Fundamentals - Hygiene and Wound Care (Ch. 32 and 33)

An older adult client has edema of the right lower extremity with redness and clear drainage. This is most likely related to what? A) Beta-hemolytic streptococcus B) Age C) Venous insufficiency D) Hemangioma

D

What type of bath is preferred to decrease the inflammation after rectal surgery? A) Bed bath B) Tub bath C) Whirlpool bath D) Sitz bath

D

A nurse is providing oral care to a client with dentures. What action would the nurse do first? A) Assess the mouth and gums. B) Don gloves. C) Wash the client's face. D) Apply lubricant.

B

Which of the following is an indication for the use of negative pressure wound therapy? A) Bone infections B) Malignant wounds C) Wounds with fistulas to body cavities D) Pressure ulcers

D

A homeless person uses the soap and towels in a public restroom to wash up. This is an example of which type of factor affecting personal hygiene practices? A) Socioeconomic class B) Culture C) Developmental level D) Health state

A

A nurse is assessing a client during a health care camp. The nurse observes that the client has poor hygiene and an itchy, infected scalp. Which of the following should the nurse ask the client to do? A) Wash hair daily B) Use dry shampoo C) Use oil-based shampoo D) Use anti-lice shampoo

A

A nurse is assessing a client with a stage IV pressure ulcer. What assessment of the ulcer would be expected? A) Full-thickness skin loss B) Skin pallor C) Blister formation D) Eschar formation

A

A nurse is brushing the hair of a client admitted to the health care facility following a fracture in the hand. The nurse implements this action based on the understanding that brushing the hair achieves which of the following? A) Facilitates oil distribution B) Cleans hair and scalp C) Removes excess oil D) Cleans the hair of dirt

A

A nurse is preparing to provide foot care to a client who has decreased mobility. Which of the following techniques should the nurse employ when providing this care? A) Use an antifungal powder on the client's feet if necessary. B) Carefully remove any corns or calluses that are present. C) Soak the client's feet for 15 to 20 minutes prior to cleansing. D) Avoid using soaps or commercial cleansers whenever possible.

A

A nurse is providing perineal care to a female client. In which direction would the nurse move the washcloth? A) From the pubic area toward the anal area B) From the anal area to the pubic area C) From side to side within the labia D) The direction does not make any difference

A

An older adult client with Parkinson's disease is unable to take care of himself. The client frequently soils his bed and is unable to clean himself independently. How should the nurse in this case ensure the client's perineal care? A) Cleanse to remove secretions from less-soiled to more-soiled areas. B) Cleanse using a cotton cloth and warm water. C) Use tissue rolls to clean the client's perineal area. D) Provide the client with a bed pan or a jar to collect the urine.

A

An older adult resident of a long-term care facility has recurring problems with dry skin. Which of the following strategies should the nursing staff utilize in order to help meet the resident's hygiene needs while preventing skin dryness? A) Use a nonsoap cleaning agent. B) Use organic soap and shampoo. C) Bathe the client more often, but without using soap or shampoo. D) Provide the client with bed baths rather than tub baths.

A

The nurse and nursing aid are providing perineal care for an incontinent client. What information is important for the nurse to consider when providing perineal care? A) Apply moisture barriers to the skin of the perineal area. B) Provide excessive hydration to the skin of the perineal area. C) Wash the perineal area frequently with soap and water. D) Aggressively cleanse the perineal area with a washcloth or towel.

A

The nurse assists the client to the bathroom sink to perform morning care. The nurse observes the client wash his face, arms, abdomen, and legs. The nurse washes the client's back and rectal area and applies soap to the back. The client brushes his teeth and ambulates to a chair in his room with assistance. How will the nurse describe the morning care on the client's chart? A) Partial care B) As-needed care C) Self-care D) Complete care

A

The nurse has completed an assessment of a client's typical hygiene practices. How should the nurse best document the findings of this assessment in the client's chart? A) Client normally bathes and washes her hair every other day; applies moisturizer to dry areas on her elbows and forearms B) Client prioritizes personal hygiene in her daily routines and is proactive with skin care C) Client bathes more often than necessary and consequently experiences dry skin

A

The nurse has completed bed bath on a client who is obese. The client asks you to sprinkle baby powder in the perineal area. Which of the following actions is correct? A) Inform the client that baby powder is not used because it may become a medium for bacterial growth. B) Carefully apply baby powder to skin folds only. C) Pour a small amount of powder into the hand and gently pat the perineal area while avoiding aerosolization of the powder.

A

The nurse is planning to bathe a client who has thigh-high antiembolism stockings in place. Which of the following actions is correct? A) Remove the antiembolism stockings during the bath. B) Leave the antiembolism stockings in place, but be sure to remove all wrinkles. C) Fold the antiembolism stockings half-way down to allow assessment of the popliteal pulse. D) Leave the antiembolism stockings in place and spot-clean any soiled areas on the stockings.

A

The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. Which of the following techniques for cleaning the penis is correct? A) Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place. B) Retract the foreskin while washing the penis, allow 10 to 15 minutes for the glans penis to dry; then, replace the foreskin in its original position.

A

The nurse would recognize which of these devices as an open drainage system? A) Penrose drain B) Jackson-Pratt drain C) Hemovac D) Negative pressure dressing

A

Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue easily bleeds when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment? A) Proliferation phase B) Hemostasis C) Inflammatory phase D) Maturation phase

A

Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Initial nursing management includes calling the physician and doing which of the following? A) Covering the wound area with sterile towels moistened with sterile 0.9% saline B) Closing the wound area with Steri-Strips C) Pouring sterile hydrogen peroxide into the abdominal cavity and packing with gauze D) Holding the wound together until the physician arrives

A

Upon review of the client's orders, the nurse notes that the client was recently started on an anticoagulant. What is an appropriate consideration when assisting the client with morning hygiene? A) Provide the client with an electric shaver. B) Provide the client with a firm bristled toothNbrush. C) Do not allow the client to shower. D) Avoid massaging the client's back with lotion.

A

When measuring the size, depth, and wound tunneling of a client's stage IV pressure ulcer, what action should the nurse perform first? A) Perform hand hygiene. B) Insert a swab into the wound at 90 degrees. C) Measure the width of the wound with a disposable ruler. D) Assess the condition of the visible wound bed.

A

Which client is most likely to require hospitalization related to problems associated with the feet? A) A client with peripheral vascular disease B) A client with osteoporosis C) A client with asthma D) A client with diabetes insipidus

A

While conducting an oral assessment, a nurse notices the client's gums are red and swollen, some teeth are loose, and blood and pus can be expressed when the gums are palpated. What condition do these symptoms indicate? A) Periodontitis B) Plaque C) Halitosis D) Caries

A

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. Which of the following is the 28. correct name of this wound? A) Stage II pressure ulcer B) Stage I pressure ulcer C) Stage III pressure ulcer D) Stage IV pressure ulcer

A

Which of the following clients ia at an increased risk for oral problems? Select all that apply. A) Comatose client B) Confused client C) Depressed client D) Client undergoing chemotherapy E) Hypertensive client

A,B,C,D

Which of the following are functions of the skin? Select all that apply. A) Protection B) Temperature regulation C) Sensation D) Vitamin C production E) Immunological

A,B,C,E

A nurse is applying cold therapy to a client with a contusion of the arm. Which of the following is an effect of cold therapy? Select all that apply. A) Constricts peripheral blood vessels B) Reduces muscle spasms C) Increases blood flow to tissues D) Increases the local release of pain-producing substances E) Reduces the formation of edema and inflammation

A,B,E

Which of the following clients would be considered at risk for skin alterations? Select all that apply. A) A teenager with multiple body piercings B) A homosexual in a monogamous relationship C) A client receiving radiation therapy D) A client undergoing cardiac monitoring E) A client with diabetes

A,C,E

What care should the nurse take when providing foot care for a client with peripheral vascular disease? Select all that apply. A) Use an emery board to file toe nail edges B) Cut the toenails short C) Cut the nail in one piece D) Avoid cutting into calluses E) Cut the nails straight across

A,D,E

A client age 78 years with diabetes needs to have his toenails trimmed. It is important for the nurse to do what? A) Remove ingrown toenails B) Cut the nail straight across C) Protect the foot from blisters D) Soak the foot in witch hazel

B

A nurse caring for a female client notes a number of laceration wounds around the cervix of the uterus due to childbirth. How could the nurse describe the laceration wound in the client's medical record? A) A clean separation of skin and tissue with a smooth, even edge B) A separation of skin and tissue in which the edges are torn and irregular C) A wound in which the surface layers of skin are scraped away D) A shallow crater in which skin or mucous membrane is missing

B

A nurse is caring for a client who is two days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time? A) Administer pain medications on a p.r.n. and regular basis. B) Assist in moving to prevent strain on the suture line. C) Tell the client that a mild fever is a normal response. D) If a scar forms over a joint, it may limit movement.

B

Which is an example of a closed wound? A) Abrasion B) Ecchymosis C) Incision D) Puncture wound

B

A school nurse is assessing children in the third grade for pediculosis capitis. What assessments should be made? A) The pubic area for growth of hair B) The head for nits on hair shafts C) The nails for evidence of cleanliness D) The body for evidence of abuse

B

On the first postoperative day, the client is assisted to the bathroom. It is important for the nurse to do what? A) Allow the client privacy B) Assess the client's safety C) Assess the client's pain D) Allow sufficient time

B

What intervention should be included on a plan of care to prevent pressure ulcer development in health care settings? A) Change position at least once each shift. B) Implement a turning schedule every two hours. C) Use ring cushions for heels and elbows. D) Do not turn; use pressure-relieving support surface.

B

Which client would be most at risk for alterations in oral health? A) Infant who is breast-fed B) Man with a nasogastric tube C) Woman who is pregnant D) Healthy young adult

B

Which of the following is a correct guideline to follow when providing a bed bath for a client? A) When cleaning the eye, move the washcloth from the outer to the inner aspect of the eye. B) Fold the washcloth like a mitt on your hand so that there are no loose ends. C) Clean the perineal area before cleaning the gluteal area. D) Change the bath water after washing each body part.

B

A female client in a reproductive health clinic tells the nurse practitioner that she douches every day. Should the nurse tell the client to continue this practice? A) Yes, this helps prevent vaginal odor. B) Yes, this decreases vaginal secretions. C) No, douching removes normal bacteria. D) No, douching may increase secretions.

C

A nurse caring for a post-operative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as which of the following? A) Serous B) Sanguineous C) Serosanguineous D) Purulent

C

A nurse inspecting a client's pressure ulcer documents the following: full-thickness tissue loss; visible subcutaneous fat; bone, tendon, and muscle are not exposed. This pressure ulcer is categorized to be at which of the following stages? A) Stage I B) Stage II C) Stage III D) Stage IV

C

A nurse is assisting a client to shave his beard. Which of the following statements accurately describes a recommended step in this process? A) Cover the client with a blanket. B) Fill a basin with cool water. C) Apply cream to area to be shaved in a layer about 1/2-inch thick. D) Shave against the direction of hair growth in upward, short strokes

C

A nurse is conducting a health history for a client with a skin problem. What question or statement would be most useful in eliciting information about personal hygiene? A) "Perhaps you don't recognize your bad body odor." B) "You must eat a lot of greasy foods to have this acne." C) "Tell me about what you do to take care of your skin." D) "Why do you only take a bath once a week?"

C

A nurse is educating a postoperative client on essential nutrition for healing. What statement by the client would indicate a need for more information? A) "I will drink a lot of orange juice and drink milk, too." B) "I will take the zinc supplement the doctor recommended." C) "I will restrict my diet to fats and carbohydrates." D) "I will drink 8 to 10 glasses of water every day."

C

A physician orders a dressing to cover a wound that is shallow with minimal drainage. What would be the best type of dressing for this wound? A) Saline-moistened dressing B) Dressing secured with Montgomery straps C) Hydrocolloid dressing D) Foam dressing

C

A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. Which response by the nurse is appropriate? A) "Oh, for gosh sakes...it doesn't look that bad!" B) "I understand, but you are going to have to look someday." C) "I respect your wish not to look at it right now." D) "You won't be able to go home until you look at it."

C

Before a long-term care resident goes to sleep at night, his dentures are placed in a denture cup with clean water. What rationale supports placing dentures in water? A) None; they should be placed in saline B) To increase comfort when replaced in the mouth C) To prevent drying and warping of plastic D) To ensure the dentures are not thrown away

C

Of the many topics that may be taught to clients or caregivers about home wound care, which one is the most significant in preventing wound infections? A) Taking medications as prescribed B) Proper intake of food and fluids C) Thorough hand hygiene D) Adequate sleep and rest

C

The mother of a child 2 years of age tells the nurse she always cleans the child's ears with a hairpin. What would the nurse tell the mother? A) "That's not good. Use a Q-tip or your finger instead." B) "You really like to keep your child clean. Good for you!" C) "That is dangerous; you might puncture the eardrum." D) "Show me exactly how you use the hairpin."

C

The wound care clinical nurse specialist has been consulted to evaluate a wound on the leg of a client with diabetes. The wound care nurse determines that damage has occurred to the subcutaneous tissues; how would she document this wound? A) Stage I pressure ulcer B) Stage II pressure ulcer C) Stage III pressure ulcer D) Stage IV pressure ulcer

C

A client is admitted to the health care facility with a diagnosis of pediculosis capitis. Which of the following would the nurse expect to find in the client? A) Diffuse scaling of the epidermis B) Itching and flaking of whitish scales C) Premature loss of hair D) Inflammation related to bites along the hairline

D

A home health nurse has a caseload of several postoperative clients. Which one would be most likely to require a longer period of care? A) An infant B) A young adult C) A middle adult D) An older adult

D

A nurse assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage? A) Clear, watery blood B) Large numbers of red blood cells C) Mixture of serum and red blood cells D) White blood cells, debris, bacteria

D

A nurse is teaching a client on home care about how to apply hot packs to an infected leg ulcer. What statement by the client indicates the need for further education? A) "I understand the rebound effect of heat." B) "I will put the heat packs only on the sore on my leg." C) "I will only leave the heat packs on for 20 minutes." D) "I will leave the heat packs on for an hour."

D

A student has been assigned to provide hygiene care to four clients. Which one would require special consideration for perineal care? A) Middle-aged man with a nasogastric tube B) Young adult man who has had a hernia repair C) Young woman who has had cosmetic surgery D) Middle-age woman with a Foley catheter

D

A student has been assigned to provide morning care to a client. The plan of care includes the information that the client requires partial care. What will the student do? A) Provide total physical hygiene, including perineal care. B) Provide total physical hygiene, excluding hair care. C) Provide supplies and orient to the bathroom. D) Provide supplies and assist with hard-to-reach areas.

D

A student has been assigned to provide morning care to a client. The plan of care includes the information that the client requires partial care. What will the student do? A) Provide total physical hygiene, including perineal care. B) Provide total physical hygiene, excluding hair care. C) Provide supplies and orient to the bathroom. D) Pro vide supplies and assist with hard-to-reach areas.

D

During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution? A) Document the assessments and intervention. B) Reinforce the dressing with additional layers. C) Administer pain medications intramuscularly. D) Notify the physician and prepare for surgery.

D

In stage III there is full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Which of the following is an accurate step when applying a saline-moistened dressing on a client's wound? A) Do not use irrigation to clean the wound before changing the dressing. B) Exert light pressure to pack the wound tightly with moistened dressing. C) Apply several dry, sterile gauze pads over the wet gauze and place the ABD pad over the gauze.

D

The plan of care for a postoperative client specifies that sterile 0.9% sodium chloride solution be used to clean the wound. What should the nurse do after reading this information? A) Question the physician about the accuracy of this agent. B) Refuse to use 0.9% normal saline on a wound. C) Document the rationale for not changing the dressing. D) Continue with the dressing change as planned.

D

What are the two major processes involved in the inflammatory phase of wound healing? A) Bleeding is stimulated, epithelial cells are deposited B) Granulation tissue is formed, collagen is deposited C) Collagen is remodeled, avascular scar forms D) Blood clotting is initiated, WBCs move into the wound

D

What nursing diagnosis would be a priority for a client who has a large wound from colon surgery, is obese, and is taking corticosteroid medications? A) Self-care Deficit B) Risk for Imbalanced Nutrition C) Anxiety D) Risk for Infection

D

Which clent would be at greatest risk for injury to the skin and mucous membranes? A) Infant 10 days old with no health problems B) adolescent 17 years of age with asthma C) Man 44 years of age with hemorrhoids D) Man 77 years of age with diabetes

D

Which of the following factors does not affect personal hygiene practices? A) Culture B) Income level C) Health state D) Gender

D

Which of the following is a recommended guideline nurses follow when using an electric heating pad on a client? A) Secure the heating pad to the client's clothing with safety pins. B) Place a heavy towel or blanket over the heating pad to maximize heat effects. C) Use a heating pad with a selector switch that can be turned up by the client if needed. D) Place a heating pad anteriorly or laterally to, not under, the body part.

D