A nurse is preparing to give a bed bath to a client who had a cerebrovascular accident (CVA). Which of the following actions should the nurse plan to take?
Wash in a distal to proximal direction.
Use a circular motion with the washcloth.
Massage legs after completing the bath.
Disconnect the IV tubing prior to performing the bath.
The Correct Answer is A
Choice A rationale:
The nurse should wash the client in a distal to proximal direction during a bed bath after a cerebrovascular accident (CVA) to prevent the risk of clot dislodgement. This method ensures that any potential clots or debris are moved away from the central circulation, reducing the risk of harm.
Choice B rationale:
Using a circular motion with the washcloth can increase friction and potentially irritate the skin. Clients with a history of CVA might have reduced sensation or mobility, making them susceptible to skin breakdown. Hence, avoiding circular motions is important to prevent skin damage.
Choice C rationale:
Massaging the legs after completing the bath can also pose a risk of clot dislodgement. It is essential to avoid vigorous massage on areas affected by deep vein thrombosis (DVT) to prevent complications like pulmonary embolism.
Choice D rationale:
There is no need to disconnect the IV tubing before performing the bath unless specifically indicated by the healthcare provider. In general, clients receiving continuous IV infusions can continue the infusion while maintaining proper infection control measures during the bath.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Cauliflower is not a good dietary choice for a client with cholelithiasis. Cholelithiasis refers to the presence of gallstones, and certain foods, including cauliflower, can exacerbate symptoms in some individuals.
Choice B rationale:
Increasing the amount of egg yolks in the diet is not advisable for a client with cholelithiasis. Egg yolks are high in cholesterol and can contribute to gallstone formation.
Choice C rationale:
This is the correct choice. Desserts like angel-food cake are a better dietary option for a client with cholelithiasis. Angel-food cake is typically low in fat and cholesterol, making it a more suitable choice for those with gallbladder issues.
Choice D rationale:
Eating choice or prime cuts of meat is not recommended for clients with cholelithiasis. These types of meat are often higher in fat, which can trigger gallbladder symptoms.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should wash the client in a distal to proximal direction during a bed bath after a cerebrovascular accident (CVA) to prevent the risk of clot dislodgement. This method ensures that any potential clots or debris are moved away from the central circulation, reducing the risk of harm.
Choice B rationale:
Using a circular motion with the washcloth can increase friction and potentially irritate the skin. Clients with a history of CVA might have reduced sensation or mobility, making them susceptible to skin breakdown. Hence, avoiding circular motions is important to prevent skin damage.
Choice C rationale:
Massaging the legs after completing the bath can also pose a risk of clot dislodgement. It is essential to avoid vigorous massage on areas affected by deep vein thrombosis (DVT) to prevent complications like pulmonary embolism.
Choice D rationale:
There is no need to disconnect the IV tubing before performing the bath unless specifically indicated by the healthcare provider. In general, clients receiving continuous IV infusions can continue the infusion while maintaining proper infection control measures during the bath.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.