A nurse is providing hygiene care for a client who is immobile. Which of the following actions should the nurse take? (Select all that apply.)
Wash the client's extremities from proximal to distal.
Check for personal items when changing the bed linens.
Shave the client's hair in the direction of the hair growth.
Place a clean gown on the strongest arm first.
Keep the bath water temperature between between 43.3 C (110F) and 46.1 C (115F)
Correct Answer : B,C,E
A. Washing the client's extremities from proximal to distal is a good practice, but it is not specifically related to caring for an immobile client.
B. Checking for personal items when changing the bed linens is important to ensure that the client's belongings are not lost or misplaced during the process.
C. Shaving the client's hair in the direction of hair growth helps prevent skin irritation and ingrown hairs.
D. The gown should be placed on the weaker arm first.
E. This is an appropriate temperature that can help client remain comfortable.
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Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Wearing a mask helps protect against the transmission of airborne particles, which is important for preventing the spread of tuberculosis.
B. Wearing a gown can provide an additional barrier to prevent the transmission of infectious material.
C. Disposing sharps here is not directly related to tuberculosis precautions. This statement is more relevant for a sharps disposal container.
D. Wearing gloves is important to prevent direct contact with potentially contaminated surfaces.
E. Hand hygiene is crucial for infection control and should be emphasized for anyone entering or exiting the room of a client in isolation.
F. "Radiation inside" is not applicable to the isolation precautions for tuberculosis. This statement is unrelated to tuberculosis precautions and may cause confusion.
Correct Answer is C
Explanation
A. Holding the client's evening dose of digoxin is not the priority at this time. The client's symptoms of confusion and drowsiness require immediate attention to determine the cause.
B. Increasing the client's fluid intake may be important for various reasons, but it is not the most urgent action in this situation. The client's altered mental status and vital signs need to be assessed first.
C. Completing a neurological check is the most appropriate action in this situation. The sudden onset of confusion and drowsiness may indicate a neurological issue that needs to be assessed promptly. This includes assessing the client's level of consciousness, pupillary response, motor function, and other neurological signs.
D. Administering the prescribed PRN antihypertensive medication is not indicated based on the client's current presentation. The client's symptoms are more suggestive of a neurological issue rather than hypertension. It's important to address the altered mental status first.
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