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 A

Explanation

Explanation

A. Turn cellular phones to silent mode

Staff members should be advised to silence their cellular phones during an active shooter situation. This helps maintain silence and prevents the ringing or vibrating of phones from potentially revealing the location of individuals hiding or seeking shelter.

Move wounded clients to a safe area before finding shelter in (option B) is not correct. In the event of an active shooter situation. The safety of both staff members and clients is paramount. If it can be done quickly and without putting oneself or others at significant risk, moving wounded clients to a safe area before finding shelter may be advisable. However, the primary focus should be on finding shelter and protecting oneself from harm.

Attempt to bargain with the shooter in (option C) is not correct. Engaging in negotiations or attempting to reason with an active shooter can be extremely dangerous and may escalate the situation. Staff members should be instructed to prioritize their own safety and follow established active shooter protocols, which often involve evacuating, hiding, or acting to incapacitate or disable the shooter as a last resort.

Wave hands to attract the attention of law enforcement in (option D) is not correct. Waving hands or making sudden movements that may be misconstrued as threatening can potentially result in harm or confusion when law enforcement or security personnel are responding to an active shooter situation. It is important to follow their instructions calmly and clearly, keeping hands visible and following their guidance to ensure everyone's safety.

In summary, the nurse should recommend turning cellular phones to silent mode, moving wounded clients to a safe area if possible, not attempting to bargain with the shooter, and avoiding actions that may be misinterpreted by law enforcement. These recommendations are aimed at prioritizing personal safety and following established protocols to minimize risks during an active shooter situation.

A. Placement of a central venous catheter B. Administration of an iron injection using Z-track technique C. Insertion of a nasogastric tube D. Irrigation of a wound with antibiotic solution

Correct Answer is A

Explanation

Explanation

A. Placement of a central venous catheter

Informed consent is a legal and ethical requirement that ensures clients have the necessary information to make autonomous decisions about their healthcare. The healthcare provider must obtain informed consent before performing any procedure that carries potential risks or benefits. Here's why the other options do not typically require informed consent:

Administration of an iron injection using Z-track technique in (option B) is not correct because, while informed consent may be required for administering certain medications or injections, the specific technique used, such as the Z-track technique, typically does not require separate informed consent. The Z-track technique is a method used to prevent leakage of the medication into subcutaneous tissues during injection.

Insertion of a nasogastric tube in (option C) is not correct because Insertion of a nasogastric tube is a common procedure performed to access the stomach or administer medications or nutrients. Informed consent is generally not required for nasogastric tube insertion as it is considered a routine procedure and is often included as part of the overall plan of care.

Irrigation of a wound with antibiotic solution in (option D) is not correct because wound irrigation is a standard procedure in wound care, and the use of an antibiotic solution may be part of the healthcare provider's prescribed treatment plan. Informed consent is typically not required for wound irrigation unless there are specific circumstances or risks associated with the procedure.

In summary, the nurse should identify that informed consent is required for A: Placement of a central venous catheter. This procedure involves the insertion of a catheter into a major blood vessel and carries potential risks and complications that require informed consent to ensure the client's understanding and agreement before proceeding

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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

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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