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 .

Answer and Explanation

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.

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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.

A. Ignore the behavior and proceed with the IV antibiotic administration. B. Instruct the patient to cease the inappropriate behavior. C. Exit the room and close the door quietly. D. Fill out an unusual occurrence report.

Correct Answer is C

Explanation

Choice A rationale
Ignoring the behavior and proceeding with the IV antibiotic administration is not the best course of action. This would be an invasion of the patient’s privacy and could potentially lead to legal issues. It is important to respect the patient’s privacy and dignity at all times.
Choice B rationale
Instructing the patient to cease the inappropriate behavior is not the best course of action. While the behavior is inappropriate, it is not the nurse’s place to reprimand the patient. This could lead to a breakdown in the nurse-patient relationship and could potentially escalate the situation.
Choice C rationale
Exiting the room and closing the door quietly is the best course of action. This respects the patient’s privacy and allows the patient and visitor to finish their activity. The nurse can then return at a later time to administer the IV antibiotic.
Choice D rationale
Filling out an unusual occurrence report is not necessary in this situation. While the behavior is inappropriate, it is not an unusual occurrence that requires reporting. The nurse should handle the situation professionally and with discretion.

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Which assessment finding is most crucial when planning to provide a complete bed bath to a bedfast client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who weighs 176 pounds is prescribed enoxaparin sodium 1.5 mg/kg/day subcutaneously. The medication is available in a 120 mg/0.8 mL prefilled syringe. How many mL should the nurse administer? (Enter numerical value only.)

Correct Answer is ["0.8"]

Explanation

Upon entering a patient’s room to administer an IV antibiotic at 0900, the nurse discovers that the patient is engaged in sexual activity with a visitor. What should be the nurse’s course of action?

Correct Answer is C

Explanation

The nurse identifies an electrolyte imbalance, elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours in a client with hepatic failure. Which intervention should the nurse include in the plan of care?

Before inserting an indwelling urinary catheter, which information about the patient is most important for the nurse to obtain?

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours. Which additional action should the nurse instruct the UAP to take each time the client is turned?

A client with a right hemopneumothorax has a chest tube connected to suction. While turning to the left side, the client becomes suddenly short of breath and anxious. What should the nurse do next?