A nurse is preparing to bathe a client. Which of the following actions should the nurse plan to take?
Fill the bath basin with tap water that is 39° C (102.2° F).
Pull the curtain around the client's bed.
Wash the client's arms and hands first.
Use a washcloth to wipe the client's eyes from the outer canthus to the inner canthus.
The Correct Answer is B
Rationale:
A. Fill the bath basin with tap water that is 39° C (102.2° F) is too warm for bathing; the recommended water temperature is typically around 37°C (98.6°F) to prevent burns or discomfort.
B. Pull the curtain around the client's bed ensures privacy for the client during the bath, which is important for maintaining dignity and confidentiality.
C. Wash the client's arms and hands first is not necessarily the first step; typically, washing the face and then moving to the rest of the body is preferred.
D. Use a washcloth to wipe the client's eyes from the outer canthus to the inner canthus is incorrect as it should be done from the inner canthus to the outer canthus to avoid spreading any discharge across the eye.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. A client who is 3 days postoperative following a craniotomy requires careful monitoring due to potential complications from brain surgery, so vital signs should be taken by a nurse.
B. A client who is 3 days postoperative following gastric bypass surgery is stable enough for an AP to obtain vital signs, as the risk of immediate postoperative complications is lower compared to more recent surgeries.
C. A client who is 2 hr postoperative following an abdominal hysterectomy requires close monitoring due to the recent surgery, so vital signs should be obtained by a nurse.
D. A client who is 1 hr postoperative following a thyroidectomy requires vigilant monitoring for potential complications from recent surgery, which should be done by a nurse.
Correct Answer is C
Explanation
Rationale:
A. Verify the AP's educational preparation prior to delegating the task is unnecessary if the AP has been trained and is competent in the task.
B. Observe the AP as she obtains the vital signs of each client is not required for routine tasks unless there is a concern about performance.
C. Determine the time frame the AP should report the results is crucial for ensuring timely and accurate reporting, which is necessary for effective patient care.
D. Ask the AP to take the vital signs of the client returning from surgery first might not be appropriate without considering the urgency of all clients’ conditions.
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