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)

Answer and Explanation

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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Correct Answer is A

Explanation

A. Wearing synthetic clothing and woolen socks can generate static electricity, which poses a fire hazard in the presence of oxygen. The client should be advised to wear cotton or natural fiber clothing, which is less likely to generate static electricity.
B. "I will make sure my visitors smoke outside" is a correct statement. It is important to avoid smoking or open flames near oxygen equipment, as oxygen is highly flammable.
C. "I will be able to tell how much oxygen I'm getting by looking at the flowmeter" is a correct statement. The flowmeter indicates the rate of oxygen delivery in liters per minute.
D. "I should call my doctor if I find it harder to concentrate" is a correct statement.
Changes in mental alertness or concentration can be a sign of inadequate oxygenation and should be reported to the healthcare provider.

A. To remove gastric acid that might cause dyspepsia B. To confirm the placement of the NG tube C. To identify delayed gastric emptying D. To determine the client's electrolyte balance

Correct Answer is C

Explanation

A. Measuring the gastric residual is a common practice before administering enteral feedings. It helps to assess if the client's stomach is emptying properly and if there is any buildup of undigested formula. This is important in identifying delayed gastric emptying, which can lead to complications if not addressed.
B. To remove gastric acid that might cause dyspepsia is not the primary purpose of measuring gastric residual. The main concern is to assess the rate of stomach emptying.
C. To confirm the placement of the NG tube is typically done using other methods, such as pH testing or an X-ray. While aspirating stomach contents through the tube can help confirm placement, it is not the primary purpose of measuring gastric residual.
D. To determine the client's electrolyte balance is not related to the purpose of measuring gastric residual. Electrolyte balance is typically assessed through blood tests and clinical signs and symptoms.

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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.)

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Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

Correct Answer is A

Explanation

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

Correct Answer is C

Explanation

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