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 D
Explanation
Rationale:
A. Reviewing preoperative laboratory test results is within the nurse’s responsibilities to ensure that all necessary tests have been completed.
B. Assessing the current health status of the client is an important preoperative task for the nurse.
C. Ensuring a signed surgical consent form is completed is within the nurse’s scope to verify that informed consent has been obtained.
D. Explaining the operative procedure, risks, and benefits is typically the responsibility of the surgeon or provider, not the nurse.
Correct Answer is B
Explanation
Rationale:
A. Blood for PaCO2 is a specialized specimen that requires venipuncture and specific handling to ensure accuracy, which should be performed by a licensed nurse or phlebotomist.
B. Random stool specimen collection is a routine task that can be delegated to the AP. It requires minimal specialized skill and is within the AP's scope of practice.
C. Wound drainage for culture requires sterile technique and proper handling to avoid contamination, which is beyond the AP's responsibilities.
D. Urine from an indwelling catheter requires specialized techniques and knowledge to ensure proper collection, and should be performed by a nurse.
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