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 D

Explanation

A. Dehydration is unlikely to cause blood-tinged urine. Dehydration can lead to concentrated urine, but it typically does not cause blood in the urine.
B. Pernicious anemia is a condition related to a deficiency in vitamin B12, which can lead to a decrease in red blood cell production. However, it is not directly associated with blood in the urine.
C. Bladder infection can cause blood in the urine, but it is more commonly associated with symptoms such as urinary frequency, urgency, and burning during urination. If blood is present, it is usually due to inflammation of the bladder lining.
D. Prostate enlargement, also known as benign prostatic hyperplasia (BPH), can cause blood-tinged urine. The prostate gland surrounds the urethra, and enlargement can lead to irritation and bleeding from the urinary tract.

A. Sheepskin heel pad B. Footboard C. Trochanter roll D. Abduction pillow

Correct Answer is B

Explanation

A. A sheepskin heel pad is primarily used for pressure ulcer prevention, not for preventing plantar flexion contractures.
B. A footboard helps maintain the feet in a dorsiflexed position, preventing plantar flexion contractures in clients with impaired mobility. This device provides support and alignment to the lower extremities.
C. A trochanter roll is used to prevent external rotation of the hips and to maintain proper alignment. It is not specifically designed to prevent plantar flexion contractures.
D. An abduction pillow is used to maintain hip alignment and prevent hip adduction. It is not designed to address plantar flexion contractures.

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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 caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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