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","D","E"]
Explanation
A) Instruct another nurse to record the prescription in the medical record:
The nurse receiving a telephone prescription is responsible for ensuring the prescription is recorded correctly in the medical record. It is not appropriate to delegate this responsibility to another nurse. The nurse should personally document the prescription to ensure accuracy and clarity.
B) Withhold the medication until the provider signs the prescription:
The nurse should not withhold the medication solely based on the provider's signature. Telephone prescriptions are valid once they are received and documented accurately by the nurse. The prescription must be signed by the provider as soon as possible, but withholding medication is not warranted unless there are other concerns with the prescription.
C) Ask the provider to spell out the name of the medication:
When receiving a telephone prescription, the nurse should ask the provider to spell out the name of the medication to avoid errors. Medication names, especially those that sound similar, need to be communicated clearly to ensure correct medication administration. This action helps prevent misinterpretation or confusion, ensuring patient safety.
D) Record the date and time of the telephone prescription:
Recording the date and time of the telephone prescription is essential for accurate documentation and legal purposes. This step ensures that there is a clear record of when the prescription was given and that the provider’s order is traceable in the client’s medical record. It also assists in meeting legal and institutional documentation requirements.
E) Request that the provider confirm the read-back of the prescription:
The nurse should read back the prescription to the provider to confirm accuracy. This action is part of the "read-back" process, a safety measure used to verify that the prescription has been communicated correctly and understood by both the nurse and the provider. This step helps reduce the risk of medication errors.
Correct Answer is C
Explanation
A) Decreased platelets: A decrease in platelet count (thrombocytopenia) is often associated with conditions such as bleeding disorders, bone marrow problems, or certain infections, but it is not a direct indicator of infection. While infections can cause a drop in platelets, this is not a specific or primary indicator of infection.
B) Decreased hemoglobin: A decrease in hemoglobin is typically indicative of anemia, which can result from a variety of causes, including nutritional deficiencies, chronic disease, or blood loss. While anemia can be associated with some infections, it is not a specific indicator of infection.
C) Increased erythrocyte sedimentation rate (ESR): An increased ESR is a nonspecific indicator of inflammation in the body and can be associated with infections, autoimmune diseases, and other inflammatory conditions. It is commonly elevated during infections, as the body responds to the inflammatory process. Therefore, an elevated ESR is a useful laboratory finding when suspecting an infection.
D) Increased iron level: Increased iron levels are typically associated with conditions such as hemochromatosis or iron overload, not with infections. During infections, iron levels can actually decrease due to the body's response to restrict iron availability to pathogens.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.