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 D
Explanation
A) "Relax your arm across your chest and I will test your elbow extension.": This instruction is not relevant to testing the plantar Babinski reflex. The Babinski reflex involves the lower extremities, specifically the foot, not the arm or elbow. This instruction pertains to testing the upper extremity and is incorrect for this context.
B) "Place your foot in my hand and I will tap the back of your heel.": This is not the correct method for testing the plantar Babinski reflex. The Babinski reflex is tested by stroking the sole of the foot, not by tapping the back of the heel. The test is designed to elicit a response from the foot, not by applying pressure to the heel.
C) "Sit on the edge of the bed while I tap your knee.": This instruction relates to testing the patellar reflex (knee jerk), not the plantar Babinski reflex. The Babinski reflex involves stroking the bottom of the foot, not tapping the knee, so this is not appropriate for the test in question.
D) "Lie down and I will stroke the bottom of your foot.": This is the correct instruction for testing the plantar Babinski reflex. The client should be in a comfortable position, typically lying down, and the nurse should gently stroke the sole of the foot from the heel to the toes to assess the reflex. A normal response in adults is for the toes to curl downward, while an abnormal response (Babinski sign) would be the extension of the big toe and fanning of the other toes.
Correct Answer is ["A","B","E","F"]
Explanation
A. Maintain a safe and private environment for the client – Anticipated. Providing a secure and private setting helps support the client emotionally and ensures confidentiality during a sensitive situation.
B. Request a consult for case management – Anticipated. Case management can coordinate follow-up care, legal support, counseling, and additional resources for the client.
C. Provide resources to the client for the local Alcoholics Anonymous chapter – Contraindicated. There is no indication that the client has an alcohol use disorder. The focus should remain on addressing the sexual assault.
D. Contact children and youth services – Contraindicated. The client is a college student and an adult. There is no mention of minors being involved, so reporting to child protective services is unnecessary.
E. Provide resources for local support services – Anticipated. Connecting the client with crisis centers, advocacy groups, and counseling services is essential for emotional and psychological support.
F. Administer sexually transmitted infection prophylaxis – Anticipated. Post-exposure prophylaxis (PEP) for sexually transmitted infections (STIs), including gonorrhea, chlamydia, and HIV, should be administered to prevent potential infection.
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