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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Administer with meals and a bedtime snack. This schedule does not ensure that the medication is administered at equally spaced intervals throughout the day, as required for 4 divided doses.
B. 1000, 1600, 2200, 0400. This schedule is not practical or feasible, as it includes a dose in the middle of the night.
C. 0800, 1200, 1600, 2000. This schedule provides equally divided doses at intervals that are practical and coincide with the client's waking hours.
D. Give in equally divided doses during waking hours. While this option mentions administering doses during waking hours, it does not specify specific times for administration, unlike option C.
Correct Answer is C
Explanation
A. Clamp the chest tube immediately with a plastic clamp. Clamping the chest tube can lead to tension pneumothorax, which is a life-threatening complication. It should never be done unless specifically instructed by a healthcare provider.
B. Apply an occlusive dressing over the chest tube site. This action is not indicated in this situation and could interfere with drainage.
C. Ensure the chest tubing is not kinked or hanging low. This is the correct intervention as a kinked or dependent chest tube can impede drainage, leading to respiratory distress.
D. Reinforce the chest tube connection to the container with tape. While ensuring the chest tube connection is secure is important, it is not the priority in this situation where the client is experiencing sudden shortness of breath.
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