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

Avoid bathing this patient until they are stable.

Only bathe the perineal area.

Perform the bath in a semi-Fowler's position.

Delegate the task to the assistive personnel.

Answer and Explanation

The Correct Answer is C

A. Avoid bathing this patient until they are stable: Hygiene is essential for preventing infection and promoting comfort. Bathing should not be entirely avoided unless the patient is critically unstable.

B. Only bathe the perineal area: While perineal care is important, other areas also require cleaning, and modifications can be made to prevent excessive exertion.

C. Perform the bath in a semi-Fowler's position: Semi-Fowler's position (30–45°) promotes lung expansion and reduces dyspnea, making it the best position for bathing a patient with breathing difficulty.

D. Delegate the task to the assistive personnel: While an assistive personnel (AP) can assist, the nurse should assess the patient first and be involved in care for clients with respiratory distress.

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Correct Answer is C

Explanation

A. Powered stand assist: Powered stand assist devices are used for clients who cannot bear weight independently, not for balance issues during ambulation.

B. Cane: A cane provides minimal support and is best for clients with mild weakness, not for those with frequent balance loss.

C. Gait belt: A gait belt provides stability and support while allowing the nurse to assist the client safely if they begin to lose balance.

D. Four-wheel walker: A four-wheel walker rolls easily, which may increase fall risk in a client with balance issues. A standard walker (without wheels) would be safer in some cases.

A. Slough tissue is present. B. Adipose tissue is present. C. Fascia tissue is present. D. Undermining is present.

Correct Answer is C

Explanation

A. Slough tissue is present: Slough tissue (yellow or white non-viable tissue) can be seen in stage III or IV ulcers but does not alone define a stage IV injury.

B. Adipose tissue is present: Fat (adipose tissue) exposure indicates a stage III ulcer, not necessarily stage IV.

C. Fascia tissue is present: Stage IV pressure injuries extend into deep tissues such as fascia, muscle, tendon, cartilage, or bone, distinguishing them from stage III ulcers.

D. Undermining is present: Undermining (tissue destruction extending under intact skin) can occur in both stage III and IV ulcers, so it is not a defining feature.

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Laboratory Test	Reference Range	Patient Results
White Blood Cells	5,000- 10,000/mm3	9,500/mm3
Neutrophil Count	2.500-8,000/mm3	5,200/mm3
HIV	Negative	Positive

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

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Naxlex Comprehensive Predictor Exams

A nurse is assisting an older adult client who sometimes loses their balance while walking. Which of the following devices is most important for the nurse to use when helping the client ambulate?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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