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 D
Explanation
Choice A rationale
While having a case management evaluation of the client’s home environment can provide valuable information and potential solutions for caregiving challenges, it does not directly address the caregiver’s immediate need for relief and support.
Choice B rationale
Hiring a private duty nurse could provide the caregiver with some time away from caregiving duties. However, this may not be a feasible option for many caregivers due to the cost associated with private nursing care.
Choice C rationale
Proposing that extended family could return to the area to help provide assistance assumes that such help is available and willing. This may not be the case for many caregivers.
Choice D rationale
Suggesting that social services be contacted to find a respite care facility for the client directly addresses the caregiver’s need for relief and support. Respite care provides temporary relief for primary caregivers, allowing them to rest and take care of their own needs. This can help to alleviate symptoms of caregiver burnout, such as poor sleep and frequent crying.
Correct Answer is A
Explanation
Choice A rationale
The unlicensed assistive personnel (UAP) is providing care to a client with influenza, a respiratory illness that can be transmitted through droplets when the client coughs or sneezes. Therefore, it is crucial for the UAP to wear a face mask while in close contact with the client to prevent the transmission of the virus. This is in line with the standard precautions for infection control, which recommend the use of personal protective equipment (PPE) such as gloves, gowns, and masks when providing care to clients with infectious diseases.
Choice B rationale
Reassigning the UAP to another client and assuming full care of the client is not the most appropriate action in this situation. While it is the nurse’s responsibility to ensure that the UAP is competent and understands the care needs of the client, it is not necessary to reassign the UAP unless there are specific concerns about their ability to provide safe and effective care.
Choice C rationale
While it is important for the UAP to alert the nurse of any changes in the client’s respiratory status, this is not the most immediate action that the nurse should take in this situation. The priority is to ensure that the UAP is wearing appropriate PPE to prevent the transmission of influenza.
Choice D rationale
A fitted respirator mask is typically used when caring for clients with airborne diseases, such as tuberculosis. Influenza is primarily spread through droplets, so a regular face mask is usually sufficient for protection.
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