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","D","E"]
Explanation
Choice A rationale
Teaching the client how to use guided imagery can be a helpful intervention for coping with feelings related to death and dying. Guided imagery can help the client to relax, reduce stress and anxiety, and find comfort.
Choice B rationale
Instructing the client and family to reconsider end of life choices is not typically an appropriate intervention. The nurse should respect the client’s end of life choices and provide support, rather than suggesting they reconsider.
Choice C rationale
Recording the client’s desire to live is not typically an intervention used in hospice care. The focus in hospice care is on providing comfort and quality of life, rather than on prolonging life.
Choice D rationale
Encouraging the family to bring the client old photographs can be a helpful intervention. Looking at old photographs can stimulate memories and conversations, providing comfort and connection.
Choice E rationale
Encouraging the family to visit frequently can be a beneficial intervention. Frequent visits can provide the client with emotional support and companionship, which can be comforting when coping with feelings related to death and dying.
Correct Answer is D
Explanation
Choice D rationale
Scheduling frequent rest periods can help manage the fatigue and concentration problems reported by the client. These symptoms are common in clients with CKD and elevated BUN and serum creatinine levels.
Choice A rationale
Administering PRN oxygen may not be necessary unless the client is showing signs of respiratory distress or hypoxia. There is no indication of this in the question.
Choice B rationale
Providing high protein snacks is not recommended for clients with CKD. High protein diets can increase the workload on the kidneys and worsen kidney function.
Choice C rationale
Monitoring glucose levels every 4 hours is not directly related to the client’s reported symptoms or the elevated BUN and serum creatinine levels.
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