Fundamental Success Questions Chapter 40

The student nursing is teaching a family member of the important of foot car for his or her mother, who has diabetes. Which safety precautions are important for the family member to know to prevent infection? (Select all that apply) 1. Cut nails frequently 2. Assess skin for redness, abrasions, and open areas daily 3. Soak feet in water for at least 10 minutes before nail care 4. Apply lotion to feet daily. 5. Clean between toes after bathing.

2. Assess skin for redness, abrasions, and open areas daily 4. Apply lotion to feet daily. 5. Clean between toes after bathing.

A cognitively impaired client is incontinent of loose stools. Which action should the nurse implement? 1. Wash the buttocks with strong soap and water. 2. Bathe immediately after bowel movement 3. Apply Talcum powder after the bath 4. Put a pad under the buttocks

2. Bathe immediately after bowel movement

A nurse is giving a client a bed bath. Which nursing action is the most important? 1. Lower the 2 side rails on the working side of the bed 2. Ensure the bathwater is at least 110 degrees 3. Fold the washcloth like a mitt on the hand. 4. Raise the bed to the highest position.

2. Ensure the bathwater is at least 110 degrees

A nurse is making an occupied bed. Which nursing action is most important? 1. Securing top linens under the foot of the mattress and mitering the corners. 2. Ensuring the client's head is supported and is in functional alignment 3. Fan-folding soiled linens as close to the client's body as possible. 4. Placing the bed in horizontal position.

2. Ensuring the client's head is supported and is in functional alignment

A nurse must make the decision to give a patient a full or partial bed bath. On what criterion does the nurse base this decision? 1. Practitioner's order for the patient's activity 2. Immediate need of the patient 3. Time of patient's last bath 4. Patient preference

2. Immediate need of the patient

Which human response, identified by the nurse, best supports the concern that a client has a reduced capacity to provide for activities of daily living? 1. Presence of joint contractures 2. Inability to wash body parts 3. Postoperative lethargy 4. Visual disorders

2. Inability to wash body parts

Which should be the nurse's first intervention after removing a bedpan from under a debilitated client who has just had a bowel movement? 1. Document results 2. Provide perineal care 3. Reposition the client 4. Cover the client with the top linens

2. Provide perineal care

The nurse delegates needed hygiene care for an elderly stroke patient which intervention would be appropriate for the nursing assistive personnel to accomplish during the bath? 1. Checking distal pulses 2. Providing ROM exercises to extremities 3. Determining type of treatment for stage 1 pressure ulcer 4. Changing the dressing over an IV site

2. Providing ROM exercises to extremities

What is the proper position to use for an unresponsive patient during oral care to prevent aspiration? (select all that apply) 1. Prone 2. Sim's 3. Semi-fowlers position with head to the side 4. Tredenlenburg position 5. Supine position.

2. Sim's 3. Semi-fowlers position with head to the side

A client just had perineal surgery. Which type of bath should the nurse expect to be prescribed for this client? 1. Sponge bath 2. Sitz bath 3. tub bath 4. Bed bath

2. Sitz bath

A nurse is caring for a client who was newly admitted to a rehab facility. After reviewing the client's record, the nurse chooses which of the following bath plans to meet the client's hygiene needs? 1. Complete bath with partial assistance 2. Towel bath with partial assistance 3. Shower with partial assistance 4. Tub bath with total assistance

2. Towel bath with partial assistance

A nurse is providing for the hygiene and grooming needs of an obese client who easily becomes short of breath when moving about. Which nursing intervention is important? Select all that apply 1. Administering oxygen during provision of care 2. Maintaining the bed in a high-fowlers position 3. Assessing the client's response to the activity 4. Bathing areas that the client cannot reach 5. Providing rest period every ten minutes.

3, 4

Which statement made by an olde adult indicates to the nurse that additional teaching about skin care is necessary? 1. I limit my baths to twice a week 2. I humidify my home in the winter 3. I apply moisturizing lotion to my body daily 4. I use a bubble-bath product when i take a bath 5. I love to relax in a hot bath before going to bed.

4 & 5

A nurse is teaching a client about how many times a day it is necessary to brush the teeth to achieve effective dental hygiene. According to the American Dental Association, how many time a day should the nurse teach the client to brush the teeth? 1. 6 2. 4 3. 3 4. 2

4. 2

A nurse is assigned to care for the following patients. Which of the patients is most at risk for developing skin problems and thus requiring thorough bathing and skin care? 1. A 44 year old who has had removal of a breast lesion and is having her menstrual period 2. A 56 year old male patient who is homeless and is admitted the the E.R. with malnutrition and dehydration and who had an IV line 3. A 60 year old female who experienced a stroke with right sided paralysis and has an orthopedic brace applied to the left leg. 4. A 70 year old patient who has diabetes and dementia and has been incontinent of stool.

4. A 70 year old patient who has diabetes and dementia and has been incontinent of stool.

A patient has had a nasogastric tube to decompress the stomach for 3 days and is scheduled for intestinal surgery in the morning. For which of the following is the client at the highest risk? 1. Physical injury 2. Ineffective social interaction 3. Decreased nutritional intake 4. Altered oral mucous membrane.

4. Altered oral mucous membrane.

A nurse must bathe the feet of a client with diabetes. Which should the nurse do before bathing this client's feet? 1. File the nails straight across with an emery board. 2. Teach the daily foot care is essential for adequate hygiene 3. Ensure a provider's prescription for hygienic foot care is obtained. 4. Assess for additional risk factors that may contribute to localized problems.

4. Assess for additional risk factors that may contribute to localized problems.

A nurse changes the sheets and pillowcase of a bed while the client sits in a chair. Of the options presented, which is the most important nursing action when changing bed linens? 1. Ensuring the hem of the bottom sheet is facing the mattress 2. Arrange the linen in the order in which it is to be used 3. Shifting the mattress up to the headboard of the bed. 4. Checking the soiled linens for personal items.

4. Checking the soiled linens for personal items.

A nurse plans to shave a male client's facial hair with a safety razor. Which of the following should the nurse implement? Select all that apply 1. Hold the razor perpendicular to the skin 2. Use long downward strokes with the razor 3. Shave in the opposite direction of hair growth 4. Ensure the patient is not receiving a anticoagulant 5. Use a hot, wet washcloth to wrap the face before shaving.

4. Ensure the patient is not receiving a anticoagulant

A nurse plans to assist a client who has impaired vision with a bed bath. Which is the most appropriate nursing intervention to facilitate for this client? 1. Providing the client with a liquid gel rather than a bar of soap. 2. Giving the client an adapted toothbrush to use when brushing the teeth. 3. Checking the client's ability to give self-care through a crack in the curtain. 4. Ensuring the client can locate bath supplies placed on the over-bed table.

4. Ensuring the client can locate bath supplies placed on the over-bed table.

Which common problem with the hair should the nurse anticipate when clients are on complete bedrest? 1. Dry hair 2. Oily hair 3. Split hair 4. Matted hair

4. Matted hair

When a nurse delegates hygiene care for a male patient to a nursing assistive personnel, the NAP must use an electric razor to shave the patient with the following diagnosis: 1. Congestive heart failure 2. Pneumonia 3. Arthritis 4. Thrombocytopenia

4. Thrombocytopenia

A school nurse teaches an adolescent who has dry skin and acne about skin care. Which statement by the adolescent indicates the info is understood? Select all that apply 1. I will scrub my face every day with a strong soap. 2. I will break pustules carefully after washing my face 3. I will apply an oil-based emollient after washing my face 4. I will bathe my face with cool water when I shower in the morning. 5. I will use mild soap to gently cleanse my face thoroughly twice a day.

5. I will use mild soap to gently cleanse my face thoroughly twice a day.

A clients asks the nurse, "Why do I have to use mouthwash if I brush my teeth?" Which rationale about the use of all mouthwashes should the nurse include when responding to this question? 1. Reduces offensive mouth odors. 2. Minimizes the formation of cavities. 3. Softens debris that accumulates in the mouth. 4. Destroys pathogens that are found in the oral cavity.

1. Reduces offensive mouth odors.

During oral care, the nurse identifies a patch of dried food and debris adhered to the hard palate of the client's mouth. Which word should the nurse use when documenting this conditions? 1. Sordes 2. Plaque 3. Glossitis 4. Stomatitis

1. Sordes

The American Dental Association suggests that patients who are at risk for poor hygiene use the following interventions for oral care: (Select all that apply) 1. Use antimicrobial toothpaste 2. Brush teeth 2 times a day 3. Use 0.12% chlorhexidine gluconate (CHG) oral rinses 4. Use soft toothbrush for oral care 5. Avoid cleaning the gums and tongue

1. Use antimicrobial toothpaste 3. Use 0.12% chlorhexidine gluconate (CHG) oral rinses 4. Use soft toothbrush for oral care

A nurse is listening to a student provide instruction to a patient who is having difficulty with activities needed to care for soft contact lenses. Which of the following statements by the nursing student might require some correction by the nurse? 1. Use tap water to clean soft lenses 2. Follow recommendations of lens manufacturer when inserting the lenses 3. Keep lenses moist or wet when not worn 4. Use fresh solution daily when storing and disinfecting lenses.

1. Use tap water to clean soft lenses

Which nursing action is common to both a bed bath and tub bath? Select all that apply 1. Obtaining a prescription from the primary health-care provider 2. Helping the client wash body parts that cannot be reached. 3. Exposing just the part of the body being washed. 4. providing privacy throughout the bath 5. Ensuring the call button is within reach

2 & 4

Which should the nurse implement when caring for a client who wears eyeglasses? Select all that apply 1. Encourage use of artificial tears while hospitalized 2. store eyeglasses in a safe place when not being worn. 3. Dry the lenses with a paper towel after they are washed 4. Limit the time that eyeglasses are worn in an effort to rest the eyes. 5. Use warm water to clean the lenses of eyeglasses at least once a day.

2 & 5

A nurse plans to provide a client with a partial bath. Place the following steps in order in which the nurse should proceed. 1. back 2. face 3. Axilla 4. Both hands 5. genital area 6. Change water

2,3,4,6,1,5

A nurse is observing a nursing assistant in a home-care setting administering a bed bath. Which issue apparent in the photo indicated the nursing assistant had violated the standards of care for bed bath? Select all that apply 1. The pillows behind the client's body should be removed before the bath. 2. The nursing assistant's uniform is in contact with the client's linens 3. The nursing assistant should be making eye contact with client 4. Client's left leg should be covered with bath blanket. 5. The nursing assistant is not wearing clean gloves.

2,4,5,

A patient with a malignant brain tumor requires oral core. The patient's level of consciousness has declined, with the patient only being able to respond to voice demands. Place the following steps in the correct order for administration of oral care 1. If patient is uncooperative or having difficulty keeping mouth open, insert an oral airway 2. Raise bed, lower side rail, and position patient close to the side of the bed with head of bed raised up to 30 degrees. 3. Using a brush moistened with chlorhexidine paste, clean chewing and inner tooth surfaces first. 4. For the patients without teeth, use a toothette moistened in chlorhexidine rinse to clean oral cavity 5. Remove partial plate or dentures if present 6. Gently brush tongue but avoid stimulating gag reflex.

2,5,1,3,6,4

A nurse teaches the client effective oral hygiene practices. Which of the following indicates that the teaching about preventing and removing dental plaque was understood by the client? Select all that apply. 1. Uses a nonbrasive toothpaste 2. Brushes the teeth with a toothbrush 3. Gargles with anti-plaque mouthwash 4. Flosses the teeth with unwaxed floss 5. Has teeth cleaned regularly by a dental hygienist

All of the above

Which of the following should the nurse implement when providing fingernail care during a client's bath? Select all that apply 1. Push cuticles back with a section of a soft washcloth 2. File nails straight across, rounding corners slightly. 3. Apply a moisturizing lotion around cuticles 4. Clean under nails with an orange stick 5. Soak hands in warm water first.

All of the above

A nurse is helping a client who has right hemiparesis to get dressed. Which action should the nurse implement? 1. Put the gown's right sleeve on first 2. Keep the client in an open-backed gown. 3. Encourage the client to dress independently. 4. Leave the right sleeve off while adjusting the tie at the neck.

1. Put the gown's right sleeve on first

Which nursing intervention most requires the nurse to consider the concept of intimate space? 1. Providing a bed bath 2. Obtaining the vital signs 3. Performing a health history 4. Ambulating the client down the hall

1. Providing a bed bath

A nurse is caring for a patient with an excessively dry mouth. Which nursing action is important when providing mouth care for this client? Select all that apply 1. wearing clean gloves 2. Providing oral care every 2 hours 3. Rinsing frequently with mouth wash 4. Cleansing 4 times a day with a water pick 5. Swabbing with sponge-tip applicator of lemon and glycerin

1 & 2

A nurse plans to meet the hygiene needs of hospitalized client who is experiencing hemiparesis because of a brain attack (cerebrovascular accident). Which is an appropriate nursing intervention? 1. Assisting the client to bathe as needed. 2. Giving total assistance with a complete bath 3. Providing minimal supervision during the bath 4. Encouraging a family member to bath the client

1. Assisting the client to bathe as needed.

A nurse is responsible for providing hair care for a client. Which should the nurse do to distribute oil evenly along hair shafts? 1. Brush the hair from the scalp toward the hair ends. 2. Lift opened fingers through the length of the hair. 3. Apply a hydrating conditioner to wet hair. 4. Comb hair with a fine-toothed comb.

1. Brush the hair from the scalp toward the hair ends.

A client is incontinent of urine and stool. For which client response should the nurse be most concerned? 1. Impaired skin integrity. 2. Altered sexuality 3. Dehydration 4. Confusion

1. Impaired skin integrity.

A nurse is bathing a client who has a fever. Why should the nurse use tepid bath water for this procedure? 1. Increases heat loss 2. Removes surface debris 3. Reduces surface tension of skin 4. Stimulates peripheral circulation

1. Increases heat loss

A nurse used long, firm, strokes distal to proximal while bathing a patient's legs because: 1. It promotes venous circulation 2. It covers a large area of the leg 3. IT completes care in a timely fashion 4. It prevent blood clots of legs.

1. It promotes venous circulation

A nurse plans to administer a foot bath to a client who is sitting in a chair and has no contraindication for this intervention. Place the following steps in the order in which they should be implemented. 1. Soak each foot individually for 5 to 20 minutes, subject to the client's tolerance, condition of the skin, and absence of a history of diabetes or peripheral vascular disease 2. Don clean gloves an d assist the client to position one foot int he water, verifying with the client the water temp. is comfortable. 3. Position a waterproof pad on the floor on which place a basic half-filled with warm water. 4. Wash each foot with rinse-free soap and clean under the nails with an orange stick. 5. Apply lotion to each foot, avoiding between the toes. 6. Dry each foot gently, especially between toes

3,2,1,4,5,6

A nurse must make an unoccupied bed. Which nursing action is most important? 1. Position the call bell in reach 2. Place a pull sheet on top of the draw sheet 3. Ensure that the bottom sheet is free of wrinkles 4. Ensure that there is a toe pleat at the foot of bed. 5. Complete one side of the bed before completing the other side

3,4

When providing morning care for a client, the nurse identifies crusty debris around the client's eyes. Which of the following should the nurse implement when cleaning the client's eyes? Select all that apply 1. Wear sterile gloves 2. Use tear-free baby soap 3. Position the client on the same side as the eye you are cleaning. 4. Wash the eyes with cotton balls from inner to outer canthus 5. Use a separate cotton ball for each stroke when washing the eyes.

3,4,5

While planning morning care, which of the following patients would have the highest priority to receive his or her bath first? 1. A patient who has just returned to the nursing unit from a diagnostic test. 2. A patient who prefers a bath in the evening when his wife visits and can help him 3. A patient who is experiencing frequent incontinent diarrheal stools and urine. 4. A patient who has been awake all night because of pain 8/10

3. A patient who is experiencing frequent incontinent diarrheal stools and urine.

A nurse is planning to shampoo the hair of a client who has a prescription for bedrest. Which should the nurse do first? 1. Wet hair thoroughly before applying shampoo 2. Encourage the use of dry shampoo 3. Brush the hair to remove tangles 4. Tape eye shields over both eyes.

3. Brush the hair to remove tangles

A nurse covers the client with a cotton blanket during a bath. Which of the following mechanisms of heat loss is prevented by the nurse's action? 1. Vasodilation 2.Conduction 3. Convection 4. Diffusion

3. Convection

The nurse observes an adult Middle Easter patient attempting to bathe himself with only his left hand. The nurse recognizes that this behavior likely relates to: 1. Obsessive compulsive behavior 2. Personal preference 3. Cultural norm 4. Controlling behaviors

3. Cultural norm

Which condition identified by the nurse places a client at the highest risk for impaired self-care when toileting? 1. Amputation of a foot 2. Early dementia 3. Fractured hip 4. Pregnancy

3. Fractured hip

A client who has a fever experienced significant diaphoresis during the night. The client states, " I am tired and I just want to sleep this morning." Which should the nurse do regarding bathing the client? 1. Wait until client feels better 2. Postpone to the afternoon 3. Give bed bath with complete assistance 4. Consult with the primary health-care provider before providing care.

3. Give bed bath with complete assistance

A nurse plans to give a client a back rub. Which product should the nurse use for this intervention? 1. Baby powder 2. Rubbing alcohol 3. Moisturizing lotion 4. Antimicrobial cream

3. Moisturizing lotion

A patient receiving chemotherapy experiences stomatitis. The nurse advises the patient to use: 1. Community mouth wash 2. Alcohol-based mouth rinse 3. Normal saline rinses 4. Firm toothbrush

3. Normal saline rinses

Integrity of the oral mucosa depends on salivary secretion. Which of the following factors impairs salivary secretion? (Select all that apply.) 1. Use of cough drops 2. Immunosuppression 3. Radiation therapy 4. Dehydration 5. Presence of oral airway

3. Radiation therapy 4. Dehydration

A nurse gives a bed bound client a bed bath. Which is the primary reason why the nurse provided hygiene care to this client? 1. Support a sense of well-being by increasing self-esteem. 2. Promote circulation by stimulating peripheral nerve endings. 3. Remove excess oil, perspiration, and bacteria by mechanical cleansing. 4. Exercise muscles by contraction and relaxation of muscles when bathing.

3. Remove excess oil, perspiration, and bacteria by mechanical cleansing.

When you are assigned to a patient who has a reduced level of consciousness and requires mouth care, which physical assessment techniques should you perform before the procedure? (select all that apply) 1. Oxygen saturation 2. Heart rate 3. Respirations 4. Gag reflex 5. Response to painful stimulus

3. Respirations 4. Gag reflex

When giving a client a bed bath, a nurse washed the client's extremities from distal to proximal. Which is the rationale for this nursing action? 1. Decreases chance of infection 2. Facilitates removal of dry skin 3. Stimulates venous return 4. Minimizes skin tear

3. Stimulates venous return

A nurse is providing hygiene to a client with peripheral neuropathy. Which action should the nurse implement? 1. Seek a prescription for foot care 2. File the toenails straight across the nail. 3. Wash the feet with lukewarm water and dry well. 4. Apply moisturizing lotion to the feet, especially between the toes.

3. Wash the feet with lukewarm water and dry well.

A nurse is providing perineal care to a male patient. Which should the nurse do? Select all that apply 1. Wash the genital area with hot, sudsy water 2. Wash the scrotum before washing the glans penis. 3. Wash the shaft of the penis while moving toward the urinary meatus 4. Wash the penis with one hand while holding it firmly with the other hand. 5. Wash the glans with circular motion, starting at the tip and then proceeding down the shaft.

4 & 5