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 C

Explanation

A. Digoxin.
Digoxin is a cardiac glycoside that helps increase the force of myocardial contraction and is generally used to treat heart failure. It does not typically pose a significant risk for cardiogenic shock.

B. Hydrochlorothiazide.
Hydrochlorothiazide is a diuretic used to manage fluid retention in heart failure. It can cause electrolyte imbalances but is not directly linked to causing cardiogenic shock.

C. Nadolol.
Nadolol is a beta-blocker, which can reduce the heart rate and the strength of heart contractions. In a client with severe heart failure, excessive beta-blockade can lead to a significant decrease in cardiac output, increasing the risk for cardiogenic shock.

D. Captopril.
Captopril is an ACE inhibitor that helps manage heart failure by reducing afterload and preload.
While it can cause hypotension, it is not typically associated with a direct risk of cardiogenic shock.

A. A Place padding around the cannula tubing. B. B Decrease the flow rate to 1 L/minute. C. C Apply lubricant to the cannula tubing. D. D Discontinue the use of the nasal cannula.

Correct Answer is A

Explanation

A. Placing padding around the cannula tubing is the appropriate intervention to address the erythema under the chin. This padding can help alleviate pressure and reduce skin irritation caused by the tubing. It's a proactive measure to prevent further discomfort or skin breakdown.
B. Decreasing the flow rate to 1 L/minute might not address the issue of pressure-related erythema, and it could compromise the client's oxygenation if not clinically indicated.
C. Applying lubricant to the tubing may not effectively reduce pressure or irritation caused by the tubing under the chin.
D. Discontinuing the use of the nasal cannula should be reserved for situations where it is medically necessary or if an alternative oxygen delivery method is available.

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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

The nurse is caring for a client with heart failure. Which of these prescribed medications places the client at risk for cardiogenic shock?

Correct Answer is C

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The nurse observes erythema under the chin of a client receiving oxygen at 2 L/minute per nasal cannula. Which intervention should the nurse implement?

Correct Answer is A

Explanation

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