Which intervention should the nurse include while caring for a client who has been diaphoretic for the past six hours?
Offering the client a bedpan every three hours.
Keeping an emesis basin near the bedside.
Providing oral care every four hours.
Changing the bed linens frequently.
The Correct Answer is D
This is because a client who has been diaphoretic for the past six hours is likely to have wet and uncomfortable bed linens that can cause skin breakdown and infection. Changing the bed linens frequently can help keep the client dry and comfortable.
Choice A is wrong because offering the client a bedpan every three hours is not related to diaphoresis and may not meet the client’s elimination needs.
Choice B is wrong because keeping an emesis basin near the bedside is not related to diaphoresis and may not be necessary unless the client has nausea or vomiting.
Choice C is wrong because providing oral care every four hours is not enough to prevent dehydration and dry mouth in a client who has been diaphoretic for the past six hours. The client may need more frequent oral care and fluid intake.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The client should not eat anything before the barium enema, as this could interfere with the visualization of the colon. The client should also take a laxative and an enema the night before the test to clear the bowel of any fecal matter.
Choice B is wrong because the client may need to have laxatives to expel the barium after the test, not before. Barium can cause constipation and impaction if not eliminated promptly.
Choice C is wrong because the client will receive the barium prior to the study by rectum, which is correct. The barium is a contrast agent that helps outline the colon on X-rays.
Choice D is wrong because the client will need to lie down during the study while retaining the barium for X-rays, which is correct. The client may also be asked to change positions to allow different views of the colon.
Correct Answer is C
Explanation
This action would cause the nurse to intervene because it increases the risk of choking and aspiration for a client with dysphagia, which is difficulty swallowing. The nurse would instruct the UAP to feed the client small amounts of food slowly, allowing time for chewing and swallowing.
Choice A is wrong because offering thickened liquids is a safe practice for a client with dysphagia. Thickened liquids allow for easier swallowing and less choking, thus decreasing the chance of aspiration.
Choice B is wrong because placing the client in an upright position is also a safe practice for a client with dysphagia. This position helps prevent food from entering the airway and facilitates swallowing.
Choice D is wrong because allowing ample time between bites is another safe practice for a client with dysphagia. This helps the client avoid feeling rushed or overwhelmed and reduces the risk of aspiration.
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