A nurse is instructing a nursing assistant on how to assist a patient with bathing.
The patient has hemiparesis on the left side due to a stroke.
Which of the following statements by the nursing assistant demonstrates understanding of the teaching?
"I will wash the patient's left side first, then move to the right side.”.
"I will wash the patient's right side first, then move to the left side.”.
"I will wash both sides of the patient at the same time, starting from the head and moving down.”.
"I will ask the patient which side they prefer to wash first, then follow their preference.".
The Correct Answer is D
Choice A rationale:
Washing the patient's left side first and then moving to the right side does not demonstrate an individualized approach or consideration for the patient's preferences and abilities. It is important to involve the patient in the decision-making process, especially when they have hemiparesis, to promote their autonomy and comfort.
Choice B rationale:
Washing the patient's right side first and then moving to the left side does not consider the patient's preference and may not align with their abilities or comfort. It is essential to prioritize the patient's preferences and needs.
Choice C rationale:
Washing both sides of the patient at the same time, starting from the head and moving down, may not be feasible or comfortable for the patient, especially if they have hemiparesis. This approach does not demonstrate an individualized care plan based on the patient's specific condition.
Choice D rationale:
Asking the patient which side they prefer to wash first and then following their preference is the most patient-centered and appropriate approach. This approach respects the patient's autonomy and ensures that their needs and comfort are prioritized during the bathing process. It allows for individualized care based on the patient's abilities and preferences.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale:
Ibuprofen 400 mg every 4 to 6 hours as needed for temperature greater than 100.5 °F (38 °C). This order is questionable because ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can potentially increase blood pressure, which could be harmful to a patient with hypertension. Furthermore, NSAIDs can mask the symptoms of infection, which could delay the diagnosis and treatment of serious infections.
Choice B rationale:
Enalapril 10 mg every morning. This order is questionable because enalapril is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. However, ACE inhibitors can cause a dry cough, which could exacerbate the patient’s existing cough due to pneumonia. Additionally, ACE inhibitors can potentially cause hyperkalemia (high potassium levels), so it’s important to monitor the patient’s electrolyte levels.
Choice C rationale:
Supplemental oxygen 10 L/min via nasal cannula. This order is questionable because a high flow rate of oxygen can potentially cause oxygen toxicity or hyperoxia, which can lead to cellular damage. The typical flow rate for a nasal cannula is between 1-6 L/min. A flow rate of 10 L/min may be too high for this patient, especially without a specified target SpO2 range.
Choice D rationale:
Continuous pulse oximetry. This order is appropriate because it allows for continuous monitoring of the patient’s oxygen saturation levels, which is crucial in a patient with pneumonia and shortness of breath.
Choice E rationale:
Send blood for a complete blood count, electrolytes, blood cultures, and procalcitonin. This order is appropriate because these tests can help monitor the patient’s overall health status and response to treatment.
Choice F rationale:
Admit to the medical floor. This order is appropriate because the patient requires hospitalization for treatment and monitoring due to his pneumonia.
Choice G rationale:
Vital signs every 4 hours. This order is appropriate because it allows for regular monitoring of the patient’s vital signs, which can help detect any changes in his condition.
Choice H rationale:
Chest x-ray now. This order is appropriate because a chest x-ray can help confirm the diagnosis of pneumonia and assess its severity.
Choice I rationale:
Sputum culture and sensitivity. This order is appropriate because it can help identify the specific organism causing the pneumonia and determine its antibiotic sensitivity, which can guide antibiotic therapy.
Choice J rationale:
Levofloxacin 500 mg intravenously every 24 hours. This order is appropriate because levofloxacin is a broad-spectrum antibiotic commonly used to treat pneumonia.
Correct Answer is A
Explanation
Choice A rationale:
Instructing the client to bring all medications, supplements, and herbs currently being taken to the next clinic appointment (Choice A) is the best course of action. This allows the healthcare provider to review the client's entire medication regimen, identify any potential interactions or duplications, and make appropriate adjustments. It promotes medication safety and ensures that the client receives the most effective and safe treatment.
Choice B rationale:
Using a medication reminder system (Choice B) is a helpful suggestion but does not address the issue of potential duplications or interactions between medications. While a reminder system can improve adherence, it does not provide a comprehensive solution to the problem of multiple prescriptions for the same indication.
Choice C rationale:
Making certain a family member knows the name and use of all medications currently being taken (Choice C) is a useful practice for medication safety but may not be sufficient to address the issue of multiple prescriptions. Relying solely on a family member's knowledge may lead to misunderstandings or omissions in the medication regimen.
Choice D rationale:
Do not take any over-the-counter drugs while taking medications prescribed by a healthcare provider (Choice D) is a relevant piece of advice for medication safety. However, it does not directly address the issue of multiple prescriptions for the same indication. It is essential for the client to have a complete and accurate record of all medications, both prescribed and over-the-counter, to ensure safe and effective treatment.
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