Ch 31 Prep U
The nurse is observing a student who is using a safety razor to shave a client. Which action would require intervention by the nurse?
pulling the razor against the direction of hair growth
The nurse is inserting a rectal tube to administer a large-volume enema. Which nursing action is performed correctly in this procedure?
Slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult.
An older adult woman has constant dribbling of urine. The associated discomfort, odor, and embarrassment may support which nursing diagnosis?
Social Isolation
The parent of a 5-year-old child tells the nurse that on two occasions her son has lost control of urination when he had to wait to go to the bathroom at school. What is the appropriate nursing response?
"Let's review the types of fluids that your child drinks in the morning."
A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding vitamin C 3 days before testing?
Avoid more than 250 mg.
A nurse is caring for a client who is being treated for bladder infection. The client reports to the nurse that he has been having difficulty voiding and feels uncomfortable. How should the nurse document the client's condition?
Dysuria
A nurse is educating a client on how to care for her dentures. What is a recommended teaching guideline?
Store dentures in cold water when not in use.
A nurse is using a bladder scanner to assess the bladder volume of a client with urinary frequency. In which position would the nurse place the client?
Supine
A nurse is delegating the collection of urinary output to an unlicensed assistive personnel (UAP). What should the nurse tell the UAP to do while measuring the urine?
Wear gloves when handling a client's urine.
Which terms is most closely associated with an acute urinary tract infection?
pyuria or the presence of pus in the urine
The nurse is teaching a nursing student about caring for a client with dentures. Which education will the nurse provide?
"Hold dentures over a plastic basin or towel when cleaning them."
Several of the clients on a geriatric subacute medicine unit are experiencing urinary incontinence from differing causes. Which statement suggests that the client requires further education?
"I make sure to limit how much I drink so that I don't have accidents."
A nurse is assessing the client's ability to perform ear care. Which statement by the client requires further education by the nurse?
"I use cotton-tipped applicators daily to remove cerumen." Explanation: Healthy ears require little to no care. Cerumen (ear wax) can accumulate, causing discomfort or decreased hearing. To care for ears, a washcloth is used to wipe the auricles and the twisted end of a washcloth can be used to clear cerumen from the ear canal. Clients should be educated to not use cotton-tipped applicatosr because it may push cerumen further back into the ear canal. Bobby pins and sharp objects should never be used to remove cerumen because they can puncture the tympanic membrane. If a client has a hearing aid device, care includes careful handling, wiping of the mold, and monitoring for dead batteries. (less)
The nurse has completed teaching regarding pediculosis. Which client statement requires further nursing teaching? "Lice can be spread by direct contact." "I will use conditioner so that the lice eggs will slide off my hair." "A pediculicide shampoo is needed to treat this condition." "I will look for eggs on hairs ¼ to ½ in (0.5 to 1.5 cm) from the scalp and skin surfaces."
"I will use conditioner so that the lice eggs will slide off my hair."
A nurse is documenting the appearance of feces from a client with a permanent ileostomy. Which scenario would she document?
"Ileostomy bag half filled with liquid feces."
A nurse is evaluating the effectiveness of health promotion teaching related to hygiene at a community workshop. Which statements by the one of the participants requires further teaching to ensure understanding? Select all that apply.
"It is important to brush your teeth regularly but flossing is not necessary since it can damage the gums." • "Hygiene does not contribute to my well-being so I can choose to not perform hygiene." • "Hygiene measures have no affect on skin." Correct Explanation: Health promotion teaching for hygiene should include proper diet and exercise to promote healthy skin; brushing and flossing teeth regularly and visiting the dentist every six months; keeping hair neat, combed, and brushed regularly; using caution with certain hair care products that can damage the hair; keeping nails clean and neatly trimmed by clipping them straight across and shaping and smoothing with an emery board; bathing and cleansing the skin regularly using lotions and creams while ensuring good cleansing of the axilla and application of deodorant and antiperspirants; and cleaning the perineal areas. Hygiene also promotes a sense of well-being and positive self-image. (less)
An older adult client tells the nurse, "I give myself a mineral oil enema every day." What is the appropriate nursing response?
"Mineral oil enemas can interfere with absorption of fat-soluble vitamins."
A client has been given fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide about the purpose for this test?
"This test detects heme, an iron compound in blood within the stool."
A nurse is taking care of a client with schizophrenia who only recently started taking her medications again. When she is off of her medications she often forgets to bathe and does not wear clothing that is appropriate for the weather. In order to assess her normal pattern of self-care while on her medications, which question would be most appropriate for the nurse to ask?
"What are your expectations about bathing at this time?" Correct Explanation: In order to assess this client's normal pattern of self-care while on her medications, it is important to assess what her expectations are. Once these expectations are established, the nurse can work with the client to achieve them. (less)
When caring for a client at the health care facility, the nurse has to record the client's urinary volume. Which amount would indicate a normal urinary volume?
2000 mL per day
Which client is most at risk for foot difficulties?
45-year-old woman with type 2 diabetes Explanation: People who are at the greatest risk for foot problems are those with poor circulation and those with diabetes. Older age can also put a person at risk but an active older adult is less at risk. A paraplegic could also be at risk for skin issues in general if the person is not active. (less)
The nurse is checking the placement of a nasogastric tube and aspirates for gastric contents. The nurse checks the pH of the aspirate and determines that the tube is in the stomach when she gets which pH measurement?
5
The nurse is caring for four clients. For which client is a sitz bath most appropriate?
51-year old with hemorrhoids
A woman age 76 years has informed the nurse that she has begun using over-the-counter laxatives because her friend told her it was imperative to have at least one bowel movement daily. How should the nurse best respond to this client's statement?
Actually, people's bowel patterns can vary a lot and some people don't tend to go every day."
A nurse caring for the skin of clients of different age groups should consider which accurately described condition?
An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions.
A nurse caring for the skin of clients of different age groups should consider which accurately described condition?
An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions. Correct Explanation: Adolescents have enlarged sebaceous glands and increased glandular secretions, which predisposes them to acne. Infants have natural immunities, but not pertaining to the mucous membranes. Secretions from skin glands occur later than age 3 months. While the skin may have more wrinkles as a person ages, the skin actually becomes thinner with age. (less)
The home care nurse visits a client and is reviewing the medications that the client uses. Which medication would the nurse identify as acting directly on the intestine to slow bowel motility, or to absorb excess fluid in the bowel?
Antidiarrheal agent
An Indian client is admitted to a facility for treatment of pneumonia. Since admission, she has been unwilling to participate in care offered by the nursing staff but is too weak to provide her own care. The nurse is planning care for this client with a diagnosis of Bathing/Hygiene: Self-Care Deficit. What would the priority nursing intervention be?
Assess the client's cultural views regarding hygiene and self-care. Correct Explanation: In accordance with the nursing process, assessment of the client's cultural views regarding hygiene will be necessary in order to plan care accordingly. Assessment of the skin using the Braden scale is a daily intervention for skin integrity. Incorporate the client's preferences into the plan of care which, will be identified during assessment of the cultural views. Bathing is a task that can be delegated to a UAP. Assigning a new care provider would not be done before an assessment is performed. (less)
The nurse has been closely monitoring a client who has recently had her indwelling urinary catheter removed. In the 6 hours since the catheter was removed, the client has yet to void. How should the nurse first respond to this assessment finding?
Assess the patient's bladder by palpation and bedside ultrasound
The nurse is preparing to provide hygiene for a client with obesity who has bedrest ordered for 3 days. What is the priority nursing intervention that will be performed to deliver hygiene care?
Check order within the plan of care for hygiene.
The nurse is preparing to insert an indwelling urinary catheter into a female client's bladder. The nurse has opened the sterile catheterization tray using sterile technique, donned sterile gloves and has opened all sterile supplies. Arrange the following steps in the correct order.
Clean each labial fold, then the area directly over the meatus. Insert the lubricated catheter into the urethra. Advance the catheter until there is a return of urine. Inflate the balloon with the correct amount of sterile saline. Discard used supplies.
A nurse is providing nail care to clients admitted to a health care facility. The nurse should know that which clients are most susceptible to nail problems?
Clients with diabetes
A nurse is going to bathe a client who is confined to bed. What does the nurse do first?
Close the door or bed curtains.
The nurse is caring for a client with diabetes who has thick toenails. What is the appropriate nursing intervention?
Contact a podiatrist to care for toenails.
A client's recent diagnosis of colorectal cancer has required a hemicolectomy (removal of part of the bowel) and the creation of a colostomy. The nurse would recognize that the client's stoma is healthy when it appears what color?
Dark pink and moist
A nurse is assessing the stoma of a client with an ostomy. What would the nurse assess in a normal, healthy stoma?
Dark red and moist
The nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the nasogastric tube?
Disconnect the nasogastric tube from suction during the assessment of bowel sounds.
The nurse is teaching a client about hearing aid care. Which teaching is appropriate? (Select all that apply.) Do not get hair spray or other chemicals on the hearing aid. Store the hearing aid in a very warm environment so that it will not crack. Carefully wipe the outer surface of the hearing aid to maintain cleanliness. Keep extra batteries on hand. Use a small knife to remove cerumen that becomes embedded in the earpiece.
Do not get hair spray or other chemicals on the hearing aid. Carefully wipe the outer surface of the hearing aid to maintain cleanliness. Keep extra batteries on hand.
The nurse is caring for an older adult client who has refused a bath for several days, and has now developed a rash on the buttocks. What is the priority nursing intervention?
Explain that cleanliness helps to remove bacteria from skin, which can prevent infection.
A nurse is making a bed occupied by a client. What is a recommended step for this procedure?
Fan-fold soiled linens as close to client as possible
A 50-year-old client comes to the clinic for an annual physical examination. Which test would the nurse expect the client to undergo as a screening test for colorectal cancer?
Fecal occult blood test
A client tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on which reasoning?
Habitual laxative use is the most common cause of chronic constipation.
A client is being discharged today from the hospital. The nurse delegates morning care to the unlicensed assistive personnel (UAP). The assessment finds that the client is able to stand and ambulate independently without weakness or dizziness. The nurse will delegate what type of care to be provided based on the assessment findings?
Independent showering
A nurse is caring for an older adult client who has been prescribed a condom catheter. What are the common problems that a client can experience when using a condom catheter? Select all that apply.
May restrict the flow of blood to the skin and tissues • May accumulate moisture beneath the sheath • May lead to frequent leakage
A nurse is providing care to a client who has undergone a colonoscopy. What would be most appropriate for the nurse to do after the procedure?
Monitor for rectal bleeding.
A 45-year-old woman has multiple sclerosis. She is able to perform most functions of self-care but recently she has been having problems with balance, which has made it hard to get dressed. Which factor is affecting this client's ability to perform self-care? Neuromuscular Sensory Motivation Cognitive
Neuromuscular
The following foods are a part of a client's daily diet: high-fiber cereals, fruits, vegetables, 2,500 mL of fluids. What would the nurse tell the client to change?
Nothing; this is a good diet.
Which medical diagnosis is most likely to necessitate testing for fecal occult blood?
Peptic Ulcer
Which nursing action is appropriate when providing foot care for a client?
Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms. Correct Explanation: Rinsing and drying the feet thoroughly, and providing moisturizer to the tops and bottom of the feet helps prevent excessive dryness and cracking of the skin. Soaking the feet can cause maceration of the tissues, which can lead to skin breakdown. The toenails of diabetic clients should be filed (not trimmed) in order to prevent injury to the feet, which can lead to infection or poor wound healing. The nurse should never cut off corns or calluses; this should only be performed by a podiatrist. (less)
A nurse is assisting a client when he is draining a continent ileostomy. The catheter suddenly becomes plugged with stool. Which action should the nurse take to rectify the problem?
Rotate the catheter tip inside the stoma.
A 43-year-old woman is undergoing chemotherapy for ovarian cancer which has metastasized. She has been experiencing increased nausea and vomiting associated with her treatment. Self-care activities have been very hard for her to complete. Which is an internal resource that the client has to help her attain her self-care goals?
She has motivation to participate in self-care.
Which is not true of urine color?
The appearance of urine streaked with blood is always abnormal.
The nurse is inserting a urinary catheter into a 63-year-old male client and encounters resistance. What is the most likely cause of the resistance?
The client has an enlarged prostate.
A nurse is assessing the freshly voided urine of a client. What characteristics of the urine would indicate a urinary problem? Select all that apply
The urine smells like ammonia. The urine is cloudy. There is pus in the urine.
A child with a day-old fever is admitted to a health care facility. Which bath will be most appropriate for the client?
Towel Bath
An older adult resident of a long-term care facility has recurring problems with dry skin. Which strategy should the nursing staff utilize in order to help meet the resident's hygiene needs while preventing skin dryness?
Use a nonsoap cleaning agent.
The nurse is caring for a client who is on warfarin therapy. Which teaching will the nurse provide? Take aspirin for headaches that develop. Reassure client that prolonged bleeding of wounds and gums is normal. Buy hard-bristle toothbrush to ensure proper oral hygiene. Use electric razor for shaving purposes.
Use electric razor for shaving purposes.
When planning for completion of a pateint's personal hygiene, it is most important to consider which of the following: a. when the patient hard his or her most recent bath b. the patient's usual hygiene practices and preferences c. Where the bathing fits in the nurse's schedule d. The time that is conveneint for the patient care assistant
b. the patient's usual hygiene practices and preferences
A nurse providing hygiene and bathing for older adult clients knows that additional safety measures may be necessary in their care. The nurse delegates some aspects of care to an unlicensed assistive personnel (UAP). Which of the following are true regarding safety of the older adult while bathing? Select all that apply.
Water temperature should be monitored carefully due to decreased temperature sensation. Use a long-handled shower brush or attachment to help with limited mobility. Use of a tub/shower seat may be necessary if balance problems are present.
When making an occupied bed, which of the following is most important for the nurse to do? a. keep the bed in the low position b. use a bath blanket or top sheet for warmeth and privacy c. constantly keep the side rails raised on both sides d. move back and forth from one side to the other when adjusting the linens
b. use a bath blanket or top sheet for warmeth and privacy
A sterile urine specimen for culture and sensitivity has been ordered for a client who has an indwelling urinary catheter. How should the nurse obtain this specimen?
Withdraw several milliliters of urine from the port on the collection tubing, using a syringe and needle
A nurse is caring for a client with constipation. The incidence of constipation tends to be high among clients that follow which diet?
a diet lacking in fruits and vegetables
A nurse is caring for an older adult client at his home. The client has had a condom catheter applied. Which describes a condom catheter?
a flexible sheath that is rolled around the penis
When providing oral care, what does the nurse recognize as the most important component of the oral care process?
a thorough, mechanical cleaning
Which action would be the priority when administering oral care to a dependent patient? a. assisting the patient to the dorsal recumbent position b. wearing disposable gloves c. using a firm toothbrush to cleanse teeth and gums d. irrigating forefully with hydrogen peroxide
b. wearing disposable gloves
A nurse is taking care of a client who needs a bed bath. Which action can the nurse delegate to an unlicensed assistive personnel (UAP)?
back massage
When collecting a urine sample from a client for examination, the nurse notes that the sample appears reddish-brown in color. What could cause this variation in color of the urine?
blood
What is occult blood?
blood that cannot be seen
Which of the following actions are appropriate steps when making an unoccupied bed? select all that apply a. first, adjust the bed to the hight position and drop the side rails b. fold reusable linens on the bed in fourths and hang them over a clean chair. c. snugly roll the soiled linens into the bottom sheet and place on the floor next to the bed. d. Place the bottom sheet with its center fold in the center of the bed e. tuck the bottom sheets securely under the head of the mattress, forming a corner according to agency policy f. place the pillow at the head of the bed with the closed end facint toward the windo
a, b, d, e
Which of the following statements accurately describe findings that may be made when perfroming a physical assessment of the oral cavity? select all that apply a. caries may exist in the teethc, resulting from the failure to remove plaque. b. gingivitis may be present involving the alveolar tissues. c. Hard deposits called tartar may be found on the teeth if plaque is allowed to build up. d. stomatitis may be noted as an inflammation of the tongue. e. chilosis may present a reddened fissures at the angles of the mouth. f. Oral maignancies may be present in the form of a dry oral mucosa
a, c, e
Which of the following are appropriate nursing measure when caring for a pateint's eyes and ears? select all that apply a. clean the eye from the inner canthus to the outer canthus using a wet, warm washcloth, cotton ball, or compress b. Use artificial tear soluiton or normal saline twice a day when the blink refelx decreased or absent c. Use a protective shiled if necessary to keep the lids closed when the blink reflex is absent. d. use boric acid to remove excess secretions from the eyes. e. Clean the patient's external ear with a washcloth-covered finger. f. use cotton-tipped swabs to clean the inner ear and remove cerumen.
a, c, f
Why is adequate oral hygiene and essential part of nursing care? select all that apply a. it promotes the patient's sense of well being b. it prevent deterioroation of the oral cavity c. it contributes to decreased incidence of aspiration pneumonia d. it elminates the need for flossing e. it decreases oropharyngeal secretions
a. promotes the patient's sense of well being b. it prevent deterioroation of the oral cavity c. it contributes to decreased incidence of aspiration pneumonia
Providing perineal care to a pateint requires which of the following? a. using a clean portion of the washcloth for each stroke b. moving from most contaminated to least contaminated area c. Using sterile gloves d. Leaving the foreskin undisturbed in an uncircumcised adult male
a. using a clean portion of the washcloth for each stroke
Which recommendation by the nurse to an adolescent patient with acne would be most appropriate? a. wash the skin twice a day b. use cosmetics liberally to cover blackheads. c. use emollients on the area d. squeeze blackheads as they appear
a. wash the skin twice a day
An 80-year-old woman tells the nurse that she just itches all the time and her skin seems very dry. How do these symptoms relate to aging skin?
activity of the glands in the skin lessens
The risk for developing colorectal cancer during one's lifetime is 1 in 19. Nurses play an integral role in the promotion of colorectal cancer screening. What are risk factors for colorectal cancer? Select all that apply.
age 50 and older a positive family history a history of inflammatory bowel disease
A client with chronic kidney disease reports not being able to urinate for the past 24 hours. A bladder scan shows no urine in the bladder. How does the nurse document this data?
anuria
When the nurse observes slight bruising on the client's left thigh during the bed bath, he takes a closer look and palpates a lump on the anterior surface of the thigh. The nurse has used the bath activity for:
assessment of tissues. Correct Explanation: Bathing promotes assessment of the client's physical condition by noting injured areas, bruises, rashes, or any other unusual signs.
A nurse is caring for an 80 year old patient who has become weak and fatigues easily. He is unable to wash his body and always asks the nurse to brush his teeth. Based on this information, which of the folowing is an appropriate nursing diagnosis for theis patient? a. risk for impaired skin integrity realted to immobility b. bathing/hygeine self care deficit related to decreased strenght and endurance c. social isolation related to lack of visitors d. impaired oral mucous membrane realted to inability to brush his teeth
b. bathing/hygeine self care deficit related to decreased strenght and endurance
A client wishes to increase fiber to promote more regular bowel movements. Which food will the nurse recommend that the client consume?
brown rice
Which of the following are recommended guidelines when performing oral care? select all that apply a. use a hard toothbrush to remove plaque from the teeth. b. ideally, brush teeth immediately after eating or drinking c. Never clean the tongue with a toothbrush d. if desired, use an automatic toothrbrush to remove debris and palque from teeth e. never use water-spray units to asssist with oral hygiene f. if desired, use alt and sodium bicarbonate as cleaning agtents for shrot-term use
b, d, f
During morning care, the patient asks the nurse to shave him with a disposable razor. Before shaving him, what should the nurse do? a. Have him sign a permission form. b. Check to see if the patient is taking anticoagualants. c. tell him that only a family member may shave a patient d. position him flat in bed
b. Check to see if the patient is taking anticoagualants
During a bath, the nurse observes that a patient has dry skin. Which action would be best? a. bath the patient more frequently b. Use an emollient on the dry skin c. massage the skin with alcohol d. Discourage fluid intake
b. Use an emollient on the dry skin
An older patient with an unsteady gait requests a tub bath. Which of the following actions would be most appropriate? a. add alphay-keri oil to teh water to prevent dry skin. b. allow the patient to lock the door to guarantee privacy c. assist the patient in and out of the tub to prevent falling d. keep the water temperature very warm becuase the patient chills easily
c. assist the patient in and out of the tub to prevent falling
Mr. James has an eye infection with a moderate amount of dishcarge. Which action would be most appropriate for the nurse to use when cleaning his eyes? a. using hydrogen peroxide b. wiping from the outer canthus to the inner canthus c. positioning him on the same side as the eye to be cleaned. d. Using only one cotton ball per eye
c. positioning him on the same side as the eye to be cleansed.
The nurse is about to bathe a female patient who has an intraveous access in place in her foreman. The patient's gown, which does not have snaps on the sleeves, needs to be removed prior to bathing. What should the nurse do? a. temporarily disconnect the IV tubing at a point close to the patient and thread it through the gown sleeve. b. cut the gown with scissors to allow arm movement c. thread the bag and tubing through the gown sleeve, keeping the line intact d. temporarily disconnect the tubing from the IV container, threading it through the gown
c. thread the bag and tubing through the gown sleeve, keeping the line intact
A student nurse studying human anatomy knows that a structure of the large intestine is the:
cecum
The nurse is caring for a client who reports burning upon urination, and an ongoing sense of needing to urinate. Which urine characteristics does the nurse anticipate?
cloudy, foul odor
Which of the following statements accurately describe appropriate environemental care for a hospitalized patient? select all that apply a. patients should not store their perosnal items in the bedside stand becuase nurses need to open and close the stand to obtain bath basin, lotion, and other items. b. patient beds should be positioned at the appropriate height with the wheels unlocked. c. principles of surgical asepsis should be followed at the bedside d. soiled dressings or anything with a strong odor whould not be placed in teh waste receptacle in the patient's room e. in general, room temperature should be between 20 and 23 celcius or 68 and 74 f. f. Nurses should avoid carrying out converstaions immediatlety outside the patient's room.
d, e, f
Which of the following interventions would the nurse include in the plan of care when providing foot care to an older patient? a. using scissors to correct and ingrown toenail b. trimming toenails as short as possible c. using an alcohol rub if the feet are dry d. Bathing the feet at least daily
d. bathing the feet at least daily
An unresponsive patient is wearing has-permeable contact lenses. How would the nusre remove these lenses? a. gently irrigate the eye with an irrigating solution from the inner canthus outward. b. grasp the lens with a gentle pinching motion c. don sterile gloves before attempting the removal procdure d. ensure that the lens is centered on the cornea before gently namipulating the lids to release it.
d. ensure that the lens is centered on the cornea before gently namipulating the lids to release it.
The nurse observes a marked inflammation of the gums, and recession and bleding fo the gums and ducments this observation using which term? a. glossitis b. caries c. cheilosis d. periodontitis
d. periodontitis
A nurse working in a clinic for older adults is providing care to a client receiving treatment for xerostomia. The nurse interprets this condition as:
decreased saliva production.
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:
facilitates oil distribution.
The nurse is scheduling tests for a client who is experiencing bowel alterations. What is the most logical sequence of tests to ensure an accurate diagnosis?
fecal occult blood test, barium studies, endoscopic examination
A client has developed edema in her lower legs and feet, prompting her physician to prescribe furosemide, a diuretic medication. After the client has begun this new medication, what should the nurse anticipate?
increased output of dilute urine
A home health nurse is visiting a client who is receiving chemotherapy for cancer treatment. Which condition may result from chemotherapy?
loss of hair
A client at the health care facility has been diagnosed with total urinary incontinence. How could the nurse describe the condition of the client?
loss of urine without any identifiable pattern or warning
A nurse is administering a prescribed solution of cottonseed oil to a client during an enema. What is the outcome of the use of cottonseed?
lubricates and softens stool
A 55-year-old client has just undergone surgery for a knee replacement. He asks the nurse if he can shave because his face is itching from the stubble. What information is a priority for the nurse to verify prior to shaving the client?
medications listed on the client's medication administration record (MAR)
A 55-year-old client has just undergone surgery for a knee replacement. He asks the nurse if he can shave because his face is itching from the stubble. What information is a priority for the nurse to verify prior to shaving the client?
medications listed on the client's medication administration record (MAR) Correct Explanation: Shaving guidelines note that pharmacologic considerations are important because clients on anticoagulant therapy or low-dose aspirin will need to use an electric razor for safety. Although it is important to assess cultural views related to shaving, the client is asking to shave so this is not a priority consideration. Allergies to soap are important to assess prior to shaving. However, shaving cream is not contraindicated. Shaving is performed as needed at the client's request. (less
Which enema solution lubricates the stool and intestinal mucosa without distending the intestine?
oil
A male client is experiencing weakness and is unable to shave himself. When assisting this client with shaving, what would be most important?
shaving in the direction of hair growth
The nurse is preparing a client to receive a hypertonic enema solution. Into which position will the nurse place the client?
sims
The nurse will place a client who is to receive a hypertonic enema solution into which position for ease of administration?
sims
A nurse is taking care of an older adult woman who demonstrates good mobility but is unable to stand for long periods of time secondary to muscle weakness. Which method for bathing would be most appropriate for this client?
sit-down shower with shower chair
A nurse is taking care of an older adult woman who demonstrates good mobility but is unable to stand for long periods of time secondary to muscle weakness. Which method for bathing would be most appropriate for this client?
sit-down shower with shower chair Correct Explanation: This client is still able to bathe herself but has difficulty standing for long periods of time. In order to foster her independence and provide her with a safe bathing environment, a sit-down shower with shower chair would be most appropriate. (less)
A 35-year-old woman is 1 day postpartum. She is reporting moderate perineal pain after giving birth and would like to clean the area. Which method of bathing is most appropriate for this client?
sitz bath
A nurse uses a catheter to collect a sterile urine specimen from a client at a health care facility. If a catheter is required temporarily, which type of catheter should the nurse use?
straight catheter
A client who has started using contact lenses visits a health care facility with an eye infection. The nurse observes that the client also has an eye abrasion. What could be the possible reason for the eye infection?
the contact lenses were not cleaned
A school nurse is assessing children in the third grade for pediculosis capitis. What assessments should be made?
the head for nits on hair shafts
A school nurse is dealing with an outbreak of pediculosis in an elementary school. Which education points should the nurse prioritize when educating the parents of students who have lice and nits?
the importance of completely finishing the prescribed treatment Correct Explanation: When educating about pediculosis, the nurse must stress the importance of finishing the treatment. Many times the client will shampoo the hair once and not follow through with a second washing. Pediculosis requires treatment and is not self-limiting. It is not necessarily a reflection of inadequate hygiene. It is also not necessary to destroy the child's clothing and bedding. (less)
A client is brought to the emergency department (ED) after a seizure. Which type of incontinence does the nurse anticipate the client may have experienced?
total
The nurse is preparing to delegate a bath for a 90-year-old client who is nonresponsive and has mild skin breakdown. Which type of bath will the nurse delegate to the unlicensed assistive personnel (UAP)?
traditional bed bath with linen change
The nurse is caring for a female client who is unconscious. The nurse should pay special attention to cleaning which area of the body?
underneath the breasts and in between skin folds Correct Explanation: Skin fold areas may be sources of odor and skin breakdown if not cleaned and dried properly. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 934. Chapter 30: Hygiene - Page 934
The nurse measures a client's residual urine by catheterization after the client voids. Which condition would this test verify?
urinary retention
Which of the following describes the term micturition?
urination:
The nurse is teaching a client with a new ostomy about skin care to preserve tissue integrity at the stomal site. Which teaching will the nurse provide regarding cleansing the stoma?
use water and mild soap
A nurse is assessing the stools of a breast-fed baby. What is the appearance of normal stools for this baby?
yellow, loose, odorless
