ATI: Personal Hygiene

A nurse is preparing to assist a client with a tub bath. Identify the sequence of steps the nurse should take. 1. Instruct the client on using safety bars when getting in and out of the tub. (Decrease the risk of slipping or falling when entering or exiting the bathtub) 2. Gather all necessary supplies. 3. Place a rubber mat on the tub floor. (Prevent the client from slipping and falling). 4. Assist the client into the bathroom. 5. Instruct the client to remain in the tub for no longer than 20 min. (Prevent vasodilation from the warm water, which could cause light-headedness or dizziness)

1. Gather all necessary supplies. 2. Place a rubber mat on the tub floor. (Prevent the client from slipping and falling). 3. Assist the client into the bathroom. 4. Instruct the client on using safety bars when getting in and out of the tub. (Decrease the risk of slipping or falling when entering or exiting the bathtub) 5. Instruct the client to remain in the tub for no longer than 20 min. (Prevent vasodilation from the warm water, which could cause light-headedness or dizziness)

A nurse in a long-term care facility is caring for a client who is on bed rest and requires frequent linen changes. Which of the following should the nurse identify as the priority rationale for frequent linen changes? A. Moisture from excessive diaphoresis can cause skin breakdown. B. Moisture on the sheets can cause discomfort to the client. C. It provides an opportunity to frequently evaluate the skin on the client's back side. D. It provides an opportunity to turn the client from side to side to facilitate clearing potential fluid from the lungs.

A. Moisture from excessive diaphoresis can cause skin breakdown. Rationale: The greatest risk to the client is skin breakdown, which can result from increased contact with the moist sheets. Increased contact with moist sheets can cause skin irritation and promote bacteria growth. Therefore, the linens should be changed frequently.

A nurse is performing a complete bed bath for a client. Which of the following actions should the nurse take? A. Raise the room temperature. B. Completely remove the linens. C. Add soap to the water in the basin before beginning the bath. D. Bathe one side of the body at a time.

A. Raise the room temperature. Rationale: The nurse should raise the temperature of the room to help keep the client warm while various parts of the body are exposed and washed.

A nurse is preparing to provide oral care for a client who is NPO. The Client tells the nurse "I do not need oral care because I haven't eaten anything," which of the following responses should the nurse make? A. "Since you are not eating, we can wait and do it before bedtime." B. "Oral care is still important even though you are not eating." C. "I'll give you a sip of water to swish around in your mouth, and then you can spit it out." D. "We will wait until your family gets here to help."

B. "Oral care is still important even though you are not eating." Rationale: The nurse should identify that bacteria are still present in the oral cavity regardless of a client's NPO status. Therefore, it is important to perform oral care to help reduce oral bacteria and keep the oral cavity moist.

A nurse is teaching a newly licensed nurse about providing oral hygiene for clients who are unconscious. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "I'll swab the client's mouth with lemon-glycerin swabs." B. "I'll swab the client's mouth with mouthwash." C. "I'll swab the client's mouth with chlorhexidine." D. "I'll swab the client's lips with a very small amount of mineral oil."

C. "I'll swab the client's mouth with chlorhexidine." Rationale: The nurse should use chlorhexidine for daily oral care for unconscious clients because evidence-based practice indicates that it improves client outcomes by preventing microbial build-up.

A nurse is planning morning hygiene care for a postoperative client. Which of the following actions should the nurse take? A. Inform the client when morning hygiene care is provided at the hospital. B. Schedule the client's morning hygiene care at the same time as their roommate. C. Ask the client in what order they typically perform their morning routine. D. Plan to provide care before the next scheduled dose of pain medication.

C. Ask the client in what order they typically perform their morning routine. Rationale: The nurse should ask the client to describe their morning routine so that they can tailor care to the individual client.

A nurse is assisting a client with personal hygiene care. Which of the following actions should the nurse take to reduce the risk of infection? A. Massage reddened areas of the client's skin. B. Wash eyes from the outer canthus to the inner canthus. C. Wash the client from the shoulder down to the fingertips with smooth, short strokes. D. Clean the least-soiled areas prior to cleaning the most-soiled areas.

D. Clean the least-soiled areas prior to cleaning the most-soiled areas. Rationale: The nurse should clean the least-soiled areas prior to cleaning the most-soiled areas because this helps prevent moving more contaminants into the cleaner areas, thereby reducing the risk of infection.

A nurse is observing an AP make a client's bed while the client is out of the room. Which of the following actions by the AP indicates an understanding of the procedure? A. The AP records the task when it is completed. B. The AP wears sterile gloves while making the bed. C. The AP changes the client's pillowcase. D. The AP reuses the client's clean blanket and spread.

D. The AP reuses the client's clean blanket and spread. Rationale: The mattress pad, sheet, blanket, and bedspread can be reused for the same client if they are not wet or soiled.