Chapter 9- Hygiene and Care of the Patients Environment
Which of the following patients have increased risk of a skin pressure injury? select all the apply.
1. A patient with obesity 2. A patient who is underweight 3. An incontinent patient 4. A patient with nasogastric tube in place 6. A patient with a spinal cord injury
A neighbor tells the nurse that he has muscle soreness and stiffness after performing a new exercise program. What would the nurse recommend? 1. A tub bath with the proper temperature of 113° to 115°F 2. A bath with the water temperature at a tepid and 98.6°F 3. A sitz bath that lasts 20-30 minutes for soaking and relaxing 4. A shower with a recommended water temperature of approximately 110°F
1. A tub bath with the proper temperature of 113° to 115°F (45° to 46°C)
What instructions would the nurse give to the UAP about applying a warm, moist compress to a small abscess in the patients axilla? select all that apply 1. Compress should be 105* to 110*F 2. Apply for 30-40 minutes 3. Report pain, exudate, or redness. 4. Notify about completion of therapy 5. Evaluate the response to therapy
1. Compress should be 105* to 110*F 3. Report pain, exudate, or redness 4. Notify about completion of therapy
Which patient is most likely to request that the room temperature be turned down? 1. Has chronic obstructive pulmonary disease 2. Has alternating chills and fever 3. Has Peripheral vascular disease 4. Has end-stage pancreatic cancer
1. Has chronic obstructive pulmonary disease
The nurse is providing discharge instructions for a patient who will be using cold therapy after knee replacement surgery. What is statement by the patient indicates a need for further instruction? Select all that apply 1. I don't have a cold pack at home like the one I had in the hospital. I will use the cold pack I use in my cooler to ice my knee. 2. I will use a cloth or a towel to wrap my cold pack in 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 one hour, leave it off for 30 minutes, and then apply it again for one 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. I don't have a cold pack at home like the one I had in the hospital. I will use the cold pack I use in my cooler to ice my knee. 4. I will leave the cold pack on my knee for one hour, leave it off for 30 minutes, and then apply it again for one hour all day long so that my knee won't swell
The nurse is caring for an older adult patient who requires assistance with everything elimination. He can walk very slowly, but is frequently incontinent of urine before he can get to the toilet. What would the nurse do to help the patient with elimination? Select all that apply 1. Instruct the UAP to be alert for the call signal and answer promptly 2. Obtain an order for an indwelling catheter until bladder training is achieved 3. Show the patient how to use a urinal and place it within his reach 4. Obtain an order for a commode chair and place it close to the bed 5. Restrict fluids to exact intervals to establish a voiding pattern 6. Make a plan with the patient to call sooner rather than delaying
1. Instructor you UAP to be alert for the call signal and answer promptly 3. Show the patient how to use a urinal and place it within his reach 4. Obtain an order for a commode chair and place it close to the bed 6. Make a plan with the patient to call sooner rather than delaying
An unconscious patient needs oral care. What instructions with the nurse gives a UAP to assure the safety of the patient? Select all that apply 1. Put the patient in a side lying position, use pillows for support as needed. 2. Report bleeding, sores in the mouth, or obvious problems with teeth or gums. 3. Check for gag reflex by gently inserting a tongue blade into the throat 4. Use a soft toothbrush to clean inner and outer surfaces of the teeth, swab mouth and tongue 5. Have an oral suction device ready and check function prior to starting. 6. Perform hand hygiene before donning clean gloves
1. Put the patient in a side lying position, use pillows for support as needed. 2. Report bleeding, sores in the mouth, or obvious problems with teeth or gums. 4. Use a soft toothbrush to clean inner and outer surfaces of the teeth, swab mouth and tongue 5. Have an oral suction device ready and check function prior to starting. 6. Perform hand hygiene before donning clean gloves
The nurse is assessing a patient who is immobile because of injuries sustained in a car accident. What areas does the nurse pay special attention to for the prevention and early detention of pressure injuries?
1. Sacrum 2. Scapulae 3. Trochanteric areas of the hips 4.Heels 5. Back of the head
The nursing student is told to observe the bowel movements of an adult patient and report any abnormalities to the nurse. What was the student report as an unexpected finding? 1. Stool was a dull clay color 2. Stool had soft, formed consistency 3. Patient reported three bowel movements this week 4. Stool have the shape of the rectum
1. Stool was dull clay color
An 11 month old infant is admitted with a tympanic temperature of 105°F. The physician orders a tepid sponge bath. The infants mother ass, what is the purpose of this bath? Which is the best response by the nurse? 1. The bath helps reduce your babies body's temperature 2. The bath is used to help prevent febrile seizures 3. The bath stimulates circulation to the skin 4. The bath helps calm and relax your baby
1. The bath helps reduce your babies body's temperature
What is a general principle to consider when using heat and cold therapy for patients? 1. The patient should be assessed for ability to perceive temperature in the area of the application 2. The patient should adjust the temperature settings for comfort. 3. The patient should move the applications around for relief 4. Application is positioned for convenient observation
1. The patient should be assessed for ability to perceive temperature in the area of the application
The nurse is assessing the oral cavity of an unconscious patient and sees tenacious, dried exudate on the tongue, teeth, and gums. Which instructions would be given to the UAP? 1. Use a moistened sponge applicator and gently clean crusts several times per shift. 2.Spray the mouth with a bulb syringe and use oral suction to remove the fluid. 3.Use a toothbrush with paste and scrub the area until the crusts are removed? 4.Wrap a gauze sponge around a tongue blade and apply hydrogen peroxide.
1. Use a moistened sponge applicator and gently clean crusts several times per shift.
The nurse is teaching the patient proper hygiene measures. What should the nurse include when teaching the patient about eyecare? 1. Wash from inner canthus to Outer canthus 2. Cleanse dried exudate with hot water 3. Avoid drying the circumorbital area after washing 4. Use a cotton-tipped applicator for each eyelid
1. Wash from inner canthus to outer canthus
A patient with dementia needs assistance with bathing. What strategies are best to help the patient accomplish this task? Select all that apply 1. maintain a relaxed demeanor, smile frequently and use a calm tone of voice. 2. demonstrate and explain the desired behaviors such as how to turn on the water. 3. Reassure frequently and say things such as, "you are doing very well. We are almost done" 4. Try to repeat the same hygiene pattern every day and wash the same body parts. 5. Use distraction rather than trying to negotiate or making demands 6. Attempt to have the same caregiver as often as possible for hygienic care.
1. maintain a relaxed demeanor, smile frequently, and use a calm tone of voice. 3. Reassure frequently and say things such as," you are doing well. We are almost done." 5. Use distraction rather than trying to negotiate or making demands 6. Attempt to have the same caregivers as often as possible for hygienic care
The nurse is evaluating the Eyecare that has been delegated to and is being provided by a new staff member. Which action is appropriate? 1.Removing dried secretions with moist gauze 2. Using soap and water on a washcloth 3. Cleansing the eyes from the outer to the inner canthus 4. Wiping plastic eyeglasses with a clean paper towel
1. removing dried secretions with moist gauze
The nurse is most concerned when applying heat therapy to which patient? 1. A patient who has been diagnosed with high blood pressure 2. A patient who is unconscious as a result of an automobile accident 3. A patient who has just returned from physical therapy for back pain 4. A patient who was recently diagnosed with type two diabetes mellitus
2. A patient who is unconscious as a result of an automobile accident
With appropriate instructions and supervision, which tasks related to hygienic care could be delegated to experienced UAP? select all that apply.
2. A patient with an indwelling urinary catheter needs assistance with pericare 5. A patient who is unconscious has secretions along the margins of the eyelids.
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 4. An arterial injury
2. A pressure injury
A patient is in her second postoperative day after an abdominal hysterectomy. The nurse plans to give the patient a bed bath. Which action is appropriate when caring for a patient's face? 1. Use only water on the patient's face 2. Ask the patient if she prefers soap or plain water 3. Use soap in all areas of the face except the eyes 4. Use a cleansing cream to cleanse her face and neck 5. Use a different area of the washcloth for each eye
2. Ask the patient if she prefers soap or plain water 5. Use a different area of the washcloth for each eye
The nurse is teaching a patient who ha diabetes about foot care. What would be included in the self-care instructions? 1. Carefully cut corns and apply moleskin. 2. Inspect feet daily for breaks in the skin. 3. Wear loose shoes or sandals to air the feet. 4. Use alcohol on a gauze pad to clean between toes.
2. Inspect feet daily for breaks in the skin.
The nurse is caring for older adult residents in an assisted living facility. What is the best strategy to prevent skin breakdown among this vulnerable group? 1. Make daily rounds and assess skin condition. 2. instruct you a P to help residence out of bed as much as possible. 3. Plan a toileting schedule for the residence at greater risk. 4. Ask the dietary department to serve high-quality protein foods.
2. Instruct UAP to help residence out of bed as much as possible.
Which instructions would the nurse provide to the UAP who will be bathing a patient with a hearing aid? Select all the apply.
2. Remove the hearing aid when washing the patients hair. 3.Clean the hearing aid with a soft dry cloth 5. Allow the patient to attempt to put the hearing aids back in after the bath 6. Notify the nurse if any drainage is noted in the ear
A patient who is paralyzed from the waist down is at risk for developing a pressure injury on the sacral area. Which intervention would the nurse use for this patient? 1. Frequently check and change the bed linens 2. Teach to shift weight every 15 minutes 3. Obtain an order for a donut cushion for sitting 4. Keep skin moist and frequently reapply lotion
2. Teach to shift weight every 15 minutes
The nurse is supervising a new UAP providing hygiene care to a patient. Which action by the UAP requires the nurse to provide additional instruction regarding hygiene care? select all that apply 1. The UAP performs hand hygiene before providing care 2. The UAP holds the clean linens against the uniform 3. The UAP places soiled linens on the floor 4. The UAP places clean linens on the patients clean overbed table 5. The UAP places soiled linens in a linen bag for transport
2. The UAP holds the clean linens against the uniform 3. The UAP places soiled linens on the floor
A sitz bath has been ordered for a patient with a history of recent vaginal delivery with extensive perineal lacerations. How would the nurse explain this treatment to the patient?
2. The purpose of the sitz bath is to cleanse and reduce inflammation
What is an expected change related to aging that necessitates more frequent oral hygiene for older adults?
2. There is a decreased production of saliva and commonly an alteration in the sense of taste
During the bed bath, the nurse covers the patient with a bath blanket. The patient asks what the bath blanket is for. Wh is the nurses best response? 1. "The bath blanket helps to prevent skin irritation." 2. "The bath blanket is part of our bathing procedure." 3. "The bath blanket helps to prevent chilling during the bath." 4. "The bath blanket is used to prevent the spread of microorganisms."
3. "The bath blanket helps to prevent chilling during the bath."
The nurse is reviewing the teaching plans of several patients on a medical unit. Which patient does the nurse correctly identifies 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. Hey 62-year-old patient who had a total hip replacement two years ago
3. A 60-year-old patient with a 30 year history of diabetes mellitus
The nurse is caring for a postpartum patient. Which assessment with the nurse perform first before starting perineal care? 1. Note present of accumulated secretions 2. Evaluate the appearance of the perineum 3. Assesses ability to perform own care 4. Ask about burning with urination
3. Assess ability to perform own care
The nurse is caring for an obese patient who needs assessment of skin and self-care abilities. The patient also needs perineal care, partial bath, and the bed linen changed. What is the best strategy to meet the needs of the patient? 1. Instruct the UAP to perform all tasks except the skin assessment 2. Asked the UAP to call when the patient's back is position for assessment 3. Assess skin and self control abilities while working with the UAP to complete care. 4. Assess his skin and self care abilities, then tell the patient to perform her own care
3. Assess his skin and self-care abilities while working with a UAP to complete care
The nurse is caring for a postpartum patient. Which assessment with the nurse perform first before starting perineal care? 1. Note present of accumulated secretions 2. Evaluate the appearance of the perineum 3. Assesses ability to perform own care 4. Ask about burning with urination
3. Assesses ability to perform own care
The nurse will delegate denture care to the unlicensed assistive personnel (UAP). What instructions would the nurse give to the UAP about the patients dentures? 1. Use hot water and mild soap 2. Let the patient wear them at night 3. Brush dentures with a soft toothbrush 4. Wrap them in a soft towel when not worn
3. Brush dentures with a soft toothbrush
A patient is in his first postoperative day. As part of his morning care, the nurse removes and cleanses his dentures. Which action demonstrates proper denture care? 1. Brushing the dentures over an open sink with the water running 2. Rinsing dentures thoroughly with hot water before brushing 3. Brushing dentures with a soft toothbrush or denture brush 4. After cleaning, storing dentures in a dry denture cup
3. Brushing dentures with a soft toothbrush or denture brush
The 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 towards the pubis 3. Cleanse from the pubis toward the anal area 4. Cleanse in circular motions around the vagina area
3. Cleanse from the pubis toward the anal area
The nurse is assessing a patient being admitted from another institution for the presence of pressure injuries. Which of the following statements is correct?
3. Documentation should include measurements and description of any injuries
The nurse is reviewing documentation from the previous shift. The nurse is correct when determining the patient has a stage three pressure injury based on which now? 1. Non-blanchable reddened areas where the skin is intact 2. Full thickness tissue loss extending through subcutaneous tissue and muscle 3. Extensive destruction of skin and adipose tissue with possible tunneling 4. Areas a full thickness skin loss with extension to the bone
3. Extensive destruction of skin and adipose tissue with possible tunneling
A patient has diffuse pancreatitis causing severe weakness. The CNA is bathing the patient. While the CNA cleanses the patient ears, which action by the CNA will prompt the nurse to intervene? 1. Cleansing the outer ear with the washcloth during the bath 2. Retracting the outer ear downward to loosen visible cerumen 3. Irrigating the ear with cool water to remove tenacious cerumen 4. Using cotton - tipped applicators to cleans the Pinna of each year 5. Placing an otoscope in the ear canal to visualize any areas that need cleaning
3. Irrigating the ear with cool water to remove tenacious cerumen 4. Using cotton - tipped applicators to cleans the Pinna of each year 5. Placing an otoscope in the ear canal to visualize any areas that need cleaning
The nurse observes the patient performing ear care. Which behavior indicates a need for additional teaching? 1. Cleans the pinna with a cotton tip swab 2. Turns the hearing aid off when not in use 3. Leaves the hearing aid by sunny window 4. Rotates a clean wash cloth to clean ear canal
3. Leaves the hearing aid by a sunny window
The nurse applies heat to a large area on the patients trunk. The patient reports feeling slightly dizzy and his pulse is rapid. What is the BEST physiologic explanation for this systemic reaction? 1. The heat application has triggered a fever 2. The trunk contains some large blood. 3. The application is causing vasodilation 4. Antibodies and leukocytes are activated
3. The application is causing vasodilation
The care plan indicates that all caregivers should encourage the patient's independence in accomplishing activities of daily living ADLs. What is the best indication that the nurses and you AP are successful with this part of the care plan? 1. The UAP waits until the patient uses the call light for assistance 2. The nurse sees that the commode chair is close to the bed. 3. The nurse observes that the patient is brushing his own teeth 4. The UAP tells the patient to independently complete ADLs
3. The nurse observes that the patient is brushing his own teeth
The patient was diagnosed with a sprained ankle and the provider recommended a cold application for 20 minutes. Which condition would cause the nurse to question the order? 1. The patients ankle is already slightly swollen. 2. the pain medication has not had time to work 3. The patient has a history of peripheral vascular disease 4. The patient tells the nurse that 20 minutes is to long.
3. The patient has a history of peripheral vascular disease
Which would be the MOST important factor to consider when planning person hygiene for a patient from a cultural background that the nurse has not previously worked with?
3. The patients individual preferences
The nurse is providing instruction to the UAP who is assisting with caring for an immobile patient who requires turning every two hours. The UAP asks the nurse why is it best to place the patient in the 30° 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 trochanter's 4. This position helps prevent pressure injuries on the occipital prominence
3. This position helps prevent pressure injuries on the greater trochanter's
Which patient is at greatest risk for skin impairment? 1. A 12 year old on bed rest 2. A seven month old was cool skin temperature 3. A 26 year old with diarrhea 4. A 60 year old in a body cast
4. A 60 year old in a body cast
The nurse notices a reddened area on the patients sacrum. What would the nurse do first? 1. Cleanse the skin with alcohol 2. Wash the area with warm water and soap. 3. Massage the area to stimulate blood flow 4. Assess for other areas of erythema
4. Assess for other areas of erythema
A family member tells the nurse that the staff is spending too much time laughing and chatting at the nurses station and is disturbing the patient rest in comfort. What would the nurse do first? 1. Instruct the staff to be more discrete and move conversations to the break room. 2. Assess other environmental factors that are interfering with patient's comfort. 3. Apologize to the family member and assure her that the situation will be corrected. 4. Assess the patient's discomfort and ask what other things are interfering with rest.
4. Assess the patient's discomfort and ask what other things are interfering with rest.
A new resident has been admitted to a long-term care facility. What is the most important thing for the nurse to assess before delegating oral hygiene to the UAP?
4. Does the resident have a gag reflux and is he able to spit out residue from toothpaste and mouthwash.
In delegating the early morning care that should occur before breakfast, what does the nurse remind the UAP to do for the patient? 1. Shampoo the patients hair and comb it 2. Assist the patient with a bath and clean gown 3. Offer the patient a back rub with warmed lotion. 4. Help the patient wash hands and face
4. Help the patient wash hands and face
The nurse is supervising a nursing student who is giving a patient a bed bath the nurse would intervene if the student performed which action? 1. Lowers the side rail to perform care 2. raises the head of the bed to a semi Fowlers position 3. Baths arms using long, firm strokes 4. Puts up all four bed rails after completing the bath
4. Put up all four side rails after completing the bath
An uncircumcised man is in the first postoperative day after a transurethral prostatectomy. When administering perineal care, which action by the nurse is correct? 1. Retracting foreskin, cleans the penis, and allow the foreskin to return to its former position. 2. Retracting foreskin, cleanse the penis, and sprinkle powder under the foreskin to facilitate retraction. 3. Retract the foreskin, cleanse the penis, and leave the foreskin slightly damp to allow retraction to its former state. 4. Retract the foreskin, cleanse the penis, and return the foreskin with a gentle forward motion.
4. Retract the foreskin, cleanse the penis, and return the foreskin with a gentle forward motion.
The nurse is providing oral care to a patient who is unconscious. The optimal position for providing oral care to this patient is to __________________ prevent choking. 1. High Fowlers position 2. Hi Fowlers position with head hyper extended 3. Supine with the head lowered 4. Side - lying with head facing to the side
4. Side - lying with head facing to the side
The patient has been changing a dressing on a pressure injury for several days and is now being seen in the physicians 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? 1. Improper dressing technique and probable infection 2. Presence of a layer of Eschar that has to be removed 3. Developing of a fungal overgrowth interfering with healing 4. The normal process of healing with heavy granulation tissue
4. The normal process of healing with heavy granulation tissue
A patient is too weak to perform her own perineal care. The student nurse includes bathing 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. Upper thighs, genitalia and anal area
The student nurse has completed her educational instructions on the correct procedures for bedmaking. Which intervention is correct for bedmaking? 1. Preparing a close bed for receiving postoperative patients 2. Shaking soiled linen before placement in the hamper 3. Mitering the corners of the bottom fitted sheet 4. Washing hands thoroughly after making a patient's bed 5. Folding and reusing the patient's bedspread if it is not soiled
4. Washing hands thoroughly after making a patient's bed
The nurse is doing discharge teaching with a female patient who is going home with a Foley catheter. Which statement by the patient indicates the need for further teaching? A. "I will wash my perineum from back to front." B. "I will use soap and water for cleaning." C. "I will pat dry my perineum after washing." D. "I will wash after each bowel movement."
A. "I will wash my perineum from back to front." The perineum needs to be cleansed from front to back in order to prevent contamination from the spread of microorganisms.
Which bath aids in the reduction of inflammation of the perineal and anal areas? A. Sitz bath B. Bed bath C. Medicated bath D. Whirlpool bath
A. Sitz bath Patients who have undergone rectal or vaginal surgery or given birth benefit from a sitz bath, which aids in reducing inflammation in the perineal and anal areas.
The home health nurse is observing a family member assist the patient with a heating pad. The nurse would intervene if the family member performs which action? 1. Assists the patient to lie on the heating pad 2. Adjust the pad to the lowest temperature setting 3.Places a cloth between the skin and the heating device 4. Check electrical cord for fraying or kinks
Assist the patient to lie on the heating pad
A patient receiving anticoagulant therapy is requesting to shave. What is the nurse's most appropriate response to the patient? A. "You will not be able to shave until the medication is stopped." B. "You will be able to shave only with an electric razor." C. "You can go ahead and shave as normal." D. "Make sure to use plenty of shaving cream."
B. "You will be able to shave only with an electric razor." People with bleeding tendencies or on anticoagulant therapy should use an electric razor to minimize the risk of being cut.
A bedfast patient has a sacral pressure injury. How often does the nurse instruct staff to reposition the patient? A. Every 4 hours B. Every 2 hours C. Every hour D. Once a shift
B. Every 2 hours A bedfast patient on complete bed rest patient should be turned at least every 2 hours. Avoid the full lateral position.
The nurse is caring for an immobile patient with incontinence. What patient problem best describes this patient's problem? A. Imbalanced nutrition: less than body requirements B. Impaired skin integrity C. Impaired urinary elimination D. Impaired physical mobility
B. Impaired skin integrity All of these are potential diagnoses, but putting all the factors together places the patient most at risk for impaired skin integrity.
Nurses set an example for patients regarding hygiene. What personal hygiene measures should the nurse display? (Select all that apply.) A. Bathe twice a day. B. Wear a clean uniform every day. C. Keep fingernails clean, short, and manicured. D. Consistently avoid the use of makeup, jewelry, or perfumes. E. Always be clean-shaven. F. Use breath mints.
B. Wear a clean uniform every day. C. Keep fingernails clean, short, and manicured. F. Use breath mints. A nurse should wear a clean uniform every day; keep fingernails clean, short, and manicured; and use breath mints to set a positive example for patients and not be offensive when providing care. Bathing once a day is sufficient. Makeup, jewelry, and perfumes should be used sparingly, but it is not necessary to eliminate their use totally. Beards can be worn but should be kept neat, short, and trimmed.
The LPN is giving a bed bath to a patient with diabetes. While assessing the skin, which area of the body needs special attention? A. Back B. Arms C. Feet D. Legs
C. Feet All areas are important, but patients with diabetes usually have decreased circulation. The feet and between the toes are areas that need special attention.
What is the purpose of positioning a patient at the 30-degree lateral position? A. Proper alignment of joints B. An alternate position to lie in C. Reduction of pressure points D. Better comfort
C. Reduction of pressure points For patients with pressure injuries or who are at risk for pressure injuries, the 30-degree lateral position is used to avoid pressure points.
A patient is noted with a pressure injury on his sacrum. The pressure injury has full-thickness skin loss with necrosis of the subcutaneous tissue. Which classification is this pressure injury? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4
C. Stage 3 Stage 3 is a full-thickness skin loss that involves damage or necrosis of subcutaneous tissue that may extend down to but not through the underlying fascia.
A patient who is hard of hearing removes his hearing aid before going to bed. What is an important step for the patient to remember when removing? A. Keep it located in the bathroom when not being worn. B. Avoid routine cleaning. C. Clean any wax buildup in the ear canal with a cotton swab. D. Turn off the battery.
D. Turn off the battery The hearing aid needs to be stored in a safe place, cleaned regularly, and turned off to prolong the battery life.
Stage 4 pressure injury
Full thickness skin loss that occurs with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures.
Stage 3 pressure injury
Full-thickness skin loss that involves damage or necrosis of subcutaneous tissue that may extend down to but not through the underlying fascia.
A cold application is ordered for the patient. What is positive effect of this treatment? 1. Vasodilation 2. Local anesthesia 3.Reduced blood viscosity 4. Increased metabolism
Local anesthesia
Stage 1 pressure injury
Nonblanchable erythema of the intact skin.
Stage 2 pressure injury
partial thickness skin loss involves epidermis, dermis or both. The ulcer is superficial and manifests as an abrasion, blister, or shallow crater.
