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","E"]
Explanation
Choice A rationale
A sudden change in behavior, especially confusion and agitation, in an elderly patient could be a sign of a urinary tract infection (UTI). Pain during urination is a common symptom of UTIs.
Therefore, it is crucial to inquire if the patient is experiencing any pain during urination.
Choice B rationale
While a high-protein diet can be beneficial for some patients, there is no direct link between increased protein intake and the alleviation of confusion or agitation in elderly patients.
Therefore, this option is not a necessary immediate action for the nurse to take.
Choice C rationale
Reviewing the patient’s current food and medication allergies is important. Certain medications or foods might cause adverse reactions, including confusion and agitation. Therefore, it is crucial to review the patient’s allergies to rule out any potential allergens as the cause of the sudden change in behavior.
Choice D rationale
A recent fall could potentially lead to a head injury, which might cause confusion and agitation. Therefore, it is important to determine if the patient has recently experienced a fall.
Choice E rationale
Providing instructions on how to take the patient’s temperature is important. Fever could be a sign of an infection or other medical condition that might cause confusion and agitation.
Therefore, knowing how to accurately measure the patient’s temperature can help monitor the patient’s condition.
Correct Answer is B
Explanation
Choice A rationale
While monitoring serum sodium levels is important in a client with DKA, it is not the most critical. Hyperglycemia can lead to a state of effective osmotic diuresis, which can cause sodium depletion.
Choice B rationale
Serum potassium levels are crucial to monitor in a client with DKA3. Despite total body potassium depletion, serum potassium levels may be high or normal upon presentation due to acidosis and insulin deficiency. However, with insulin treatment, potassium will shift back into the cells, potentially leading to life-threatening hypokalemia.
Choice C rationale
Blood urea nitrogen (BUN) might be elevated due to dehydration, but it is not the most critical lab value to monitor in the management of DKA3.
Choice D rationale
Urine ketones are not as important to monitor as serum potassium in DKA. The presence of ketones in urine only confirms that the body is breaking down fat, not the severity of DKA3.
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