A nurse is assisting a client who requests to take a tub bath. Which of the following actions should the nurse take?

Check on the client every 10 min during the bath.

Add bath oil to the water after the client gets into the tub.

Drain the tub water before the client gets out.

Allow the client to remain in the bath for 30 min.

Answer and Explanation

The Correct Answer is C

Answer is: Drain the tub water before the client gets out.

Explanation: This is the correct answer because it reduces the risk of slipping and falling for the client, especially if they have limited mobility or balance problems. The other options are incorrect because:

Checking on the client every 10 min during the bath is not enough to ensure their safety and comfort. The nurse should check on them more frequently, such as every 5 to 10 minutes, depending on their needs and preferences.
Adding bath oil to the water after the client gets into the tub is not a good idea because it can make the water slippery and increase the risk of falling. The nurse should add bath oil to the water before the client gets into the tub, or use a non-slip mat or shower chair.
Allowing the client to remain in the bath for 30 min is too long and can cause dehydration, hypothermia, or skin irritation. The nurse should instruct the client to remain in the tub for no longer than 20 min, unless otherwise ordered by a physician.

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Correct Answer is A

Explanation

A.Emptying the ostomy pouch before removing the skin barrier reduces the risk of spillage and makes the procedure less messy. It is also more comfortable for the client and helps prevent leakage of stool onto the skin, which can cause irritation.

B. It’s generally recommended to change an ostomy appliance when the bowel is least active, such as before meals or several hours after eating. Changing it one hour after breakfast may coincide with increased bowel activity, which can increase the risk of leakage and make the change more challenging.

C.Moisturizing soaps should be avoided when cleaning the skin around the stoma because they can leave a residue that interferes with the adhesion of the skin barrier, potentially leading to leakage. The nurse should use a mild, non-moisturizing soap or just water to clean the area to ensure proper adhesion of the appliance.

D.The opening on the skin barrier should closely match the size of the stoma, with a slight gap of about 1/8 inch (0.3 cm) around it to avoid pressure on the stoma while also protecting the surrounding skin. Creating an opening that is 0.5 inches (1.27 cm) larger than the stoma would leave too much skin exposed, increasing the risk of irritation and infection.

A. "The headaches should decrease as you get used to the medication." B. "Swallow the tablet whole to minimize your headaches." C. "You should take the medication on an empty stomach to prevent a headache." D. "You can discontinue the medication until the headache goes away."

Correct Answer is A

Explanation

A. Correct. Isosorbide dinitrate is a medication used to prevent angina. Headaches are a common side effect when starting the medication, but they often decrease over time as the body adjusts.
B. Incorrect. Swallowing the tablet whole will not necessarily minimize headaches associated with isosorbide dinitrate.
C. Incorrect. Taking the medication on an empty stomach is not typically necessary to prevent headaches.
D. Incorrect. Discontinuing the medication without consulting a healthcare provider is not recommended, as abrupt discontinuation could lead to worsening of symptoms.

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A nurse is assisting a client who requests to take a tub bath. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with another nurse about how to change an ostomy appliance for a client who has a sigmoid colostomy. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is caring for a client who reports he has headaches after taking chewable isosorbide dinitrate. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

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