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
Explanation
A. Observing the client's respiratory status is the priority action because a decreased level of consciousness can potentially lead to compromised airway and respiratory function. It's crucial to monitor for signs of respiratory distress or compromise, such as changes in respiratory rate, depth, and effort.
B. Monitoring intake and output every 8 hr is an important nursing responsibility, but it is not the top priority when the client's respiratory status is in question.
C. Elevating the head of the client's bed 30° to 45° is a standard practice to prevent aspiration and promote optimal digestion during enteral feedings. While important, it is not the immediate priority in this situation.
D. Checking residual volume every 4 to 6 hr is a part of enteral feeding management, but it is not the priority when the client's respiratory status is a concern.
Correct Answer is C
Explanation
A. Rubbing hands and arms to dry is not the correct action for hand hygiene. After applying soap, hands should be rinsed thoroughly with water and then dried using a clean towel or air dryer.
B. Adjusting the water temperature to feel hot is not recommended for hand hygiene.
Water that is too hot can be uncomfortable and may even cause skin irritation. The water should be comfortably warm.
C. Applying 4 to 5 mL of liquid soap to the hands is the correct action. This provides an adequate amount of soap to create a good lather for effective handwashing.
D. Holding the hands higher than the elbows is not a necessary step for hand hygiene.
The focus should be on thoroughly cleaning the hands, not on the position of the hands in relation to the elbows.
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