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. Dorsal surface of the foot B. Dorsal surface of the hand C. Pinnae of the ears D. Conjunctivae

Correct Answer is D

Explanation

A) The dorsal surface of the foot is not the most reliable site to assess for cyanosis in individuals with dark skin because the skin pigmentation can mask the bluish tint that indicates reduced oxygenation.
B) Similarly, the dorsal surface of the hand may not clearly show cyanosis due to the thickness and pigmentation of the skin, which can obscure the color change.
C) The pinnae of the ears may also not be the best indicator of cyanosis in dark-skinned individuals because peripheral areas like the ears can be affected by environmental temperatures, leading to misleading color changes.
D) The conjunctivae, however, are a mucous membrane where the skin pigmentation does not affect visibility. Therefore, it is an appropriate site for assessing cyanosis as it allows for the observation of subtle changes in color that indicate hypoxia. This is why the conjunctivae are the correct site to examine for cyanosis in a client with dark skin.

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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 assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

Correct Answer is D

Explanation

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