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 ["A","C","D"]
Explanation
Choice A rationale
Orange juice is a clear liquid and is allowed in the Mormon faith.
Choice B rationale
Hot chocolate is not a clear liquid and is not typically consumed by individuals who follow Mormon beliefs due to its caffeine content.
Choice C rationale
Apple juice is a clear liquid and is allowed in the Mormon faith.
Choice D rationale
Chicken broth is a clear liquid and is allowed in the Mormon faith.
Choice E rationale
Black coffee is not a clear liquid and is not typically consumed by individuals who follow Mormon beliefs due to its caffeine content.
Correct Answer is D
Explanation
Choice D rationale
Seeking clarification of the type of advance directive the client has is the most appropriate response. A living will typically outlines a person’s wishes for end-of-life care, but it may not specifically address emergency situations like cardiac arrest.
Choice A rationale
Scheduling a client and family conference to review the plan of care may be helpful, but it is not the immediate priority. The nurse first needs to understand the client’s wishes as outlined in their advance directive.
Choice B rationale
Explaining that living wills cannot be followed by emergency personnel is not entirely accurate. While it’s true that emergency personnel initiating resuscitative measures may not have immediate access to a person’s living will, in a hospital setting, a person’s known wishes should be respected as much as possible.
Choice C rationale
Checking the client’s arm for a “Do Not Resuscitate” (DNR) bracelet is not the most appropriate response. While some people may choose to wear such a bracelet, not all do. Furthermore, a DNR order is just one type of advance directive, and it’s important to clarify what specific directives the client has in place.
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