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.

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Correct Answer is D

Explanation

A. Plan to observe the secured IV site after the insertion procedure.
This is a proactive step, but it does not address the immediate need to correct the new nurse’s choice of dressing.

B. Remind the nurse to tape the gauze dressing securely in place.
While securing the dressing is important, it is not the best practice to use a gauze dressing for IV sites as it obscures the view of the insertion site.

C. Confirm that the nurse has gathered the necessary supplies.
Confirming supplies is important, but this does not address the incorrect dressing choice.

D. Instruct the nurse to use a transparent dressing over the site.
This is the correct answer because a transparent dressing allows for continuous visual inspection of the IV site for signs of infection or infiltration, which is crucial for patient safety.

A. For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect catheterized specimens. B. Urinate immediately into a urinal, and the lab will collect the specimen every 6 hours for the next 24 hours. C. Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours. D. Cleanse and meatus, discard the first portion of voiding, and collect the rest in a sterile bottle.

Correct Answer is C

Explanation

A. This instruction is incorrect because it suggests collecting catheterized specimens, which is not necessary for a creatinine clearance test. Catheterization may increase the risk of contamination and is not typically performed for this test.
B. This instruction is incorrect because it does not involve the collection of a complete 24-hour urine specimen. Collecting specimens every 6 hours would not provide an accurate measurement of creatinine clearance over a 24-hour period.
C. This instruction is correct. For a 24-hour urine collection, the client should urinate at a specified time to start the collection period, discard this urine, and then collect all subsequent urine produced over the next 24 hours. This ensures that the entire 24-hour period is captured for analysis.
D. This instruction is incorrect because it does not involve the collection of all urine produced over a 24-hour period. Additionally, discarding the first portion of voiding is not necessary for a creatinine clearance test and may lead to inaccurate results.

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

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the CLIENT?

Correct Answer is C

Explanation

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