A nurse is assisting a client who had a lower extremity amputation with a bath. Which of the following actions should the nurse take?

Instruct the client to stay in the bathtub no longer than 20 min.

Fill the bathtub with water at 48 C (118.4° F).

Use bath oil in the client’s bathtub

Provide the client with non-slip bath strips in the bathtub.

Answer and Explanation

The Correct Answer is D

A.   The duration of time in the bathtub should be based on the client's tolerance but should not exceed 20 minutes.
B.   Water temperature should be warm but not excessively hot to avoid burns or discomfort.
C.   Bath oils can make the bathtub slippery and increase the risk of falls. They should be avoided.
D.   Providing non-slip bath strips enhances safety and helps prevent the client from slipping in the bathtub.

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Correct Answer is B

Explanation

A. Leaving the client during a seizure can lead to injury. The nurse should stay with the client.
B. Placing a towel under the client's head helps protect the head from injury during a seizure.
C. Placing the client in the prone position can compromise the airway and increase the risk of aspiration.
D. Holding the client's arms and legs still can be difficult and may result in injury to the client or the nurse. The priority is to protect the client from injury during the seizure.

A. Instruct the client on use of call light. B. Apply an ambulation alarm to the client’s leg. C. Apply restraints to the client PRN. D. Raise the four side rails of the client’s bed. E. Check on the client hourly

Correct Answer is ["A","B","D","E"]

Explanation

A. Instructing the client on the use of the call light allows them to easily summon assistance when needed.
B. Applying an ambulation alarm helps monitor the client's movement, especially if there is a risk of falls or wandering.

C. Applying restraints is not the first-line intervention and should only be used when less restrictive measures are ineffective, and the client is at risk of harm to themselves or others.
D. Raising the four side rails of the client’s bed is a safety measure to prevent falls and ensure the client's protection.

E. Checking on the client hourly is an essential intervention to monitor the client’s mental status and ensure safety. Frequent assessments allow for early identification of complications related to opioid use, such as respiratory depression or increased sedation.

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A nurse is assisting a client who had a lower extremity amputation with a bath. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who has a prescription for scheduled opioid analgesia and notes a change in the client’s mental status. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

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