ch.40 Hygiene NCLEX questions

During bathing your patient experiences shortness of breath and labored breathing with a respiratory rate of 30. The bed is in a flat position. You change the bed position to: A. Trendelenburg's. B. Reverse Trendelenburg's. C. Fowler's. D. Semi-Fowler's.

C

Pediculosis Capitis is better known as what highly infectious condition? A. Scabies B. Herpes Simplex C. Head Lice D. Thinning of the hair

C

The six links in the chain of infection include

1. etiologic agent (microorganism) 2. reservoir (source) 3. portal of exit from reservoir 4. method of transmission 5. portal of entry to susceptible host 6. susceptible host

Which of the following actions would best help prevent skin breakdown in a patient who is incontinent of stools and very weak and drowsy? A. Checking frequently for soiling B. Washing the perineal area with strong soap and water C. Placing the call light within easy reach D. Keeping a pad under the patient

A

You are helping a female patient bathe. As you are about to perform perineal care, the patient says, "I can finish my bath." The patient has discomfort and burning in the perineal area. What action do you need to take initially? A. Explain to the patient that, because of her symptoms, you need to observe the perineal area. B. Insist that you are supposed to complete the care. C. Honor the patient's request to complete her own perineal care to avoid any embarrassment. D. Ask the patient if a family member can complete the care instead.

A

A patient who is cognitively impaired and has dementia requires hygiene care. The patient often displays aggressive behavior such as screaming and hitting during the bath. Which techniques make the bathing experience less stressful for both the nurse and the patient? (Select all that apply.) A. Allow the patient to perform as much of the care as possible. B. Start by washing the face. C. Try an alternative to traditional bathing such as the "bag bath." D. Use restraints to prevent the patient from injuring self or the nurse.

A, C

A male nurse is caring for a 32-year-old female Muslim patient who has an indwelling Foley catheter. After introducing himself to the patient, the nurse learns that the patient does not want him to help her with personal hygiene care. Which of the following is(are) appropriate actions? (Select all that apply.) A. Finding a female nurse to help the patient B. Convincing the patient that he will work quickly and provide as much privacy as possible C. Skipping hygiene care for the day except for the parts that the patient can complete independently D. Asking the patient if she prefers a family member assist with the care

A, D

The parent of a toddler is cleaning the child's teeth. Which of the following statements indicates a need for further teaching? A. "I'll brush my child's teeth with a hard toothbrush." B. "I'll give a fluoride supplement daily or as recommended by the physician or dentist, unless my drinking water is fluoridated." C. "I'll schedule an initial dental visit for my child at about 2 or 3 years or as soon as all 20 primary teeth have erupted." D. "I'll seek professional dental attention for any problems such as discoloring of the teeth, chipping, or signs of infection such as redness and swelling."

A. "I'll brush my child's teeth with a hard toothbrush." "I'll brush my child's teeth with a soft toothbrush."

During discharge planning, the nurse is teaching the client how to prevent dry skin. Which of the following statements is false? A. Bathe daily using soap or detergent only. B. Use bath oils, but take precautions to prevent falls caused by slippery tub surfaces. C. Humidify the air with a humidifier or by keeping a tub or sink full of water. D. Use moisturizing or emollient creams that contain lanolin, petroleum jelly, or cocoa butter to retain skin moisture.

A. Bathe daily using soap or detergent only. Use cleansing creams to clean the skin rather than soap or detergent, which cause drying and, in some cases, an allergic reaction.

The nurse discovers a fire in a client's room. The first priority for the nurse is A. Ensuring the client's safety. B. Calling the fire department. C. Trying to extinguish the fire. D. Closing the doors to other rooms.

A. Ensuring the client's safety.

The client is complaining of shortness of breath. His Respirations are 28 & labored. The bed is currently in flat position. The nurse puts bed in which position? A. Fowler's B. Semi-Fowler's C. Trendelenburg D. Reverse Trendelenburg

A. Fowler's. Fowler's is semi-sitting position which should ease client's breathing.

Which of the following actions is not appropriate for the nurse bathing a person with dementia? A. Move quickly and let the person know when you are going to move him or her. B. Use a supportive, calm approach and praise the person often. C. Gather everything you will need for the bath before approaching the person. D. Help the person feel in control.

A. Move quickly and let the person know when you are going to move him or her. Move slowly and let the person know when you are going to move him or her.

Universal precautions refers to what? A. Treating all bodily fluids as if infectious. B. Wearing UV sunglasses outside. C. Never leaving your house. D. Protecting yourself against Universal aliens.

A. Treating all bodily fluids as if infectious.

The CDC recommends antimicrobial hand cleansing agents in all of the following situations except: A. When there are unknown multiple nonresistant bacteria. B. Before invasive procedures C. In special care units, such as a nursery or ICU D. Before caring for a severely immunocompromised client

A. When there are unknown multiple nonresistant bacteria.

When providing foot care for a client, the nurse would perform which of the following? A. When washing, inspect the skin of the feet for breaks or red or swollen areas. B. Does not cover the feet and between the toes with creams or lotions to moisten the area. C. Does not check the water temperature before immersing the feet. D. Wash the feet every other day, and dry them well, especially between the toes.

A. When washing, inspect the skin of the feet for breaks or red or swollen areas. Does cover the feet and between the toes with creams or lotions to moisten the area. Does check the water temperature before immersing the feet. Wash the feet every day, and dry them well, especially between the toes.

An antigen is a: -Host that produces antibodies in response to natural (________) or artificial (_______) antigens -Substance that induces a state of sensitivity or immune responsiveness (__________) -Host that receives natural (_________) OR Artificial (__________) antibodies -produced by another source Part of the body's plasma proteins

An antigen is a: -Host that produces antibodies in response to natural (infectious microorganisms) or artificial (vaccines) antigens; With active immunity, the Host produces antibodies in response to natural (infectious microorganisms) or artificial (vaccines) antigens -Substance that induces a state of sensitivity or immune responsiveness (immunity); An antigen is a Substance that induces a state of sensitivity or immune responsiveness (immunity) -Host that receives natural (FROM A NURSING MOTHER) OR Artificial (from an injection of immune serum) antibodies produced by another source; With passive (or acquired) immunity the host receives natural (FROM A NURSING MOTHER) OR Artificial (from an injection of immune serum) antibodies produced by another source -Part of the body's plasma proteins; Antibodies are Part of the body's plasma proteins

A nurse caring for a male patient observes the nursing assistive personnel (NAP) performing perineal care. Which of the following observed actions indicates a need for further teaching for the NAP? The NAP: A. Used clean gloves. B. Did not retract the foreskin before cleansing. C. Used the clean portion of washcloth for each cleansing wipe. D. Used a circular motion to cleanse from urinary meatus outward.

B

The nurse is assisting a patient with rheumatoid arthritis to bathe at the sink. During the bath the patient states that she is tired. The nurse notices the patient is breathing rapidly and the pulse is rapid. What is the nurse's best response? A. Finish the bath quickly B. Help the patient return to bed C. Leave the patient alone to rest in the chair at the sink for a few minutes D. Instruct the patient to take deep breaths and try to relax

B

Too frequent bathing and the use of hot water frequently lead to what? A. Rash B. Dry, flaky skin and loss of protective oils C. Exceptional hygiene D. Reduction of illness and disease

B

What is the priority concern when providing oral hygiene for a patient who is unconscious? A. Thoroughly brushing all tooth and oral surfaces B. Preventing aspiration C. Controlling mouth odor D. Applying local antiseptic such as chlorhexidine

B

You ask the nursing assistive personnel (NAP) to clean a patient who has been incontinent of urine. Several minutes later you pass the open door of the room and see the NAP changing the patient's gown and linen. Which of the following requires your immediate attention? A. Room temperature is overly warm. B. Room door is open to the hallway. C. Television volume is too loud. D. Strong odor of urine is detected.

B

A patient who is receiving chemotherapy has inflamed gums and oral mucosa and painful sores in the mouth. Which of the following oral care actions are appropriate? (Select all that apply.) A. Decreasing frequency of oral hygiene B. Applying water-soluble moisturizing gel on the oral mucosa C. Encouraging intake of soft foods D. Using commercial mouthwash

B, C

Your patient wears full dentures. His usual denture care includes taking the teeth out once a day to brush. He wears the dentures overnight. You are concerned that he might be at risk for developing denture-induced stomatitis. Which points do you include in a teaching plan for denture care? (Select all that apply.) A. Remove dentures overnight once a week while they soak in a cleansing bath. B. Do not wear damaged or poorly fitting dentures. C. Observe mouth for reddened areas under the dentures and small red sores on the roof of the mouth. D. See dentist regularly. E. Rinse dentures after meals. F. Clean dentures every night with cleanser, rinsing well before replacing in mouth at bedtime.

B, C, D, E

The nurse is caring for a patient who has reduced sensation in both feet. Which of the following should the nurse do? (Select all that apply.) A. Avoid cleaning the feet until an order from the health care provider is received. B. Wash the feet with lukewarm water and then dry well. C. Apply moisturizing lotion to the feet, especially between the toes. D. File the toenails straight across.

B, D

The nurse is discussing foot care w/ client who was recently diagnosed w/ diabetes. Which statement by client indicates need for further teaching? A. "I am going to use a mirror to check my feet." B. "I enjoy walking barefoot around the house." C. "I will file my nails." D. "I will increase the time that I wear new shoes each day."

B. "I enjoy walking barefoot around the house." Client needs to avoid walking barefoot as that could cause injury which may result in infection. Also, neurological impairment is likely which may result in decreased sensation. Client would be unaware of injury.

Describe the technique used to remove contaminated rubber gloves. A. Have a co-worker assist you in removing the rubber gloves. B. Skin to Skin, Rubber to Rubber. C. Rubber to Rubber, Skin to Skin. D. Rubber to Skin, Skin to Rubber.

B. Skin to Skin, Rubber to Rubber.

Which of following means freedom from disease-causing organisms? A. Medical asepsis B. asepsis C. surgical asepsis D. sepsis

B. asepsis. Asepsis is freedom from disease-causing microorganisms. Medical asepsis includes all practices intended to confine a specific microorganism to specific area, limiting number, growth, & transmission of microorganisms. Surgical asepsis, or sterile technique, refers to those practices that keep an area or object free of all microorganisms; it includes practices that destroy all microorganisms & spores. Sepsis is state of infection & can take many forms, including septic shock

The nurse recognizes that her older-adult patient needs additional teaching about skin care when the older adult says, "I should: A. Bathe twice a week. B. Rinse well after using soap. C. Use hot water for bathing. D. Drink plenty of fluids.

C

While planning morning care, which of the following patients would receive the highest priority to receive his or her bath first? A. A patient who just returned to the nursing unit from surgery and is experiencing pain at a level of 7 on a scale of 0 to 10 B. A patient who prefers a bath in the evening when his wife visits and can help him C. A patient who is experiencing frequent incontinent diarrheal stools D. A patient who has just returned from diagnostic testing and complains of being very fatigued

C

A nurse is explaining "infection" to nursing student. Which statement demonstrates need for more teaching? A. A local infection is limited to specific body part where microorganisms remain. B. If microorganisms spread & damage different parts of body, it is systemic infection. C. Acute infections may occur slowly, over a long period, & may last months or years. D. Nosocomial infections are classified as infections that are associated w/ delivery of health care services in health care facility.

C. Acute infections may occur slowly, over a long period, & may last months or years. chronic infections may occur slowly, over a long period, & may last months or years. A local infection is limited to specific body part where microorganisms remain. - true If microorganisms spread & damage different parts of body, it is systemic infection. - true Nosocomial infections are infections that are associated w/ delivery of health care services in health care facility. - true

Which of the following statements is correct regarding personal hygiene of the client? A. Gloves are not needed for bathing a client. B. It is best when performed by nursing staff. C. Clients should be encouraged to perform their own perineal care. D. Reddened areas on the skin should be massaged during the bath.

C. Clients should be encouraged to perform their own perineal care. Gloves are needed for bathing a client. It is best when performed by the client. Reddened areas on the skin should never be massaged during the bath.

The client is unresponsive & requires total care by nursing staff. Which assessment does nurse check first before providing special oral care to client? A. Presence of pain B. Condition of the skin C. Gag reflex D. Range of motion

C. Gag reflex. client will be positioned in sidelying position w/ head of bed lowered b/c client is at risk for aspiration. absence of gag reflex lets nurse know that client has no natural defense (cough) & is at higher risk for aspiration.

Which of the following consists primarily of nucleic acid and therefore must enter living cells in order to reproduce? A. Fungi B. Bacteria C. Viruses D. Parasites

C. Viruses. Viruses consist primarily of nucleic acid & therefore must enter living cells to reproduce. Fungi include yeasts & molds. Bacteria are by far most common infection-causing microorganism. Parasites live on other living organisms.

If you are exposed to a bodily fluid, what is the first thing you should do? A. Contact your supervisor. B. Seek medical treatment. C. Wash thoroughly. D. Dial 911.

C. Wash thoroughly.

A nurse teaching a family member caregiver how to bathe the patient explains the importance of using long strokes on the patient's extremities, moving from distal to proximal. Which explanation does the nurse include? Long strokes moving from distal to proximal are used to: A. Decrease the chance of infection. B. Help remove dry, flaky skin. C. Prevent skin trauma. D. Stimulate venous return.

D

Which of following is most practical & inexpensive method for sterilizing in home? A. Gas B. Moist heat C. Radiation D. Boiling water

D. Boiling water. Boiling a minimum of 15 minutes is advised for disinfection of articles in home

Hepatitis B and C can be spread by. A. Having unprotected sex with an infected person. B. Blood-to-blood contact with an infected person. C. Eating food or drinking water infected with feces. D. Both A and B.

D. Both A and B.

HIV is spread from person to person by. A. Shaking hands, kissing or hugging. B. Unprotected anal, oral, or vaginal sexual contact. C. Sharing needles to inject recreational drugs. D. Both B and C.

D. Both B and C.

Human Immunodeficiency Virus (HIV) is. A. A bacterial illness treated with antibiotics. B. A virus which has no cure, but can be controlled with medicine. C. The virus that causes AIDS. D. Both B and C.

D. Both B and C.

The nurse is observing unlicensed assistive personnel (UAP) perform perineal care for client. Which action indicates that nurse needs to discuss additional teaching with UAP? A. Uses a clean portion of washcloth for each stroke. B. Wipes from pubis to rectum. C. Uses clean gloves. D. Does not retract foreskin.

D. Does not retract foreskin. It is important to retract foreskin to remove smegma that collects under foreskin & can cause bacterial growth.

What are the main diseases of concern when discussing the blood borne pathogen standard? A. HAV, HDV, HEV. B. PVC, BVD, HIB. C. PCP, H2O, CDC D. HIV, HBV, HCV

D. HIV, HBV, HCV

What is it called when a client is not able to perform one or more activities of daily living (adl)? A. Risk for injury B. Personal preference C. Precautionary feedback D. Self-care deficit

D. Self-care deficit

The client is in surgery & will be returning to his bed via stretcher. Which bed option reflects that nurse appropriately planned ahead for this client? A. Open bed in low position B. Occupied bed in low position C. Closed bed in high position D. Surgical bed in high position

D. Surgical bed in high position. Both the placement of linens for surgical bed & placing bed in high position facilitate client's transfer from stretcher into bed.

Inflammation is local & nonspecific defensive response of tissues to an injurious or infectious agent. Which of following is not sign of inflammation? A. Pain B. Swelling C. Redness D. Fatigue

D. fatigue. Five signs of inflammation: Pain Swelling Redness Heat Impaired function of part (if injury is severe)

WHICH OF THE FOLLOWING STATEMENTS ABOUT DISINFECTANTS IS INCORRECT? A DISINFECTANT IS A CHEMICAL PREPARATION, SUCH AS PHENOL OR IODINE COMPOUNDS, USED ON INANIMATE OBJECTS. DISINFECTANTS ARE FREQUENTLY CAUSTIC AND TOXIC TO TISSUES. DISINFECTANTS AND ANTISEPTICS OFTEN HAVE SIMILAR CHEMICAL COMPONENTS, BUT THE DISINFECTANT IS A LESS CONCENTRATED SOLUTION. A DISINFECTANT IS AN AGENT THAT DESTROYS PATHOGENS OTHER THAN SPORES.

DISINFECTANTS AND ANTISEPTICS OFTEN HAVE SIMILAR CHEMICAL COMPONENTS, BUT THE DISINFECTANT IS A LESS CONCENTRATED SOLUTION. DISINFECTANTS AND ANTISEPTICS OFTEN HAVE SIMILAR CHEMICAL COMPONENTS, BUT THE DISINFECTANT IS A more CONCENTRATED SOLUTION

WHICH TYPES OF PRECAUTIONS ARE USED FOR CLIENTS KNOWN OR SUSPECTED TO HAVE SERIOUS ILLNESSES TRANSMITTED BY PARTICLE DROPLETS LARGER THAN 5 MICRONS? AIRBORNE DROPLET CONTACT CONNECTION

DROPLET AIRBORNE - SMALLER THAN 5 MICRONS DROPLET CONTACT - TRANSMITTED BY DIRECT CLIENT CONTACT OR ITEMS IN THE CLIENT'S ENVIRONMENT CONNECTION - DO NOT EXIST

T or F: If you wear gloves when cleaning up an accident site, it is not necessary to wash your hands afterwards.

False

T or F: Uncontaminated sharps may be disposed in regular trash bags.

False

A NURSE IS MAKING THE CLIENT BED. WHICH OF THE FOLLOWING ACTIONS SHOULD THE NURSE NOT DO? HOLD THE SOILED LINEN CLOSE TO HIS OR HER UNIFORM. AVOID SHAKING THE SOILED LINEN IN THE AIR BECAUSE SHAKING CAN DISSEMINATE MICROORGANISMS. WHEN STRIPPING AND MAKING A BED, CONSERVE TIME AND ENERGY BY STRIPPING AND MAKING UP ONE SIDE AS MUCH AS POSSIBLE BEFORE WORKING ON THE OTHER SIDE. Linen for one client is never placed on another client's bed.

HOLD THE SOILED LINEN CLOSE TO HIS OR HER UNIFORM. HOLD THE SOILED LINEN away from HIS OR HER UNIFORM.

T or F: A quarter cup of household bleach to one gallon of water provides a strong enough solution to effectively decontaminate most surfaces, tools, and equipment if left for 10 minutes.

True

IDENTIFY THE MOST COMMON TYPE OF NOSOCOMIAL INFECTION URINARY TRACT INFECTION PNEUMONIA BACTEREMIA CLOSTRIDIUM DIFICILE-ASSOCIATED DIARRHEA

URINARY TRACT INFECTION PNEUMONIA - 2ND MOST COMMON

IDENTIFY THE CORRECT STATEMENT ABOUT VACCINES: VACCINES ARE SUSPENSIONS OF WHOLE OR FRACTIONATED BACTERIA OR VIRUSES THAT HAVE BEEN TREATED TO MAKE THEM PATHOGENIC. VACCINES ARE ADMINISTERED TO REDUCE AN IMMUNE RESPONSE. ALL VACCINES ARE COMPLETELY EFFECTIVE AND ENTIRELY SAFE. VACCINES STIMULATE ACTIVE IMMUNITY BY INDUCING THE PRODUCTION OF ANTIBODIES AND ANTITOXINS.

VACCINES STIMULATE ACTIVE IMMUNITY BY INDUCING THE PRODUCTION OF ANTIBODIES AND ANTITOXINS. VACCINES ARE SUSPENSIONS OF WHOLE OR FRACTIONATED BACTERIA OR VIRUSES THAT HAVE BEEN TREATED TO MAKE THEM NONPATHOGENIC. VACCINES ARE ADMINISTERED TO INDUCE AN IMMUNE RESPONSE AND SUBSEQUENT IMMUNITY. ALL VACCINES ARE COMPLETELY EFFECTIVE AND ENTIRELY SAFE.