A nurse is preparing to provide a complete bed bath for a client. Which of the following actions should the nurse take?
Offer the client a bedpan once the bath is complete.
Don sterile gloves prior to providing perineal care for the client.
Remove the client's top sheet after placing a bath blanket over it.
Ask the client's partner to leave the room until the bath is complete.
The Correct Answer is C
A. Offer the client a bedpan once the bath is complete.
The client should be offered the bedpan before the bath to ensure comfort.
B. Don sterile gloves prior to providing perineal care for the client.
Clean gloves are appropriate for bed baths and perineal care unless the client has open wounds.
C. Remove the client's top sheet after placing a bath blanket over it.
Maintains client privacy and warmth during the bath.
D. Ask the client's partner to leave the room until the bath is complete.
The client should be consulted first-respect autonomy and preferences before asking visitors to leave.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E","F"]
Explanation
A. Administer Rh, D immune globin prior to surgery
If client is Rh-negative, Rhogam is necessary to prevent isoimmunization.
B. Obtain a complete blood count
Needed preoperatively to assess for anemia, especially with ongoing bleeding.
C. Remind client to be NPO prior to surgery
Standard pre-op instruction to reduce risk of aspiration under anesthesia.
D. Explain the surgical procedure to the client
Explaining procedures is the provider’s responsibility, not the nurse’s.
E. Prepare client for insertion of 18-gauge peripheral IV
A large-bore IV is needed for fluid resuscitation and possible blood transfusion.
F. Verify consent form is signed by the client
It is the nurse’s role to confirm that consent was obtained and documented.
G. Assist with administration of AB positive blood products if needed
The client must receive type-specific blood unless it’s an emergency, in which case O negative is preferred.
Correct Answer is B
Explanation
A. Check for prescription for restraints.
Restraints are a last resort; nurse should attempt de-escalation first.
B. Speak to the client in a low, calm voice.
De-escalation and calm communication are first-line responses to agitation.
C. Ask security personnel to escort the client.
Escalates tension and should not be first-line.
D. Stand directly in front of the client and instruct them to sit.
Standing in front of an agitated person can be confrontational and may provoke aggression.
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