Ch. 32 practice questions

Which client is most at risk for foot difficulties? - 91-year-old man with renal insufficiency - 80-year-old man with coronary artery disease - 34-year-old woman who is paraplegic - 45-year-old woman with type 2 diabetes

45-year-old woman with type 2 diabetes

The nurse is caring for four clients. For which client is a sitz bath most appropriate? - 51-year old with hemorrhoids - 42-year old recovering from a C-section delivery - 73-year old with pneumonia who can get up to bedside commode - 60-year old who is 1-day post-op from a knee replacement

51-year old with hemorrhoids

A 71-year-old client is concerned about brown patches of skin on their face and forearm. What is the appropriate nursing statement? - "Those spots are senile lentigines and may be cancerous." - "Older people often have splotchy skin due to seborrheic keratoses." - "Those are senile lentigines and are common in older adults." - "Those spots are benign and are known as seborrheic keratoses."

"Those are senile lentigines and are common in older adults."

A nurse is providing nail care for feet to clients admitted to a health care facility. What should the nurse look for while performing nail care for a client with a long history of diabetes? - Cold feet - Breaks in skin integrity and fungal nail infection - Redness and swelling in the joint of the big toe with reports of pain - A bony bump on the joint at the base of the big toe

Breaks in skin integrity and fungal nail infection

The nurse is caring for a female client who is unconscious. The nurse should pay special attention to cleaning which area of the body? - the antecubital fossa and popliteal space - underneath the breasts and in between skinfolds - underneath the fingernails and toenails - the inner and outer canthus of each eye

underneath the breasts and in between skinfolds

Which modification to bathing should be implemented for a client who is incontinent? - Decrease the frequency of bathing to preserve skin integrity. - Use special perineal skin cleaners and moisture barriers. - Perform a full bed bath each time the client has an episode of incontinence. - Use a topical antiseptic, such as povidone-iodine, in the perineal area.

Use special perineal skin cleaners and moisture barriers.

A home health nurse is visiting a client who is receiving chemotherapy for cancer treatment. What question would the nurse ask to assess for complications or side effects of chemotherapy? - "Have your nails become dry and brittle?" - "Have your mouth and lips become sore and inflamed with ulcers?" - "Have you noticed any changes in your skin color?" - "Have you noticed a change in the color of your hair?"

"Have your mouth and lips become sore and inflamed with ulcers?"

The nurse is teaching a nursing student about caring for a client with dentures. Which education will the nurse provide? - "Store dentures in a peroxide solution if not worn continuously." - "Use your ungloved hands to remove an unconscious client's dentures." - "Hold dentures over a plastic basin or towel when cleaning them." - "Clean dentures with hot water to eliminate bacteria."

"Hold dentures over a plastic basin or towel when cleaning them."

The nurse is providing hygiene education for a family who will soon take an older adult client home from the hospital. Which statement by a family member requires further nursing instruction? - "I should install grab bars in the shower or tub at arm level of my loved one." - "I should provide soap for daily bathing to remove debris and keep my loved one's skin moist." - "I should check the bath water temperature before allowing my loved one to bathe." - "I should obtain a tub or shower seat because my loved one has mobility issues."

"I should provide soap for daily bathing to remove debris and keep my loved one's skin moist."

The parents of 3 young children have discussed the dental health needs of their children with the nurse. Which statement indicates the need for further instruction? - "Tartar cannot be brushed or flossed way." - "Fluoride treatments are needed until my children reach the age of 14." - "If my children do not have cavities by the age of 10, fluoride treatments can be discontinued." - "Brushing is important to remove bacteria from the mouth and teeth."

"If my children do not have cavities by the age of 10, fluoride treatments can be discontinued."

A nurse is evaluating the effectiveness of health promotion teaching related to hygiene at a community workshop. Which statements by 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." - "Bathing regularly and applying lotion and cream as needed are important." - "Hygiene measures have no affect on skin." - "Hygiene does not contribute to my well-being so I can choose to not perform hygiene." - "It is important to include hair care and shampooing along with brushing in your hygiene routine."

"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."

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 kind of soap do you like to use?" - "Do you want to bathe regularly?" - "What are your expectations about bathing at this time?" - "Are you not able to bathe yourself?"

"What are your expectations about bathing at this time?"

The nurse is helping a client perform oral hygiene. When asked whether the client flosses, the client states, "I don't like to floss because it makes my gums bleed." What is the appropriate nursing response? Select all that apply. - "Flossing removes plaque and food debris that a toothbrush may miss." - "When flossing, be certain to choose waxed floss." - "I understand; flossing makes my gums bleed too." - "The chance of tooth and gum disease can be reduced by flossing." - "You can use flossing in place of brushing teeth."

- "Flossing removes plaque and food debris that a toothbrush may miss." - "The chance of tooth and gum disease can be reduced by flossing."

A client reports developing repeated furuncles in the groin area. What statement(s) made by the client indicates to the nurse that education about prevention will be required? Select all that apply. - "All of the items that I use that touch the area are washed in hot water and bleach." - "I ruptured the furuncle so that hydrogen peroxide and an antibiotic cream can be applied." - "I use a separate towel from other members of my household." - "I use good hand hygiene before and after washing the area and applying the prescribed medication." - "I have aspirated the drainage with a needle to relieve the pressure and the pain."

- "I ruptured the furuncle so that hydrogen peroxide and an antibiotic cream can be applied." - "I have aspirated the drainage with a needle to relieve the pressure and the pain."

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. - Carefully wipe the outer surface of the hearing aid to maintain cleanliness. - Store the hearing aid in a very warm environment so that it will not crack. - Use a small knife to remove cerumen that becomes embedded in the earpiece. - Keep extra batteries on hand.

- Keep extra batteries on hand. - Do not get hair spray or other chemicals on the hearing aid. - Carefully wipe the outer surface of the hearing aid to maintain cleanliness.

A sitz bath would be most appropriate for which client? - 69-year-old with impaired circulation to the lower extremities - 33-year-old who is one day postpartum - 57-year-old who has just had surgery to repair a hernia - 41-year-old with intractable migraines

33-year-old who is one day postpartum

The nurse is assisting with morning care for a group of clients. For which clients is a safety razor contraindicated? Select all that apply. - 26-year-old who is suicidal and requests to shave - 68-year-old taking anticoagulants for deep venous thrombosis - 30-year-old with inflammation of facial skin - 45-year-old with liver disease and impaired clotting - 45-year-old with pneumonia who prefers to shave twice daily

68-year-old taking anticoagulants for deep venous thrombosis 45-year-old with liver disease and impaired clotting 26-year-old who is suicidal and requests to shave 30-year-old with inflammation of facial skin

A nurse is caring for a client who is unconscious and notes in the client's history that the client wears contact lenses. What is the most appropriate action by the nurse at this time? - Contact the client's caregiver and ask if the client wears contacts. - Assess both eyes for contact lenses. - Ask the unlicensed assistive personnel (UAP) to remove the contact lenses. - Contact the health care provider for a prescription to remove the contact lenses.

Assess both eyes for contact lenses.

An older adult client recently suffered a stroke. The client is bedbound from the resultant paralysis of the right arm and right leg. Which intervention by the nurse is the best strategy to maintain skin integrity? - Provide a diet high in carbohydrates. - Avoid hot water during bathing. - Scoot the client up in bed with assistance. - Perform active and passive range-of-motion (ROM) four times daily.

Avoid hot water during bathing.

The nurse provides care for a female client who had a stroke 2 days ago. Which action(s) does the nurse take to facilitate health of the client's integumentary system? Select all that apply. - Perform back massage to promote circulation - Provide hot water foot soaks to relax client - Perform perineal care by cleansing the area from the anus toward the pubic area in one stroke - Shampoo the hair with the client in bed using a tray to drain the water - Bathe the client in bed to prevent unnecessary physical stress

Bathe the client in bed to prevent unnecessary physical stress Perform back massage to promote circulation Shampoo the hair with the client in bed using a tray to drain the water

Which statements accurately describe findings the nurse would document when performing a physical assessment of the oral cavity? Select all that apply. - Cheilosis may present as reddened fissures at the angles of the mouth. - Hard deposits of tartar may be found on the teeth if plaque is allowed to build up. - Gingivitis may be present involving the alveolar tissues. - Stomatitis may be noted as an inflammation of the tongue. - Oral malignancies may be present in the form of a dry oral mucosa. - Caries may exist in the teeth, resulting from the failure to remove plaque.

Caries may exist in the teeth, resulting from the failure to remove plaque. Hard deposits of tartar may be found on the teeth if plaque is allowed to build up. Cheilosis may present as reddened fissures at the angles of the mouth.

The nurse is providing perineal care for clients in a hospital setting. What is an appropriate nursing action when providing this type of care? - Dry the cleaned areas and apply an emollient as indicated. - Do not retract the foreskin in an uncircumcised male. - Powder the area to prevent the growth of bacteria. - Always proceed from the most contaminated area to the least contaminated area.

Dry the cleaned areas and apply an emollient as indicated.

A nurse is providing oral care to a client and observes that a significant amount of blood is coming from the client's gums. Which actions are appropriate responses? Select all that apply. - Arrange for prompt referral to a dentist. - Assess the client's level of consciousness before proceeding. - Apply a small amount of baking soda to the client's gums as a cauterizing agent. - Encourage the client to rinse his or her mouth and spit. - Check the client's most recent platelet level after providing care.

Encourage the client to rinse his or her mouth and spit. Check the client's most recent platelet level after providing care.

The nurse is caring for a client with diabetes who has thick toenails. What is the appropriate nursing intervention? - Clean under the toenails with a wooden orange stick. - Use a handheld electric rotary file to reduce the length of the toenails. - File, rather than cut the nails. - Clip the toenails with large clippers.

File, rather than cut the nails.

A nurse assisting a client with contact lens removal finds that the hard contact is not over the cornea. What would be the appropriate intervention in this situation? - Remove the contact with a contact remover. - Gently slide the hard lens over the cornea and remove it with gloved fingers. - Remove the contact from the area it is located using gloved fingers. - Do not attempt to remove the contact because this will cause damage to the cornea.

Gently slide the hard lens over the cornea and remove it with gloved fingers.

The unlicensed assistive personnel (UAP) is remaking the bed in a hospital room where the client was just discharged. The nurse observes the UAP performing the action pictured above. What initial instruction should the nurse provide to the UAP? - Inform the UAP that she should be wearing gloves. - Tell the UAP that it is best to do this with a partner. - Remind the UAP that a gown and gloves should be worn. - Teach the UAP about the chain of infection.

Inform the UAP that she should be wearing gloves

A nurse is going to bathe a client who is confined to bed. After reviewing the client's record, what does the nurse do next? - Perform hand hygiene. - Raise bed to high position. - Close the door or bed curtains. - Lay a towel across the client's chest.

Perform hand hygiene.

A nurse is caring for a client who has had difficulty sleeping. What nursing intervention may facilitate the client's rest? - Engaging in a therapeutic conversation - Providing a back rub before bed - Providing multiple stimuli to make the client tired - Giving the client something to drink

Providing a back rub before bed

The nurse is caring for a woman who informs the nurse that she needs assistance to remove and clean her glass eye. What actions by the nurse are most appropriate to accomplish the task? - Pull the inner canthus toward the bridge of the nose and lift under the glass. - Pull up the upper lid and place your index finger under the glass edge. - Apply pressure over the eye with your index finger and thumb under the eye. - Pull down on the lower lid and exert slight pressure below the lid.

Pull down on the lower lid and exert slight pressure below the lid.

A nurse is shaving a male client's face. Which should the nurse do? - Pull the skin taut and use short, upward strokes. - Shave against the direction of hair growth, using short strokes. - Pull the skin taut and shave in the direction of hair growth using short strokes. - Let the skin hang loose and shave in long, downward strokes.

Pull the skin taut and shave in the direction of hair growth using short strokes.

Which nursing action is appropriate when providing foot care for a client? - For diabetic clients, trim the nails with nail clippers. - Soak the feet in a solution of mild soap and tepid water. - Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms. - Cut off any corns or calluses.

Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms.

A nurse is educating a client on how to care for dentures. What is a recommended teaching guideline? - Wrap dentures in a napkin when not using them. - Keep dentures near you in the bed for easy access. - Store dentures in cold water when not in use. - Remove dentures whenever possible to rest the gums.

Store dentures in cold water when not in use.

The nurse is assisting a 56-year-old female who has undergone a mastectomy with her morning care. Which action by the client requires further teaching by the nurse? - The clients applies cosmetics after her bath. - The client provides care independently. - The client applies deodorant. - The client uses a bag bath.

The client applies deodorant.

A female nurse is assisting an older man who has dementia with a bath in his hospital room. Which approach should the nurse take? - The nurse should have a male nurse bathe the client. - The nurse should call a family member and have him or her bathe the man. - The nurse should bathe the man herself, as he has dementia. - The client should be allowed to complete as much of the bath as he can.

The client should be allowed to complete as much of the bath as he can

A nurse is caring for a client with a decreased level of consciousness (LOC). When performing mouth care, what action by the nurse will decrease complications of oral care? - The client should be placed in a position of comfort. - The client should remain in an upright position to avoid the tongue blocking the airway. - The client should be placed in a side-lying position to prevent aspiration. - The client should be placed in the lithotomy position.

The client should be placed in a side-lying position to prevent aspiration.

When bathing a client, the nurse notices that the client has a rash on her arms. What would be an appropriate nursing intervention? - Avoid washing the area because cleansing agents will only make the rash worse. - Do not use over-the-counter products on unknown rashes. - Use a moisturizing lotion on a wet rash to prevent itching. - Use a tepid bath to relieve inflammation and itching.

Use a tepid bath to relieve inflammation and itching.

Which are recommended guidelines for daily care of a client who has an indwelling urinary catheter? Select all that apply. - Inspect the meatus for drainage and note the characteristics of the urine. - Perform care of the indwelling urinary catheter before perineal care. - Clean 6 to 8 in of the catheter, moving from the meatus downward. - Put on sterile gloves before cleaning the catheter. - Use an antiseptic cleaning agent or plain soap and water on a clean washcloth. - Slightly pull on the catheter during the cleaning motion to dislodge crusts.

Use an antiseptic cleaning agent or plain soap and water on a clean washcloth. Clean 6 to 8 in of the catheter, moving from the meatus downward. Inspect the meatus for drainage and note the characteristics of the urine

The nurse is caring for a client who is on warfarin therapy. Which teaching will the nurse provide? - Use an electric razor for shaving purposes. - Reassure the client that prolonged bleeding of wounds and gums is normal. - Buy a hard-bristled toothbrush to ensure proper oral hygiene. - Take aspirin for headaches that develop.

Use an electric razor for shaving purposes.

The nursing student is providing hygiene education for a family who will soon take an older adult client home from the hospital. Which teaching provided by the nursing student requires nursing instructor intervention? - Soap should be used sparingly so the client's skin does not become overly dry. - Use bath oil in the tub to decrease dry skin. - Obtain a tub or shower seat if the client has mobility issues. - Grab bars should be placed in the shower or tub at arm level.

Use bath oil in the tub to decrease dry skin.

The nurse is caring for a client that is comatose. What action by the nurse will prevent complications related to the provision of oral care? - Place the client in high Fowler's position. - Place the client in the supine position with head lowered. - Put the client in the prone position. - Use small amounts of water and an oral suction device.

Use small amounts of water and an oral suction device.

A registered nurse is overseeing the care of several residents of a long-term care facility. Which task would be inappropriate to delegate to unlicensed assistive personnel (UAP)? - Providing a tub bath to a resident who is unable to mobilize independently - Providing oral care to a client who has cognitive deficits and a decreased level of consciousness - Using a tool to remove a contact lens that has adhered to the resident's eye - Shaving the face of a resident who has worn a beard for several years

Using a tool to remove a contact lens that has adhered to the resident's eye

In which situation would it be appropriate to shave the beard of an unconscious client without his permission? - When the beard becomes tangled - When inserting an endotracheal tube - To facilitate skin care - To facilitate use of a nebulizer

When inserting an endotracheal tube

A nurse is helping an older woman undress and notices the woman's knee-high hose have left deep indentations. The woman has diabetes. Does this pose a risk to the client? - No, knee-high hose are more comfortable. - Yes, these can obstruct lower extremity circulation. - No, the indentations will go away. - Yes, these are a safety hazard and should not be worn.

Yes, these can obstruct lower extremity circulation.

A client has a diagnosis of Bathing/Hygiene Self-care Deficit due to recent surgery and decreased strength. An appropriate goal to include in the client's plan of care would be: - client will verbalize the need to use to use the bedpan by the end of shift. - client will recognize the need for self-care. - client will participate in self-care measures by the end of the week. - client will consent to no hygiene measures.

client will participate in self-care measures by the end of the week.

When an adolescent client asks the nurse how to care for long hair, the nurse should instruct the client that: - lubricants or oils should not be used. - hair should be washed as often as necessary. - braids should be undone every day. - combs should be washed as often as necessary.

hair should be washed as often as necessary.

An older adult client is reporting dry, itching skin. The nurse should assess: - how often the client is bathing. - when the client's last tub bath was. - when the severe itching occurs. - what linens they are using.

how often the client is bathing.

When the nurse cleanses the client's leg during a bed bath, it will allow for: - decreased restless leg syndrome. - promotion of social interaction. - increased circulation. - assessment of pain.

increased circulation.

The nurse is providing oral care to a client who is unable to complete their own activities of daily living. While providing care, the nurse notices some bleeding. Following a full assessment and chart review, which potential cause(s) of oral bleeding will the nurse use to create a client-centered plan of care? Select all that apply. - dyspnea with exertion - recent unwitnessed fall - prescription for warfarin - low platelet count - altered mental status - current chemotherapy treatment - prescription for carvedilol - diagnosis of periodontitis

prescription for warfarin diagnosis of periodontitis current chemotherapy treatment low platelet count

The nurse is observing a student who is using a safety razor to shave a client. Which action would require intervention by the nurse? - washing the skin with soap and water prior to shaving - rinsing the razor after each stroke of the razor - applying direct pressure to an area that is bleeding - pulling the razor against the direction of hair growth

pulling the razor against the direction of hair growth

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? - bag bath - sitz bath - sit-down shower chair - partial bath at a wash basin

sitz bath

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 fact that the health problem is self-limiting - the importance of teaching their children adequate personal hygiene habits - the need to destroy all clothing and bedding that the child has used - the importance of completely finishing the prescribed treatment

the importance of completely finishing the prescribed treatment

A pediatric nurse is providing a health promotional education program to a group of preschool parents. One parent asks the nurse the following question: "I have started buying bottled water. How will this affect my children?" It is important for the nurse to educate the mothers that: - the preschool child should only drink milk. - there is a need to determine if the bottled water has fluoride. - the preschool child should not drink bottled water. - the parent should alternate bottle and tap water.

there is a need to determine if the bottled water has fluoride.