quiz 9 hygiene body mechanics

Which intervention is correct for preventing the spread of infection while following the correct procedure for bed making?

Washing hands after handling any soiled linens.

A nurse is reinforcing teaching with a client about hand hygiene. Which of the following client statements indicates a need for further teaching?

"I should wash my hands until they appear clean".

A male client tells the nurse that he does not want the female assistive personnel (AP) involved in his care. Which of the following statements should the nurse give?

"I'll notify the charge nurse of your request to have only male staff members assigned to care for you."

When preparing a sponge bath water for a patient, the nurse should make sure that the water temperature is:

110-115 degrees Fahrenheit.

When there is sustained skin pressure especially over the body prominences, the nurse will plan to have the client's position changed every:

120 minutes (or 2 hours)

** Picture Question*** How should the nurse stage the following pressure ulcer?

2

The nurse explains that the purpose of a sitz bath is to reduce inflammation in the perineal and anal area. How long should a client remain in a sitz bath?

20-30 minutes.

To give an effective back rub to a client, it must last at least:

3-5 minutes

The nurse attempts to avoid a pressure injury for a bedridden patient by turning the patient frequently. What is the most favorable position for the nurse to move this patient into?

30 Degree Lateral position.

The nurse lowers the head of the bed to place the client on the bedpan, then raises the head of the bed to which angle?

30 degrees.

Before giving the client a bath, the nurse assures that the room temperature is between:

68-74 Degrees Fahrenheit.

Which client would be at the greatest risk for skin impairment?

A 70-year-old in a full body cast.

Immersion of the buttocks and perineum in a small basin of continuously circulating water is called a:

A Sitz Bath.

When shaving a client, it is appropriate to use an electric razor instead of a straight razor when:

A bleeding tendency is present.

When providing hand and foot care, the person best prepared to provide nail care for clients with extremely hard toenails is the:

A podiatrist.

The nurse assesses the client's skin for signs of impaired skin integrity and recognizes that a major manifestation is:

A pressure ulcer.

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse take to prevent the development of skin breakdown?

Apply a barrier ointment to the skin.

After cleaning a patient's dentures, the nurse replaces them:

By putting in the upper denture first.

A nurse is providing hygiene care for a client who is immobilized. Which of the following actions should the nurse take? (Select all that apply.)

Check the bed linens when removing them for personal items. Keep the bath water's temperature between 43.3°C (110° F) and 46.1° C (115° F). Shave the client's hair in the direction of the hair growth.

A nurse is assisting a client with range-of-motion exercises of the hip. Which of the following terms should the nurse use when documenting the client moving her leg so that she is tracing circles with her foot?

Circumduction.

When moving or transferring older patients, it is essential to avoid pulling them across bed linens because this may cause:

Friction

The nurse must follow the principles of medical asepsis while making the patient's bed. One of these principles relates to the handling of linen. Soiled linen must be:

Held away from the uniform.

A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to interrupt the transmission of the client's infection?

Performing hand hygiene before, during and after any direct contact with a patient.

The client recovering from a hemorrhoidectomy has been in the sitz bath for five minutes when he complains of dizziness. The nurse should:

Remove him from the Sitz bath immediately and assist him back into bed.

A nurse is caring for a client who is recovering from a stroke. Which of the following information should the nurse include when reinforcing teaching with members of the client's family about re-positioning the client? (Select all that apply.)

Remove pillows prior to re-positioning. Elevate the bed to waist height. Stand with their feet wide apart. Face the direction of movement when repositioning the client.

A nurse is planning preventive care for a client who is at risk for pressure ulcers and requires bed rest. Which of the following actions should the nurse take?

Reposition the client at least once every two hours.

When washing the patient's face and cleansing the eyes, you would wash the eyelids from the:

The inner to the outer canthus of the eye.

The nurse is performing a backrub for the client. To begin the backrub, the nurse starts at the:

The sacral area.

Upon inspection of a client's skin, a nurse identifies a stage 3 pressure ulcer on the sacrum. Which of the following statement by the nurse describes a stage 3 pressure ulcer?

There is a full-thickness skin loss with a full crater.

A nurse is performing ADL's on a client who is unconscious. With the help of an assistive personnel, the nurse re-positions the client to a right lateral position to brush his teeth. The client's daughter asks why the nurse brushes her father's teeth while lying on his side. Which of the following rationales should the nurse give the family member?

To prevent aspiration problems.

One reason the nurse focuses on oral hygiene is to maintain a healthy state of the oral cavity. What is another reason to promote oral hygiene?

To stimulate the appetite.

A nurse in a long-term care facility is caring for a client who is unresponsive. When performing oral hygiene for the client, which of the following actions should the nurse take?

Turn the client on his side before starting oral care.

The nurse should cleanse the meatus-catheter junction of a patient with an indwelling catheter in place at least:

Twice per day