A nurse is performing a bed bath for a client who has a respiratory infection. Which of the following actions should the nurse take?

Apply sterile gloves prior to bathing the client.

Replace the top linens with a bath blanket.

Apply clean linens to the bed before bathing the client.

Fill the basin with hot water.

Answer and Explanation

The Correct Answer is B

A. Apply sterile gloves prior to bathing the client.: Clean, non-sterile gloves are sufficient for personal hygiene unless there is contact with broken skin or body fluids.

B. Replace the top linens with a bath blanket.: A bath blanket provides warmth and maintains the client's privacy/modesty while the top linens are being laundered.

C. Apply clean linens to the bed before bathing the client.: Linens should be changed after the bath to ensure the new linens stay dry and clean.

D. Fill the basin with hot water.: Water should be warm (usually 43°C to 46°C or 110°F to 115°F) to prevent burns and skin irritation.

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Free Nursing Study Resources

Correct Answer is ["C","D"]

Explanation

A. Elevate the client's hand above the level of the heart.: The hand should be kept dependent (below heart level) to increase blood flow to the fingertips.

B. Squeeze the client's finger until a blood drop forms.: Excessive squeezing (milking) can cause hemolysis or dilute the specimen with interstitial fluid.

C. Prick the side of the client's finger.: The sides of the finger have fewer nerve endings and better vascularity than the center of the fingertip.

D. Apply clean gloves.: Standard precautions must be followed when handling blood.

E. Cleanse the client's finger with an iodine swab.: Iodine can interfere with results (especially glucose). Alcohol is typically used and must be allowed to dry completely.

A. Clammy skin B. Bradycardia C. Calf swelling D. Tortuous veins

Correct Answer is C

Explanation

A. Clammy skin: This is a non-specific finding often associated with shock or hypoglycemia, not typically localized DVT.

B. Bradycardia: DVT does not cause a slow heart rate; however, if a DVT becomes a pulmonary embolism, it would cause tachycardia.

C. Calf swelling: Unilateral edema (swelling in one calf), along with warmth and redness, is a classic sign of a DVT and should be reported immediately.

D. Tortuous veins: These are varicose veins, which are a sign of chronic venous insufficiency but are not an acute finding indicative of a DVT.

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A nurse is performing a bed bath for a client who has a respiratory infection. Which of the following actions should the nurse take?

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