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 A
Explanation
Rationale:
A. Assessment includes the current status and vital signs of the client, which are part of the information the nurse provides to assess the client’s condition.
B. Situation describes the problem or concern that prompted the communication, not detailed vital signs.
C. Background provides context or history relevant to the situation but does not include current vital signs.
D. Recommendation involves suggesting actions or solutions but does not include the current condition details.
Correct Answer is D
Explanation
Rationale:
A. A staff nurse typically does not function as the incident commander; this role is usually filled by someone with a leadership or administrative position in disaster planning.
B. An actual disaster cannot replace a drill because drills are designed to prepare staff for specific scenarios and ensure readiness.
C. A physician is not required to triage victims; this task can be performed by trained triage nurses or other designated personnel.
D. Regular disaster drills are essential for ensuring preparedness and assessing the effectiveness of disaster response plans.
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