client to remain in the bath for 30 min: While the client may enjoy a bath, staying in the tub for too long can lead to skin irritation, dehydration, or overheating, especially for older adults or clients with medical conditions. The client should not stay in the water for prolonged periods. A typical recommendation would be to allow the bath to last about 10-20 minutes, depending on the client’s condition and safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Rolls from back to abdomen: Rolling from back to abdomen is a typical developmental milestone for a 4-month-old infant. By this age, infants usually have increased muscle strength and coordination, allowing them to start rolling over. This movement helps build their core strength, which is important for later developmental milestones like sitting up and crawling.
B) Moves objects to mouth: It is common for a 4-month-old to move objects to their mouth as they begin exploring the world around them. This action is a key part of sensory development and helps infants develop their hand-to-mouth coordination. Additionally, this behavior assists in teething and the development of oral motor skills.
C) Anterior fontanel closed: The anterior fontanel normally closes between 12 to 18 months of age. If it is closed at 4 months, it may suggest abnormal cranial growth, such as craniosynostosis, where the sutures of the skull close too early. This could lead to increased pressure on the brain, which can cause developmental delays or other complications, so the provider should be notified for further assessment.
D) Posterior fontanel closed: The posterior fontanel typically closes by 2 to 3 months of age. If it is closed by 4 months, it is completely normal and indicates proper cranial development. The closing of the posterior fontanel helps ensure the skull's bones are fusing together as expected, and it does not raise any concerns at this stage.
Correct Answer is D
Explanation
A) Steatotic liver disease: Steatotic liver disease, or fatty liver disease, is typically associated with excess fat in the liver, often linked to alcohol use, obesity, or diabetes. While it can affect liver function, it is not primarily associated with deficiencies in iron and vitamin B12. Therefore, this condition is not directly related to the lab findings of low iron and vitamin B12.
B) Leukemia: Leukemia is a type of cancer that affects the blood and bone marrow, leading to abnormal white blood cell production. While leukemia can cause anemia as a secondary effect due to bone marrow dysfunction, it is not typically characterized by deficiencies in both iron and vitamin B12 simultaneously. The lab findings are more consistent with a nutritional or absorption issue rather than leukemia.
C) Hepatitis: Hepatitis refers to inflammation of the liver, usually caused by a viral infection or other factors. While hepatitis can lead to various blood abnormalities, it is not specifically linked to both iron and vitamin B12 deficiencies. Hepatitis more commonly affects liver function and may cause jaundice, but it does not directly explain low iron and B12 levels.
D) Anemia: Both iron and vitamin B12 are essential for the production of healthy red blood cells. Iron deficiency can lead to iron-deficiency anemia, and vitamin B12 deficiency can cause pernicious anemia. Therefore, low levels of both iron and vitamin B12 suggest the possibility of anemia, and the nurse should monitor the client for signs and symptoms of this condition, such as fatigue, pallor, and weakness.
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