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

2+ pitting edema of the feet.

Pallor.

Orthopnea.

Right-sided paralysis.

Answer and Explanation

The Correct Answer is C

A.   2+ pitting edema of the feet. While edema requires monitoring and may necessitate some adjustments in care, it does not directly impact the ability to provide a bed bath.
B.   Pallor. Pallor indicates potential anemia or poor circulation but does not directly impact the provision of a bed bath.

C.   Orthopnea. Orthopnea, difficulty breathing when lying flat, is critical to consider when planning a bed bath. The client may need to be positioned with the head elevated to facilitate breathing and ensure comfort during the bath.
D.   Right-sided paralysis. Paralysis requires careful handling to prevent injury, but it is not as

immediately critical to the bathing process as orthopnea, which directly affects the client's ability to breathe comfortably.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Compare muscle strength bilaterally. While hyperkalemia can lead to muscle weakness, assessing muscle strength bilaterally is not the most critical intervention in this scenario. The priority is to assess for cardiac manifestations of hyperkalemia.
B. Determine apical pulse rate and rhythm. Hyperkalemia can cause life-threatening cardiac dysrhythmias, including bradycardia, heart block, and ventricular tachycardia. Assessing the apical pulse rate and rhythm can provide essential information about cardiac function and help identify potential dysrhythmias.
C. Assess strength of deep tendon reflexes. Hyperkalemia can affect neuromuscular function, leading to hyperreflexia or diminished reflexes. While assessing deep tendon reflexes is
important, it is not as critical as assessing cardiac function in a client with known hyperkalemia.
D. Observe color and amount of urine. While changes in urinary output and characteristics may indicate renal impairment associated with hyperkalemia, the priority in this situation is to assess for cardiac manifestations of hyperkalemia.

A. Oxygen is less toxic when it is humidified with a hydration source. B. Avoid administration of oxygen at high levels for extended periods. C. Increase oxygen rate during sleep to compensate for slower respiratory rate. D. Taking a sedative at bedtime slows respiratory rate, which decreases oxygen needs.

Correct Answer is B

Explanation

A. Oxygen is less toxic when it is humidified with a hydration source. While humidification can prevent drying of the respiratory mucosa, it does not directly relate to the principle of avoiding high levels of oxygen for extended periods.
B. Avoid administration of oxygen at high levels for extended periods. This is the correct principle. Prolonged exposure to high levels of oxygen can lead to oxygen toxicity, which can cause lung damage. Oxygen therapy should be titrated to maintain adequate oxygenation without exposing the patient to excessive oxygen levels.
C. Increase oxygen rate during sleep to compensate for slower respiratory rate. This statement is incorrect. Oxygen therapy should be adjusted based on the patient's oxygen saturation levels and respiratory status, not solely on sleep patterns.
D. Taking a sedative at bedtime slows respiratory rate, which decreases oxygen needs. While sedatives can depress respiratory rate, leading to decreased oxygen needs, this is not a general principle of oxygen administration. Oxygen therapy should be based on the patient's oxygenation needs rather than medications they are taking.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Oxygen at 5 L/minute per nasal cannula is being administered to a 10-year-old child with pneumonia. When planning care for this child, which principle of oxygen administration should the nurse consider?

Correct Answer is B

Explanation

The nurse is monitoring a client with Cushing's disease in the postanesthesia care unit (PACU) after a hypophysectomy. Which intervention is most important for the nurse to include in the client's plan of care?

An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasm when taking the blood pressure using the same arm. After confirming the presence of the spasms, which action should the nurse take?

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Exhibits Based on the client's status at 1400, the nurse should plan to do which of the following? Select all that apply.

A client admitted to the hospital with a suspected ruptured diverticulum develops signs and symptoms of septic shock. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care?

The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured in the arms because the client has casts on both arms and is unable to be measured in the legs because the client is in the supine position. Which action should the nurse implement?