Which assessment finding is most crucial when planning to provide a complete bed bath to a bedfast client?
Pallor
Right-sided paralysis
2+ pitting edema of the feet
Orthopnea .
The Correct Answer is D
Choice A rationale
While pallor can indicate various health issues such as anemia or low blood flow, it is not the most crucial finding when planning to provide a complete bed bath to a bedfast client.
Choice B rationale
Right-sided paralysis could affect the client’s ability to assist with the bath and could require special care or positioning. However, it is not the most crucial finding in this context.
Choice C rationale
2+ pitting edema of the feet could indicate fluid overload or poor circulation, but it is not the most crucial finding when planning to provide a complete bed bath.
Choice D rationale
This is the correct answer. Orthopnea, or difficulty breathing while lying flat, is the most crucial finding in this context. If a client has orthopnea, they may need to be positioned in a way that allows them to breathe comfortably during the bath.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.8"]
Explanation
Step 1: Convert the client’s weight from pounds to kg. 1 kg is approximately 2.2 lbs. So, 176 lbs
÷ 2.2 = 80 kg (rounded to the nearest whole number).
Step 2: Calculate the total mg of enoxaparin sodium needed per day. The prescription is for 1.5 mg/kg/day. So, 80 kg × 1.5 mg/kg/day = 120 mg/day.
Step 3: Calculate the mL of enoxaparin sodium needed. The medication is available in a 120 mg/0.8 mL prefilled syringe. So, 120 mg ÷ 120 mg/0.8 mL = 0.8 mL. The nurse should administer 0.8 mL.
Correct Answer is ["B","C","D","E","F","G"]
Explanation
Choice A rationale
Lamb’s wool is typically used for padding to prevent pressure sores and does not directly relate to the administration of oxygen therapy. Therefore, it is not necessary when a patient is put on oxygen.
Choice B rationale
Sterile water is used in oxygen therapy to provide humidification, which prevents the drying and irritation of the respiratory mucosa. Therefore, it is necessary when a patient is put on oxygen.
Choice C rationale
Tape can be used to secure the oxygen delivery device, such as a nasal cannula, to the patient’s face. Therefore, it is necessary when a patient is put on oxygen.
Choice D rationale
A suction canister is used to collect respiratory secretions during suctioning procedures, which may be necessary for patients with excessive secretions or difficulty clearing secretions.
Therefore, it is necessary when a patient is put on oxygen.
Choice E rationale
A humidifier bottle is used in oxygen therapy to provide humidification, which prevents the drying and irritation of the respiratory mucosa. Therefore, it is necessary when a patient is put on oxygen.
Choice F rationale
A nasal cannula is a device used to deliver supplemental oxygen to a patient who needs oxygen therapy. Therefore, it is necessary when a patient is put on oxygen.
Choice G rationale
A flowmeter is used in oxygen therapy to control the rate of oxygen flow to the patient. Therefore, it is necessary when a patient is put on oxygen.
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