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.

Answer and Explanation

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.

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Correct Answer is ["B","D","E","F","H","I"]

Explanation

Rationale:

A. Typically involved in helping clients with activities of daily living due to physical or cognitive impairments, which is not the primary focus in this scenario.

B. May be involved if there is a need for possible surgical management due to complications or disease progression. Surgical intervention can be necessary for Crohn's disease, particularly if there are abscesses, strictures, or fistulas.

C. While important in general rehabilitation, physical therapy is not specifically indicated in this case unless there are complications affecting physical mobility.

D. The provider ordered Magnetic Resonance Enterography (MRE) to evaluate the small intestines and pelvis. A radiologist will interpret imaging studies to assess disease severity, fistulas, strictures, or abscesses.

E. Essential for managing nutritional needs, especially given the client's weight loss and inability to keep food down. A dietitian can help develop a plan to address nutritional deficiencies and manage symptoms through diet.

F. A specialist in gastrointestinal diseases who will likely be a key member of the team for managing and evaluating the client's Crohn's disease, overseeing medical and therapeutic interventions.

G. Generally involved if there are issues with swallowing or speech, which is not indicated here.

H. The client is on corticosteroids and may need immunosuppressive therapy, which requires medication management. A pharmacist ensures the correct dosage, drug interactions, and education on potential side effects.

I. Important for addressing psychosocial issues, such as the client's frustration and possible depression. They can assist with coping strategies, support services, and facilitating access to community resources.

A. Set a target date. B. Use tactics to alert staff nurses that a change is needed. C. Evaluate the effectiveness of the change. D. Assess the problem.

Correct Answer is A

Explanation

Rationale:

A. Set a target date is crucial during the moving stage to create a timeline for implementation and facilitate progress towards the change.

B. Use tactics to alert staff nurses that a change is needed is part of the earlier stage of planning and communicating the need for change, not specifically the moving stage.

C. Evaluate the effectiveness of the change occurs after the change has been implemented, not during the moving stage.

D. Assess the problem is part of the initial stage of change, not the moving stage.

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A nurse is preparing to bathe a client. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","D","E","F","H","I"]

Explanation

A charge nurse plans to use effective change strategies when implementing a change in a nursing procedure on the medical-surgical unit. Which of the following actions should the charge nurse take during the moving stage of change?

Correct Answer is A

Explanation

A nurse is caring for four postoperative clients. The nurse can delegate obtaining vital signs to an assistive personnel (AP) for which of the following clients?

An assistive personnel (AP) reports to the nurse that a client who is 3 days postoperative following an abdominal hysterectomy has a dressing that is saturated with blood. Which of the following tasks should the nurse delegate to the AP?

A nurse in an acute care setting is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the assistive personnel (AP)?

An RN is making nursing staff assignments for his team consisting of himself, two licensed practical nurses (LPNs), and an assistive personnel (AP). Which of the following clients should he assume responsibility for?

A nurse manager has received information from the facility's risk management department that a former client is pursuing a lawsuit. The nurse manager should anticipate a deposition will be required during which phase of the legal process?

An RN from the maternal-newborn unit is being floated to a medical-surgical unit. Which of the following clients should the charge nurse on the medical-surgical unit plan to assign to the RN?

A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which of the following assignments is an example of overdelegation?

A volunteer assigned to the pediatric unit reports to the charge nurse for an assignment. Which of the following assignments is unsafe for the volunteer?