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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. If the nurse administers the next bag at 1700, the current bag will run out before then, leaving the client without IV fluid for some time.
B. Correct. If the nurse administers the next bag at 1600, the current bag will have infused 750 ml by then, leaving 250 ml to infuse over the next hour. This will ensure a continuous and consistent infusion rate of 125 ml/hr.
C. Incorrect. If the nurse administers the next bag at 1500, the current bag will have infused only 625 ml by then, leaving 375 ml to infuse over the next hour. This will result in a faster infusion rate of 187.5 ml/hr, which may cause fluid overload or hyperglycemia in the client.
D. Incorrect. If the nurse administers the next bag at 1800, the current bag will run out before then, leaving the client without IV fluid for some time.
Correct Answer is ["B","C","E"]
Explanation
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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