Chapter 31 Hygiene
The nurse is caring for an older adult client who has refused a bath for several days, and has now developed a rash on the buttocks. Which statement by the nurse should be made first? "Getting a bath helps to remove the bacteria from your skin, which is what is causing the rash on your buttocks." "Would you prefer to use the lavender soap or the oatmeal soap to wash with?" "When would you rather take your bath: in the morning or evening?" "Why don't you help wash your legs and feet?"
"Getting a bath helps to remove the bacteria from your skin, which is what is causing the rash on your buttocks." Explanation: The client needs education about why bathing is important. Knowledge deficit, and fear of loss of independence and/or privacy, may be impacting the client's choice. The nurse will first provide information about the reason that bathing is important, and then assure the client that privacy will be maintained, empowerment will be given, and autonomy will be respected.
The nurse is teaching a nursing student about caring for a client with dentures. Which education will the nurse provide? "Use your ungloved hands to remove an unconscious client's dentures." "Clean dentures with hot water to eliminate bacteria." "Store dentures in a peroxide solution if not worn continuously." "Hold dentures over a plastic basin or towel when cleaning them."
"Hold dentures over a plastic basin or towel when cleaning them." Explanation: Gloves should always be used to remove an unconscious client's dentures. Dentures should be cleaned in cold or tepid water, and then replaced into the client's mouth so the gum lines do not begin to change. When not worn continuously, dentures should be stored in water in a covered container. Holding dentures over a plastic basin or towel when cleaning them is appropriate, so if dentures are dropped, they will not break.
A nurse is caring for a client with limited physical mobility. The nurse has completed bathing the client and a student nurse asks, "Why are you making a trochanter roll?" After reviewing the image, which response by the nurse to the student would be most accurate? "I want to reposition the client to reduce the risk of skin breakdown." "I am placing the new linens under the rolled, soiled linens to avoid contamination." "The position of the client helps me to assess skin integrity before performing a back massage." "This is not a trochanter roll. I am tucking the draw sheet tightly so it does not move when the client is in bed."
"I am placing the new linens under the rolled, soiled linens to avoid contamination." Explanation: When making an occupied bed, it is important for the nurse to use clean linen and make the near side of the bed first. Then, the nurse places the bottom sheet in the center of the bed. Next, the nurse opens the sheet and pulls the bottom sheet over the corners at the head and foot of the mattress. Next, the nurse pushes the sheet toward the center of the bed, pulling it taut and positioning it under the old linens to avoid contaminating the new linen. In the image, the position of the client is for making an occupied bed, not for assessing the skin as the old linen is covering the client's skin. The nurse is not tucking the draw sheet tightly; it is the fitted (bottom) sheet that is displayed in the image.
A nurse is assessing the client's ability to perform ear care. Which statement by the client requires further education by the nurse? "I use a washcloth to clean the auricles and cerumen when needed." "I use cotton-tipped applicators daily to remove cerumen." "I never use bobby pins or other sharp objects when cleaning cerumen." "I clean my ear mold on my hearing aid daily before use."
"I use cotton-tipped applicators daily to remove cerumen." Explanation: Healthy ears require little to no care. Cerumen (ear wax) can accumulate, causing discomfort or decreased hearing. To care for ears, a washcloth is used to wipe the auricles and the twisted end of a washcloth can be used to clear cerumen from the ear canal. Clients should be educated to not use cotton-tipped applicators because it may push cerumen further back into the ear canal. Bobby pins and sharp objects should never be used to remove cerumen because they can puncture the tympanic membrane. If a client has a hearing aid device, care includes careful handling, wiping of the mold, and monitoring for dead batteries.
A nurse is assessing the client's ability to perform ear care. Which statement by the client requires further education by the nurse? "I use a washcloth to clean the auricles and cerumen when needed." "I use cotton-tipped applicators daily to remove cerumen." "I never use bobby pins or other sharp objects when cleaning cerumen." "I clean my ear mold on my hearing aid daily before use." TAKE ANOTHER QUIZ
"I use cotton-tipped applicators daily to remove cerumen." Explanation: Healthy ears require little to no care. Cerumen (ear wax) can accumulate, causing discomfort or decreased hearing. To care for ears, a washcloth is used to wipe the auricles and the twisted end of a washcloth can be used to clear cerumen from the ear canal. Clients should be educated to not use cotton-tipped applicators because it may push cerumen further back into the ear canal. Bobby pins and sharp objects should never be used to remove cerumen because they can puncture the tympanic membrane. If a client has a hearing aid device, care includes careful handling, wiping of the mold, and monitoring for dead batteries.
A nurse is assisting a client with his bed bath. The client states, "I can do it myself." Which is the nurse's best response? "I really have limited time. Let me give you your bath right now." "I will set up your bath for you, and you can use the call button to let me know if you need help." "You will need to sit up for your bath, and then I will change your bed." "You will be able to take your bath by yourself tomorrow when you can get up."
"I will set up your bath for you, and you can use the call button to let me know if you need help." Explanation: The nurse must value and support the client becoming independent in care.
The nurse has completed teaching regarding pediculosis. Which client statement requires further nursing teaching? "I will look for eggs on hairs ¼ to ½ in (0.5 to 1.5 cm) from the scalp and skin surfaces." "Lice can be spread by direct contact." "I will use conditioner so that the lice eggs will slide off my hair." "A pediculicide shampoo is needed to treat this condition."
"I will use conditioner so that the lice eggs will slide off my hair." Explanation: Hair conditioner coats the hairs and protects the nits. The nurse must intervene to teach the client to only use the pediculicide shampoo; not conditioner. Eggs may attach to hairs ¼ to ½ in (0.5 to 1.5 cm) from the scalp and skin surfaces, and lice can be spread by direct contact.
A nurse is caring for a client who is unconscious and notes in the client's history that the client wears contact lenses. What is the most appropriate action by the nurse at this time? Assess both eyes for contact lenses. Ask the unlicensed assistive personnel (UAP) to remove the contact lenses. Contact the client's caregiver and ask if the client wears contacts. Contact the health care provider for a prescription to remove the contact lenses.
Assess both eyes for contact lenses. Explanation: Upon noting the history of contact lenses, it would be most appropriate to assess both eyes for the presence of contact lenses. Some people wear contacts in only one eye. Removal of contact lenses may be delegated to the UAP, but only after proper assessment by the nurse. Contacting the client's caregiver would not provide the nurse with the needed information. The health care provider does not need to be contacted unless an injury is present.
A nurse is providing nail care for feet to clients admitted to a health care facility. What should the nurse look for while performing nail care for a client with a long history of diabetes? A bony bump on the joint at the base of the big toe Breaks in skin integrity and fungal nail infection Cold feet Redness and swelling in the joint of the big toe with reports of pain
Breaks in skin integrity and fungal nail infection Explanation: Clients with diabetes will be more susceptible to infection from breaks in skin integrity and nail problems. People with diabetes are more susceptible to fungal toenails and foot injury because of poor circulation and lack of feeling. A bunion, a bony bump on the joint at the base of the big toe, is not specific to clients with diabetes and can be caused by wearing tight, narrow shoes. Cold feet can be caused by things other than diabetes, such as atherosclerosis. Red inflamed joint of the big toe with reports of pain can indicate the client is suffering from gout and may not be attributable to diabetes.
Which aspect of denture care is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? Brushing the dentures Assessing the oral cavity for inflammation Teaching the client about importance of denture care Planning when denture care will be implemented
Brushing the dentures Explanation: Brushing the dentures is within the scope of practice for the UAP and therefore it is appropriate to delegate this aspect of denture care. Assessment, planning, and teaching fall within the scope of practice for the nurse and are not appropriate for delegation to the UAP.
A nurse is caring for a client who has been transported for a diagnostic test. The nurse is changing the client's bed linens and moves them to the location in the image. Which anticipated outcome is most plausible based on the nurse's actions? Contaminants can be transferred onto the furniture and spread microorganisms. Some hospital policies allow for temporary placement of soiled lines on furniture. An incident report will be created and sent to risk management. The furniture will be tagged for removal from the hospital premise due to contamination.
Contaminants can be transferred onto the furniture and spread microorganisms. Explanation: Placing soiled linens on the floor or on furniture in a client's room is not appropriate. This action could further soil and contaminate the furniture because the floor is heavily contaminated. It is not an acceptable infection control practice for health care facilities to allow temporary placement of soiled lines on furniture and would not be noted in hospital policies. An incident report is not required, education and reinforcement of hospital procedures and infection control principles is warranted. It is not cost-effective for health care institutions to remove furniture that is soiled by linens. The furniture will be cleaned per hospital guidelines depending on the degree of contamination.
The nurse is providing perineal care for clients in a hospital setting. What is an appropriate nursing action when providing this type of care? Always proceed from the most contaminated area to the least contaminated area. Do not retract the foreskin in an uncircumcised male. Dry the cleaned areas and apply an emollient as indicated. Powder the area to prevent the growth of bacteria.
Dry the cleaned areas and apply an emollient as indicated. Explanation: When providing perineal care it is important to completely dry the skin and apply emollient in order to prevent skin breakdown. Perineal care should be given by proceeding from the least contaminated area to the most contaminated area; this prevents cross-contamination. Infection and skin breakdown may occur if the foreskin is not retracted when cleansing the penis of a male. It is also imperative to replace the foreskin when finished cleansing the penis, thus preventing constriction of the penis. Powdering the perineal area is not recommended because the powder becomes a medium for bacterial growth.
The nurse is providing perineal care for clients in a hospital setting. What is an appropriate nursing action when providing this type of care? Always proceed from the most contaminated area to the least contaminated area. Do not retract the foreskin in an uncircumcised male. Dry the cleaned areas and apply an emollient as indicated. Powder the area to prevent the growth of bacteria. TAKE ANOTHER QUIZ
Dry the cleaned areas and apply an emollient as indicated. Explanation: When providing perineal care it is important to completely dry the skin and apply emollient in order to prevent skin breakdown. Perineal care should be given by proceeding from the least contaminated area to the most contaminated area; this prevents cross-contamination. Infection and skin breakdown may occur if the foreskin is not retracted when cleansing the penis of a male. It is also imperative to replace the foreskin when finished cleansing the penis, thus preventing constriction of the penis. Powdering the perineal area is not recommended because the powder becomes a medium for bacterial growth.
A client is being discharged today from the hospital. The nurse delegates morning care to the unlicensed assistive personnel (UAP). The assessment finds that the client is able to stand and ambulate independently without weakness or dizziness. The nurse will delegate what type of care to be provided based on the assessment findings? Complete bed bath Partial care Independent showering The client should not be bathed
Independent showering Explanation: Weakness, dizziness, and fear of falling may prevent a person from entering a tub or shower or from bending to wash their lower extremities. Even while hospitalized, independence is encouraged so allowing the client to shower independently would be appropriate. The client is not unstable enough to prohibit hygiene measures.
The unlicensed assistive personnel (UAP) is remaking the bed in a hospital room where the client was just discharged. The nurse observes the UAP performing the action pictured above. What initial instruction should the nurse provide to the UAP?
Inform the UAP that she should be wearing gloves. Explanation: Gloves should be worn while changing a client's bedding, but a gown is not normally necessary unless the client was on contact precautions. The chain of infection underlies these directives, but the immediate priority is changing the UAP's behavior. Changing a bed can safely be done alone.
The unlicensed assistive personnel (UAP) is remaking the bed in a hospital room where the client was just discharged. The nurse observes the UAP performing the action pictured above. What initial instruction should the nurse provide to the UAP? Inform the UAP that she should be wearing gloves. Remind the UAP that a gown and gloves should be worn. Tell the UAP that it is best to do this with a partner. Teach the UAP about the chain of infection.
Inform the UAP that she should be wearing gloves. Explanation: Gloves should be worn while changing a client's bedding, but a gown is not normally necessary unless the client was on contact precautions. The chain of infection underlies these directives, but the immediate priority is changing the UAP's behavior. Changing a bed can safely be done alone.
The nurse is teaching a client about hearing aid care. Which teaching is appropriate? Select all that apply. Keep extra batteries on hand. Do not get hair spray or other chemicals on the hearing aid. Store the hearing aid in a very warm environment so that it will not crack. Use a small knife to remove cerumen that becomes embedded in the earpiece. Carefully wipe the outer surface of the hearing aid to maintain cleanliness.
Keep extra batteries on hand. Do not get hair spray or other chemicals on the hearing aid. Carefully wipe the outer surface of the hearing aid to maintain cleanliness. Explanation: Extra batteries should be kept in case the battery of the hearing aid goes out or fails. Avoid exposing the device to extreme heat, water, cleaning chemicals, or hair spray. Clean cerumen that has become embedded in the earpiece with a special instrument that comes with the hearing aid. If this is not available, use a thin needle as a substitute. The outer surface of the hearing aid should be occasionally wiped clean to maintain cleanliness. It is not appropriate for the client to store the hearing aid in a very warm environment or use a small knife to remove the cerumen in the earpiece.
A new mother has brought her infant into the pediatric clinic. The infant has a red rash on the buttocks. What should the nurse instruct the mother? Leave the baby's buttocks open to air for 2 hours each day. Apply gentian violet to the buttocks with every diaper change. Change diaper as soon as it is soiled and apply cornstarch. Keep the diaper and buttocks clean and dry and apply zinc oxide.
Keep the diaper and buttocks clean and dry and apply zinc oxide. Explanation: Keeping the skin as dry and clean as possible helps preserve its integrity. The diaper area should be inspected with each change. Skin barrier products, such as those containing zinc oxide, are used to protect skin at risk for damage caused by excessive exposure to water and irritants, such as urine and feces. Application of one of these products forms a thin layer on the surface of the skin to repel potential irritants.
A school nurse is conducting a teaching session for the parents of elementary school students. She is discussing the topic of head lice. Why is this age group more susceptible to transmission of head lice than other groups? Lice are transmitted by head-to-head contact during play and by sharing of personal items. It is known that children have poor hygiene practices. Preschool and elementary age children are the only group that can contract head lice. Lice are most active during the day when children are, so they attract this age group.
Lice are transmitted by head-to-head contact during play and by sharing of personal items. Explanation: Preschool and elementary age students are at greatest risk for contracting head lice. However, anyone can contract head lice at any time regardless of hygiene measures or socioeconomic class. Head lice are transmitted during close hair-to-hair contact during play, sports, on the playground, at slumber parties, or at camp. These are all activities of these age groups. Sharing close personal items also puts them at risk for contracting head lice. Head lice are best detected at night in the dark when they are most active.
A student is walking down the hall carrying soiled linen against her uniform while taking it to the soiled utility room. What instruction should the nursing instructor provide to the student? Linen should be held away from the uniform and carried in some type of receptacle to prevent the spread of microorganisms. Linen should always be Linen should be held away from the uniform and carried in some type of receptacle to prevent the spread of microorganisms. Explanation: Dirty linen should be held away from contact with the uniform to prevent the spread of microorganisms. Soiled linen should not be carried in the hallway because dropping the linen spreads microorganisms. Linen should be handled with gloves if soiling is present. If the client is in isolation precautions, linens are disposed of in special bags and linen is taken from the room in those protective receptacles. Linens do spread microorganisms and should not be shaken in the room when making the bed, but rather unfolded.handled with gloves and left in the client's room to prevent spread of microorganisms. Linen should be changed weekly to prevent the spread of microorganisms. Linens do not spread microorganisms.
Linen should be held away from the uniform and carried in some type of receptacle to prevent the spread of microorganisms. Explanation: Dirty linen should be held away from contact with the uniform to prevent the spread of microorganisms. Soiled linen should not be carried in the hallway because dropping the linen spreads microorganisms. Linen should be handled with gloves if soiling is present. If the client is in isolation precautions, linens are disposed of in special bags and linen is taken from the room in those protective receptacles. Linens do spread microorganisms and should not be shaken in the room when making the bed, but rather unfolded.
A student is walking down the hall carrying soiled linen against her uniform while taking it to the soiled utility room. What instruction should the nursing instructor provide to the student? Linen should be held away from the uniform and carried in some type of receptacle to prevent the spread of microorganisms. Linen should always be handled with gloves and left in the client's room to prevent spread of microorganisms. Linen should be changed weekly to prevent the spread of microorganisms. Linens do not spread microorganisms.
Linen should be held away from the uniform and carried in some type of receptacle to prevent the spread of microorganisms. Explanation: Dirty linen should be held away from contact with the uniform to prevent the spread of microorganisms. Soiled linen should not be carried in the hallway because dropping the linen spreads microorganisms. Linen should be handled with gloves if soiling is present. If the client is in isolation precautions, linens are disposed of in special bags and linen is taken from the room in those protective receptacles. Linens do spread microorganisms and should not be shaken in the room when making the bed, but rather unfolded.
Which statement accurately describes a recommended step when changing the sheets on an unoccupied bed? Loosen all linen as you move around the bed, from the head of the bed on the far side to the head of the bed on the near side. Fold reusable linens (such as sheets, blankets, or spread) in half and hang them over a clean chair. Snugly roll all the soiled linen inside the top sheet and place directly into the laundry hamper. Place the top sheet on the bed with its centerfold at the head of the bed and with the hem even with the bottom of the mattress.
Loosen all linen as you move around the bed, from the head of the bed on the far side to the head of the bed on the near side. Explanation: Loosen all linen as you move around the bed, from the head of the bed on the far side to the head of the bed on the near side. Fold reusable linens (such as sheets, blankets, or spread) in place on the bed in fourths and hang them over a clean chair. Snugly roll all the soiled linen inside the bottom sheet and place directly into the laundry hamper. Place the top sheet on the bed with its centerfold in the center of the bed and with the hem even with the head of the mattress.
A nurse is caring for a client who has had difficulty sleeping. What nursing intervention may facilitate the client's rest? Providing a back rub before bed Giving the client something to drink Engaging in a therapeutic conversation Providing multiple stimuli to make the client tired
Providing a back rub before bed Explanation: A back rub is used after a bath or as a nursing intervention for the following: assessment of skin, improving circulation, decreasing pain, decreasing anxiety, improving sleep, and providing a means of communication between the nurse and the client. Stimulating the environment through conversation or multiple stimuli will only increase the level of alertness of the client.
Which nursing action is appropriate when providing foot care for a client? Soak the feet in a solution of mild soap and tepid water. Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms. For diabetic clients, trim the nails with nail clippers. Cut off any corns or calluses.
Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms. Explanation: Rinsing and drying the feet thoroughly, and providing moisturizer to the tops and bottom of the feet helps prevent excessive dryness and cracking of the skin. Soaking the feet can cause maceration of the tissues, which can lead to skin breakdown. The toenails of diabetic clients should be filed (not trimmed) in order to prevent injury to the feet, which can lead to infection or poor wound healing. The nurse should never cut off corns or calluses; this should only be performed by a podiatrist.
A client is undergoing chemotherapy for ovarian cancer which has metastasized. She has been experiencing increased nausea and vomiting associated with treatment. Which is an internal resource that the client has to help her attain her self-care goals? She has hot water to bathe in. She has good mobility around her home. She has motivation to participate in self-care. She has family and friends who help her with self-care.
She has motivation to participate in self-care. Explanation: An internal resource is one that comes from within the client. An external resource is one her environment and community offer her.
A nurse is educating a client on how to care for dentures. What is a recommended teaching guideline? Remove dentures whenever possible to rest the gums. Wrap dentures in a napkin when not using them. Keep dentures near you in the bed for easy access. Store dentures in cold water when not in use.
Store dentures in cold water when not in use. Explanation: The nurse should encourage the client to wear the dentures, if not contraindicated. Dentures enhance appearance, assist with eating, facilitate speech, and maintain the gum line. Denture fit may be altered if dentures are not used for long stretches. The nurse should encourage the client to refrain from wrapping the denture in paper towels or napkins because they could be mistaken for trash. In addition, the nurse should encourage the client to refrain from placing the dentures in the bed clothes because they can be lost in the laundry. The client should store dentures in cold water when not in the mouth. Leaving dentures dry can cause warping, leading to discomfort when worn.
The nurse is providing oral care to an unconscious client. Which piece of equipment would be important to use in order to individualize care for this client? Suction toothbrush Emesis basin Towel Toothpaste
Suction toothbrush Explanation: A suction toothbrush provides a means to remove oral hygiene products and saliva from the unconscious client's mouth, thereby preventing aspiration. A regular toothbrush and an oral suction catheter may also be used. An emesis basin, towel, and toothpaste would be expected for use for any client during oral care.
The nursing student is providing hygiene education for a family who will soon take an older adult client home from the hospital. Which teaching provided by the nursing student requires nursing instructor intervention? Obtain a tub or shower seat if the client has mobility issues. Use bath oil in the tub to decrease dry skin. Grab bars should be placed in the shower or tub at arm level. Soap should be used sparingly so the client's skin does not become overly dry. TAKE ANOTHER QUIZ
Use bath oil in the tub to decrease dry skin. Explanation: Bath oils can be added to a basin when administering a bed bath. However, they should never be used in the tub or shower, as they increase the risk of falls. All other options are correct.
A nurse is helping an older woman undress and notices the woman's knee-high hose have left deep indentations. The woman has diabetes. Does this pose a risk to the client? No, the indentations will go away. No, knee-high hose are more comfortable. Yes, these are a safety hazard and should not be worn. Yes, these can obstruct lower extremity circulation.
Yes, these can obstruct lower extremity circulation. Explanation: Knee high stockings may obstruct circulation. This is particularly true in the older woman. The individual with diabetes has an increased risk for circulatory impairments and should avoid them. Although the indentations will eventually go away they pose a hazard. Some individuals may feel that knee-high hose may be more comfortable; however, they do present a potential health hazard. Safety of the hose is not a consideration in this scenario.
A woman is being treated for breast cancer with 5-FU and cisplatin in large doses. She should expect: anxiety. alopecia. dandruff. seborrhea.
alopecia. Explanation: Most commonly, hair loss (alopecia) is caused by cancer treatment.
A nurse is caring for an older adult client who is weak and unable to care for his glasses and dentures. When assisting with cleaning the dentures, the nurse should: clean the dentures over a plastic basin or towel. thoroughly rinse the dentures with hot water. avoid the use of a toothbrush to clean removable bridges. store the dentures in an open cup containing only mouthwash.
clean the dentures over a plastic basin or towel. Explanation: The nurse should clean the dentures over a plastic basin or towel to prevent breakage if dropped. Cool or lukewarm water should be used for cleansing; hot water may warp the plastic material of which most dentures are made. The nurse should use a toothbrush to clean removable bridges and store the dentures in a covered cup containing plain water. w
A client has a diagnosis of Bathing/Hygiene Self-care Deficit due to recent surgery and decreased strength. An appropriate goal to include in the client's plan of care would be: client will participate in self-care measures by the end of the week. client will recognize the need for self-care. client will verbalize the need to use to use the bedpan by the end of shift. client will consent to no hygiene measures.
client will participate in self-care measures by the end of the week. Explanation: Bathing/hygiene self-care deficits resulting from hospitalization and complications require return of strength and motor abilities. It does not mean the client does not want to participate in hygiene and personal care. An appropriate goal would be to have the client actively participate in hygiene and self-care.
A nurse is providing oral care for a client who has been in a coma for 2 weeks. Which statement should guide the nurse's care plan? A client who is in a coma has an exaggerated gag reflex that creates a risk for aspiration. White patches may be present that indicate a fungal infection called thrush. Oral tissue and structure integrity are not generally affected by a client's cognitive level. A client who is comatose is at high risk for developing bleeding gums.
ect response: White patches may be present that indicate a fungal infection called thrush. Explanation: White patches in the oral mucosa indicate thrush. Alterations in cognitive function and/or consciousness increase the risk for alterations in oral tissue and structure integrity. A client who is receiving chemotherapy is at high risk for bleeding gums, which is unrelated to a client who is in a coma. Clients who are in a coma generally have a diminished or absent gag reflex.
When an adolescent client asks the nurse how to care for long hair, the nurse should instruct the client that: braids should be undone every day. combs should be washed as often as necessary. hair should be washed as often as necessary. lubricants or oils should not be used.
hair should be washed as often as necessary. Explanation: Shampooing removes dirt and oil from the hair and scalp. Clean hair makes clients feel good about their appearance and enhances feelings of self-worth. For clients who style their hair in small braids, the braids are not undone for shampooing and may need to have a lubricant or oil applied daily to prevent hair strands from breaking. Combs should be kept clean for overall hygiene.
A 55-year-old client has just undergone surgery for a knee replacement. He asks the nurse if he can shave because his face is itching from the stubble. What information is a priority for the nurse to verify prior to shaving the client? medications listed on the client's medication administration record (MAR) cultural views and attitudes toward facial hair and grooming client's allergies to soap since shaving cream is contraindicated in the hospital the last time shaving was performed because clients can only shave twice weekly in the hospital
medications listed on the client's medication administration record (MAR) Explanation: Shaving guidelines note that pharmacologic considerations are important because clients on anticoagulant therapy or low-dose aspirin will need to use an electric razor for safety. Although it is important to assess cultural views related to shaving, the client is asking to shave, so this is not a priority consideration. Allergies to soap are important to assess prior to shaving. However, shaving cream is not contraindicated. Shaving is performed as needed at the client's request.
A kindergarten student is sent to the school nurse because she has been vigorously scratching her scalp for a few hours. The nurse's first action will be to assess the child for the presence of: pediculosis. alopecia. ticks. fleas.
pediculosis. Explanation: Infestation with lice is called pediculosis and results in frequent scratching and marks on the scalp. Alopecia is the absence or loss of hair. Ticks and fleas can cause itching, but they are common infections to animals and not humans.
The nurse working at a long-term care facility supervises while the unlicensed assistive personnel (UAP) bathes an older adult client. The nurse determines the UAP requires intervention when the UAP: tests the water temperature prior to helping the client into the tub. places a large quantity of soap on the washcloth. bathes the client using gentle patting motions. inspects the feet while bathing the client.
places a large quantity of soap on the washcloth. Explanation: The nurse should intervene when observing the UAP apply a large quantity of soap to the washcloth since soap is very drying to the older adult client and should be used sparingly. It is appropriate to use a gentle patting motion while bathing since older adults have thin skin, decreased skin elasticity, and increased fragility of blood vessels in the dermis. The feet of the older adult client should always be inspected during bathing and other times of assessment to detect lesions, foot ulcers, and other alterations in skin integrity. Testing water temperature prior to entering the tub is done to prevent burns or hypothermia.
A 35-year-old woman is 1 day postpartum. She is reporting moderate perineal pain after giving birth and would like to clean the area. Which method of bathing is most appropriate for this client? sitz bath sit-down shower chair bag bath partial bath at a wash basin
sitz bath Explanation: A sitz bath washes the pelvic area with warm water and can help to decrease inflammation after birth.
A client reports having a history of gingivitis. The nurse correctly recognizes that this condition may be caused by which? Select all that apply. thermal extremes poor oral hygiene diet with soft fruits and cooked vegetables adverse reaction to medications bacteria
thermal extremes poor oral hygiene adverse reaction to medications bacteria Explanation: The gums are made up of the oral mucosa, which covers the bone supporting the tooth; the alveolar bone, which forms sockets around the teeth; and the periodontal ligament, which joins the teeth to the bone. Inflammation in these tissues, called gingivitis or periodontitis, can be caused by local irritation from bacteria, plaque, tartar, and food impaction. Mechanical, chemical, or thermal extremes may also contribute to inflammation of the oral mucosa. Soft foods would not cause the plaque or tarter buildup that can lead to gingivitis.
A nursing student is changing the client's bed. Which action requires intervention from the nursing instructor? placing the bed in a high position removing the call light attached to the bed sheet tossing soiled linen on the floor placing the clean linen on a dry bedside table
tossing soiled linen on the floor Explanation: Soiled linen should be placed directly into a pillow case or laundry hamper to prevent transferring microorganisms. Placing soiled linen on the floor requires intervention by the instructor to prevent the unnecessary spread of microorganisms. Placing the bed in a high position is appropriate, as it reduces back strain. Anything attached to the linens should be removed prior to changing the bed, and clean linen should be placed on a clean, dry surface, such as the bedside table or chair.
The nurse is preparing to delegate a bath for a 90-year-old client who is nonresponsive and has mild skin breakdown. Which type of bath will the nurse delegate to the unlicensed assistive personnel (UAP)? traditional bed bath with linen change shower with assist bag bath tub bath
traditional bed bath with linen change Explanation: A traditional bed bath with linen change provides the greatest opportunity for full cleansing. The client is unable to perform assistance with a shower, and is not a candidate for a tub bath. Although a bag bath may be useful, the traditional bed bath with linen change provides the best opportunity for infection control in observance of the mild skin breakdown that has been noted.
The nurse is caring for a female client who is unconscious. The nurse should pay special attention to cleaning which area of the body? underneath the breasts and in between skinfolds underneath the fingernails and toenails the inner and outer canthus of each eye the antecubital fossa and popliteal space
underneath the breasts and in between skinfolds Explanation: Skinfold areas may be sources of odor and skin breakdown if not cleaned and dried properly. The antecubital fossa (inner portion of arm) and popliteal space (behind the knee) are not skinfold areas that require cleaning. The eyes, toenails, and fingernails are not sources of odor.
When an adult client from Indonesia refuses a complete bath on the day after abdominal surgery, the nurse should: understand that his culture may influence his hygiene and ask him his preference. ask another nurse to assist in giving the client a complete bath every other day. give the client a bath pan and tell him she will return when he has finished. encourage the client to bathe daily as part of protection from infection.
understand that his culture may influence his hygiene and ask him his preference. Explanation: Preferences for hygiene vary widely among individuals and across cultures.
The nurse is educating an adolescent on how to treat acne. What would the nurse include as an education point? Gently squeeze the infected areas to release the infection. Wash your face less frequently to avoid removing beneficial oils. Keep hair off the face and wash hair daily. Use cosmetics and emollients to cover the condition.
Keep hair off the face and wash hair daily. Explanation: Keeping hair off the face and washing the hair daily will help prevent oil from transferring from the hair to the skin, causing clogged pores. The client should avoid squeezing or picking infected areas because this can spread the infection and cause scarring. The adolescent should be taught to gently wash the face twice a day with a mild cleanser and warm (not hot) water.
Which client is most at risk for foot difficulties? 80-year-old man with coronary artery disease 45-year-old woman with type 2 diabetes 91-year-old man with renal insufficiency 34-year-old woman who is paraplegic
45-year-old woman with type 2 diabetes Explanation: People who are at the greatest risk for foot problems are those with poor circulation and those with diabetes. Older age can also put a person at risk, but an active older adult is less at risk. A paraplegic could also be at risk for skin issues in general if the person is not active.
A nurse caring for the skin of clients of different age groups should consider which accurately described condition? An infant's skin and mucous membranes are protected from infection by a natural immunity. Secretions from skin glands are at their maximum from age 3 months on. The skin becomes thicker and more leathery with aging and is prone to wrinkles and dryness. An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions.
An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions. Explanation: Adolescents have enlarged sebaceous glands and increased glandular secretions, which predisposes them to acne. Infants have natural immunities, but not pertaining to the mucous membranes. Secretions from skin glands occur later than age 3 months. While the skin may have more wrinkles as a person ages, the skin actually becomes thinner with age.
A client has a nasogastric tube following abdominal surgery. Which intervention(s) does the nurse perform to prevent an alteration in the client's oral health? Select all that apply. Apply lubricant to the lips and nostrils Offer water to rinse the mouth every hour Encourage the client to swallow saliva naturally Assist the client to brush teeth at least every 4 hours Swab oral mucosa with lemon-glycerin swabs as needed.
Apply lubricant to the lips and nostrils Offer water to rinse the mouth every hour Encourage the client to swallow saliva naturally Assist the client to brush teeth at least every 4 hours Explanation: To prevent an alteration in the client's oral health, the nurse applies lubricant to the lips and nostrils of the client. The nurse offers water or mouthwash to rinse the mouth every hour. The nurse also encourages the client to swallow saliva naturally and assists the client to brush teeth at least every 4 hours. Assisting the client to brush the teeth at least once every day is not frequently enough to maintain optimal oral care for the client with a nasogastric tube. Lemon glycerin swabs and other alcohol-based mouthwashes and products are drying agents and should not be used.
Which intervention(s) does the nurse use in perineal care for a postoperative uncircumcised client? Select all that apply. Clean the penile shaft from the tip downward toward the scrotum Retract foreskin and wash the glans penis Clean the genitals after the buttocks, with client in a side-lying position Cleans the tip of the penis from the urethral meatus outward in a circular motion Place the client in the supine position to perform perineal care
Clean the penile shaft from the tip downward toward the scrotum Retract foreskin and wash the glans penis Cleans the tip of the penis from the urethral meatus outward in a circular motion Explanation: Proper perineal care for the uncircumcised male client includes starts with placing the client in a side-lying position and then cleaning the penile shaft from the tip downward toward the scrotum, retracting foreskin and washing the glans penis, and cleaning the tip of the penis from the urethral meatus outward in a circular motion. Cleaning the client's genitals after the buttocks, with client in a supine position both risks contamination of the client's skins with fecal matter and makes it difficult to clean the anal area with the client laying on the area to be cleaned.
A nurse is making the bed of a client whose limited mobility prevents her from leaving the bed. What should the nurse do when performing this procedure? Remove all covers and/or bath blankets from the client. Fold linen that is to be reused over the overbed table. Assist client to turn toward nurse's side of the bed. Fan-fold soiled linens as close to the client as possible.
Fan-fold soiled linens as close to the client as possible. Explanation: Correct steps in this procedure include the following: Place a bath blanket over the client. Have the client hold onto the bath blanket while you reach under it and remove top linens. Fold linen that is to be reused over the back of a chair. Assist the client to turn toward the opposite side of the bed, and reposition a pillow under the client's head. Fan-fold soiled linens as close to the client as possible. Reference:
A client with iron deficiency has a common complication that results in an inflammation of the tongue. What is the term used for this condition? Glossitis Gingivitis Periodontitis Stomatitis
Glossitis Explanation: Glossitis is an inflammation of the tongue. Gingivitis is an inflammation of the gingival, the tissue that surrounds the teeth (gums). Periodontitis is a marked inflammation of the gums that also involves degeneration of the periosteum and bone. Stomatitis is an inflammation of the oral mucosa.
A nurse is examining an adult client with inflammation of the gums. The nurse observes bleeding gums. What additional information should the nurse acquire to help determine next steps? How many cavities the client has had How often the client sees the dentist for oral care How often the client brushes and flosses the teeth The client's history of oral surgery
How often the client brushes and flosses the teeth Explanation: The assessment points to gingivitis. Gingivitis is a condition in which there is inflammation of the gums that bleed easily when the person brushes the teeth. This condition can be fixed with longer and more frequent brushing and flossing. Knowing how often the client brushes and flosses the teeth will help determine if the cause is from dental plaque from poor oral hygiene or another cause. Knowing the history of oral surgery and cavities or how often the client sees the dentist is important, but it is not helpful in determining next steps related to the finding.
Which nursing actions are recommended guidelines when performing oral care? Select all that apply. Use a hard toothbrush to remove plaque from the teeth. Ideally, brush teeth immediately after eating or drinking. Never clean the tongue with a toothbrush. If desired, use an automatic toothbrush to remove debris and plaque from teeth. Never use water-spray units to assist with oral hygiene. If desired, use salt and sodium bicarbonate as cleaning agents for short-term use.
Ideally, brush teeth immediately after eating or drinking. If desired, use an automatic toothbrush to remove debris and plaque from teeth. If desired, use salt and sodium bicarbonate as cleaning agents for short-term use. Explanation: Ideally, the client should brush the teeth after eating or drinking to help prevent tooth decay; if not able to brush, rinsing is beneficial. Automatic toothbrushes are acceptable for removing debris and plaque from teeth. Salt and sodium bicarbonate should only be used for short-term use in place of toothpaste because they lack fluoride. Soft toothbrushes prevent injury to the gums. The tongue should be brushed to decrease bacterial growth and halitosis. Water spray units can help remove debris from the oral cavity.
The nurse is changing a client's bedding. When removing the soiled sheets, what is the nurse's best action?
It is important to avoid any unnecessary contact with a client's soiled bedding to maintain the principles of infection control. The nurse must hold the bedding away from the front of his or her torso. Gloves must be worn during this task.
A nurse makes an occupied bed that is stained with fecal matter. What should the nurse do with the dirty linens? Roll the linens into a ball and place them in a biohazard bag. Place the linens on the floor on top of a protective pad and roll them in the pad before placing in the linen hamper. Place a protective pad over and under the soiled linens to protect the clean linens. Place them in a garbage bag and mark "disinfect" on the outside of the bag.
Place a protective pad over and under the soiled linens to protect the clean linens. Explanation: If linens are soiled with fecal matter, the nurse should obtain an extra towel or protective pad and place it under and over the soiled linens so that new linens will not be in contact with soiled linens. Linens are not placed in biohazard bags and destroyed, nor are they placed in garbage bags.
A nurse is shaving a male client's face. Which should the nurse do? Pull the skin taut and shave in the direction of hair growth using short strokes. Let the skin hang loose and shave in long, downward strokes. Shave against the direction of hair growth, using short strokes. Pull the skin taut and use short, upward strokes.
Pull the skin taut and shave in the direction of hair growth using short strokes. Explanation: The skin on the face is more sensitive and needs to be shaved with the direction of hair growth in short strokes to prevent discomfort. The skin should be pulled taut so that the razor can cut the hair more effectively.
A female nurse is assisting an older man who has dementia with a bath in his hospital room. Which approach should the nurse take? The client should be allowed to complete as much of the bath as he can. The nurse should have a male nurse bathe the client. The nurse should bathe the man herself, as he has dementia. The nurse should call a family member and have him or her bathe the man.
The client should be allowed to complete as much of the bath as he can. Explanation: When assisting with basic hygiene, it is important to respect individual client preferences and give only the care that clients cannot, or should not, provide for themselves. Thus, the nurse should let the client bathe himself to the extent that he can effectively do so. Bathing is performed in a matter-of-fact and dignified manner. If this approach is followed, clients generally do not find care by a person of the opposite gender to be offensive or embarrassing. Just because the man has dementia does not mean that he is not capable of bathing himself, at least in part. Calling a family member to bathe the client is both unnecessary and impractical.
A nurse is delegating shaving of a client who is prescribed anticoagulant therapy to the unlicensed assistive personnel (UAP). What information is most important for the nurse to include for this client? The client should use an electric razor. The client prefers shaving gel over shaving cream. The client likes to shave while in the shower. The client would like the spouse to assist with shaving.
The client should use an electric razor. Explanation: A client who is prescribed anticoagulant therapy is at risk for bleeding; therefore, it would be important to use an electric razor rather than a blade. Before shaving a client, it is important to assess shaving preferences and this information should be shared with the UAP, but these are not as important as preventing bleeding.
The acute care nurse is preparing to bathe a client and notices that the client is wearing a regular hospital gown and has continuous intravenous (IV) fluids infusing. Which action by the nurse is most appropriate? Thread the IV bag and tubing though the arm of the regular gown, then replace it with a snap-arm gown at the end of the bath. Disconnect the IV tubing from the IV bag and quickly thread it through the arm of the gown. Cut the arm of the regular gown and replace it with a snap-arm gown at the end of the bath. Leave the gown in place, taking care to keep it dry.
Thread the IV bag and tubing though the arm of the regular gown, then replace it with a snap-arm gown at the end of the bath. Explanation: Thread the IV bag and tubing though the arm of the regular gown, then replace it with a snap-arm gown at the end of the bath. The IV tubing and IV fluids should not be discontinued, if possible. Leaving the gown in place is inappropriate as the client needs a clean gown after a bath. A nurse should avoid cutting the regular gown if possible.
The nurse is providing care for a client and observes that the eyeglasses are cloudy and soiled. What action should the nurse take to be sure the lenses are clean and not damaged during cleaning? Dry the lenses very carefully with a paper towel Use hot water when cleaning the plastic frames to remove debris Use a special cleaning solution for eye glass lenses Use a silicone tissues to clean plastic lenses
Use a special cleaning solution for eye glass lenses Explanation: Clean eyeglasses over a towel, so that if they slip they will not become scratched or broken. Use warm water and soap or a special cleansing preparation. Hot water may warp plastic lenses and frames. Rinse the glasses well after cleaning them with soap and water; dry them with a clean, soft cotton cloth. Paper products that are made of wood pulp increase the risk of scratching the lenses, so do not use a dry paper tissue to clean eyeglasses. Do not use silicone tissues to clean plastic lenses.
When providing oral care, what does the nurse recognize as the most important component of the oral care process? a thorough, mechanical cleaning application of moisturizing ointment to the lips selection of toothpaste use of a mouthwash or breath freshener
a thorough, mechanical cleaning Explanation: No mouthwash, breath freshener, ointment, or paste replaces a thorough, mechanical cleaning of the oral cavity. Following the steps for cleaning the mouth thoroughly is more important than the agent used.
When the nurse cleanses the client's leg during a bed bath, it will allow for: assessment of pain. increased circulation. decreased restless leg syndrome. promotion of social interaction.
increased circulation. Explanation: Bathing increases circulation and helps maintain muscle tone and joint mobility.
