Chapter 9 - Hygiene and Care of the Patient's Environment PRACTICE QUESTIONS

Unstageable/unclassified ulcers

-An unstageable pressure ulcer involves full-thickness tissue loss -a wound base covered by slough (yellow, tan, green, or brown) and eschar in the wound bed that is usually tan, brown, or black -the true depth and stage of the ulcer cannot be determined until the base of the wound has been exposed -Stable eschar on the heels provides a natural biologic cover. Do not remove it

Types of therapeutic baths

-Cool water tub bath -Warm water tub bath -Hot water tub bath -Sitz bath

Stages of a pressure ulcer

-Stage I -Stage II -Stage III -Stage IV -Unstageable/unclassified -suspected deep tissue injury

A neighbor tells the nurse that he has muscle soreness and stiffness after performing a new exercise program. What would the nurse recommend? 1. A tub bath with the proper temp of 113 to 115 degrees 2. A bath with the water temperature at a tepid 98.6 degrees 3. A sitz bath that lasts 20-30 minutes for soaking and relaxing 4. A shower with a recommended water temperature of 109.4 degrees

1. a tub bath with the proper temp of 113 to 115 degrees. Hot baths with this temperature provide relief for sore muscles. A tepid bath of 98.6 can be used to lower elevated body temperatures. Warm baths of 109.4 help to relieve tension, although many people prefer to shower. A sitz bath is used primarily to reduce inflammation for patients who have had perineal or anal surgery.

When cleansing this area, the nurse should use clear, clean water only. 1. eyes 2. urinary meatus 3. rectal meatus 4. nares

1. eyes

A patient with severe crippling rheumatoid arthritis is confined to bed for extended periods. An erythematous area over the coccyx that has the potential to become an open lesion is noted. The nurse is correct in reporting this area to the health care provider as having the potential to become what? 1. An inflammatory ulcer 2. A pressure ulcer 3. A stasis ulcer 4. An arterial ulcer

2. A pressure ulcer

Which condition contradicts a massage? 1. Infection 2. Pulmonary embolism 3. Asthma 4. Ileus

2. Pulmonary embolism

What is the purpose of positioning a patient at the 30-degree lateral position? 1. proper alignment of joints 2. an alternate position to lie in 3. reduction of pressure points 4. better comfort

3. reduction of pressure points. For patients with pressure ulcers who are at risk for pressure ulcers, the 30-degree lateral position is used to avoid pressure points

Which type of perineal care should be performed at least twice a day? 1. rectal 2. vaginal 3. urinary catheter care 4. uncircumcised care

3. urinary catheter care

During the bed bath, the nurse covers the patient with a bath blanket. The patient asks what the bath blanket is for. What is the correct response? 1. "The bath blanket helps to prevent skin irritation." 2. "The bath blanket is part of our bathing procedure." 3. "The bath blanket is used to prevent the spread of microorganisms." 4. "The bath blanket is used to prevent chilling."

4. "The bath blanket is used to prevent chilling."

Which patient is at greatest risk for impairment? 1. Child on bed rest 2. Infant with cool skin temperature 3. Young man with diarrhea 4. A 60-year-old patient in a body cast

4. A 60-year-old patient in a body cast

The nurse is supervising a nursing student who is giving a patient a bed bath. The nurse would intervene if the student performed which action? 1. Lowers the side rail to perform care 2. Raises the head of the bed to a semi-fowler's position 3. Bathes arms using long, firm strokes 4. Puts up all four side rails after completing the bath

4. Puts up all four side rails after completing the bath Putting up all four side rails is considered a form of restraint, which requires an order.

A 64-year-old patient with terminal cancer is too weak to perform her own perineal care. The student nurse includes bathing which areas as part of perineal care? 1. Back and buttocks 2. Eyes, ears, and nose 3. Upper torso and thighs 4. Upper thighs, genitalia, and anal area

4. Upper thighs, genitalia, and anal area

Assisting a patient with hygiene gives the nurse an opportunity to perform a complete and thorough ________________.

physical assessment

Stage 3 of a pressure ulcer

-involves full thickness of tissue loss in which subcutaneous fat is sometimes visible, but bone, tendon, and muscle are not exposed -If slough is present, it doesn't obscure the depth of tissue loss -possible features are undermining and tunneling -The depth of a stage 3 pressure ulcer depends on its anatomic location

Stage IV pressure ulcer

-involves full thickness tissue loss with exposed bone, tendon, or muscle -sometimes slough or eschar is present on some parts of the wound bed -the ulcer often includes tunneling or undermining -because these ulcers extend into muscle and supporting structures, the patient is at risk for osteomyelitis

Stage 2 of a pressure ulcer

-involves partially thickness loss of dermis -appears as a shallow open ulcer -usually shiny or dry -red or pink wound bed without slough or bruising (bruising raises the suspicion of deep tissue injury) -Some stage 2 ulcers manifest as intact or open serum-filled blisters -Do not use the term stage 2 to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation

Stage 1 of a pressure ulcer

-localized area of skin -particularly over a bony prominence -intact with nonblanchable redness -skin with darker tones may not have visible blanching, but color is likely to differ from the surrounding area -The wound characteristics may vary: areas may be painful, firm, soft, warm, or cool compared with adjacent tissue -this stage is typically difficult to detect in patients with dark skin tones

What are the conditions that place patients at risk for oral disorders?

-paralysis -serious illness -upper-extremity activity limitations -state of unconsciousness -disorientation -diabetes -NPO status -radiation therapy -chemotherapy drugs -oral surgery

What determines the extent of the patients bath and methods used for bathing?

-the patient's capabilities -the degree of hygiene required -the physicians order, as in the case of therapeutic baths

Suspected tissue or deep tissue injury

-wound appears as a localized purple or maroon area of discolored intact skin or a blood-filled blister (this is caused by underlying soft tissue damage from pressure or shear) -Characteristics of the area range from painful, mushy, boggy, or warm to cool compared to adjacent tissue -in patients with dark skin tones, deep tissue injury is sometimes difficult to detect but often starts with a thin blister over a dark wound bed. -The wound sometimes becomes covered with thin eschar -Even with prompt treatment, some wounds evolve rapidly, exposing additional layers of tissue

An unconscious patient needs oral care. What instructions should the nurse give to the UAP to ensure the safety of the patient? (select all that apply) 1. Position the patient upright; use pillows for support as needed 2. Report bleeding, sores in the mouth, or obvious problems with teeth or gums 3. Check for gag reflex by gently inserting a tongue blade into the throat 4. Use a soft toothbrush and brush teeth as for any other patient 5. Have an oral suction device ready and check function prior to starting 6. Perform hand hygiene before donning clean gloves.

1, 2, 4, 5, 6. use pillows for support as needed 2. Report bleeding, sores in the mouth, or obvious problems with teeth or gums 4. Use a soft toothbrush and brush teeth as for any other patient 5. Have an oral suction device ready and check function prior to starting 6. Perform hand hygiene before donning clean gloves. An upright position and oral suctioning are used to prevent aspiration. (Facility policy may vary, but oral suctioning is not an invasive procedure and UAPs, conscious patients, and family members can be taught to use this device.) The UAP can observe for and report conditions if the nurse specifies what to watch for. Brushing someone else's teeth should mimic the action that you would use to brush your own teeth, unless the patient has special conditions, such as hard, dried secretions. Gloves and hand hygiene are always part of oral care. Checking for gag reflex is a nursing responsibility.

A patient with dementia needs assistance with bathing. What strategy(ies) is/are best to use to help the patient accomplish this task? (select all that apply) 1. Maintain a relaxed demeanor, smile frequently, and use a calm tone of voice 2. Demonstrate and explain the desired behavior, such as turning on the water. 3. Reassure frequently and say things such as "You are doing so well. We are almost done" 4. Try to repeat the same hygiene pattern every day and wash the same body parts 5. Use distraction rather that trying to negotiate or make demands 6. Attempt to have the same caregivers as often as possible for hygienic care

1, 3, 5, 6 1. Maintain a relaxed demeanor, smile frequently, and use a calm tone of voice 3. Reassure frequently and say things such as "You are doing so well. We are almost done" 5. Use distraction rather that trying to negotiate or make demands 6. Attempt to have the same caregivers as often as possible for hygienic care Being relaxed, calm, and reassuring are useful. Using distraction is more useful than negotiating, and making demands is likely to increase agitation. Demonstrating and explaining desired behavior is a good strategy, but for the safety and efficiency the nurse is more likely to finish the bath without trying to teach the patient with dementia how to accomplish the task. Repeating patterns is a good general strategy, but for hygiene the washing of body parts should be prioritized on a daily basis. Having consistent caregivers is the ideal

An 11 month old infant is admitted with a tympanic temperature of 105 degrees. The physician orders a tepid sponge bath. The infant's mother asks, "what is the purpose of this bath?" Which is the best response by the nurse? 1. "The bath helps reduce your baby's body temperature." 2. "The bath is used to help prevent febrile seizures." 3. "The bath stimulates circulation to the skin." 4. "The bath helps calm and relax your baby."

1. "The bath helps reduce your baby's body temperature."

A 72-year old patient has diffuse pancreatitis. The nurse cleanses her ears while giving her a soothing bed bath. Which intervention for cleansing her ears is correct for this bah? 1. Cleansing the outer ear with the washcloth during the bath 2. Retracting the outer ear downward to loosen visible cerumen 3. Irrigating to remove tenacious cerumen 4. Using cotton tipped applicators to remove cerumen

1. Cleansing the outer ear with the washcloth during the bath

Which patient is most likely to request that the room temperature be turned down? 1. Has chronic pulmonary disease 2. Has alternating chills and fever 3. Has peripheral vascular disease 4. Has end-stage pancreatic cancer

1. Has chronic pulmonary disease Patients with chronic pulmonary disease will often request a cooler temperature or even a fan, because they have to work harder to obtain adequate oxygen. The patient with chills and fever could request that the temperature be lowered, but may also request warm blankets for chilling. Patients with peripheral vascular disease often report coldness of extremities. Critically ill patients are more likely to need warmer room temperatures

The nurse is caring for an elderly patient who requires assistance with elimination. He can walk very slowly, but is frequently incontinent of urine before he can get to the toilet. What should the nurse do to help the patient with elimination? (select all that apply) 1. Instruct the UAP to be alert for the call signal and answer promptly 2. Obtain an order for an indwelling catheter until bladder training is achieved. 3. Show the patient how to use a urinal and place it within his reach 4. Obtain an order for a commode chair and place it close to the bed 5. Restrict fluids to exact intervals to establish a voiding pattern 6. Make a plan with the patient to call sooner, rather than delaying

1. Instruct the UAP to be alert for the call signal and answer promptly 3. Show the patient how to use a urinal and place it within his reach 4. Obtain an order for a commode chair and place it close to the bed 6. Make a plan with the patient to call sooner, rather than delaying The patient has functional incontinence, so the staff must help the patient compensate for the difficulty in getting to the toilet. Currently an indwelling catheter and restricting fluids are not appropriate interventions for this patient

The nurse is evaluating the eye care that has been delegated to and is being provided by a new staff member. Which action is appropriate? 1. Removing dried secretions with moist gauze 2. Using soap and water on a washcloth 3. Cleansing the eyes form the outer to the inner canthus 4. Wiping plastic eyeglasses with a clean paper towel

1. Removing dried secretions with moist gauze. Dried secretions can be gently wiped with a moist gauze or cotton ball. If soap gets in the eye, it will cause pain and irritation. Eyes should be cleaned from inner can scratch plastic lenses.

The nursing student is told to observe the bowel movements for an adult patient and report any abnormalities to the nurse. What should the student report as an unexpected finding? 1. Stool was a dull clay color 2. Stoll had soft, formed consistency 3. Patient had 2 bowel movements 4. Stoll had the shape of the rectum

1. Stool was a dull clay color The student would report the abnormal clay color of the stool, which should be a brown color. Clay-colored stool suggests that the patient is having some problem in the digestive tract

The nurse is assessing the oral cavity of an unconscious patient and sees tenacious, dried exudate on the tongue, teeth, and gums. what instructions should be given to the UAP? 1. Use a moistened sponge applicator and gently clean crusts several times per shift 2. Spray the mouth with a bulb syringe and use oral suction to remove the fluid 3. Use a toothbrush with paste and scrub the area until the crusts are removed 4. Wrap a gauze sponge around a tongue blade and apply hydrogen peroxide

1. Use a moistened sponge applicator and gently clean crusts several times per shift. This patient will require frequent gentle mouth care several times a day for a period of days to remove the crusting. Scrubbing is likely to cause bleeding. Hydrogen peroxide can impair wound healing and would also create significant bubbling and frothing for a patient who has no control over the gag reflex. Flushing with a bulb syringe creates a potential for aspiration

A sitz bath cleanses which area? 1. perineal and rectal area 2. axillae 3. Labia folds 4. Femoral areas

1. perineal and rectal area

What's the temp of a warm water tub bath?

109.4 degrees

What's the temp of a hot water tub bath?

113-115 degrees

If external pressure on the skin or tissues continues without relief for more than ______ hours, cells in the involved layers of skin tend to undergo necrosis

2

Nurses set an example for patients regarding hygiene. What personal hygiene measures should the nurse display? (select all that apply) 1. Bathe twice a day 2. Wear a clean uniform every day 3. Keep fingernails clean, short, and manicured 4. Consistently avoid the use of makeup, jewelry, or perfumes 5. Always be clean-shaven 6. Use breath mints

2, 3, 6, A nurse should wear a clean uniform every day; keeping fingernails clean, short, and manicured; and use breath mints to set a positive example for patients and not be offensive when providing care. Bathing once a day is sufficient. Makeup, jewelry, and perfumes should be used sparingly, but it is not necessary to eliminate their use totally. Beards can be worn but should be kept neat, short, and trimmed.

A 50-year-old patient is in her second postoperative day after an abdominal hysterectomy. The nurse plans to give the patient a bed bath. Which action is most appropriate when caring for the patient's face? 1. Use only water 2. Ask the patient her preferences 3. Use soap in all areas except the eyes 4. Use a cleansing cream

2. Ask the patient her preferences

The nurse is reviewing documentation from the previous shift. The nurse is correct when determining the patient has a stage III pressure ulcer based on which note? 1. Nonblanchable reddened areas where the skin is intact 2. Full-thickness tissue loss extending through subcutaneous tissue 3. Extensive destruction of skin and muscle with possible tunneling 4. Areas of full-thickness skin loss with extension to the bone

2. Full-thickness tissue loss extending through subcutaneous tissue

The nurse is caring for an immobile patient with incontinence and poor nutrition. What nursing diagnosis best describes this patient's problem? 1. Imbalances nutrition: less than body requirements 2. Impaired skin integrity 3. Impaired urinary elimination 4. Impaired physical mobility

2. Impaired skin integrity All of these are potential diagnoses, but putting all the factors together places the patient most at risk for impaired skin integrity. Imbalanced nutrition: less than body requirements is a potential diagnosis, but it is also a contributing factor to a greater risk for this patient. Impaired physical mobility is a valid diagnosis, but it is also a contributing factor to a greater risk for this patient

The nurse is teaching a patient who has diabetes about foot care. What should be included in the self-care instructions? 1. Carefully cut corns and apply moleskin 2. Inspect feet daily for breaks in the skin 3. Wear loose shoes or sandals to air the feet 4. Use alcohol to increase dryness between the toes

2. Inspect the feet daily for breaks in the skin Patients with diabetes should be taught to visually inspect the feet because diabetes can cause changes in peripheral sensation. In addition, even small injuries are a risk because of poor wound healing. The other options are incorrect.

The nurse is caring for elderly residents in an assisted-living facility. What is the best strategy to prevent skin breakdown among this vulnerable group? 1. Make daily rounds and assess skin condition 2. Instruct UAPs to help residents out of bed as much as possible 3. Plan a toileting schedule for the residents at greatest risk 4. Ask the dietary department to serve high-quality protein foods

2. Instruct UAPs to help residents out of bed as much as possible Getting the residents out of bed is the most important intervention because immobility ad pressure on tissues will cause skin breakdown. Daily assessment would be ideal, but it is unlikely to occur in an assisted living facility. A toileting schedule can help those with incontinence problems, but incontinence is only one of many risk factors that elderly people will have. High-quality protein is important, but protein is only one nutrient among many that are required for skin integrity

A patient who is paralyzed from the waist down is at risk for developing a pressure ulcer on the sacral area. Which intervention would the nurse use for this patient? 1. Frequently check and change the bed linens 2. Teach to shift weight every 15 minutes. 3. Obtain an order for a donut cushion for sitting. 4. Keep skin moist and frequently reapply lotion.

2. Teach the patient to shift weight every 15 minutes Patients who are paralyzed from the waist down (paraplegic) should be taught to use arms to shift weight frequently. Changing wet linens is always appropriate, but this intervention is more important for incontinent patient. Paraplegic patients should be assisted to master bowel and bladder training, so that incontinence is less of an issue. Donut cushions are not recommended because they can impair circulation. The skin should be clean and dry.

The nurse is supervising a new UAP providing hygiene care to a patient. Which action by the UAP requires the nurse to provide additional instruction regarding hygiene care? (select all that apply) 1. The UAP performs hand hygiene before providing care 2. The UAP holds the clean linens against the uniform 3. The UAP places soiled linens on the floor 4. The UAP places clean linens on the patient's overhead table 5. The UAP places soiled linens in a linen bag for transport

2. The UAP holds the clean linens against the uniform 3. The UAP places soiled linens on the floor.

The nurse is providing instruction to the UAP who is assisting with caring for an immobile patient who requires turning every 2 hours. The UAP asks the nurse why it is best to place the patient in the 30-degree lateral position. Which response by the nurse is correct? 1. "This position helps prevent pressure ulcers on spinous processes." 2. "This position helps prevent pressure ulcers on the ischial tuberosities 3. "This position helps prevent pressure ulcers on the greater trochanters." 4. "This position helps prevent pressure ulcers on the occipital prominence."

3. "This position helps prevent pressure ulcers on the greater trochanters."

What room temperature is good for a patient's hospital room? 1. 78 to 80 degrees 2. 65 to 70 degrees 3. 68 to 74 degrees 4. 68 to 80 degrees

3. 68 to 74 degrees

The nurse is reviewing teaching plans of several patients on a medical unit. Which patient does the nurse correctly identify as most at risk for development of complications for the feet? 1. A 30-year old patient whose career requires extensive standing 2. A 55-year old disoriented patient 3. A 60-year old patient with diabetes mellitus 4. A 62-year old patient with total hip replacement

3. A 60-year old patient with diabetes mellitus

The nurse is caring for a postpartum patient. Which assessment should the nurse perform first before starting perineal care? 1. Note presence of accumulated secretions 2. Evaluate the appearance of episiotomy 3. Assess ability to perform own care 4. Ask about burning with urination

3. Assess ability to perform own care Most people prefer to do their own pericare, so the nurse would first assess ability and willingness. Next the nurse could assess secretions, wound site, and other symptoms. Then the patient can perform the hygiene or the nurse can perform it if the patient prefers.

The nurse is caring for a new patient who needs assessment of skin and self-care abilities; perineal care; partial bath, and the bed linen changed. The patient is very obese. What is the best strategy to meet the needs of the patient? 1. Instruct the UAP to perform all tasks except the skin assessment 2. Ask the UAP to call when the patient's back is positioned for assessment 3. Assess skin and self-care abilities while working with the UAP to complete care 4. Assess the skin and self-care abilities, then allow the patient to perform her own care

3. Assess skin and self-care abilities while working with the UAP to complete care Obese patients represent a challenge because it is difficult for one (sometimes two) person(s) to accomplish tasks that require moving the patient. It is faster and safer for everyone if the nurse and UAP work together. The nurse can simultaneously assess and perform hygienic care. After the initial assessment of skin and self-care, the nurse could adapt the strategies; for example, ask a second UAP to help or instruct patient to do select aspects of hygiene care

An 82-year old patient is in his first postoperative day. As a part of his morning care, the nurse removes and cleanses his dentures. Which of the following techniques is correct? 1. Work over an open sink convenient to the water faucet. 2. Rinse dentures thoroughly with hot water 3. Brush dentures with a soft toothbrush 4. Hold dentures securely in the palm of the hand

3. Brush dentures with a soft toothbrush

An older adult patient wears dentures, and the nurse will delegate the denture care to the UAP. What instructions should the nurse give to the UAP about the patient's dentures? 1. Use hot water and a mild soap 2. Let the patient wear them at night 3. Brush dentures with a soft toothbrush 4. Wrap them in a soft towel when not worn.

3. Brush dentures with a soft toothbrush Dentures are cleaned with a soft toothbrush and stored in a container with a solution of the patient's choice.

Which type of patient is prone to develop a pressure sore? 1. Asthmatic patient who is up ad lib 2. COPD patient who requires assistance to the bathroom 3. Chronic renal failure patient who requires assistance out of bed 4. Confused female with a diagnoses of pneumonia who is lethargic and unable to utilize the call light for assistance

3. Chronic renal failure patient who requires assistance out of bed

A 50-year-old patient was discharged home with a Foley catheter. The student nurse instructs the patient in the proper procedure for cleansing the female perineal area. What teaching should the nurse include in the discharge instructions? 1. Cleanse the area in circular motions around the rectum. 2. Cleanse from the rectum toward the pubis 3. Cleanse from the pubis toward the rectum 4. Cleanse in circular motions around the vaginal area

3. Cleanse from the pubis towards the rectum

Which skin integrity problem can occur when improperly lifting or pulling a patient up in bed? 1. Rubbing 2. Shearing 3. Friction 4. Abrasion

3. Friction -shearing is skin to skin, friction is skin to surface

The nurse observes the patient performing ear care. Identify which behavior indicated a need for additional teaching? 1. Cleans the pinna with a cotton-tipped swab 2. Turns the hearing aid off when not in use 3. Leaves the hearing aid by a sunny window 4. Rotates a clean washcloth to clean ear canal

3. Leaves hearing aid by a sunny window The hearing aid should not be placed in the sun, by a heating element, or near the stove. The other actions are correct.

Which is a type of substance used for a medicated bath? 1. Betadine 2. Saline 3. Oatmeal 4. Oil

3. Oatmeal

Which type of physician should be consulted for a diabetic patient with thick, long, yellow toenails? 1. Surgeon 2. Family-practice physician 3. Podiatrist 4. Pediatrician

3. Podiatrist

The nurse instructed the UAP to encourage the patient's independence in accomplishing ADLs. Which behavior best indicates that the UAP understood what to do? 1. The UAP waits until the patient uses the call light for assistance 2. The nurse sees that the commode chair is close to the bed 3. The nurse observes that the patient is brushing his own teeth 4. The UAP tells the nurse that the patient is independent for ADLs

3. The nurse observes that the patient is brushing his own teeth If the patient is brushing his own teeth, this is a signal of actual independence in accomplishing tasks. The patient may or may not call for help when needed; the nurse would have to assess the patient's understanding and use of the call light. The position of the commode chair is typical; the nurse should assess the patient's ability to independently and safely get to the chair. The UAP can tell the nurse that the patient is independent, but the nurse should verify this information with the patient. (note: observe the nurse should have given better instructions. An inexperienced UAP may not know how to encourage independence.)

While completing the bath, the nurse notices a reddened area on the patient's sacrum. What should the nurse do first? 1. Cleanse the skin with alcohol 2. Wash the area with hot water and soap 3. Massage the area vigorously 4. Assess for other areas of erythema

4. Asses for other areas of erythema The nurse would continue to assess the patient for additional areas of redness. Other potential areas include scapulae, ears, elbows, heels, inner and outer malleoli, inner and outer knees, back of head, ischial tuberositis, trochanteric areas of the hips, and heels.

A family member tells the nurse that the staff is spending too much time laughing and chatting at the nurse's station and it is disturbing the patient's rest and comfort. What should the nurse do first? 1. Instruct the staff to be more discreet and move conversation to the break room. 2. Assess other environmental factors that are interfering with the patient's comfort. 3. Apologize to the family member and assure the situation will be corrected 4. Assess the patient's discomfort and ask what other things are interfering with rest.

4. Assess the patient's discomfort and ask what other things are interfering with rest. The nurse would asses the patient's discomfort and solicit opinions about how to make the situation more tolerable. A noisy staff could be the only problem, but the family member's comment could also be the "tip of the iceberg" and thus the nurse would try to seek out other sources of irritation. Based on the assessment of the patient, the nurse may decide to use the other options.

In delegating early morning care that should occur before breakfast, what does the nurse remind the UAP to do for the patient? 1. Shampoo the patient's hair and comb it 2. Assist the patient with a bath and clean gown 3. Offer the patient a backrub with warmed lotion 4. Help the patient wash hands and face

4. Help the patient wash hands and face Before breakfast care includes assisting to ambulate to the bathroom, washing face and hands, and oral hygiene if the patient desires it. The other tasks are typically performed after breakfast, unless the patient has procedures, treatments, or diagnostic testing

An 80-year-old uncircumcised man is in the first postoperative day after a transurethral prostatectomy. When administering perineal care, which action by the nurse is correct? 1. Retract the foreskin, cleanse the penis, and allow the foreskin to return to its former position 2. Sprinkle powder under the foreskin to facilitate retraction 3. Leave the foreskin slightly damp to allow retraction to its former state 4. Retract the foreskin, cleanse the penis, and return the foreskin with a gentle forward motion.

4. Retract the foreskin, cleanse the penis, and return the foreskin with a gentle forward motion.

The nurse is providing oral care to an 82-year-old patient who is unconscious. The optimal position for providing oral hygiene to this patient is ___________ to prevent choking. 1. High fowler position 2. High fowler position with head hyperextended 3. Supine with the head lowered 4. Side-lying with head facing to the side

4. Side-lying with head facing to the side

The patient has been changing a dressing on a pressure ulcer for several days and is now being seen in the physician's office. The patient states, "There is a lot of pink tissue at the base of the ulcer." The nurse explains to the patient that this is the result of what process? 1. Improper dressing technique and probable infection 2. Presence of a layer of eschar that has to be removed 3. Development of a fungal overgrowth interfering with healing 4. The normal process of healing with healthy granulation of tissue

4. The normal process of healing with healthy granulation of tissue

The nurse is teaching a patient proper hygiene measures. What should the nurse include when teaching the patient about eye care? 1. Wash from the outer canthus to the inner canthus 2. Cleanse dried exudate with hot water 3. Avoid drying circumorbital area after washing 4. Use a different section of the washcloth for each eye

4. Use a different section of the washcloth for each eye.

The student nurse has completed her educational instructions on the correct procedures for bed making. Which intervention is correct for bed making? (select all that apply) 1. Preparing a closed bed for receiving postoperative patients 2. Shaking soiled linen before placement in the hamper 3. Mitering the corners of the bottom fitted sheet 4. Washing hands thoroughly after handling soiled linen 5. Folding and reusing the patient's bedspread if it is not soiled

4. Washing hands thoroughly after handling soiled linen 5. Folding and reusing the patient's bedspread if it is not soiled

Which is not a factor affecting personal hygiene? 1. social practices 2. cultural variables 3. knowledge 4. product preferences

4. product preferences

The recommended room temperature for most adult patients is ______________.

68-78 degrees F

What's the temp of a cool water tub bath?

98.6 degrees

True or False: Routine hygiene would include trimming or shaving an unsightly beard, mustache, or sideburns for surgical procedures or to maintain personal cleanliness.

False. A male patient's beard, mustache, or sideburns are never removed without consent of he patient, except for emergency purposes

True or false: Medicare and Medicaid will cover the costs of treating pressure ulcers that develop during the patient's hospitalization if the condition is well documented

False. As of October 2008, Medicare and Medicaid stopped covering the costs of treating pressure ulcers that developed during the patient's hospitalization

True or false: Urinary incontinence is expected among very elderly adults

False. Incontinence is not an expected change that is associated with aging

True or false: When the external pressure against the skin is greater that the pressure in the capillary bed, blood flow increases to the adjacent tissues

False. When the external pressure against the skin is greater than the pressure in the capillary bed, blood flow decreases to the adjacent tissues

Patients who are immobilized, poorly nourished, and have reduced sensation are at risk for impaired _________________.

Skin integrity

True or false: Although the rules of touch are typically unspoken and unwritten, they are usually visible to the observer

True

Inserting objects into the internal auditory canal can damage the _________________________ or cause the ___________________ to become impacted in the canal

tempanic membrane, cerumen (earwax)