Chapter 27, Hygiene and Personal Care & Skin integrity/Wound Care

What is the removal of devitalized tissue from a wound called? 1. Debridement 2. Pressure reduction 3. Negative pressure wound therapy 4. Sanitization

1. Debridement Debridement is the removal of nonliving tissue, cleaning the wound to move toward healing.

A nurse administers an analgesic medication to a patient with a stage IV pressure ulcer who needs to have a dressing change. When does the nurse perform the dressing change in relation to administering the analgesic? 1. Before the administration 2. 90 minutes after administration 3. Immediately after administration 4. 30 minutes after administration

4. 30 minutes after administration The nurse should plan the dressing change for 30 minutes after the analgesic is administered. During this time, the peak effect of the medication is reached, and the patient has an optimum comfort level and maximum control over pain. Dressing changes should always be done after an analgesic is given, not before. Changing the dressing immediately after administration or 90 minutes after administration would not allow for optimum effect of the analgesic to control pain.

The nurse performs debridement for a patient who has a wound on the hand. After the process, the patient reports pain and bleeding at the site of the wound. Which form of debridement had the nurse used in the patient? 1. Panafil 2. Accuzyme 3. Hydrocolloid 4. Damp/Wet-to-dry dressing

4. Damp/Wet-to-dry dressing Mechanical debridement removes the necrotic and viable tissues from the wound, resulting in bleeding and pain at the site of wound. Whirlpools and wet/damp-to-dry dressings are the main forms of mechanical debridement. Panafil and Accuzyme are topical agents used for enzymatic debridement, which is slow and is selective to necrotic tissues; therefore, it would not cause bleeding. Hydrocolloids are comfortable for the patient and would not cause pain.

A patient has a stage III pressure ulcer on the coccyx. Which food will be most beneficial in improving the healing process? a. Food high in vitamin D b. Whole-grain carbohydrates c. High-calorie, high-protein drink d. Food high in fat and water content

A stage III pressure ulcer takes months to heal, and nutrition is an important aspect of care. Important nutritional components related to healing are calories, protein, vitamins A and C, and minerals zinc and copper. Therefore, the supplements high in calories and protein would be most beneficial.

The primary health care provider has instructed the nurse to provide vacuum-assisted therapy (VAC) to a patient with a diabetic ulcer. What should the nurse assess in the patient to prevent complications? Select all that apply. A. Fistula B. Osteomyelitis C. Pressure ulcer D. Dehisced wound E. Traumatic wound

A, B, VAC is contraindicated when a fistula is present or if the patient has developed an infection of the bone known as osteomyelitis. If VAC were applied to a patient with a fistula, the fistula would worsen and wound healing would be further delayed. If VAC were applied to a patient with osteomyelitis, the infection might spread from the localized site and become systemic. Pressure ulcers, dehisced wounds, and traumatic wounds are indications for VAC therapy. In VAC, localized subatmospheric pressure draws the edges of a wound toward its center. It reduces edema and promotes granulation tissue formation in the wound. These VAC actions facilitate quicker wound healing of pressure ulcers, dehisced wounds, and traumatic wounds, than would be possible without VAC therapy.

After assessing the wound of a patient, the nurse orders a wound culture. Which findings in the patient necessitated this intervention? Select all that apply. A. Presence of a foul odor in the wound B. Presence of serous drainage from the wound C. Presence of purulent drainage from the wound D. Presence of sanguinous drainage from the wound E. Presence of high amount of drainage from the wound

A, C, E The nurse may order a wound culture if the nurse suspects that the wound is infected. Foul odor, purulent drainage, and an increased amount of drainage are characteristics of infection. Serous drainage is a clear watery fluid and it is a common characteristic of wounds. Sanguinous drainage usually indicates bleeding and is bright red.

Which nursing diagnosis is a priority for a patient who needs assistance with activities of daily living? a. Self-Care Deficit b. Deficient Knowledge c. Risk for Activity Intolerance d. Readiness for Enhanced Self-Care

Answer: a A patient who has an impaired ability to complete bathing, mouth care, toileting, grooming, dressing, and eating without assistance has a Self-Care Deficit. Deficient Knowledge implies that the patient does not have certain information. Risk for Activity Intolerance may be a concern if a patient's level of activity is reduced, but this nursing diagnosis is not related to needing assistance. A diagnosis of Readiness for Enhanced Self-Care means that the patient is ready to perform activities to enhance health.

Which technique is used to collect an aerobic culture specimen from a wound? a. Collect the specimen immediately after removing the old dressing. b. Apply sterile gloves, then open the culture tube. c. Always be sure to culture any necrotic tissue. d. Irrigate the wound before collecting the culture material.

Answer: d The wound should be irrigated with normal saline before the culture is taken so the dressing is removed, then the wound is irrigated. Sterile gloves are not necessary because the hands will grasp the outside of the culture tube, which is not sterile, so clean gloves can be worn. The culture specimen is taken in draining tissue, not necrotic tissue, so that the swab is covered in exudate.

A patient is admitted with a stage II pressure ulcer. What characteristics of a pressure ulcer is the nurse likely to find during a wound assessment? 1. It has a red-pink wound bed without slough. 2. The subcutaneous fat is visible. 3. It may include undermining and tunneling. 4. The wound extends to muscles and bones.

1. It has a red-pink wound bed without slough. A stage II pressure ulcer has a partial thickness loss of dermis and is shallow. It has a red-pink wound bed without slough. The subcutaneous fat is visible in a stage III ulcer due to a full thickness tissue loss. A stage III and IV wound involves undermining and tunneling. A stage IV wound extends to the muscles and bones, as there is a full thickness tissue loss.

Which statement is true about wet-to-dry dressings for mechanical debridement of a wound? 1. It should be removed when partially dry. 2. It causes slight bleeding when removed. 3. It should be only moist, not wet, when applied. 4. It should be left in place for at least 12 hours.

3. It should be only moist, not wet, when applied. Wet-to-dry dressings used for mechanical debridement of wounds should be moist, not wet. Application of moist gauze hydrates the wound and helps with quick drying. The gauze should be removed when totally dried, so that it gets stuck to the necrotic tissue. It may not cause bleeding when removed. The dressing is positioned in the wound and held in place by an outer dressing or gauze wrap for four to six hours. This much time would be needed for the gauze to dry and stick to the underlying tissue.

The nurse recognizes that her older-adult patient needs additional teaching about skin care when the older adult says, "I should: 1. Bathe twice a week." 2. Rinse well after using soap." 3. Use hot water for bathing." 4. Drink plenty of fluids."

3. Use hot water for bathing." Warm water is typically the most comfortable for the patient. Hot water dries the skin by removing natural oils more quickly and could be dangerous if the patient has decreased sensation.

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? 1. Collection of wound drainage 2. Reduction of abdominal swelling 3. Reduction of stress on the abdominal incision 4. Stimulation of peristalsis (return of bowel function) from direct pressure

Correct 3. Reduction of stress on the abdominal incision A binder placed over the abdomen can provide protection to the abdominal incision by offering support and decreasing stress from coughing and movement.

Which area of the body is most likely to be excoriated? a. Elbows b. Facial skin c. Cervical spine d. Perineum

ANS: D Areas of the body that are prone to excoriation are those exposed to bodily fluids such as stool, urine, gastric juices, or sweat, as well as where skin touches skin.

Which actions by the nurse concerning oral care on an unconscious patient are considered safe? (Select all that apply.) a. Performing oral care with the patient in a supine position b. Performing oral care with the patient turned to the side c. Installing suction equipment at the bedside d. Providing oral care every 2 hours e. Using a hard-bristle toothbrush

Answers: b, c, d Oral care on an unconscious patient is performed with the patient turned to one side so that fluid can drain out of the side of the mouth. Suction equipment is used to remove fluid and secretions during oral care on an unconscious patient. Oral care should be provided at least every 2 hours for patients who are unconscious, receiving nothing by mouth (NPO), intubated, or receiving oxygen by a mask. An unconscious patient may aspirate if oral care is done in the supine position. A hard-bristle brush may damage the oral mucosa.

Which statements are true regarding back massage? (Select all that apply.) a. Only a licensed massage therapist can perform back massage. b. Back massage may stimulate the deep muscles. c. Massage provides relaxation and comfort. d. Tapotement stimulates the skin. e. A massage may promote sleep.

Answers: b, c, d, e Back massage provides relaxation, increases circulation, stimulates the skin and deep muscles, and promotes sleep. Nursing personnel can perform a back massage during care, before bedtime, or any other time to help the patient relax.

While assessing a patient who has a sacral pressure ulcer, the nurse finds that it is a stage II pressure ulcer. Which finding in the patient led the nurse to this conclusion? 1. Presence of a pink wound bed 2. Presence of a tunnel in the wound 3. Presence of a lip around the wound 4. Presence of nonblanchable erythema

Correct 1. Presence of a pink wound bed In a stage II pressure ulcer, the thickness of the dermis is lost. The skin forms an open wound that extends to the deeper layers of the skin. The presence of a pink wound bed is caused by the rupture of blood vessels around the wound. The presence of nonblanchable erythema at the site of the wound is characteristic of a stage I pressure ulcer. This is caused by excessive vasodilation. Undermining and tunneling in the wound are typical of a stage III pressure ulcer. A tunnel is a narrow passage that extends outward from the edge of the wound. Undermining refers to an area of tissue loss along the edges of the wound, forming a "lip" around the wound.

While providing a bed bath, the nurse observes that a patient has reddened areas on the back. Which measure taken by the nurse would be most helpful in this situation? 1. Keep the patient in a supine position 2. Expose the reddened areas of the patient to light 3. Apply talcum powder all over the reddened areas 4. Do not massage any reddened areas of the patient

Correct 4. Do not massage any reddened areas of the patient During a bath, the nurse refrains from massaging any reddened areas, as this may cause further skin breakdown. The nurse does not apply talcum powder, as this may cause irritation and make the area susceptible to bacterial infections. The nurse does not expose the reddened areas to light, because this increases the redness of the skin due to inflammation. Keeping the patient is a supine position will aggravate the condition; the patient should be turned.

Which cells play an important role in cleaning the patient's wound? Select all that apply. A. Platelets B. Cytokines C. Fibroblasts D. Neutrophils E. Macrophages

Correct D, E Neutrophils and macrophages clean the wound by cleaning away bacteria and debris. They provide the first line of defense of the immune system through phagocytosis. Platelets, cytokines, and fibroblasts play important roles in wound healing, but they do not clean the wound. They produce growth factors, which help in the formation of new tissues.

What is the most appropriate dressing for a pressure ulcer that is draining a large amount of exudate, extends through the fascia and into the deeper tissues including muscles and bone, and has granulation tissue in the wound bed? a. Alginate dressing b. Damp to dry dressing c. Hydrocolloidal dressing d. Gauze dressing reinforced with ABD pads

ANS: A Alginate dressings absorb a large amount of drainage. A damp to dry dressing debrides and could harm healthy granulation tissues. Hydrocolloidal dressings could be used in this type of wound if the exudate was a small to moderate amount. A gauze dressing may dry out and cause damage when removed.

Which assessment finding by the nurse indicates a complication from oxygen via nasal cannula? a. Dry nasal passages b. Inability to speak clearly c. Increased nasal drainage d. Skin breakdown on the chin

ANS: A Oxygen via nasal cannula can be drying to the nares. Use of a nasal cannula does not affect the patient's ability to speak and should not increase drainage. Pressure areas from a nasal cannula may include the nares, the cheeks, and the top front crease of the auricle of the ear but not the chin.

What does a Braden Score of 14 indicate to the nurse? a. High risk for the development of pressure ulcers b. Low risk for the development of pressure ulcers c. The need for a special mattress d. The presence of a pressure ulcer

ANS: A The lower the score the higher the risk of pressure ulcer formation. While research continues as to where the cut off for risk should be, it is generally accepted that a Braden of 16-18 indicates an increased risk for pressure ulcer development. The Braden score does not indicate which interventions, such as a special mattress, to use. It does not indicate whether an ulcer already exists.

Which hygienic care instructions by the nurse should be given to a patient who is being discharged on an anticoagulant? (Select all that apply.) a. Use an electric razor for shaving. b. Brush teeth with a soft toothbrush. c. Trim beard with double blade safety razor. d. Use caution when trimming nails with clippers. e. Deeply massage unused muscles while bathing.

ANS: A, B, D Due to the risk of bleeding, only electric razors should be used by patients on anticoagulants for trimming facial hair and shaving. A soft toothbrush reduces the risk of damage to the gums. Other sharp instruments such as nail clippers are used with caution to avoid cutting skin. Deep massage may cause bruising in patients on anticoagulants.

Which can be delegated to the unlicensed personnel on the nursing unit? (Select all that apply.) a. Morning care including a bath, linen change, and application of a barrier ointment b. Dressing changes with application of an enzymatic ointment c. Turning and positioning a patient during dressing changes d. Assessment of the skin and wounds e. Obtaining a wound culture f. Removal of a simple drain.

ANS: A, C Hygiene and applying a barrier ointment and turning and position are the only choices that fall within the scope of practice of an unlicensed member of the health care team. Enzymatic ointment is a medication and cannot be delegated. Assessment is a nursing activity that cannot be delegated. Obtaining a wound culture is not a task that can be delegated to UAP. Removal of a drain is done by a specially trained nurse or the surgeon.

Which statements are correct concerning bathing a hospitalized patient? (Select all that apply.) a. A complete bed bath is for patients who are bedridden. b. All hospitalized patients need a complete bed bath. c. Bathing removes dead skin, bacteria, and body fluids. d. Male personnel must always perform male perineal care. e. Keeping skin clean and dry helps prevent breakdown.

ANS: A, C, E Bedridden patients need complete bed baths. Bathing keeps skin clean and helps prevent breakdown while removing skin, bacteria, and bodily fluids. Each patient is assessed to determine the level of care and bathing assistance needed. Personnel can perform perineal care on patients of the opposite sex, treating the patient with dignity and professionalism.

Which is the most appropriate treatment choice for a wound with a shallow pink wound bed and minimal drainage? a. Use of an enzymatic debriding agent b. A moisture retentive dressing such as a hydrocolloid c. Gauze moistened with 0.9% normal saline d. An aginate covered with a foam dressing

ANS: B A pink moist wound bed would indicate the presence of granulation tissue. A moist wound environment is essential for the development of epithelial tissue and so a moisture retentive dressing is appropriate. Gauze is more labor intensive and does not provide the moisture retentive environment needed for wound healing. Debridement would harm healthy granulation tissue. Alginate is too absorbent for a minimally draining wound.

Which statement by a patient with the nursing diagnosis of Self-Care Deficit would indicate attainment of the goal: Patient will actively participate in bathing within 24 hours after surgery? a. "I need help with my bath." b. "I was able to wash my own feet today." c. "I am going to need assistance at home." d. "Could you help me brush my teeth this morning?"

ANS: B An increase in the patient's ability to care for his or her own hygienic needs indicates achievement of goals related to Self-Care Deficit. The other statements indicate continued dependence with activities of daily living.

The nurse is planning care for patients on the hospital unit. For which patient will it be most appropriate to use cold therapy? a. For any patient who requests a cold compress b. For a male patient with a stage I pressure ulcer c. For a female patient with a sprained ankle with edema d. For stimulating vasodilatation and improved blood flow in an immobile patient

ANS: C Cold therapy causes vasoconstriction and decreases edema and pain. Like heat therapy, the application of cold therapy requires a doctor's order that includes the area to be treated, the length of time to be treated, and what device should be used. Vasoconstriction would be detrimental for the patient with a pressure ulcer since blood flow is decreased.

Which nursing action is necessary for patient safety during a bed bath? a. All four side rails are always kept in the raised position during the bath. b. The bed is always in the low and locked position while bathing the patient. c. The top side rail is raised opposite the side where the nurse is standing. d. The bed is always kept in a flat position with a pillow under the patient's head.

ANS: C The bed is raised to a comfortable working position and the side rail is lowered on the side where the nurse is standing. It is important to leave the bed in the low and locked position with the top side rails up when the bath is finished and the nurse is leaving the room. The position of the bed and the patient during the bath is dependent on the patient's condition and comfort level.

Which is the most important strategy in the prevention of wound infections? a. The use of sterile dressings at all times b. A high protein diet with vitamin C supplements c. The use of antibiotics in all patients with wounds d. Careful and consistent hand hygiene

ANS: D Many wounds do not require a sterile dressing or antibiotics. While nutrition is very important in wound healing, hand hygiene remains the most important method to prevent wound infections.

In planning care on the hospital unit, the nurse prioritizes care for assigned patients with regard to skin integrity. Which patient would be the nurse's highest priority for skin issues? a. A 50-year-old female with diabetes who has an ulcer on her foot b. An 80-year-old man with incontinence due to clostridium difficile c. A 22-year-old cocaine addict with a compound fracture of the tibia d. A 75-year-old female with CHF and a history of breast cancer

ANS: A While all of the patients have potential for skin integrity issues, the diabetic who also has an ulcer on her foot is at greatest risk for complications from impaired skin integrity. Any patient who is incontinent should receive diligent nursing care with each incontinence episode. A cocaine addict may have problems that will impair healing, which the nurse can manage with nutritional counseling and substance abuse counseling. The CHF patient has no known skin issues.

. Which procedure is correct when making an occupied bed? a. The bed is left in the low and locked position for patient safety. b. The bed is made starting at the head and working toward the feet. c. Soiled linen is loosened on one side of the bed and rolled under the patient. d. Making an occupied bed cannot be delegated to unlicensed assistive personnel.

ANS: C When making an occupied bed, one side of the bed is stripped and made first while the patient is rolled to the opposite side. The patient is then rolled over the linens and the second side is made. Bed making may be delegated to unlicensed assistive personnel after reviewing specific patient limitations.

Which action by a female patient lets the nurse know that the patient has understood perineal care teaching? a. The patient washes her perineum with a circular motion beginning at the urinary meatus. b. The patient washes her perineum from front to back using a clean washcloth. c. The patient washes her perineum from back to front with long, firm strokes. d. The patient washes her perineum lightly to prevent tissue damage.

Answer: b The female perineum is always washed from front to back, washing the area near the urinary meatus first and working back to the anus to avoid introducing organisms into the urinary tract. A circular motion is used for a male patient, washing around the urinary meatus first and then washing down the shaft of the penis. Firm strokes can be used so that the area is well cleaned.

An ambulatory diabetic patient states that she is unable to reach her feet to clip her toenails. The patient's toenails are long and thick. What is the next step the nurse should take? a. Soak the patient's feet, and trim her toenails using clippers. b. Delegate foot care of this patient to the unlicensed assistive personnel (UAP). c. Assess the patient's self-care status. d. Ask for a referral to a podiatrist.

Answer: d Referral to a podiatrist is appropriate when the diabetic patient is unable to care for her feet. Soaking is contraindicated for patients with diabetes due to the risk skin breakdown. Clippers are not appropriate if nails are thick. Delegation of nail care to the UAP is inappropriate for patients with peripheral neuropathy. The nurse already knows the patient's self-care status with regard to her feet.

Which intervention should be initiated by the nurse caring for a patient with urinary or fecal incontinence? a. Using a heat lamp to dry the skin b. Changing the adult brief every 8 hours c. Cleansing frequently with hot water and a strong soap d. Using an incontinence cleanser and a moisture barrier ointment

Answer: d Skin care for the incontinent patient should include cleansing as needed using a mild, pH-neutral soap and warm (not hot) water, to prevent the stripping of oils from the skin and reduction in the skin's normally acidic pH. Application of a moisture barrier ointment protects the skin from the moisture and irritation that can result from urinary or fecal incontinence. An adult brief should be changed with every incontinence episode. A heat lamp could further damage delicate skin.

The nurse has delegated care of a patient's dentures to unlicensed assistive personnel. Which statement by the assistive personnel indicates an understanding of denture care? a. "It is not necessary to use a toothbrush in the patient's mouth since the patient does not have teeth." b. "I will wrap the dentures in a tissue so that they will not get damaged and place them on the bedside table within reach of the patient." c. "I will put on clean gloves and brush the dentures gently with a toothbrush and toothpaste." d. "I will soak the dentures in the sink and then place them in a denture cup labeled with the patient's name."

ANS: C Dentures are brushed with a regular toothbrush and toothpaste over a sink that has been padded with a washcloth to prevent breakage if they are accidentally dropped. The patient's mouth should be cleansed with a soft brush or toothette after the dentures are removed and before they are reinserted. Never wrap dentures in a tissue because they may accidently be discarded. Soaking dentures in a sink where nurses and patients wash their hands is contraindicated because pathogens may be present in the sink.

Which statement accurately describes proper technique for performing male perineal care? The nurse a. washes the patient from the back of the perineum toward the penis. b. washes with a circular motion starting with the urinary meatus. c. places the patient in the prone position with supporting pillows. d. places the patient in the dorsal recumbent position.

ANS: B During male perineal care the penis is cleansed with soap and water using a circular motion starting at the urinary meatus in order to keep pathogens away from the urinary tract. The shaft of the penis is then cleansed using firm downward strokes. The patient is usually in the supine position with the bed either flat or the head of the bed raised.

What does wound irrigation require? a. A bulb syringe and 0.9% normal saline b. Personal protective equipment including goggles c. Use of an antiseptic solution such as Betadine d. Twice daily dressing changes

ANS: B Splashing can occur during irrigation and therefore there is a need for PPE, including goggles. A bulb syringe does not provide sufficient psi to adequately irrigate a wound, and antiseptic solutions are toxic to cells and should be avoided. Dressings are changed when soiled or according to PCP order.

Which is correct concerning the use of pain medication in the care of a patient with a chronic wound such as a pressure ulcer? a. It is rarely needed as chronic wounds are not as painful as acute wounds due to nerve damage. b. It should not be used in the elderly as they are at risk for constipation, a side effect of many pain medications. c. It should only be considered if the pain score is greater than "5" on a regular basis during dressing changes. d. It should be incorporated into the overall treatment plan based on the patient's reported pain level and assessment of the patient.

ANS: D All wounds are potentially painful and all patients should have pain treated appropriately. Untreated pain has both a physiological and psychological impact on the individual experiencing pain. There are many treatment options including systemic and topical agents as well as complementary and alternative methods.

Which statement is most accurate about hearing aid and ear care for hospitalized patients who are hard of hearing? a. Hard of hearing patients should wear hearing aids at all times while hospitalized. b. Hearing aids should be cleansed daily with soap and water before reinsertion. c. Cerumen is removed with a cotton-tipped applicator before inserting hearing aids. d. Hearing aids are cleansed with a dry cloth and stored in a labeled container.

ANS: D Hearing aids are an electronic device and therefore are cleansed with only a dry cloth. Some patients prefer to remove their hearing aids while sleeping. Using cotton-tipped applicators is contraindicated in any patient because the cerumen may be pushed further into the ear canal. When not in use, hearing aids are stored in a container labeled with the patient's name to prevent misplacement.

A patient who is on bed rest has a stage I pressure ulcer on the sacrum and is recovering from a pelvic injury sustained in a motor vehicle accident. What is the priority nursing diagnosis for this patient? a. Ineffective coping related to pelvic injury b. Risk for Infection related to open wound site c. Risk for impaired tissue integrity and pain related to motor vehicle accident d. Impaired skin Integrity related to pressure, secondary to immobility

ANS: D The patient has impaired skin integrity, which would be the priority. There is no information indicating that the patient is not coping or that there is an open wound. Nursing diagnoses are stated with one diagnosis in each statement.

Based on knowledge of areas at greatest risk for development of a pressure ulcer in the bedridden patient, the nurse identifies which position to minimize this risk? a. 30-degree side-lying b. Sitting with the head of the bed elevated 75 degrees c. 90-degree side-lying d. Lying supine with the bed flat at all times

Answer: a Although pressure ulcers can result in any anatomic area, the sacrum is at highest risk in the bedridden client owing to forces of pressure, friction, and shear. Turning the patient from side to side, while making sure the horizontal plane of the body is at a 30-degree angle to the bed, will keep the patient off the sacrum and also off the greater trochanter, which is another risk area. The head of the bed should not be raised more than 30 degrees if the patient is supine, because greater angles increase the risk of friction and shear on the sacrum. Sacral ulcers also may develop if the patient is supine and is not moved at all.

Which statement best describes the healing process for a surgical wound that has been closed with the use of sutures? a. The edges of the wound are approximated. b. New tissue fills the sides and base of the wound. c. The proliferate phase is longer with surgical wounds. d. Debridement aids in the surgical healing process.

Answer: a Approximated wounds have the edges brought together. Surgical incisions closed with sutures are approximated. Tissue filling in the sides and base of the wound would be an example of secondary intention. The proliferate phase is shorter in surgical wounds. Debridement would damage a surgical wound, causing delayed healing.

On initial assessment of a patient, the nurse notices an area of redness over the right trochanter that, when pressed lightly, does not blanch. What does this assessment finding indicate to the nurse? a. The presence of an infection in the area b. The presence of a stage I pressure ulcer c. An allergic reaction to the sheets d. The need to apply a cold compress to reduce inflammation

Answer: b Nonblanchable erythema over an area of pressure defines a stage I pressure ulcer. An infection is likely to occur in an open sore and would be associated with signs of redness, warmth, and green or yellow exudate. An allergic reaction would manifest as a rash or itchy area. Cold compresses would cause vasoconstriction and further damage because the blood flow has already been restricted.

A patient diagnosed with head lice has an order for pediculicidal shampoo. Which statement is true about this shampoo? a. It can be used on only patients with the ability to stand in the shower. b. It can cause central nervous system side effects, including dizziness. c. It is used by pregnant women and young children. d. It is safe for patients with seizures.

Answer: b Pediculicidal shampoos can have central nervous system side effects, including dizziness, headache, and seizures. Their use is contraindicated for patients with a history of seizures and for pregnant women and young children

Which safety precaution is a priority for the nurse when bathing a patient with peripheral neuropathy? a. Keeping the top two side rails up during the bath b. Checking the bath water temperature before the bath c. Encouraging independence with perineal care during the bath d. Facilitating range-of-motion exercises and dangling before the bath

Answer: b The patient with peripheral neuropathy may not be able to distinguish extremes of hot and cold. To prevent burns from extremely hot water, the nurse checks the water temperature before beginning the bath and each time clean water is obtained. It is important to keep the top two side rails up when not at the bedside to facilitate turning and positioning. Facilitating range-of-motion exercises and as much independence as possible is important for all patients rather than being a specific safety concern for the patient with peripheral neuropathy. Dangling is important to implement with patients who have been bedridden and may experience orthostatic hypotension.

Four days after abdominal surgery, the patient is getting out of bed and feels something "pop" in his abdominal wound. An increase in amount of drainage from the wound is seen, and further examination shows that the sutured incision is now partially open, with tissue protruding from the wound. What is the nurse's next action? a. Apply Steri-Strips to close the wound edges. b. Cover the wound with saline-moistened gauze, and notify the physician. c. Assure the patient that this is common, and document the findings. d. Apply a binder to pull the wound edges together and provide support to the edges.

Answer: b This is likely to be an evisceration of the surgical wound and, as such, may require surgical intervention. The normal saline keeps the wound and tissue moist until they can be evaluated by the physician. Steri-Strips can be used to reinforce a closed wound when sutures or staples are removed but are not used to try to close a wound that has opened and has tissue protruding through. False reassurance should not be given. A binder is used to support a closed incision and should not be applied to a wound with tissue protruding.

Which patient is at highest risk for impaired wound healing? a. A 22-year-old with a pelvic fracture incurred in a motor vehicle accident b. A 49-year-old with a history of smoking two packs a day who just had abdominal surgery c. A 72-year-old with diabetes and cardiovascular disease who had surgical repair of a broken hip d. A 90-year-old with no chronic health conditions with a small blistered burn on the hand

Answer: c Although all of these patients have risk factors for impaired healing, the 72-year-old patient has the most risk factors: increased age, comorbid conditions of diabetes and cardiovascular disease, and an injury that often affects the ability to move independently. The 22-year-old accident victim does not have any risk factors other than the pelvic fracture. The 49-year-old surgical patient who smokes is at risk for delayed healing due to vasoconstriction but would not have as great a risk as the 72-year-old. The burn with a blister is not a deep injury, and the patient has no risk factors other than age.

An alert and oriented elderly male patient has been admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). He is unshaven, has unkempt hair, and has a foul body odor. Asking which hygiene-related assessment question is a priority for the nurse? a. "Do you have friends or family nearby?" b. "Can you raise your arms up to brush your teeth?" c. "Do you become short of breath during your shower?" d. "Are you able to get in and out of your bed at home?"

Answer: c Knowing the COPD patient's activity tolerance helps the nurse formulate a plan for ongoing hygiene care in the hospital and after discharge. Having friends and family nearby may be helpful, but until the activity tolerance is known, his need for outside assistance is not known. A complete assessment of physical capabilities, including his ability to brush his teeth and whether he can get in and out of bed, is important after his activity tolerance has been assessed.

A patient who has suffered a stroke is unable to maintain his position while seated in a chair without sliding down. His physician has ordered him to be up in a chair for part of the day. What does the nurse recognize as the patient's greatest risk factor for development of pressure ulcers? a. Moisture from incontinence b. Nutritional deficiencies c. Pressure and shear d. Aging

Answer: c Sitting in a chair increases pressure on the seating surface and the inability to maintain position, resulting in sliding down adding the destructive element of shear. Nutritional deficits, moisture, and skin changes with age can be contributing factors for pressure ulcer development but do not relate to being up in the chair.

4. What should the nurse do before leaving a patient's room after giving a complete bed bath? a. Place the call light within reach, and leave the bed as it was during the bath. b. Lower the bed to its lowest position, raise all four side rails so that the patient does not fall out of bed, and place the call light within reach. c. Lower the bed to its lowest position, raise the top two side rails to assist the patient in turning and positioning, and place the call light within reach. d. Leave the bed in a position that is comfortable for the caregiver because more care will be needed, raise the top two side rails, and place the call light within reach.

Answer: c The bed is always left in the lowest position so that it is closer to the floor. The top two side rails aid the patient in turning and positioning. The call light is placed within reach of the patient so that the nurse can be called if needed. Leaving the bed in a working or higher position increases the danger of falling if the patient tries to get out of bed. Raising all four side rails is considered a restraint.

Which statement indicates an understanding by the unlicensed assistive personnel of eye care during a patient's bath using washcloths and a bath basin? a. "The eyes are washed with soap and water from the inner canthus to the outer canthus." b. "The eyes should always be washed using sterile normal saline and a gauze sponge." c. "The eyes are washed from the outer canthus to the inner canthus using water only." d. "The eyes are washed with water using a clean part of the washcloth for each eye."

Answer: d Eyes are washed with water only from the inner canthus to the outer canthus to prevent the spread of pathogens into the tear ducts. A clean section of the washcloth is used for each eye to avoid cross-contamination. Soap is irritating to the eye and is therefore contraindicated. It is unnecessary to use sterile saline for routine cleansing of the eye.

The nurse is caring for a patient who has decreased sensation in both feet. Which of the following should the nurse do? Select all that apply. A. Avoid cleaning the feet until an order from the health care provider is received. B. Monitor the temperature of bath water C. Inspect feet for redness, sores, and dry areas. D. File the toenails straight across. E. Advise the patient that going barefoot will help keep skin on the feet dry and healthy.

B, C, D Damage to peripheral nerves occurs for a variety of reasons. Patients with neurologic deficits, such as peripheral neuropathy secondary to diabetes, may not be able to identify extremes of hot and cold. The nurse should monitor the temperature of bath water for patients with decreased sensation. Burns may result if skin is exposed to extremely hot water during bathing. Neglecting to file and trim fingernails and toenails can result in trauma to the skin through inadvertent scratches. If the patient has decreased sensation in the lower extremities, the feet are inspected for redness, sores, and dry areas. Patients with peripheral neuropathy should not soak their feet due to drying of the tissue and the risk of infection. File and/or trim the nails (straight across) if within facility policy. Care is taken to avoid any nicks or cuts in the skin when cutting toenails of any patient with circulatory impairment in the lower extremities due to their decreased ability to heal.

A patient presents with itching and a reddened scalp from head lice. What precautions does the nurse take to prevent the spread of lice? 1. Droplet precautions 2. Contact precautions 3. Airborne precautions 4. Protective isolation precautions

Correct 2. Contact precautions Contact precautions should be instituted for a patient with pediculosis. Symptoms such as itching and a reddened scalp are observed in a patient who has the contagious scalp infection pediculosis, caused by head lice. This infection is spread either by direct contact or by indirect contact through the sharing of combs, hats, or linens. Pediculosis is not a droplet infection. Droplet precautions would be given to patients who have tuberculosis, for example, as the patient can spread the infection when coughing. Airborne precautions are established to prevent the transmission of infections that can be spread through the air, including polio and smallpox, not pediculosis. Protective isolation precautions are useful for immunocompromised patients.

A patient complains of heartburn and a bitter-tasting fluid regurgitating into his mouth during sleep. In which position will the patient feel comfortable? 1. Prone 2. Supine 3. Laeral recumbent 4. Reverse Trendelenburg's

Correct 4. Reverse Trendelenburg's The patient has symptoms of gastric esophageal reflux disorder. In reverse Trendelenburg's position, the entire bed frame is tilted with the foot of the bed down. This promotes gastric emptying and prevents esophageal reflux. Therefore, the patient will be comfortable in this position. The prone position is a very uncomfortable position as it exerts more pressure on the abdomen. Supine and lateral recumbent positions should be avoided as they promote gastric reflux.

The nurse applies a bandage to a patient's hand. What should the nurse assess in the patient after application of the bandage? Select all that apply. A. Pallor B. Paresthesia C. Pulselessness D. Presence of odor E. Presence of drainage

Correct A, B, C After applying the bandage to the patient's hand, the nurse should check the five P's of circulation within 30 minutes. If the nurse finds any symptoms such as pallor, paresthesia, or pulselessness, the nurse should remove the bandage and reapply it to reduce the constriction. Presence of odor or drainage are normal assessment measures of a wound and do not indicate constriction of the bandage.

The nurse is caring for a bed-ridden patient. What actions should the nurse perform as a part of evening care to promote sleep? Select all that apply. A. Change soiled linens. B. Provide oral hygiene. C. Provide a massage. D. Help patient wash their face and hands. E. Prepare the patient for scheduled tests.

Correct A, B, C, D As part of evening care, the nurse should offer the bed-ridden patient personal hygiene care. This will help the patient relax and also promotes sleep. Changing soiled bed linens makes the patient comfortable. Massage provides relaxation and comfort, increases circulation, and promotes sleep. Oral hygiene and washing the face and hands before sleep makes the patient feel clean. Making the patient ready for scheduled tests is done in early morning care.

A nurse works in a long-term care unit. Which patients would be at high risk of developing pressure ulcers? Select all that apply. A. A patient with spinal cord injury B. A comatose patient C. A patient with urinary incontinence D. An immobile patient with excessive wound drainage E. A postoperative patient after a laparoscopic cholecystectomy

Correct A, B, C, D The patient with spinal injury is immobile and is dependent on the healthcare team for changes in position. This patient is at risk of developing pressure ulcers due to remaining in the same position for long time. A comatose patient has impaired perception of pain and pressure and is at increased risk of developing pressure ulcers. The patient with urinary incontinence is at risk of impaired skin integrity due to the urine irritating the skin. The patient may develop pressure ulcers due to constant exposure to moisture. The patient who is immobile and has excessive wound drainage may be at an increased risk due to the skin being exposed to moisture. The patient who underwent laparoscopic cholecystectomy is active and not immobile. The patient is not at risk of developing pressure ulcers.

A patient with a hearing impairment uses a hearing aid and reports hearing a whistling sound. What are the possible causes of this whistling sound? Select all that apply. A. Volume too high B. Fluid in ear canal C. Water in the device D. Cerumen in ear canal E. Hair spray on the device

Correct A, B, D A patient using a hearing aid may hear whistling sounds if there is any fluid inside the ear canal. Therefore, before inserting a hearing aid, the patient should make sure there is no water in the ear canal. Cerumen, or earwax, in the ear canal also causes a whistling sound; therefore the nurse should remove any earwax before the patient inserts the hearing aid. Volume too high can lead to a whistling sound, requiring the volume to be turned down to eliminate the whistling. The presence of water in the device or hair spray on the device may interfere with its functioning, but would not cause a whistling sound.

The nurse is caring for an older adult who has been diabetic for 10 years. Which signs and symptoms of peripheral neuropathy should the nurse observe? Select all that apply. A. Decreased sensation B. Abnormal gait C. Shiny appearance of the skin D. Absent or decreased pulses E. Muscle wasting of the lower extremities

Correct A, B, E A diabetic patient showing signs of foot deformities, abnormal gait, and muscle wasting of lower extremities may have peripheral neuropathy. These signs occur due to damage to the nerves controlling the function of the muscles. Patients with neurologic deficits, such as peripheral neuropathy secondary to diabetes, may have decreased sensation. Absent or decreased pulses or shiny appearance of the skin are signs of decreased vascular insufficiency.

The nurse understands that dehiscence of a wound may occur if there is partial or total separation of the wound layers. Which patients would be at increased risk of wound dehiscence? Select all that apply. A. A malnourished patient B. An obese patient C. A young adult D. A female patient E. A patient with wound infection

Correct A, B, E A malnourished patient may have poor wound healing which may lead to wound dehiscence. Obesity may increase strain on surgical incisions. In addition, fat tissue has poor wound healing. Infection interferes with the wound healing process and may increase the risk of wound dehiscence. A young adult may have a better wound healing and has less risk of wound dehiscence. Gender may not affect wound healing and dehiscence.

A nurse assesses an elderly patient admitted to the hospital after a fall. What assessment findings could place the patient at risk of developing pressure ulcers? Select all that apply. A. The patient has urinary incontinence. B. The patient suffers from Alzheimer's. C. The patient is immobilized due to a leg fracture. D. The patient has impaired sensory perception. E. The patient is confused but can express pain and discomfort.

Correct A, C, D Patients with urinary incontinence who cannot take care of personal hygiene have prolonged exposure to moisture. This can soften the skin, making it more susceptible to ulcer formation. Immobility also puts a patient at a risk of pressure ulcers as the patient cannot move voluntarily to relieve pressure from affected body parts, causing prolonged pressure. Patients with impaired sensory perception are not able to feel or express pain and discomfort in the areas under pressure. Alzheimer's disease does not put a patient at risk for pressure ulcer development. A patient who can express pain and discomfort is at a low risk of developing ulcers as he or she can verbalize about painful areas.

What are the benefits of bandaging for a patient with a leg wound? Select all that apply. A. Promotes venous return B. Reduces bacterial colonization C. Increases hemostatic pressure D. Promotes granulation tissue formation E. Decreases blood pooling in the lower extremities

Correct A, C, E A bandage is placed over wound dressings to secure them and provide support. The bandage is wrapped from distal to proximal to promote venous return, increase hemostatic pressure, and decrease pooling in the lower extremities. Blood is lost through wounds; this decreases blood volume and affects venous return. A decrease in blood volume decreases the fluid content in the body, and hemostatic pressure is decreased. Due to the decreased pressure, the blood may become pooled in the lower extremities, decreasing venous return. Therefore, a bandage is applied to negate these effects. Vacuum-assisted therapy (VAC) reduces bacterial colonization and promotes granulation tissue formation in the wound.

The nurse is helping a male patient with shaving. Which actions should the nurse perform when shaving? Select all that apply. A. Give the patient the choice between shaving cream and soap. B. Use long strokes around the chin and lips. C. Do not rinse the razor between strokes. D. Apply warm water to the patient's face with a washcloth for 2 to 3 minutes. E. Use separate electric razors for each patient.

Correct A, D, E because of infection control considerations. Allowing the patient to make choices about care gives the patient a sense of empowerment. Moist warmth softens the hair for easier removal and lowers the risk of nicks. Hold the skin taut; using short strokes, shave in the opposite direction of hair growth. Rinse the razor with warm water after each stroke. Razor blades and electric razors should be used on only one patient because of infection control considerations.

The nurse educator is teaching a group of unlicensed assistive personnel (UAP) about perineal care. Which statements made by the UAP indicate effective learning? Select all that apply. A. "Perineal care is not documented as a patient intervention." B. "Perineal care is provided while maintaining a patient's privacy." C. "Perineal care may include providing a sitz bath for the patient." D. "Perineal care must be performed by family in the Arab culture." E. "Perineal cleansing is performed from the anus to the urinary meatus."

Correct B, C

Which areas should the nurse specifically check when assessing the skin of an obese patient? Select all that apply. A. Face B. Groin C. Perineal area D. Front and back of legs E. Beneath the patient's breasts

Correct B, C, E In a patient who is obese, the nurse should give special attention to body areas such as the groin area, the perineal area, and the area beneath the patient's breasts. Moisture collects in these areas and can irritate the skin surfaces. The face and the front and back of the legs are not susceptible to the adverse effects of excessive moisture.

A patient who is receiving cancer therapy has inflamed gums and oral mucosa and painful sores in the mouth. Which of the following oral care actions are appropriate? Select all that apply. A. Decreasing frequency of oral hygiene B. Brushing with a soft-bristle brush C. Rinsing the oral cavity frequently with a baking soda, salt, and water mixture D. Using commercial mouthwash E. Taking frequent sips of water or sucking on ice cubes

Correct B, C, E Routine oral hygiene reduces the severity and incidence of oral problems during cancer therapy. Basic guidelines include: brushing with a soft-bristle brush and baking soda or fluoride toothpaste after meals and before bedtime; Rinsing the oral cavity frequently with a baking soda, salt, and water mixture; Applying a lip balm to keep the lips from drying; Taking frequent sips of water or sucking on ice cubes to keep oral mucosa moist. These strategies reduce the risk of oral soft tissue infection in patients undergoing cancer therapy. Preventing dryness of the lips reduces the risk for tissue injury. Many commercial mouthwashes contain alcohol, which dries oral mucosa and causes pain.

The nurse is providing oral hygiene for an unconscious patient. Which actions should the nurse perform? Select all that apply. A. Use fingers to hold the patients' mouth open. B. Use disposable oral swabs dipped in cleaning solution to clean oral tissues. C. Carefully consider the assistance of unlicensed assistive personnel. D. Use a bite block or oral airway to hold the mouth open. E. Use disposable oral swabs dipped in water to clean oral tissues.

Correct C, D, E Carefully consider whether or not to delegate oral care of an unconscious person to UAP; check facility policy for delegation in this situation. If the procedure is to be delegated, UAP must be carefully trained and instructed on positioning and suctioning techniques. .A bite block or an oral airway prevents inadvertent injury to the provider (the normal reflex of oral stimulation is to bite down). Use disposable oral swabs dipped in water to clean oral tissues (cheeks, roof of mouth, bottom of mouth, and tongue). Use a new swab for each area. The use of disposable swabs that are frequently replaced prevents the spread of microorganisms. Swabs remove excess debris and dead tissue; the water keeps oral tissues moist. Using fingers to hold the patient's mouth open may cause an accidental human bite. It can transmit infection causing microorganisms. Disposable swabs should be dipped in water, not cleaning solution.

A patient with multiple fractures has casts that make it difficult to move voluntarily. A nurse notices red skin in the spinal area that blanches on applying pressure. What measures does the nurse take to decrease the risk of development of pressure ulcers in this patient? Select all that apply. A. Position the patient in the most comfortable position and do not move. B. Cover the hyperemic skin area with a sterile dressing and apply antiseptics. C. Check the skin around the casts regularly for any signs of impaired skin integrity. D. Take care to avoid friction injuries during repositioning, bathing, or transferring of the patient. E. Use good hygiene techniques to ensure the patient's skin is clean and dry after bowel movements.

Correct C, D, E When a nurse suspects a developing pressure ulcer, other areas should be checked for impaired skin integrity, especially around casts. It helps in early detection and prompt treatment. The nurse should ensure that the skin of the patient is clean and dry and not overly moistened for prolonged periods of time. Excess moisture increases the risk of pressure ulcers. When repositioning, bathing, or transferring the patient, care should be taken to avoid friction injuries to the affected area or other areas. The patient should be repositioned at regular intervals to relieve pressure and avoid pressure being exerted on one or the same body parts constantly. The area of hyperemic skin should not be covered, but inspected at regular intervals for abnormal hyperemia, induration, or nonblanching.

A nurse is caring for a group of patients with wounds that are healing by primary intention. The nurse is caring for which patients? Select all that apply. A . A patient with a pressure ulcer B. A patient with a chronic wound C. A patient with a surgical incision D. A patient with a full-thickness wound E A patient with a traumatic approximated wound

Correct C, E, Surgical incisions and traumatic approximated wounds are examples of acute wounds that heal by primary intention. The edges of acute wounds can be approximated; thus, such wounds tend to heal fast with minimal scar formation. Pressure ulcers are examples of chronic wounds. These types of wounds require the formation of new tissues to fill the wound bed. This entire process is time consuming and is referred to as healing by secondary intention. Full-thickness wounds tend to heal slowly and leave scarring and heal by either secondary or tertiary intention.

The nurse understands that the healing process of a full-thickness wound occurs in three phases. Arrange the phases of wound healing in the correct order. 1. Proliferative phase 2. Maturation 3. Inflammatory phase

Correct Inflammatory, proliferative, maturation The actual phases of wound healing are the same for all full-thickness wounds regardless of type or causation. The three phases of healing are the inflammatory phase, which includes the process of homeostasis; the proliferative phase; and the maturation phase.

Which techniques of physical assessment does the nurse use to evaluate the skin while providing a complete bed bath for a patient? 1. Inspection and palpation 2. Palpation and percussion 3. Percussion and auscultation 4. Auscultation and inspection

Correct 1. Inspection and palpation While performing a complete bed bath, the nurse has the opportunity to observe the patient's body to assess for any signs of disease. Through inspection and palpation, the nurse notes the color, texture, warmth, and intactness of the skin. Through deep palpation, the nurse may identify the size and shape of the organs as well. Percussion is a method of physical examination that involves tapping on a body surface to determine its underlying structure. Auscultation is used to listen to the internal sounds of the body. The nurse does not use percussion and auscultation while providing a complete bed bath to the patient.

The nurse is caring for a pregnant patient with diabetes mellitus. Which intervention performed by the nurse may increase the risk of skin breakdown in the patient. 1 . The nurse provides warm water for the patient to soak the feet. 2 . The nurse inspects both of the feet for redness or dry areas. 3 . The nurse does not use pediculicidal shampoos on the patient. 4 . The nurse gives the patient a back massage using effleurage. and does not damage the skin.

Correct 1. The nurse provides warm water for the patient to soak the feet. Soaking the feet of a diabetic patient is contraindicated. Diabetic patients have a decreased ability to heal, and soaking their feet may lead to skin breakdown. Inspecting the feet for redness and dry areas will decrease the risk of skin breakdown. Pediculicidal shampoos are contraindicated in pregnant patients because they can impair fetal growth and development inutero; avoiding their use decrease the risk of skin breakdown. Providing a back massage using effleurage helps to relieve back pain

Which intervention does the nurse perform when preparing to give a complete bath to an obese Hispanic female patient with peripheral neuritis? 1. Use a mechanical lift while bathing the patient 2. Ask the patient to check the water temperature 3. Wash the patient's hair weekly with mild shampoo 4. Cleanse the patient's anus followed by the urinary meatus

Correct 1. Use a mechanical lift while bathing the patient While providing a bath for an obese patient, the nurse may have difficulty moving and positioning the patient. To provide a complete bath and to clean abdominal folds, under the breast, and the groin, the nurse would use a mechanical lift to move and position the patient. While providing perineal care, the nurse cleans the patient's urinary meatus, followed by the anus. This helps to prevent the entry of bacteria into the urinary tract and reduces the risk of urinary tract infections. Patients of African descent clean their hair once a week, as their hair tends to be dry, whereas Hispanic patients prefer regular washing of hair. A patient with peripheral neuritis may have impaired sensation and may not be able to judge the water's temperature. Therefore, the nurse should check and adjust the temperature of water to 40.5° to 43.3°C rather than asking the patient to check the water temperature.

A nurse observes a wound with intermittent suturing. What is the defining characteristic of intermittent suturing? 1. The suture is stronger and deeper. 2. Each suture is tied and knotted individually. 3. The suture line is made from one continuous piece of material. 4. The suture has the first tie or knot at the beginning and the second knot at the end of the line.

Correct 2. Each suture is tied and knotted individually. There are three primary methods of suturing: intermittent suturing, continuous suturing, and retention suturing. An intermittent suture is tied and knotted individually, and a single piece of thread is used for one suture. Stronger and deeper sutures are made in retention suturing, which means that the sutures will remain or be retained within the body. Continuous suturing, made from one continuous piece of material, has the first tie or knot at the beginning of the wound and its second at the opposite end of the wound.

The nurse is assisting a patient with rheumatoid arthritis to bathe at the sink. During the bath the patient states that she is tired. The nurse notices the patient is breathing rapidly and the pulse is rapid. What is the nurse's best response? 1. Finish the bath quickly 2. Help the patient return to bed 3. Leave the patient alone to rest in the chair at the sink for a few minutes 4. Instruct the patient to take deep breaths and try to relax

Correct 2. Help the patient return to bed The report of fatigue and rapid respirations and pulse indicates that the patient is not tolerating the activity and needs to rest. Leaving the patient alone at the sink is not safe.

What is the priority concern when providing oral hygiene for a patient who is unconscious? 1. Thoroughly brushing all tooth and oral surfaces 2. Preventing aspiration 3. Controlling mouth odor 4. Applying local antiseptic such as chlorhexidine

Correct 2. Preventing aspiration Although thorough and effective cleaning is needed, measures to prevent aspiration of oral secretions and/or cleaning agents into the lungs take priority since aspiration can lead to lower respiratory infections.

The nurse is giving a bed bath to a female patient from an Arabic culture. Which measure does the nurse take while caring for the patient? 1. The nurse should refrain from washing the patient's hair very often. 2. The nurse should restrict male nurses from performing perineal care. 3. The nurse should abstain from shaving the patient's armpits and legs. 4. The nurse should restrict family members from being present during the bath.

Correct 2. The nurse should restrict male nurses from performing perineal care. In the Arab culture, male nurses are prohibited from examining the perineal areas or providing perineal care to a female patient. Therefore, only female nurses are allowed to assess and provide this care to the female patients. Women of some cultures do not shave their armpits and legs, and the nurse respects their cultures by not performing such practices. While caring for patients of African descent, the nurse does not wash the hair often, as these patients tend to have dry hair. The presence of a family member during a bath is only allowed if the patient requests their presence.

While providing perineal care for a male patient, the nurse finds that the patient has an erection, which makes the nurse uncomfortable. What does the nurse do in such a situation? 1. Clean from the urinary meatus to anus 2. Document the occurrence in the record 3. Stop the perineal care and finish it later 4. Administer central nervous system depressants

Correct 3. Stop the perineal care and finish it later Perineal care may stimulate the male genitals and cause an erection. In this situation, if the nurse is uncomfortable, the nurse may stop cleaning for a time and continue it later. An erection is normal and therefore need not be documented as an incident. The nurse does not administer central nervous system depressants unless these are prescribed by the primary healthcare provider. A woman's perineal area is cleaned from the urinary meatus back to the anus, unlike males.

A visiting nurse arrives at the home of an older adult who is diabetic. The nurse asks the patient to walk around the room. What is the nurse's most likely motive for observing the patient's gait? 1. The nurse suspects that the patient has pain during walking. 2. The nurse suspects that the patient wears the wrong footwear. 3. The nurse suspects that there is a loss of cutaneous sensation in the patient's foot. 4. The nurse just wants to observe the patient's gait, as it has to be documented in the assessment sheet.

Correct 3. The nurse suspects that there is a loss of cutaneous sensation in the patient's foot. The patient has diabetes. One of the common complications of diabetes is peripheral neuropathy, a loss of sensation in the lower limbs. Loss of sensation could cause an abnormal gait. The patient may not feel pain due to peripheral neuropathy, so the gait may not be affected by pain. Wearing wrong footwear may not cause a gait problem. Documentation is one of the reasons for gait assessment; but is more relevant to assessment of peripheral neuropathy.

The nurse is teaching a group of nursing students about bathing a patient. What instructions should the nurse include in the teaching? Select all that apply. A. Wash the eye from outer to inner canthus. B. Bathe arm using long, firm strokes from axilla to fingers. C. Wash, rinse, and dry the arm, moving from fingers to shoulder. D. Soak any crusts on eyelids with a damp cloth before attempting removal. E. Wash, rinse, and dry forehead, cheeks, nose, neck, and ears without soap, if the patient prefers.

Correct C, D, E The arm should be bathed from fingers to shoulder to promote venous return. Soaking any crusts on the eye helps to ease removal of the crust from the eye. Soaps tend to dry the skin. Therefore, if the patient prefers not to use soap, the face should be washed with water. The eye should be washed from inner to outer canthus to prevent secretions form entering the nasolacrimal duct.

Which instruction does the nurse include when teaching a group of unlicensed assistive personnel (UAP) about key points to be followed while giving a perineal bath to a female patient? 1. Soak the perineal area prior to cleansing 2. Wash from the urinary meatus to the anus 3. Clean the perineal area on an hourly basis 4. Have a family member present during the bath

Correct 2 Wash from the urinary meatus to the anusThe nurse cleanses the perineal area of a female patient from the front to the back. Therefore, the nurse washes the urinary meatus first and then proceeds toward the anus. This intervention helps to prevent infestations of pathogenic organisms into the urinary tract. Not all patients require perineal baths on an hourly basis. Soaking the perineal area before cleansing is a therapeutic procedure called a sitz bath, which is provided to a postpartum patient or after perineal surgery. The nurse should be aware that the female patient might not be comfortable having a family member present during a perineal bath.

The nurse is making an occupied bed for a patient on a hot day. The nurse wears gloves after performing hand hygiene and loosens the top linen at the foot of the bed. The soiled bedspread and blanket are removed and discarded in a linen bag. Then the patient is positioned on the far side of the bed with the patient facing away from the nurse. The nurse finds that the mattress is wet and covers it with linen. Which of the steps followed by the nurse may lead to spread of infection? 1. Placing the soiled blanket in a laundry bag 2. Placing the soiled bedspread in laundry bag 3. Positioning the patient facing away from the nurse 4. Applying the linen over the wet mattress

Correct 4 Applying the linen over the wet mattress When making an occupied bed, a nurse should assess the requirements of the patient and take measures to reduce the transmission of microorganisms. If linen is applied on a wet mattress, there is a risk for transmission of microorganisms to the patient. Therefore, the nurse should wipe off the moisture with a towel and clean the mattress with disinfectant before applying the fresh linen. The soiled blanket and bedspread should be discarded in the linen bag to prevent the spread of infection. Positioning the patient away from the nurse makes the linen change easier.

Which features are characteristic of a closed drainage system such as a Jackson-Pratt (JP) drain? (Select all that apply.) a. Works by gravity b. Provides for early discharge c. Usually is inserted in surgery d. Reduces the amount of antibiotics required e. Allows for accurate measurement of wound drainage f. Allows bacteria to migrate up the drain from the surrounding dressing

Correct c,e JP drains usually are inserted at surgery. Unlike an open drainage device such as the Penrose drain, a JP drain does not allow drainage to soak into the surrounding dressing and allows for an accurate measurement of the drainage. JP drains work by suction, not gravity. Discharge and antibiotic use are not dependent on the type of drain. Bacteria migration from the dressing will not occur because a JP drain is a closed system.