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 B

Explanation

Choice A rationale:
Providing a continuous passive motion (CPM) device is not necessary for a client following a total hip arthroplasty. CPM devices are more commonly used after knee arthroplasty to improve joint mobility.
Choice B rationale:
Ensuring the client has an elevated toilet seat at home is important following a total hip arthroplasty. The elevated seat reduces the amount of hip flexion required during toileting, which helps prevent hip dislocation and strain on the surgical site.
Choice C rationale:
Providing a trapeze bar is not essential for a client following a total hip arthroplasty. Trapeze bars are typically used to assist with repositioning in bed for clients with limited mobility, but they are not specific to hip arthroplasty recovery.
Choice D rationale:
Providing a compression garment is not necessary after total hip arthroplasty. Compression garments are often used for conditions like venous insufficiency or to manage swelling, but they are not routinely used for hip arthroplasty recovery.

A. The client's bed has a three-prong plug attached to the electrical cord. B. A protective cover is inserted into an unused outlet. C. An IV pump is plugged into an outlet near a sink. D. An electrical cord is coiled and secured to the floor.

Correct Answer is C

Explanation

Choice A rationale:

A three-prong plug attached to the electrical cord of the client's bed is not a safety hazard. It is a standard plug type used in many electrical devices and poses no immediate danger if properly installed.

Choice B rationale:

Inserting a protective cover into an unused outlet is actually a safety measure to prevent electrical accidents. It is not a hazard but a recommended practice.

Choice C rationale:

Plugging an IV pump into an outlet near a sink is a safety hazard. Water and electricity are a dangerous combination, and any spill or leakage around the outlet could lead to electrical shock or damage to the equipment.

Choice D rationale:

Coiling and securing an electrical cord to the floor can be a potential tripping hazard, but it is not as hazardous as having an electrical device near a sink. Tripping hazards can cause falls, while the combination of water and electricity is more likely to cause serious injuries.

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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

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Correct Answer is B

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Correct Answer is C

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