nur 107 - Week One Lab Videos

A male patient receiving perineal care tells the nurse "It has started to hurt a little down there." What is the nurse's best response? A. "When did you start experiencing the pain?" B. "Rate the pain on a scale of 1 to 10." C. "I'll assess your perineal area for the possible cause of the pain." D. "Would you like some pain medication before I continue with your care?"

A. "When did you start experiencing the pain?" Rationale: A nurse should ask the patient about his concerns and the perineal pain first. This is the best response for the nurse. The nurse should assess the area before asking the patient to rate the amount of pain on a scale of 1 to 10. The nurse should assess the perineal area for the cause of pain after she has asked the patient about his concerns and the perineal pain. The nurse must assess the area before offering pain medication.

The nurse is directing nursing assistive personnel (NAP) to make an occupied bed. What will the nurse say to minimize the risk of disease transmission to staff and patient during the bed change? A. "You'll need to apply Standard Precautions during this task." B. "Soiled linen should be rolled toward your uniform." C. "Soiled linen should be kept away from your uniform." D. "Keep the linen bag at the foot of the bed."

A. "You'll need to apply Standard Precautions during this task." Rationale: Telling the NAP to apply Standard Precautions will minimize the risk of disease transmission during the bed change. Soiled linen should be kept away from the NAP's uniform to minimize the risk of disease transmission to the staff. Placing the linen hamper at the foot of the bed will not minimize the risk of disease transmission to staff and patient during a bed change.

When changing a patient's gown, the nurse will place the bed in which position? A. A comfortable working height for the nurse B. A height that allows the patient full range of motion C. Locked and low D. All side rails raised

A. A comfortable working height for the nurse Rationale: The bed is raised to a comfortable working height so that the nurse can reach the patient safely and easily. The bed's height has little effect on the patient's range of motion. Locked and low is not necessarily the best position in which to place the bed for the nurse's comfort and the patient's safety. Having all side rails raised is considered a restraint and would make it difficult for the nurse to access the patient.

For which patient would the nurse most likely ask for a podiatrist consult for nail care? A. A middle-aged man with type 2 diabetes mellitus who feels tingling in his right foot. B. A middle-aged man with mobility impairment that has lasted several weeks after a fall from a ladder. C. An older adult woman with dementia who has broken her pelvis after falling on the kitchen floor. D. A 12-year-old girl with a broken foot.

A. A middle-aged man with type 2 diabetes mellitus who feels tingling in his right foot. Rationale: A podiatrist should assess and develop a regular schedule of nail care for any patient with diabetes and peripheral neuropathy or vascular insufficiency. This patient is known to have diabetes, and the tingling in his foot may indicate peripheral neuropathy. An otherwise healthy patient with temporarily limited mobility will probably not need to see a podiatrist. A patient with dementia will require help with nail care, particularly during the lengthy recovery from a broken pelvis, but it is unlikely that the expertise of a podiatrist will be required. An otherwise healthy child with a broken foot will probably not need to see a podiatrist.

When preparing to provide mouth care to a patient who is in a coma, the nurse first ensures patient safety by doing what? A. Assessing the patient's gag reflex B. Inspecting the patient's oral cavity C. Placing the bed in a flat position D. Connecting the suction equipment

A. Assessing the patient's gag reflex Rationale: Assessing the patient's gag reflex by placing a tongue blade on the back half of the tongue reduces the risk of choking by determining the patient's ability to swallow before mouth care is administered. The nurse inspects the oral cavity after assessing the patient's gag reflex. The nurse places the bed in a flat position before providing mouth care but after assessing the gag reflex. Suction equipment might be needed if the nurse first determines that the patient has an absent or poor gag reflex.

Which instruction would the nurse give when asking nursing assistive personnel (NAP) to give a complete bed bath to a patient? A. Do not massage any reddened areas on the patient's skin. B. Be sure to wash the patient's face with soap. C. Disconnect the intravenous tubing when changing the gown. D. Wear gloves if necessary.

A. Do not massage any reddened areas on the patient's skin. Rationale: The nurse should instruct the NAP not to massage any reddened areas on the patient's skin. When washing the face, the NAP should ask the patient if he or she wants soap to be used. Intravenous tubing should not be disconnected when changing the patient's gown. The NAP should be instructed to wear gloves when bathing a patient.

The nurse has washed a patient's arms. Which area should the nurse wash next? A. Hands B. Chest C. Abdomen D. Legs

A. Hands Rationale: The hands should be washed next. The chest should be washed after the hands. The abdomen should be washed after the chest. The legs should be washed after the abdomen.

After applying sterile gloves, the patient states she is uncomfortable and would like to move to her left side. What is the best way for the nurse to keep the gloves sterile while waiting for nursing assistive personnel (NAP) to position the patient for a sterile dressing change? A. Interlocking the fingers and keeping the hands above waist level B. Keeping the arms at the sides, with elbows bent and gloved hands pointing up C. Leaving the room momentarily D. Stepping back from the bedside where NAP are working

A. Interlocking the fingers and keeping the hands above waist level Rationale: Once the gloves have been applied, the fingers should be interlocked and held in front of the body above waist level. Keeping the arms at the sides, with elbows bent and gloved hands pointing up is not appropriate sterile technique. Leaving the room is not appropriate; the nurse will stay in the treatment area after gloving. Stepping back from the bedside and other traffic areas is prudent, since turbulent air can contaminate gloves, but it is not the most important step the nurse can take to keep gloves sterile.

The nurse is preparing to make an occupied bed for a patient who is on aspiration precautions. What will the nurse do to ensure the safety of this patient during the bed change? A. Keep the head of the bed no lower than a 30-degree angle. B. Fold a pillow in half and place it under the patient's head. C. Lower the bed to a flat position and place two pillows beneath the patient's head. D. Ask another caregiver to hold the patient's head during the bed change.

A. Keep the head of the bed no lower than a 30-degree angle. Rationale: For a patient on aspiration precautions, the nurse should keep the head of the bed no lower than a 30-degree angle. Folding a pillow in half and placing it under the patient's head, lowering the bed to a flat position and placing two pillows under the patient's head or having another caregiver hold the patient's head while changing the bed will not prevent aspiration.

Which nursing action is most therapeutic in response to a cognitively impaired patient who demands to know when his daughter is coming to visit? A. Marking the date of the visit on the patient's wall calendar B. Evaluating the patient's understanding of the concept of time and date C. Telling the patient when his daughter will be visiting and ensuring that he verbalizes his understanding D. Calling the daughter to suggest that she visit sooner than she had planned

A. Marking the date of the visit on the patient's wall calendar Rationale: Marking the date of the visit on the patient's wall calendar is the most therapeutic option, because it will serve as a permanent visual cue to remind the patient of the date each time he becomes anxious about his daughter's visit. Evaluating the patient's understanding of the concept of time and date is not the correct option, because the patient's deficiencies have already been determined. Discussing the date of the visit with the patient is not the correct option because, even if the patient momentarily understands and can be reassured, it is likely that his anxiety or disorientation will return. Persuading the patient's daughter to hasten her visit is not the correct option, because it does not address the patient's anxiety regarding the date of her visit.

When preparing to clean a patient's dentures using the sink, the nurse first protects the dentures by doing what? A. Padding the sink basin with a washcloth B. Performing hand hygiene C. Filling the sink with cold water D. Filling the sink with hot water

A. Padding the sink basin with a washcloth Rationale: Padding the sink basin with a washcloth helps protect the patient's dentures from being damaged during the cleaning process. Although performing hand hygiene is appropriate and reduces the risk of infection, doing so protects the patient, not the dentures. Cold water must not be used on dentures because it may cause them to crack. Hot water must not be used on dentures because it may cause them to warp.

What will the nurse do first when preparing to apply personal protective equipment (PPE) before caring for a patient in isolation? A. Perform hand hygiene B. Put on the gown C. Put on clean gloves D. Apply eyewear

A. Perform hand hygiene Rationale: Before applying PPE, the nurse should perform hand hygiene.

The nurse is preparing to change the soiled linen of a patient's unoccupied bed. Which precaution minimizes the risk of transmitting microorganisms? A. Perform hand hygiene and apply clean gloves. B. Place fresh linen on a clean bedside table or chair. C. Put soiled linen in a pillow case before placing in a hamper. D. Roll soiled linen together with the dirty sides toward the center.

A. Perform hand hygiene and apply clean gloves. Rationale: Performing proper hand hygiene and using treatment gloves minimizes the risk of transmitting microorganisms. Placing fresh linen only on clean surfaces would reduce exposure of the linen to microorganisms, but would not minimize the risk of transmitting microorganisms. Placing soiled linen in a pillowcase and rolling soiled linen together with the dirty sides toward the center would do little to minimize the risk of transmitting

The nurse has just helped a patient into the bathtub. Before leaving the bathroom, what would the nurse do to help ensure the patient's safety? A. Show him how to use the call signal. B. Place an "Occupied" sign on the door. C. Check the cleanliness of the room. D. Remove unneeded supplies from the bathroom.

A. Show him how to use the call signal. Rationale: As a safety measure, the nurse would show the patient how to use the call signal before leaving the bathroom. Placing an "Occupied" sign on the door would help ensure the patient's privacy, not his safety. Checking the cleanliness of the room would not help ensure the patient's safety. Removing unneeded supplies from the bathroom would not help ensure the patient's safety.

The nurse is reviewing placement of an unfitted bottom sheet with nursing assistive personnel (NAP) assigned to make an unoccupied bed. What should the nurse include in this teaching? A. The lower hem of the sheet should lie seam down and even with the bottom edge of the mattress. B. Keep enough material to miter the lower mattress corners. C. Apply the drawsheet on the cleaned mattress first. D. Make the top of the bed first, moving to the bottom of the bed.

A. The lower hem of the sheet should lie seam down and even with the bottom edge of the mattress. Rationale: When making an unoccupied bed, the lower hem of the bottom sheet should lie seam down and even with the bottom edge of the mattress. The corners of the lower mattress are not mitered. If used, the drawsheet is placed over the bottom sheet. All linen is first applied on one side of the bed and then on the other.

When preparing to help a male patient shave, why does the nurse first review the patient's medical history? A. To determine the patient's risk of bleeding B. To see how often he prefers to shave C. To learn which is his dominant hand D. To determine whether he can perform the task himself

A. To determine the patient's risk of bleeding Rationale: When preparing to help a male patient shave, the nurse first reviews the patient's medical history to determine his risk of bleeding.

The nurse is planning to insert an oral airway into an unconscious patient before performing mouth care. In which direction is the airway initially inserted into the patient's mouth? A. Upside down, or with the curve facing up B. Right side up, or with the curve facing down C. With the curve angled toward the patient's left cheek D. With the curve angled toward the patient's right cheek

A. Upside down, or with the curve facing up Rationale: The oral airway should be inserted upside down into the patient's mouth, and then turned sideways and over the tongue to keep the teeth apart. The oral airway should not be inserted right side up, because the curve must fit over the patient's tongue. The curve cannot be angled toward the patient's cheek.

Which of the following interventions directly related to patient safety must the nurse consider when providing perineal care to an elderly male patient with a catheter? A. Wear clean gloves during care. B. Assess the patient's ability to provide self-care. C. Encourage the patient to report any pain originating from the catheter. D. Monitor the amount of urine in the drainage bag to prevent overflow.

A. Wear clean gloves during care. Rationale: The use of gloves is directed toward preventing the transmission of infection and is therefore directly related to patient safety. Assessing the patient's ability to provide personal hygiene pertains to patient autonomy and is not directly related to patient safety. Although encouraging the patient to report pain and attempting to identify its origin is appropriate, it is not directly related to patient safety. Monitoring the amount of urine in the drainage bag to prevent overflow of urine is an appropriate intervention; however, it does not necessarily pertain to male perineal care and is not directly related to patient safety.

When are sterile nonlatex gloves recommended for a sterile procedure? A. When there is a possible sensitivity issue B. When the staff member prefers them C. When latex gloves are not conveniently available D. When the patient prefers them

A. When there is a possible sensitivity issue Rationale: The possibility of a serious allergic reaction to latex necessitates the use of nonlatex gloves when the patient or nurse is sensitive to latex. Staff preference is not a reason to select nonlatex sterile gloves. Staff should use latex gloves unless there is a sensitivity issue. Unless the patient has a known latex allergy, he or she is not usually consulted regarding the type of glove a staff member uses.

The nurse is discussing the guidelines for proper use of PPE by nursing assistive personnel (NAP). Which statement made by the NAP requires follow-up by the nurse? A. "When in doubt, I wear gloves." B. "I really dislike wearing a mask, so it's the first thing I take off." C. "I always do hand hygiene when entering and leaving a patient's room." D. "I wear a mask whenever I am caring for a patient who's coughing."

B. "I really dislike wearing a mask, so it's the first thing I take off." Rationale: Statement B requires follow-up because the gloves should be removed first when removing PPE, to minimize the chance of contaminating both the mask and the face. The remaining are appropriate statements and require no follow-up.

What would the nurse instruct nursing assistive personnel (NAP) to report when caring for a patient in a wrist restraint? A. "Tell me if the patient's pulse changes." B. "Tell me if the skin under the restraint becomes abraded or raw." C. "Let me know if you think she's ready for them to come off." D. "Let me know if the patient needs anything for pain."

B. "Tell me if the skin under the restraint becomes abraded or raw." Rationale: When caring for a patient in a wrist restraint, the nurse would instruct NAP to report the condition of the skin beneath the restraint. When caring for a patient in a wrist restraint, the nurse would assess the patient for pulse changes in the extremity to which the restraint has been applied. This skill would not be delegated to NAP. Patient assessment is a nursing responsibility, and the nurse would make the determination of when a patient's restraints can be removed, in accordance with agency policy and all applicable laws and regulations. Assessment of pain is a nursing responsibility and cannot be delegated to NAP.

The nurse delegates a patient's back massage to nursing assistive personnel (NAP). Which statement by the NAP requires the nurse to follow up? A. "She likes that special lotion her daughter brought. I'll see if she wants me to use it." B. "The muscles of her lower back twitch when I start to rub it, but they calm down if I keep massaging her." C. "She's been complaining of soreness in her shoulders. I'll give them special attention." D. "The family usually visits about now. I'll check and see if she wants to wait until later."

B. "The muscles of her lower back twitch when I start to rub it, but they calm down if I keep massaging her." Rationale: This statement requires follow-up, since massage may aggravate muscle spasms, indicated by the muscle twitching. This unexpected outcome must be reported to the nurse in charge or to the health care provider. Application of lotion is a part of the massage process and using the patient's special lotion may enhance the therapeutic result of the intervention. No follow-up is required, since massage is indicated to help reduce pain from muscle tension and the patient's preference as to when the massage is given may be considered.

The nurse is assisting a patient with a tub bath. After the patient has been safely positioned in the tub, he tells the nurse, "I'll call you when I'm done." What is the nurse's best response? A. "All right. Just holler when you're ready, and I'll come and help you get out of the tub." B. "Well, I'll check back with you in about 5 minutes to see if you need anything." C. "That's not safe. I'll wait right outside the door for you to finish." D. "I'll be back in 15 minutes. That should be enough time for you to finish up."

B. "Well, I'll check back with you in about 5 minutes to see if you need anything." Rationale: Checking back in about 5 minutes represents the safest way of caring for a patient who is taking a tub bath, since it allows for frequent patient-nurse communication. "Just holler" is not the safest way of monitoring a patient who is taking a tub bath, since the nurse may not hear the patient and thus would not be able to respond to him. The nurse's waiting to be summoned by the patient is inappropriate, the alternative of waiting right outside the door is not realistic and does not allow the nurse to check on the patient. It is not safe to allow 15 minutes to elapse before checking on a patient who is taking a tub bath.

To which patient might the nurse apply a physical restraint? A. An 83-year-old patient with dementia and a history of wandering whose fall risk assessment indicates a high risk of falling. B. A 42-year-old critical care patient with a traumatic brain injury who has repeatedly tried to pull out her shunt. C. A 74-year-old patient confined to bed who is at risk of pressure ulcers. D. A 60-year-old patient with dementia who seemed increasingly confused shortly after having had restraints applied for 1 hour that morning.

B. A 42-year-old critical care patient with a traumatic brain injury who has repeatedly tried to pull out her shunt. Rationale: The critical care nurse might apply a physical restraint to keep this 42-year-old patient from injuring herself by dislodging her shunt. Disruption of therapy causes patient injury, pain, or discomfort and increases the risk of infection. There is no evidence that the use of restraints prevents falls or reduces wandering. Research has shown that patients suffer fewer injuries if left unrestrained. Use of physical restraints does not prevent pressure injuries; to the contrary, pressure injury formation is a possible complication associated with the use of physical restraints. Any patient with a physical restraint must be monitored frequently for skin integrity, pulse, temperature, and color, as well as sensation and range of motion of the restrained body part. The nurse would not apply a physical restraint to a patient who had exhibited increased confusion, disorientation, or agitation during the previous application of a restraint. Instead, the nurse would evaluate the cause of the behavior and try to eliminate it, provide appropriate sensory stimulation, reorient the patient, use restraint alternatives, and enlist the family's support if possible.

The nurse wants to offer some diversional activity to a patient with dementia. The patient's family has told the nurse that he is a bit of a loner who enjoyed a 40-year career as an aircraft mechanic. The patient seems frustrated and bored. What is the best activity for the nurse to offer him? A. Weekly pet therapy with a golden retriever B. A jigsaw puzzle of an appropriate level of difficulty C. A crossword puzzle book of an appropriate level of difficulty D. Frequent card games with other patients

B. A jigsaw puzzle of an appropriate level of difficulty Rationale: A jigsaw puzzle is a good choice, because it is a solitary activity that offers tactile stimulation and engages the patient's mental faculties, attributes that are likely to be familiar and pleasurable to him. Pet therapy would offer this patient tactile stimulation, but the activity would not be frequent enough to relieve his boredom. Doing crossword puzzles is an appropriately solitary activity for this patient, but it offers little tactile stimulation; in addition, a word puzzle is unlikely to appeal to this mechanically inclined patient. The family has told the nurse that the patient prefers to keep to himself, so social interaction is unlikely to provide meaningful, welcome stimulation that will relieve his boredom and frustration.

n providing foot care, the nurse would soak the feet and hands of which patient? A. A 30-year-old man with type 1 diabetes. B. An 86-year-old woman with generalized weakness. C. A 56-year-old patient with vascular insufficiency who was bathed the day before. D. A 56-year-old patient with vascular insufficiency who was not bathed the day before.

B. An 86-year-old woman with generalized weakness. Rationale: Hand and foot soaking is contraindicated in any patient with diabetes, vascular insufficiency, or peripheral neuropathy because of the inability to sense temperature and the increased risk of trauma and infection. The 86-year-old woman, however, has none of these conditions, and the nurse would soak her hands and feet.

When preparing to assist a patient with a gown change, the nurse will promote infection control by doing what after performing hand hygiene? A. Placing the gown in the linen hamper B. Applying clean gloves C. Determining whether the gown being changed is wet or soiled D. Measuring the patient's temperature to determine whether it is elevated

B. Applying clean gloves Rationale: The nurse will promote infection control by applying clean gloves after performing hand hygiene. The nurse will dispose of the dirty gown after finishing the gown change. The nurse will apply gloves when changing a patient's gown whether or not the gown being changed is wet or soiled. Standard infection-control measures must be observed regardless of the patient's temperature.

As the nurse is preparing to provide perineal care to a female patient with limited mobility, the patient says, "I can do that myself." Which action would be the priority? A. Provide all the necessary supplies and linen for this task. B. Assess the patient's ability to perform proper perineal care. C. Ensure that the patient has privacy while performing perineal care. D. Document any complaints of irritation or pain in the perineal area.

B. Assess the patient's ability to perform proper perineal care. Rationale: Determining the appropriateness of self-care by assessing the patient's ability to provide her own perineal care is the priority action. Although it is a nursing responsibility to provide all the items necessary for the patient to perform this task, ensuring the patient's privacy, and documenting patient complaints, doing so would not take priority over assessing the patient's ability to perform perineal care.

A new nursing assistive personnel (NAP) is making a surgical bed for a patient who is having abdominal surgery. Where will you instruct the NAP to place the waterproof pad on this bed? A. Over the mattress B. Over the bottom sheet C. Over the top sheet D. A waterproof pad should not be used for this patient

B. Over the bottom sheet Rationale: If a waterproof pad is used, it is placed over the bottom sheet, where it can draw away any wound drainage or other body fluids from the patient's skin. A waterproof pad can be used for any patient for whom the nurse or NAP deems the intervention necessary.

The nurse is changing the bed linen of a patient on bed rest. When the nurse is ready to make the other side of the bed, what will the nurse do before having the patient turn onto the side that has already been made? A. Lower the head of the bed B. Raise the side rails C. Apply the top sheet D. Discard the soiled linen in the linen bag

B. Raise the side rails Rationale: The nurse will raise the side rails to reduce the risk of a fall. The head of the bed will have been lowered before the bed change begins unless the patient is on aspiration precautions. A clean top sheet is applied only after the entire bottom sheet is in place. The soiled linen is not placed in the linen bag until the nurse has finished placing the bottom sheet on the bed.

A patient with difficulty breathing requests a back massage. In which position would the nurse instruct nursing assistive personnel (NAP) to place the patient during the massage? A. Prone B. Side-lying C. Supine D. Fowler's

B. Side-lying Rationale: For a patient with respiratory difficulty, back massage is performed in the side-lying position. The patient's back would not be accessible in the supine and Fowler's positions. The patient could experience difficulty breathing in the prone position.

What must the nurse avoid when brushing the tongue of an unconscious patient? A. Dislodging bacteria B. Stimulating the gag reflex C. Moistening the oral mucosa D. Using suction

B. Stimulating the gag reflex Rationale: If the patient has a gag reflex, the nurse must be careful not to stimulate it while brushing the back of the tongue, since gagging could cause aspiration of secretions. Dislodging bacteria so that it can be removed and moistening mucosa are primary reasons for brushing the tongue. Suction may be used to remove oral secretions and bacteria as the tongue is brushed.

What would the nurse instruct nursing assistive personnel (NAP) to report when performing denture care for a patient? A. The amount of time it takes to clean the patient's dentures B. The appearance of any cracks in the dentures C. Any dietary preferences of the patient that could affect the teeth D. Whether the patient uses mouthwash

B. The appearance of any cracks in the dentures Rationale: NAP is instructed to report to the nurse if the dentures have any cracks. Such damage could injure the patient's oral cavity, and the space could become colonized with bacteria. NAP need not report to the nurse how long it takes to perform denture care for a patient, the patient's dietary preferences or whether the patient uses mouthwash.

While performing catheter care, the nurse moves her hand, allowing the patient's labia to close around the catheter. Why would the nurse repeat this part of the care? A. The catheter may have traumatized the labia. B. The labia have contaminated the area. C. The patient's perineal area must be reassessed for infection. D. The nurse must ensure that the catheter is not pulling on the bladder.

B. The labia have contaminated the area. Rationale: The nurse will repeat the perineal care because the labia closed around the catheter and contaminated the perineal area. The catheter will not traumatize the labia. The nurse will assess the patient's perineal area for signs of infection and then repeat the perineal care to ensure cleanliness, not to re-assess for infection. The nurse must ensure that the catheter is not pulling on the bladder; however, the cleansing must be repeated because the labia closed around the catheter and contaminated the area.

Why would the nurse instruct nursing assistive personnel (NAP) to hand the patient a mirror before trimming his moustache and beard? A. To distract him so that he will stay still B. To allow him to point out which areas he would like to have trimmed C. To promote his sense of independence D. To keep his hands away from his face

B. To allow him to point out which areas he would like to have trimmed Rationale: The nurse would instruct the NAP to hand the patient a mirror to allow him to point out which areas he would like to have trimmed.

Why must the nurse check the flow rate after changing the gown of a patient who is receiving intravenous fluids infused by gravity? A. To make sure the patient's position change has not sealed off the drip chamber B. To check whether manipulation of the intravenous container and tubing has disrupted the flow rate C. To see if an increase in the patient's heart rate has accelerated the flow rate D. To make the standard periodic flow rate adjustment

B. To check whether manipulation of the intravenous container and tubing has disrupted the flow rate Rationale: The nurse will check the flow rate of the infusion after a gown change because handling the intravenous tubing and container can disrupt the flow rate. A position change cannot seal off the drip chamber because it is part of an apparatus hanging from a pole. An increase in the patient's heart rate would not change the flow rate of the intravenous infusion. The flow is adjusted only as needed to achieve the prescribed rate; it is not adjusted at regular intervals.

After performing back massage for a patient experiencing pain, what is the primary reason the nurse asks her to rate her current pain level on a scale of 1 to 10? A. To determine how soon the next massage should be offered B. To evaluate the effectiveness of the massage in relieving pain C. To determine if it is time to give the patient another dose of analgesic medication D. To help gauge the patient's level of consciousness

B. To evaluate the effectiveness of the massage in relieving pain Rationale: The nurse asks the patient to rate her current pain level in order to evaluate the effectiveness of the massage in relieving pain. Knowing the patient's level of discomfort might help the nurse determine when to offer the next massage, but that is not the nurse's main reason for asking the patient to rate her pain. Obtaining the patient's self-report of pain is not part of a neurologic examination, which the nurse need not perform after a massage.

When making a surgical bed, why does the nurse avoid shaking the linen being removed from the bed? A. To keep the linen folded correctly B. To prevent contamination to the environment and the nurse's uniform C. To keep it separate from the towels and washcloths in the linen bag D. To reduce the amount of time needed to make the bed

B. To prevent contamination to the environment and the nurse's uniform Rationale: The nurse avoids shaking the used linen in order to prevent contamination to the environment and the nurse's uniform with microorganisms. Linen is not folded before it is laundered. Sheets and towels need not be kept separate before they are laundered. This action does not pertain to time or efficiency.

When a nursing assistive personnel (NAP) enters the room of a patient in a belt restraint, he finds the patient's gown bunched around the patient's chest and the patient asking for help. What would the NAP do? A. Check the patient's blood pressure and pulse before smoothing the gown B. Untie the restraint and smooth the patient's gown C. Put on the call light for help D. Ask the patient what specific help she would like

B. Untie the restraint and smooth the patient's gown Rationale: The NAP would untie the restraint, smooth the patient's gown, and replace the restraint. Checking the patient's blood pressure and pulse is not appropriate at this time. Putting on the call light is not appropriate, since the call light is intended to summon the NAP. Asking the patient what help is needed is not appropriate. The difficulty is obvious, and the patient may have a cognitive impairment that makes clear expression of his or her needs impossible.

The nurse is preparing to give a patient a bath using a disposable bath-in-a-bag product. What should the nurse do first? A. Remove the patient's gown. B. Warm the product in the microwave. C. Obtain a washbasin. D. Gather towels and washcloths.

B. Warm the product in the microwave. Rationale: Warming the product is the first thing the nurse should do to prepare for the bath. The patient's gown should not be removed until the bath begins. A washbasin is not needed for this type of bath. Towels and washcloths are not needed for this type of bath.

The nurse is delegating a female patient's perineal care to nursing assistive personnel (NAP). Which instruction would the nurse give to ensure the NAP's safety while performing this care? A. Wear sterile gloves. B. Wear clean gloves. C. Wear an isolation gown. D. Use hot water.

B. Wear clean gloves. Rationale: Wearing clean gloves is the best way to ensure the NAP's safety while performing perineal care. Wearing sterile gloves and an isolation gown are not necessary to ensure the NAP's safety while performing perineal care. Using hot water would not ensure the NAP's safety while performing perineal care, and doing so could be harmful to the patient.

Which action would the nurse encourage an older adult with foot problems to take at home? A. Apply oval pads to treat corns. B. Wear socks made of natural fibers. C. Carefully shave off calluses with a razor blade. D. If a bandage is needed, apply gauze squares with adhesive tape.

B. Wear socks made of natural fibers. Rationale: Natural fibers, such as cotton, absorb perspiration and "breathe." Use of oval pads for corns can exert pressure on toes, thereby decreasing circulation to surrounding tissues. Patients should seek professional treatment for corns. A patient should never trim corns or calluses with a razor blade or scissors. Doing so puts the patient at risk of cutting the skin, which can lead to infection. The thin, delicate skin of an older adult is prone to tearing when adhesive tape is removed.

What would the nurse instruct the nursing assistive personnel (NAP) to do before making an unoccupied bed if the mattress is soiled? A. Wash the mattress with hot water. B. Wipe off moisture with antiseptic solution, and dry thoroughly. C. Flip the mattress. D. Apply a waterproof pad over the soiled area.

B. Wipe off moisture with antiseptic solution, and dry thoroughly. Rationale: It is necessary to wipe off any moisture using a washcloth moistened with antiseptic solution and then to dry the area thoroughly before making the bed. Washing the mattress with hot water would not clean the soiled area. Flipping the mattress would not clean the soiled area. Applying a waterproof pad over the soiled area would not clean the mattress.

The nurse has one bed alarm available and can use it for any of the following patients, all of whom have dementia. Having an alarm is most important for which patient? A. A patient who has refused most meals for the past week and whose weight has dropped by 10% in the past month. B. A patient who has become verbally combative with health care team members in recent weeks. C. A patient who was returned to the unit last week by staff in an adjacent assisted living facility. D. A patient whose abdominal feeding tube is covered with an abdominal binder.

C. A patient who was returned to the unit last week by staff in an adjacent assisted living facility. Rationale: A patient who was returned to the unit last week by health care team members in an adjacent assisted living facility is the correct answer, because the nurse will use the alarm for the patient who has recently been found wandering. Refusal of meals and associated weight loss are not addressed by placement of a bed alarm. This patient's combativeness is not necessarily associated with attempts to get out of bed without assistance, neither does it necessarily correlate with a higher risk of falling. The presence of a feeding tube, disguised or not, does not increase the likelihood that the patient will try to get out of bed without assistance.

Which patient should not have his or her feet soaked during a complete bed bath? A. A patient with arthritis B. A patient who has just complained of shoulder pain C. A patient with diabetes mellitus D. A patient who is nauseated

C. A patient with diabetes mellitus Rationale: Soaking the feet is contraindicated in a patient with diabetes mellitus, because such patients may have reduced sensation in the feet. Soaking the feet is not contraindicated in a patient with arthritis, shoulder pain or one who is nauseated.

Which action ensures that a patient will not have unnecessary pain during a linen change? A. Discontinue the bed change if the patient expresses or displays physical signs of pain. B. Explain the procedure to the patient before beginning the linen change. C. Administer a prescribed analgesic 30 to 60 minutes before the bed change if needed. D. Postpone the bed change if the patient reports having physical pain before you begin.

C. Administer a prescribed analgesic 30 to 60 minutes before the bed change if needed. Rationale: Administering a prescribed analgesic 30 to 60 minutes before the linen change helps prevent unnecessary pain by giving the medication time to take effect before the patient is moved during the bed change. The remaining options do not pertain to pain prevention.

When making a surgical bed with no patient present, at which time is it unnecessary to perform hand hygiene? A. Before making the bed. B. After gloving, washing the mattress with an antiseptic solution, and ungloving. C. After disposing of soiled linen that is not visibly soiled. D. After fanfolding the sheets to complete the open bed.

C. After disposing of soiled linen that is not visibly soiled. Rationale: The nurse need not perform hand hygiene after disposing of linen that is not visibly soiled. The nurse would perform hand hygiene before beginning the process of bedmaking. The nurse would apply gloves to wash the mattress with an antiseptic solution, and perform hand hygiene after removing and discarding the gloves. The nurse would perform hand hygiene after making the bed.

What is the best way for the nurse to ensure that the patient is comfortable while he is being shaved? A. Administer a prescribed analgesic 30 minutes before beginning the procedure. B. Gently pull the skin taut in order to avoid nicks and cuts. C. Ask the patient if he is comfortable several times during the procedure. D. Encourage the patient to shave himself if he is capable of doing so.

C. Ask the patient if he is comfortable several times during the procedure. Rationale: To ensure that the patient remains comfortable while he is being shaved, simply ask him several times how he feels. Unless the provider has specified administration of an analgesic, it is unnecessary to give one before shaving a patient. Gently pulling the skin taut is appropriate. It is appropriate to encourage the patient to shave himself if he can.

When preparing to delegate a patient's back massage to nursing assistive personnel (NAP), the nurse would do what first? A. Observe the NAP performing the skill B. Determine if the NAP has enough muscle endurance to give a complete back massage C. Assess the NAP's understanding of the proper technique for back massage D. Have the NAP determine whether the patient is interested in a back massage

C. Assess the NAP's understanding of the proper technique for back massage Rationale: When delegating a skill to NAP, it is a nursing responsibility to determine the NAP's ability to perform the skill correctly. It is not necessary to observe the NAP unless there is reason to believe that proper technique needs to be reinforced. If the NAP has the skill to perform a back massage, it is not necessary to evaluate his or her muscle endurance. The nurse determines the patient's need for and acceptance of a back massage before delegating the skill to NAP.

Which action would the nurse perform first when preparing to apply sterile gloves? A. Perform hand hygiene. B. Place the package on a stable, flat surface. C. Assess the glove packaging for wetness or tears. D. Open the outer packaging.

C. Assess the glove packaging for wetness or tears. Rationale: The nurse first assesses the packaging for wetness or tears; any breach in the packaging compromises the sterility of the gloves. The nurse performs hand hygiene after selecting the gloves and placing them on the work surface. The nurse places the package of gloves on the work surface after inspecting the integrity of the package. The nurse opens the outer packaging after inspecting the integrity of the packaging, placing the package on the work surface, and performing hand hygiene.

How can the nurse promote infection control while providing perineal care for a female patient who has a catheter? A. By avoiding the application of tension on the catheter. B. By patting, not rubbing, the skin dry after thoroughly rinsing it. C. By cleansing the patient's labia from the pubic area toward the rectum. D. By using warm water to cleanse the patient's entire perineal area.

C. By cleansing the patient's labia from the pubic area toward the rectum. Rationale: Cleansing the labia from the pubic area toward the rectum minimizes the risk of introducing microorganisms from the rectum to the urethra and vagina. Although avoiding tension on the catheter is encouraged in order to prevent its accidental dislodgment, this precaution does not pertain to infection control. Patting the skin dry, rather than rubbing it, helps minimize skin damage, but this action does not pertain to infection control. Cleansing with soap and water reduces the number of microorganisms in the perineal area. Using warm water alone, however, has little effect.

A patient with left-sided muscle weakness is prescribed a bath every other day. Which precaution would help the nurse reduce this patient's risk of falling? A. Maintain the water temperature at 104°F. B. Allow the patient to remain in the bath for 45 minutes. C. Decline the patient's request to add scented oil to the bathwater. D. Discuss the patient's level of fatigue after the bath.

C. Decline the patient's request to add scented oil to the bathwater. Rationale: Declining the patient's request to add scented oil to the bathwater will reduce her risk of falling. Bath oil increases the patient's likelihood of slipping and therefore should not be used. Monitoring the water temperature may reduce scalding risk or improve the patient's comfort but would not reduce her risk of falling. Limiting the amount of time the patient spends in the tub would not reduce her risk of falling. Assessing the patient's level of fatigue is appropriate but would not reduce her risk of falling.

The nurse is helping a patient get out of a bathtub, and the patient appears to be unsteady on her feet. What should the nurse do to help ensure the patient's safety? A. Drape a bath towel over the patient's shoulders. B. Demonstrate how to use the call light for assistance. C. Drain the bathtub before the patient gets out. D. Apply lotion to the patient's freshly dried skin.

C. Drain the bathtub before the patient gets out. Rationale: When helping an unsteady patient get out of a bathtub, the nurse should first drain the tub. Doing so reduces the patient's risk of falling. Draping a bath towel over the patient's shoulders is appropriate but will not help ensure the safety of an unsteady patient who is getting out of a bathtub. Demonstrating how to use the call light is appropriate but will not help ensure the safety of an unsteady patient who is getting out of a bathtub. Applying lotion to freshly dried skin is appropriate but will not help ensure the safety of an unsteady patient who is getting out of a bathtub.

What is the primary reason the nurse ensures that a patient's indwelling urinary catheter drainage tubing is free of kinks? A. Kinks in the tubing cause the patient unnecessary discomfort. B. Kinks allow the drainage bag to become overly full. C. Kinks are associated with the development of urinary tract infection (UTI). D. Kinks result in scant, dark amber-colored urine.

C. Kinks are associated with the development of urinary tract infection (UTI). Rationale: Kinks in the drainage tubing obstruct the flow of urine into the drainage bag, which can cause UTI. Kinking of the drainage tubing interferes with proper urine drainage, perhaps making the patient uncomfortable; preventing infection, however, is more important than promoting comfort. Kinks in the drainage tubing do not result in an overly full drainage bag. In fact, they do the opposite (obstruct urine drainage into the bag), which can cause UTI. The development of scant, dark amber-colored urine is probably a result of dehydration, not kinked tubing. Kinks in the drainage tubing obstruct the flow of urine into the drainage bag, which can cause UTI.

What can the nurse do to keep the patient from becoming chilled while receiving a bath with a disposable bath-in-a-bag product? A. Dry each body part with a warmed towel after washing. B. Wash the product off of the skin with a warm, moistened washcloth. C. Lightly cover the patient with a bath towel. D. Keep the patient's gown on for the bath.

C. Lightly cover the patient with a bath towel. Rationale: Covering the patient with a bath towel will help prevent chilling as the product dries. After using the disposable bath product, the skin is allowed to air dry for 30 seconds. The disposable bath-in-a-bag product is not washed off of the skin. The patient's gown should be removed for the bath.

A patient is being given a bed bath. The nurse realizes that another washcloth is needed to complete the bath. What is one way in which the nurse can ensure the patient's safety? A. Use the call light to ask someone else to bring a washcloth. B. Raise all four side rails on the patient's bed. C. Make sure the call light is within the patient's reach. D. Raise the bed to its highest position.

C. Make sure the call light is within the patient's reach. Rationale: Placing the call light within easy reach reduces the likelihood that the patient will fall while trying to get out of bed in the nurse's absence. Asking someone else to bring the washcloth is not particularly realistic. Raising all four side rails on the bed is considered a restraint and raises the risk of falling. The patient's bed should be in the locked, low position, to minimize the risk of falling if the patient tries to get out of bed.

A patient has removed her dentures and placed them on the bedside stand. What would the nurse do to protect the patient's dentures? A. Wrap the dentures in a paper towel. B. Store the dentures in the patient's bedside stand, and notify other staff of where they have been placed. C. Obtain a denture cup, label it with the patient's name, and store the dentures in a safe place. D. Wrap the dentures in a damp washcloth, and place them in a denture cup.

C. Obtain a denture cup, label it with the patient's name, and store the dentures in a safe place. Rationale: To keep the dentures from getting lost or being thrown away, they should be placed in tepid water in a denture cup labeled with the patient's name, and then stored in a safe place. Dentures cannot be safely stored in a paper towel. The dentures could still be damaged if they are not placed in a proper container before storage; in addition, notifying other staff of where the dentures have been stored is impractical. Wrapping the dentures in a damp washcloth and placing them in a denture cup is not a safe way to store the dentures.

When making an unoccupied bed, where would the nurse place a waterproof pad? A. Directly on the mattress. B. Beneath the drawsheet. C. Over the bottom sheet. D. Over the top sheet.

C. Over the bottom sheet. Rationale: The waterproof pad is placed over the bottom sheet or drawsheet. A waterproof pad would not be useful if placed directly on the mattress, beneath the drawsheet or over the top sheet.

What will the nurse do when a gown change is needed for a patient who is receiving intravenous fluids delivered by a pump? A. Document that the tubing had to be disconnected in order to change the gown B. Ask another nurse to monitor the pump during the gown change C. Pause the infusion by pressing the sensor on the pump D. Help the patient maintain good hygiene until the infusion is discontinued and the gown can be changed

C. Pause the infusion by pressing the sensor on the pump Rationale: The infusion is paused briefly to allow the gown to be changed. The tubing should never be disconnected to change a patient's gown. It is not necessary for another nurse to monitor the pump; the infusion can simply be paused during the gown change. A gown change need not be postponed because the patient is receiving intravenous fluids.

The nurse who is preparing to make an unoccupied bed should do what to ensure his or her personal safety? A. Put on sterile gloves. B. Place the call light within the nurse's reach. C. Place the bed at a comfortable working height. D. Place a laundry bag on the bedside chair.

C. Place the bed at a comfortable working height. Rationale: Placing the bed at a comfortable working height may help prevent injury when making an unoccupied bed. Sterile gloves need not be worn to make an unoccupied bed. Moving the call light to another location and placing a laundry bag on the bedside chair will not help to ensure the nurse's safety.

Which action should be avoided when providing hair care for a bed-bound patient with a history of dizziness? A. Raising the patient quickly into a sitting position after completing a bed shampoo. B. Getting water into the patient's ears during the rinsing phase of the shampoo. C. Placing the neck in a hyperextended position during the shampoo process. D. Having the entire shampooing process last longer than 15 minutes.

C. Placing the neck in a hyperextended position during the shampoo process. Rationale: Placing the neck in a hyperextended position during the shampoo process can trigger dizziness, particularly in a patient with a history of dizziness. Raising any patient quickly into a sitting position is not a good idea, but doing so is not of greater concern for a bed-bound patient with dizziness. Getting water into any patient's ears should be avoided, but doing so is not of greater concern for a bed-bound patient with dizziness. The length of the shampooing process does not pertain to dizziness.

A nursing assistive personnel (NAP) has finished making a surgical bed for a patient in surgery. How would the nurse instruct the NAP to leave the bed to transfer the surgical patient safely? A. Raise the head of the bed to a 30-degree angle. B. Raise the top two side rails. C. Raise the height of the bed. D. Release the bed wheels.

C. Raise the height of the bed. Rationale: A surgical bed is placed in the high position, at the level of the stretcher, with side rails down, wheels locked, and the head of the bed flat. This position facilitates safe transfer of the patient from the stretcher to the bed. The head of the bed must be flat to facilitate safe transfer of the patient from the stretcher to the bed. The side rails must be down to facilitate safe transfer of the patient from the stretcher to the bed. The wheels must be locked to keep the bed stationary as the surgical patient is transferred from the stretcher to the bed.

The nurse has delegated measurement of a patient's vital signs and catheter care to nursing assistive personnel (NAP). Which observation should the NAP report to the nurse immediately? A. Rectal temperature of 99.6° F B. Pulse rate of 88 beats per minute C. Redness noted on the external urethral meatus D. 200 mL of pale yellow urine in the drainage bag

C. Redness noted on the external urethral meatus Rationale: Redness surrounding the external urethral meatus is a sign of impaired skin integrity and should be reported to the nurse immediately. This rectal temperature is within normal limits; a catheterized patient's temperature should be closely monitored, however, since an elevated temperature may indicate that UTI has developed. This pulse rate is within normal limits; a catheterized patient's pulse rate should be closely monitored, however, since tachycardia may indicate that UTI has developed. This urine output and color are within normal limits; a catheterized patient's urine output should be monitored closely, however, to observe its characteristics (color, odor, cloudiness) and volume for signs of UTI.

The nurse observes the nursing assistive personnel (NAP) providing perineal care to a male patient. Which observation of care requires the nurse's follow-up? A. Assisting the patient into the supine position in bed. B. Cleansing the tip of the penis with a circular motion, starting at the meatus. C. Reserving the cleansing of the tip of the penis as the final step in perineal care. D. Using a gloved hand to grasp the shaft of the penis in order to retract the foreskin.

C. Reserving the cleansing of the tip of the penis as the final step in perineal care. Rationale: Proper cleansing requires that the tip of the penis be cleansed first, to minimize the introduction of pathogens to the meatus. The nurse's observation of improper technique requires follow-up teaching. Unless the supine position is contraindicated for this patient, this action is appropriate and requires no follow-up. Cleansing the tip of the penis with a circular motion and using a gloved hand to grasp the shaft of the penis in order to retract the foreskin are correct and requires no follow-up.

When delegating patient care that requires nursing assistive personnel (NAP) to use personal protective equipment (PPE), it is necessary for the nurse to do what first? A. Discuss what equipment and supplies to bring to the patient's room B. Document that the care was delegated to the NAP C. Review the patient's need for a specific isolation precaution D. Observe the NAP donning the appropriate PPE

C. Review the patient's need for a specific isolation precaution Rationale: A first action the nurse will do is review with the assistive nursing personnel (NAP) the patient need for a specific isolation precaution and the necessary personal protective equipment (PPE). The nurse will review with the NAP what equipment and supplies to bring into the patient's room, but this will not be her first action. Documentation is not usually required. Observation is not necessary unless the nurse has sufficient doubt regarding the NAP's ability to select the appropriate PPE or execute the precautions.

What is the most important step the nurse can take to minimize the risk of tearing a sterile glove when applying it to the hands? A. Using powdered sterile gloves B. Keeping the fingernails trimmed and smoothly filed C. Selecting the proper glove size D. Drying the hands thoroughly before applying the gloves

C. Selecting the proper glove size Rationale: Improper glove size is the leading cause of glove tears. Most sterile gloves are powdered. Since using unpowdered gloves is usually not an option, using powdered gloves does not reduce the risk of tearing a sterile glove. Keeping the fingernails well-trimmed and smoothly filed is prudent, but it is not the most important step the nurse can take to reduce the risk of tearing a glove. Drying the hands thoroughly before applying gloves is prudent, but it is not the most important step the nurse can take to reduce the risk of glove tears.

Why would the nurse plan to perform foot care for a patient with peripheral vascular disease (PVD), rather than delegate this activity to nursing assistive personnel (NAP)? A. The patient prefers that the nurse provide the care. B. NAP are not trained to perform foot care. C. The patient's elevated risk of infection makes it unsafe for NAP to perform the care. D. The patient's condition requires that he remain on bed rest.

C. The patient's elevated risk of infection makes it unsafe for NAP to perform the care. Rationale: For patients with circulatory compromise, elevated risk of infection, nail and foot care cannot be delegated to NAP. The patient's wishes have no bearing on whether this care can be delegated. NAP are trained to perform nail and foot care; however, such care cannot be delegated for patients with circulatory compromise. Even if a patient with PVD were placed on bed rest, such an order would have no bearing on whether the skill of foot care could be delegated.

When brushing the teeth of an unconscious patient, why is the toothbrush held so that its bristles are at a 45-degree angle to the gum line? A. To give the nurse a firm grip on the brush handle B. To ensure that the bristles reach all tooth surfaces C. To allow the bristles to reach beneath the gum line D. To reduce pressure on sensitive oral tissues

C. To allow the bristles to reach beneath the gum line Rationale: The toothbrush is held at this angle to allow the bristles to sweep away plaque beneath the gum line. Holding the toothbrush so that its bristles are at a 45-degree angle does not necessarily ensure a firm grip on the brush handle, allow the bristles to reach all tooth surfaces or reduce pressure on sensitive oral tissues.

Why does the nurse instruct nursing assistive personnel (NAP) to remove the wrist restraint of a confused patient every 2 hours? A. To try a less restrictive type of restraint if a more confining restraint has proved effective B. To double-check the size by inserting one finger between the wrist and the restraint C. To check the skin integrity and range of motion of the wrist D. To comply with Joint Commission standards

C. To check the skin integrity and range of motion of the wrist Rationale: The nurse instructs the NAP to remove the wrist restraint of a confused patient every 2 hours to ensure that the wrist is checked for skin integrity, pulse, temperature, color, sensation, and range of motion. In acute care settings, the health care provider must order the least restrictive type of restraint first, not after a more confining restraint has proved effective. The nurse would select the appropriate size restraint for the patient, according to the manufacturer's instructions, when the restraint is initially applied, and he or she would double-check the fit when the restraint is applied, not 2 hours later. The fit need not be checked at 2-hour intervals thereafter. The Joint Commission policy states that, in most circumstances, a physical restraint may be maintained up to 4 hours in an adult.

What is the primary reason the nurse encourages the patient to participate in hair care? A. To free up the staff's time for patient care B. To make sure the care is performed according to the patient's preferences C. To encourage the patient's sense of independence D. To allow the nurse to evaluate the patient's ability to manipulate objects

C. To encourage the patient's sense of independence Rationale: The nurse encourages the patient to participate in hair care to promote his or her sense of independence. The nurse encourages the patient to participate in hair care to promote a sense of independence; hair care is a patient care activity. A patient can often express his or her preferences, even when unable to participate in hair care; the nurse encourages participation mainly in order to promote the patient's sense of independence. The patient's participation in hair care allows the nurse to observe the patient's dexterity; however, the nurse encourages participation primarily in order to promote the patient's sense of independence.

For a surgical bed, why is the linen formed into a triangle and fanfolded away from the side on which the patient will be transferred? A. To protect the linen from soiling B. To ensure that the toe pleat is not pulled out C. To keep the linen out of the way during the transfer D. To keep the flat sheet taut during the transfer

C. To keep the linen out of the way during the transfer Rationale: The linen is formed into a triangle and fanfolded in order to keep the linen out of the way as the patient is transferred from the stretcher. Patient safety, not hygiene, is of paramount concern during the transfer. A surgical bed does not have a toe pleat. Fanfolding the linen has no effect on the flat sheet.

When removing a gown worn as personal protective equipment (PPE) while caring for a patient in isolation, why does the nurse avoid touching the outside of the gown? A. To ensure that the gown can be reused B. To protect the nurse's uniform C. To prevent touching contaminated material with unprotected hands D. To fold the gown correctly for reuse by the same nurse

C. To prevent touching contaminated material with unprotected hands Rationale: The nurse will avoid touching the outside of the gown to ensure that an ungloved hand does not touch the contaminated gown. Whether the gown is discarded or washed and reused is irrelevant. Precaution is not observed to protect the nurse's uniform. If the gown is to be reused, even by the same nurse, it must be washed first; folding after use is therefore unnecessary.

When caring for a patient with Alzheimer's disease, why does the nurse cover the external urinary collection catheter? A. To protect the bed from being soiled B. To avoid offending visitors who would otherwise see the device C. To reduce the patient's access to the device D. To keep the patient from trying to get out of bed alone

C. To reduce the patient's access to the device Rationale: When caring for a patient with Alzheimer's disease, the nurse may camouflage the external urinary collection catheter to reduce the patient's access to the device. Covering the device does not protect the bed from being soiled. Visitors' sensibilities are not relevant. Unassisted ambulation attempts are an unrelated problem.

Why would the nurse encourage a male patient to use an electric razor for shaving? A. To reduce the use of hospital supplies B. To reduce the risk of infection C. To reduce the risk of bleeding from a disposable razor D. To encourage him to shave himself

C. To reduce the risk of bleeding from a disposable razor Rationale: The nurse would encourage a male patient to use an electric razor to reduce the risk of bleeding associated with use of disposable razors.

The nurse is bathing a patient who is unconscious. What should the nurse do to ensure safe care of the patient's eyes? A. Remove eye crusts with soapy water. B. Avoid closing the patient's eyes. C. Use eye patches or shields taped in place. D. Tape the patient's eyelids closed.

C. Use eye patches or shields taped in place. Rationale: An eye shield or patch should be placed over each eye and taped in place. Soap should not be used to cleanse the eyes. The eyes should be closed gently, using the back of a fingertip. Tape should not be used on the eyelids.

hich protocol does not vary among institutions? A. Acceptability of wearing artificial nails in patient care areas B. Use of impervious transparent dressings to cover open lesions on nurse's hands during sterile procedures C. Use of sterile gloves for sterile procedures D. Sterile gloves are only available in "one size fits all"

C. Use of sterile gloves for sterile procedures Rationale: By definition, a procedure is not sterile if sterile gloves are not worn. Many, but not all, health care institutions prohibit artificial nails and extenders in clinical areas. Review your agency's policy before performing a sterile procedure. In some settings, nurses are allowed to cover open lesions with a sterile, impervious, transparent dressing. In other settings, the presence of such a lesion may prevent the nurse from participating in a sterile procedure. Review your agency's policy before performing a sterile procedure. Sterile gloves are available in various sizes, such as 6½ and 7. The availability of gloves will vary among institutions.

Which statement made by nursing assistive personnel (NAP) assigned to care for a patient with dementia requires the nurse to follow up? A. "I encouraged his son and daughter-in-law to stay with him during visiting hours, if possible, even if they run out of things to talk about." B. "He can't see his Foley because it's covered by his boxer shorts." C. "I'll ask the patient every hour or so whether he needs to use the bathroom." D. "He doesn't understand much of what anyone says to him today, so I didn't put in his hearing aids."

D. "He doesn't understand much of what anyone says to him today, so I didn't put in his hearing aids." Rationale: This statement requires the nurse to follow up, because the patient will become all the more disoriented if he cannot hear what is going on around him. This statement is appropriate, because having familiar visitors for extended periods helps orient the patient to his environment and decrease anxiety and restlessness. This statement is appropriate, because positioning catheters, tubes, and drains out of sight reduces the patient's access to them, allowing medical treatment to be administered without interruption. This statement is appropriate, because being offered an opportunity to void regularly reduces the likelihood that the patient will try to reach the bathroom alone.

The nurse has delegated a male patient's perineal care to the nursing assistive personnel (NAP). Which statement made by the NAP requires the nurse's follow-up? A. "I will check to see if he cleans himself well." B. "I will let you know if I see any redness or drainage." C. "I will ask him if he is experiencing any pain in that area." D. "I will be sure to use hot, soapy water to be sure he's clean."

D. "I will be sure to use hot, soapy water to be sure he's clean." Rationale: This is an inappropriate statement since warm, not hot, water and mild soap should be used when cleansing the perineal area to minimize irritation. This statement requires the nurse's follow-up. Reflecting attention to the patient's ability to effectively provide perineal cleansing requires no follow-up. The statement regarding observation of the patient's skin requires no follow-up. Observation of the patient's comfort level requires no follow-up.

he nurse is delegating to nursing assistive personnel (NAP) the perineal care of a female patient who is totally dependent and confined to bed. Which statement by the NAP requires the nurse's follow-up? A. "I'll ask for assistance if I need help positioning her." B. "I'll see if she's up to the care right now." C. "I'll let you know if I notice any signs of redness or discharge." D. "I'll be sure to use hot, soapy water, since she has been incontinent."

D. "I'll be sure to use hot, soapy water, since she has been incontinent." Rationale: To minimize skin irritation, warm water and mild soap should be used when cleansing the perineal area, so this statement requires the nurse's follow-up. Positioning a totally dependent patient is likely to require more than one person, so this requires no follow-up. It is appropriate to evaluate the patient's ability and willingness to have the care performed at this time, so this requires no follow-up. Observing the patient's perineal area for signs of skin damage or discharge is appropriate, so this requires no follow-up.

he nurse is discussing the risk of falling with the wife of a patient with cognitive impairment. What is the nurse's best response when the patient's wife says, "I don't like him being tied down in the bed?" A. "I'm sure you don't want him to fall again." B. "Can you suggest an alternative?" C. "What did you do to prevent him from falling when he was at home?" D. "We will try all other alternatives before using physical restraints."

D. "We will try all other alternatives before using physical restraints." Rationale: The nurse stating they will try all other alternatives before using physical restraints is the correct answer because the response attempts to reassure the family that restraints will be used only as a last resort. The nurse stating that you don't want him to fall again is not the correct answer because it appears to use guilt to secure family consent. Asking the patient's wife for an alternative suggestion is not the correct answer because it indicates impatience with the family's concerns and places an inappropriate responsibility on the patient's wife. Asking the patient's wife what she did to prevent him from falling when he was at home is not the correct option, because it appears to place responsibility for the patient's safety on the family. In addition, the patient's condition and circumstances are different in the facility than they were at home, so using the same fall-prevention strategies is likely to be ineffective.

For which of the following patients would it be necessary to use a disposable shampoo cap, rather than a shampoo board? A. An older adult woman with a drainage tube in place following a mastectomy. B. An older adult man with a history of bleeding problems. C. A young woman whose arm and leg have been immobilized on the right side following a car accident. D. A young man who has sustained a fracture of the upper spine in a football game.

D. A young man who has sustained a fracture of the upper spine in a football game. Rationale: Head and neck injuries, such as this young man's spinal fracture, are a contraindication to use of a shampoo board because neck hyperextension could cause further injury. An older adult female patient with a drainage tub following a mastectomy can sit up in a chair or be placed on a stretcher for her hair to be washed using a shampoo board. Bleeding problems are not a contraindication to having one's hair washed using a shampoo board. A patient with immobilized extremities can be transferred to a stretcher for her hair to be shampooed using a shampoo board.

A patient tells the nurse that at home he cleans his dentures after every meal and before going to bed. When would denture care be planned for this patient while hospitalized? A. After breakfast and before going to bed B. With morning care C. With morning and evening care D. After every meal and before going to bed

D. After every meal and before going to bed Rationale: Dentures should be cleaned as often as natural teeth. The patient performs denture care at home after every meal and at bedtime, so this schedule should be maintained while the patient is hospitalized. Cleaning the dentures after breakfast and before going to bed is not frequent enough for this patient. Providing denture care only with morning care is not frequent enough for this patient. Providing denture care only with morning care and evening care is not frequent enough for this patient.

What is the most effective way to prevent infection when providing catheter care for a patient? A. Properly dispose of soiled linen. B. Perform hand hygiene before positioning the patient. C. Secure the catheter to the patient's leg or abdomen. D. Cleanse from the meatus outward.

D. Cleanse from the meatus outward. Rationale: Securely holding the catheter and cleansing from the meatus outward is the most effective way to prevent infection when providing catheter care. Properly disposing of soiled linen is an infection control measure, but its effect in preventing infection during catheter care is negligible. Performing hand hygiene before positioning the patient is an infection control measure, but its effect in preventing infection during catheter care is negligible. Securing the catheter to the leg (in a female patient) or abdomen (in a male patient) will prevent the catheter from pulling on the bladder and will therefore reduce the risk of CAUTI; however, it is not the most important infection control measure listed.

The nurse is preparing to provide perineal care for a female patient who is on bed rest. Which patient position should the nurse use for this care? A. Supine B. Prone C. Side-lying D. Dorsal recumbent

D. Dorsal recumbent Rationale: Dorsal recumbent is the correct patient position to use when performing perineal care. The supine, prone, and side-lying positions are not used when performing perineal care.

Which personal protective equipment (PPE) will the nurse wear if there is a risk of a blood splash when caring for a patient? A. Gown B. Gown and gloves C. Gown, gloves, and mask D. Gown, gloves, mask, and eye protection

D. Gown, gloves, mask, and eye protection Rationale: Wearing a gown, gloves, mask, and eye protection is the correct PPE to don. The eyes must be protected if there is risk of a blood splash. Wearing a gown is not enough personal protection in the event of a blood splash.

The nurse would not offer back massage to which of the following patients? A. Patient with abdominal pain B. Patient who has a controlled-release transdermal analgesic patch C. Patient who receives peritoneal dialysis for renal failure D. Patient who is receiving continuous epidural analgesia

D. Patient who is receiving continuous epidural analgesia Rationale: Back massage is contraindicated for any patient with an epidural catheter in place for continuous delivery of an epidural analgesic. Back massage is not contraindicated for a patient with abdominal pain. The side-lying position can be used. It is not contraindicated for a patient with a transdermal patch. Massage is a nonpharmacologic intervention that can enhance the effect of an opiate or opioid analgesic. It is not contraindicated for a patient who receives dialysis for chronic renal failure. In fact, it is a nonpharmacologic intervention that might help the patient to relax.

Which nursing action reduces the risk of falling as a patient is getting into or out of a bathtub? A. Add 1 oz of bath oil to the tub water before the patient gets into the tub. B. Place an "Occupied" sign on the bathroom door. C. Fill the tub half full of water at 110°F to 115°F. D. Place a skidproof disposable bath mat in front of the tub.

D. Place a skidproof disposable bath mat in front of the tub. Rationale: Placing a skidproof disposable bath mat in front of the tub will reduce the risk of falling as a patient is getting into or out of a bathtub. Adding any amount of oil to the tub water will increase the risk of falling as a patient is getting into or out of a bathtub. Placing an "Occupied" sign on the bathroom door will not reduce the risk of falling as a patient is getting into or out of a bathtub. Filling the tub half full of water at 110°F to 115°F will not reduce the risk of falling as a patient is getting into or out of a bathtub.

What will the nurse do right after placing a clean top sheet on the patient? A. Make a cuff with the top of the sheet. B. Make a horizontal toe pleat. C. Tuck the remaining portion of the sheet under the foot of the mattress. D. Remove the bath blanket.

D. Remove the bath blanket. Rationale: After applying a clean top sheet, the nurse will ask the patient to hold on to the sheet as the bath blanket is removed. After the bath blanket has been removed, the nurse makes a cuff by turning the edge of the top sheet down over the top edge of the blanket. The nurse makes a horizontal toe pleat after making a cuff at the top of the sheet. The nurse tucks the remaining portion of the sheet and blanket beneath the foot of the mattress.

When changing the soiled gown of a patient with left-sided paralysis, what will the nurse do first? A. Remove the sleeve from the weaker arm B. Roll the patient into a prone position C. Help the patient assume a side-lying position D. Remove the sleeve from the stronger arm

D. Remove the sleeve from the stronger arm Rationale: The nurse will begin on the unaffected side to allow easier manipulation of the gown over the body part that has reduced range of motion. The nurse will remove the sleeve from the weaker arm after the sleeve has been removed from the stronger arm. A gown is not changed with the patient in the prone position. A gown is not changed with the patient in the side-lying position.

Which action is most important in minimizing the patient's risk for injury when preparing to shave a patient with a history of bleeding? A. Fully explain the process to the patient in order to secure his cooperation. B. Pay particular attention to technique in order to avoid nicks and cuts. C. Ensure that the provider has ordered the intervention. D. Review current platelet count and anticoagulation studies.

D. Review current platelet count and anticoagulation studies. Rationale: Reviewing the patient's most recent laboratory studies will give the nurse information with which to make other decisions to help ensure his safety, such as whether to use an electric razor. Explaining the process is appropriate; this option does not directly affect the patient's risk for injury through bleeding. Paying special attention to technique is appropriate; the necessity of using extreme caution has not yet been determined. It is appropriate to review the provider's orders; such an order is not usually needed to perform routine hygiene care.

Under what circumstances would the nurse assume responsibility for providing denture care for a patient? A. Assessment of the oral cavity shows mucositis due to chemotherapy. B. The patient's previous set of dentures was misplaced or thrown away. C. The dentures belong to the hospital or other facility, rather than to the patient. D. The patient is unable to care for the dentures on his or her own.

D. The patient is unable to care for the dentures on his or her own. Rationale: If a patient is unable to care for his or her dentures because of physical limitations, diminished consciousness, or other difficulties, the nurse becomes responsible for providing denture and oral care. The presence of mucositis due to chemotherapy would prompt the nurse to instruct the patient in proper oral hygiene techniques, such as use of a saline rinse, but would not lead the nurse to assume responsibility for the patient's denture care. The patient losing a set of dentures would not prompt the nurse to assume responsibility for the patient's denture care. Dentures are a patient's personal property and would not be owned by the hospital or other health care facility.

When preparing to assist a patient with hair care, why does the nurse first check the patient's scalp for inflammation? A. To determine what type of shampoo to use B. To plan enough time to perform hair care C. To determine if the patient can perform the care independently D. To ensure that the care can be performed without injuring the scalp

D. To ensure that the care can be performed without injuring the scalp Rationale: The nurse first checks the scalp for inflammation to ensure that care can be performed without injuring the scalp.

What is the purpose of parting the patient's hair into sections? A. To identify the areas to be groomed B. To style the hair attractively C. To check for pediculosis (head lice) D. To make brushing and combing more effective

D. To make brushing and combing more effective Rationale: Parting the patient's hair into sections makes grooming more effective; hair is easier to work with in small sections as it is combed and brushed from the scalp to the ends of the hair. All of the patient's hair is groomed. Parting the hair into sections makes it easier to work with. Parting the patient's hair into sections makes it easier to work with but does not necessarily help the nurse style the hair attractively. Although the nurse checks the patient's hair for infestation, it is not necessary to part the hair in order to do so.

What is the primary reason an unconscious patient is placed in the side-lying position when mouth care is provided? A. To make the oral cavity easily accessible B. To prevent possible musculoskeletal injury C. To reduce plaque buildup in the mouth D. To reduce the risk of aspiration

D. To reduce the risk of aspiration Rationale: An unconscious patient is placed in the side-lying position when mouth care is provided because this position prevents pooling of secretions at the back of the oral cavity, thereby reducing the risk of aspiration. Although the side-lying position does allow the nurse to reach the oral cavity easily, accessibility, reducing the risk of musculoskeletal injury, and the reduction of plaque buildup in the mouth are not the reasons this position is used.

What is the primary reason for performing perineal care on a male patient with incontinence? A. To provide comfort and a relaxed, refreshed feeling B. To promote personal hygiene while minimizing perineal odor C. To remove all microorganisms from the patient's perineal area D. To reduce the risk of skin breakdown in the patient's genital and perineal area

D. To reduce the risk of skin breakdown in the patient's genital and perineal area Rationale: Incontinence increases the risk of skin breakdown, but proper perineal care minimizes the damaging effect that urine and feces have on the patient's skin. Although comfort is a reason for performing male perineal care, it is not the primary reason for providing such care to a male patient with incontinence. Promoting personal hygiene and minimizing perineal odor are expected outcomes of performing male perineal care, they are not the primary reasons for providing such care to a male patient with incontinence. Proper perineal cleansing reduces the number of microorganisms on the skin, but it cannot eliminate them.

A patient with diabetes remarks during foot care that she has been letting her skin air-dry after bathing at home because her doctor told her to use plenty of moisturizer on her hands and feet. What should the nurse teach the patient? A. To apply moisturizer after air-drying thoroughly B. To apply moisturizer while the skin is still wet C. To skip the moisturizer D. To towel-dry thoroughly before applying moisturizer

D. To towel-dry thoroughly before applying moisturizer Rationale: The nurse would encourage this patient to towel dry thoroughly before applying moisturizer. Allowing the skin to air-dry promotes fungal growth and maceration of tissues.

All of the following factors are known to increase the risk of urinary tract infection (UTI) except which one? A. History of fecal incontinence B. Use of an indwelling urinary catheter C. Drainage tubing is kinked D. Use of plain soap instead of an antiseptic cleanser for perineal hygiene

D. Use of plain soap instead of an antiseptic cleanser for perineal hygiene Rationale: Use of an antiseptic cleanser has not been shown to decrease the risk of catheter-associated urinary tract infection (CAUTI). Mild soap and warm water are adequate for perineal hygiene during catheter care. E. coli is the most common cause of CAUTI. E. coli colonizes the bowel; soiling from fecal incontinence therefore increases the risk of CAUTI. The risk of UTI increases with the use of an indwelling catheter, particularly if the catheter is left in place for more than a few days. Kinks in the drainage tubing obstructs the flow of urine into the drainage bag, which can cause UTI.