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Zorluk: OrtaBasic Care and Comfort

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.

  1. Assist with a partial bed bath while ensuring the posterior chest dressing remains dry and intact.Cevap
  2. B
    Position the client in a flat, supine position to facilitate continuous, uninterrupted sleep.
  3. Provide a warmed blanket and dim the overhead room lights to promote relaxation.Cevap
  4. D
    Remove the oxygen cannula temporarily to wash the client's face thoroughly.
  5. Perform oral hygiene using moistened sponge swabs to alleviate mucous membrane dryness.Cevap
  6. F
    Raise all four side rails on the bed to prevent the weak client from falling.

Cevap

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.

Adım Adım Çözüm

1
Analyze the client's clinical status and recent procedure.
The client is weak, post-thoracentesis, on bed rest, and requires continuous oxygen therapy.
Understanding the clinical context is essential to determine safe basic care interventions.
2
Evaluate each care intervention for safety and appropriateness.
Bathing with dressing protection, environmental comfort measures, and oral care are safe and indicated.
These actions promote hygiene and comfort without compromising respiratory status or violating safety protocols.
3
Identify contraindicated actions that compromise safety.
Flat positioning, removing the oxygen cannula, and raising all four side rails are identified as unsafe.
These actions increase the risk of respiratory distress, hypoxia, and constitute unauthorized restraint use.

Anahtar Kavram

Safe Implementation of Basic Care and Comfort Interventions
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