A practical nurse is providing basic care for an older adult client who is weak and on prescribed bed rest following a right-sided thoracentesis. The client is receiving continuous oxygen therapy via nasal cannula. Which actions should the nurse include in the plan of care? Select all that apply.
- Assist with a partial bed bath while ensuring the posterior chest dressing remains dry and intact.Answer
- BPosition the client in a flat, supine position to facilitate continuous, uninterrupted sleep.
- Provide a warmed blanket and dim the overhead room lights to promote relaxation.Answer
- DRemove the oxygen cannula temporarily to wash the client's face thoroughly.
- Perform oral hygiene using moistened sponge swabs to alleviate mucous membrane dryness.Answer
- FRaise all four side rails on the bed to prevent the weak client from falling.
Answer
The correct actions are to assist with a partial bed bath while protecting the dressing, provide a warmed blanket with dimmed lights, and perform oral hygiene using moistened swabs.
Providing a partial bed bath while keeping the dressing intact maintains hygiene without risking infection at the puncture site. Dimming lights and providing a warmed blanket are effective nonpharmacological comfort measures that promote rest. Using moistened swabs for oral care safely relieves the mucous membrane dryness often caused by continuous oxygen therapy.
Step-by-Step Solution
Key Concept
Safe Implementation of Basic Care and Comfort Interventions