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

A. If the client is independent, give them privacy to bathe, if they prefer. If leaving a client unattended, check on them every 5 minutes or more frequently as needed. Ensure the client knows how to use safety items such as shower chairs and grab bars.

B. Adding bath oil to the water after the client is in the tub can create a slippery surface, increasing the risk of falls. Bath oil should be added before the client enters the tub or avoided if there is a risk of slipping.

C. Draining the tub water before the client gets out helps prevent slips and falls that can occur if the client attempts to exit the tub while the water is still present. This practice enhances safety by reducing the risk of accidents.

D. Tub baths or very warm showers can lead to a person feeling faint, nauseous, or tired. Baths should not last longer than 20 minutes and should be discontinued at the first sign of patient discomfort, weakness, or complaints of feeling faint.

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Correct Answer is C

Explanation

A.Wearing a face mask does not increase the risk of injury. In fact, it helps protect the client from infections, especially if they have concurrent neutropenia, which is common in conditions affecting the bone marrow.

B.Green, leafy vegetables are rich in vitamin K, which plays a role in clotting. However, they do not directly increase the risk of injury in a client with thrombocytopenia. While vitamin K affects clotting factors, thrombocytopenia primarily involves a deficiency of platelets, which are necessary for clot formation.

C.Clients with thrombocytopenia have a low platelet count, which increases their risk of bleeding. Using a firm-bristled toothbrush can cause gum trauma and bleeding, leading to complications such as prolonged bleeding or infection. A soft-bristled toothbrush or an alternative oral hygiene method (such as an oral swab) is recommended to minimize injury.

D.Adequate sleep does not increase the risk of injury. In fact, it may support overall health and immune function.

A. "Draw up the insulin lispro and insulin glargine in separate syringes." B. "Expect insulin glargine to be cloudy." C. “Take an extra dose of insulin lispro prior to aerobic exercise." D. "Anticipate that the insulin glargine will peak in 3 hours."

Correct Answer is A

Explanation

Insulin lispro is a rapid-acting insulin, while insulin glargine is a long-acting insulin. It is important to keep them separate to maintain their individual properties and avoid any potential interactions or changes in their effectiveness.

Insulin glargine is a clear solution and should not appear cloudy. Cloudiness in insulin can indicate contamination or improper storage.

The instruction to "take an extra dose of insulin lispro prior to aerobic exercise" is not recommended. The client should consult with their healthcare provider to determine if any adjustments to their insulin regimen are necessary for exercise. Typically, adjustments are made based on the individual's blood glucose levels and anticipated intensity and duration of exercise. Insulin glargine is a long-acting insulin that provides a steady release of insulin over a prolonged period, without distinct peaks or valleys in its action. Its onset of action is gradual and its effect lasts for approximately 24 hours.

It is important for the client to receive accurate and appropriate instructions regarding their insulin regimen. The nurse should clarify any misunderstandings and provide accurate information to promote safe and effective diabetes management.

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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 collecting data from a client who has thrombocytopenia. The nurse should identify that which of the following findings increases the client's risk for injury?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who has diabetes mellitus and is taking insulin lispro and insulin glargine. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

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