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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The client's daily peak expiratory flow (PEF) measures 85% above personal best.

Choice A rationale:

Salmeterol is a long-acting beta-agonist used to treat asthma. Improvement in the client's daily peak expiratory flow (PEF) of 85% above their personal best indicates effective bronchodilation and better asthma control.

Choice B rationale:

ABGs showing a pH level of 7.32 are not indicative of the effectiveness of salmeterol. ABG values assess the client's acid-base balance and gas exchange, but they do not directly reflect the action of the medication.

Choice C rationale:

A decrease in forced expiratory volume after treatment with medication indicates a lack of response to the therapy, not an effective outcome. It suggests the medication is not adequately controlling the client's asthma symptoms.

Choice D rationale:

Wheezing limited to expiration is not a clear indicator of medication effectiveness. Wheezing can be present in various respiratory conditions and is not solely associated with asthma control. Exhibit. The correct answer is choice B: Increase the rate of the infusion by 160 units/hr.

A. Take this medication on an empty stomach. B. Avoid drinking grapefruit juice while taking this medication. C. Change positions slowly while taking this medication. D. This medication can cause insomnia. E. It is possible to experience involuntary movements while taking this medication.

Correct Answer is ["B","D"]

Explanation

Choice A rationale:
Lurasidone does not necessarily need to be taken on an empty stomach. It can be taken with or without food.
Choice B rationale:

Avoiding grapefruit juice is essential with lurasidone as it can interfere with the drug's metabolism and increase the risk of side effects.
Choice C rationale:
Changing positions slowly is relevant for medications that can cause orthostatic hypotension, but lurasidone is not typically associated with this side effect.
Choice D rationale:
Lurasidone can cause insomnia in some individuals, so it is important for the client to be aware of this potential side effect. It is best taken in the evening to minimize this effect.
Choice E rationale:
While involuntary movements (extrapyramidal symptoms) can occur with some antipsychotic medications, lurasidone has a lower risk of causing these side effects compared to older antipsychotics. It is not a major concern with lurasidone treatment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who takes salmeterol to treat moderate asthma. Which of the following findings should indicate to the nurse that the medication has been effective?

Correct Answer is A

Explanation

A nurse is teaching a client who has schizophrenia a new prescription for lurasidone. Which of the following information should the nurse include in the teaching?(Select all that apply.).

Correct Answer is ["B","D"]

Explanation

A nurse is providing teaching about health promotion activities for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

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A nurse is assessing a client who has suspected appendicitis. Which of the following manifestations should the nurse expect?(Select all that apply.).

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