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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Instructing the client to hold the drainage bag at waist height when ambulating is incorrect because the drainage bag should always be kept below the level of the bladder to prevent urine from flowing back into the bladder, which could lead to a urinary tract infection (UTI).
B. Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe.
C. Securing the tubing with adhesive tape to the lower abdomen is correct because it helps prevent accidental pulling or tugging on the catheter, which could cause discomfort or dislodgement. Properly securing the tubing also helps maintain a continuous flow of urine and reduces the risk of infection.
D. Coiling the tubing on the bed above the collection bag is incorrect because it can cause urine to flow back into the bladder, increasing the risk of infection and compromising the effectiveness of the drainage system. The tubing should be kept below the level of the bladder to ensure proper drainage.
Correct Answer is B
Explanation
A. Incorrect. When removing tape, it is best to pull in the direction of hair growth to minimize skin trauma.
B. Correct. When performing a wet-to-dry dressing change, the wound should be cleaned from the center to the outer edges to prevent introducing contaminants into the wound.
C. Incorrect. Wet-to-dry dressings are typically used to debride wounds by allowing the moist dressing to dry and adhere to wound debris. Moistening the dressing before removal can disrupt this process.
D. Incorrect. Sterile gloves are not typically necessary for performing a wet-to-dry dressing change, as it is a clean technique.
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