The nurse is supervising a new UAP providing hygiene care to a patient . Which action requires the nurse to provide additional instruction regarding hygiene care ? ( Select all that apply . )
- The UAP performs hand hygiene before providing care.
- The UAP holds the clean linens against the uniform
- The UAP places soiled linens on the floor.
- The UAP places clean linens on the patient’s clean overbed table
- The UAP places soiled linens in a linen bag for transport .
2,3
During the bed bath , the nurse covers the patient with a bath blanket . The patient asks what the bath blanket is for. What is the nurse’s best response ?
- “The bath blanket helps to prevent skin irritation
- The bath blanket is part of our bathing procedure “
- “The bath blanket helps to prevent chilling during the bath .
- ” The bath blanket is used to prevent the spread of microorganisms .
3
A patient with severe crippling rheumatoid arthritis is confined to bed for extended periods . An erythematous area over the coccyx that has the potential to become an open lesion is noted . The nurse is correct in reporting this area to the health care provider as having the potential to become what ?
1. An inflammatory injury
2. A pressure injury
3. A stasis injury t
4. An arterial injury
2
A patient is too weak to perform her own perineal care . The student nurse includes bathing in which areas as part of perineal care ?
1. Back and buttocks
2. Lower back , upper thighs
3. Upper torso and thighs
4. Upper thighs , genitalia , and anal area
4
Which patient is at greatest risk for skin impairment ?
1. A 12 -year -old on bed rest
2. A 7 -month - old with cool skin temperature
3. A 26 - year -old with diarrhea
4. A 60 - year - old in a body cast
4
A patient is in her second postoperative day after an abdominal hysterectomy. The nurse plans to give the patient a bed bathWhich action is appropriate when caring for the patient’s face? (Select all that apply
- Use only water on the patient’s face.
- Ask the patient if she prefers soap or plain water
- Use soap in all areas of the face except the eyes
- Use a cleansing cream to cleanse her face and neck
- Use a different area of the washcloth for each eye
2,5
The nurse is teaching the patient proper hygiene measures. What should the nurse include when teaching the patient about eye care?
- Wash from the inner canthus to the outer canthus
- Cleanse dried exudate with hot water
3.Avoid drying the circumorbital area after washing - Use a cotton-tipped applicator for each eyelid.
1
An 11-month-old infant is admitted with a tympanic temperature of 105F (40.6C) The physician orders a tepid sponge bath The infant’s mother asks”What is the purpose of this bath? Which is the best response by the nurse?
- The bath helps reduce your baby’s body temperature .
- “The bath is used to help prevent febrile seizures”
- The bath stimulates circulation to the skin.”
- The bath helps calm and relax your baby”
1
An uncircumcised man is in the first postoperative day after a transurethral prostatectomyWhen administering perineal care, which action by the nurse is ?
- Retract the foreskin, cleanse the penis, and allow the foreskin to return to its former position.
2 Retract the foreskin, cleanse the penis, and sprinkle powder under the foreskin to facilitate retraction - Retract the foreskin , cleanse the penis, and leave the foreskin slightly damp to allow refraction to its former state.
- Retract the foreskin , cleanse the penis , and return the foreskin with a gentle forward motion
4
A patient was discharged home with a Foley catheter The student nurse instructs the patient in the proper procedure for cleansing the female perineal area .
What teaching point should the nurse include in discharge Instructions?
1. Cleanse the area in circular motions around the rectum.
2. Cleanse from the rectum toward the pubis
3.Cleanse from the pubis toward the anal area.
4. Cleanse in circular motions around the vaginal area
3
The nurse is reviewing the teaching plans of several patients in a medical unit. Which patient does the nurse correctly identify as most at risk for development of complications of the feet ?
1. A 55-year -old disoriented patient
2. A 30- year-old patient whose career requires extensive standing
3.A 60 -year- old patient with a 30-year history of diabetes mellitus
4. A 62-year -old patient who had a total hip replacement 2 years ago
3
The nurse is providing oral care to a patient who is unconsciousThe optimal position for providing oral hygiene to this patient is to prevent choking
- High Fowler’s position
- High Fowler’s position with head hyperextended
3.Supine with the head lowered
4.Side- lying with head facing to the side
4
. A patient has diffuse pancreatitis causing severe weakness. The CNA is bathing the patient. While the CNA cleanses the patient’s ears, which action by the CNA will prompt the nurse to intervene? (Select all that apply
- Cleansing the outer ear with the washcloth during bath
- Retracting the outer ear downward to loosen visible cerumen
- Irrigating the ear with cool water to remove tenacious cerumen
- Using cotton- tipped applicators to cleanse the pinna of each ear
- Placing an otoscope in the ear canal to visualize any areas that need cleaning
3,4,5
The student nurse has completed her educational instructions on the correct procedures for bed making. Which intervention is correct for bed making(Select all that apply.)
- Preparing a closed bed for receiving postoperative patients
- Shaking soiled linen before placement in the hamper
- Mitering the corners of the bottom fitted sheet
- Washing hands thoroughly after making a patient’s bed
- Folding and reusing the patient’s bedspread if it is not soiled
4
A patient is in his first postoperative day. As part of his moming care, the nurse removes and cleanses his dentures. Which action demonstrates proper denture care?
- Brushing the dentures over an open sink with the water running
- Rinsing dentures thoroughly with hot water before brushing
- Brushing dentures with a soft toothbrush or denture brush
- After cleaning, storing dentures in a dry denture cup
3
The nurse is providing instruction to the UAP who is assisting with caring for an immobile patient who requires turning every 2 hours. The UAP asks the nurse why it is best to place the patient in the 30-degree lateral position. Which response by the nurse is correct ?
1.This position helps prevent pressure injuries on spinous processes “
2. “ This position helps prevent pressure injuries on the Ischial tuberosities .
3. This position helps prevent pressure injuries on the greater trochanters “
4. “ This position helps prevent pressure injuries on the occipital prominence .”
3
- The nurse is reviewing documentation from the previous shift. The nurse is correct when determining the patient has a stage 3 pressure injury based on which note ?
- Nonblanchable reddened areas where the skin is intact
- Full-thickness tissue loss extending through subcutaneous tissue and muscle
- Extensive destruction of skin and adipose tissue with possible tunneling
- Areas of full-thickness skin loss with extension to the bone
3
The patient has been changing a dressing on a pressure injury for several days and is now being seen in the physician’s office . The patient states , “There is a lot of pink tissue at the base of the wound.” The nurse explains to the patient that this is the result of what process ?
- Improper dressing technique and probable infection
- Presence of a layer of eschar that has to be removed
- Development of a fungal overgrowth interfering with healing
- The normal process of healing with healthy granulation tissue
4
The nurse is most concerned when applying heat therapy to which patient ?
- A patient who has been diagnosed with high blood pressure
- A patient who is unconscious as the result of an automobile accident
- A patient who has just returned from physical therapy for back pain
- A patient who was recently diagnosed with type 2 diabetes mellitus
2
The nurse is providing discharge instructions for a patient who will be using cold therapy after knee replacement surgery. What statement by the patient indicates the need for further instruction ? ( Select all that apply )
1.don’t have a cold pack at home like the one in the hospital .
2.I will use the cold pack in my cooler to ice my knee.” i will use a cloth or towel to wrap my cold pack when I get home so that I don’t damage my skin when I’m applying it to my knee . “
3. “ My friend says that using a bag of frozen vegetables works well as an ice pack as long as you wrap it in a cloth.”
4. i will leave the cold pack on my knee for 1 hour, leave it off for 30 minutes , and then apply it again for 1 hour all day long so that my knee won’t swell “
5. “The cold pack really helps the pain in my knee. I will use it at home so that I hopefully won’t have to take a lot of pain medication
1,4
. A nurse is performing mouth care for a client who is unconscious . Which of the following actions should the nurse take?
A. Turn the client’s head to the side.
B. Place two fingers in the client’s mouth to open it.
C. Brush the client’s teeth once per day .
D. Inject a mouth rinse into the center of the client’s mouth .
A. Turn the client’s head to the side.
A nurse is instructing a client who has diabetes mellitus about foot care . Which of the following guidelines should the nurse include ? (Select all that apply .)
A. Inspect the feet daily .
B. Use moisturizing lotion on the feet .
C. Wash the feet with warm water and let them air dry .
D. Use over -the - counter products to treat abrasions .
E. Wear cotton socks .
a,b,e
. A nurse is planning care for a client who develops dyspnea and feels tired after completing morning care . Which of the following actions should the nurse include in the client’s plan of care ?
A. Schedule rest periods during morning care .
B. Discontinue morning care for 2 days .
C. Perform all care as quickly as possible .
D. Ask a family member to come in to bathe the client .
a
. A nurse is beginning a complete bed bath for a client . After removing the client’s gown and placing a bath blanket over the body , which of the following areas should the nurse wash first ?
A. Face
B.Feet
C. Chest
D. Arms
a
