Chapter 7, Course Point 311

The nurse is providing nail care to a client. Which assessment findings require notification of the client's health care provider?

Nails curled around the tip of the toes; Red and swollen skin around the great toe; Bleeding under the nail bed and from the sides of the toes; Blackened great toe nail

The nurse in the emergency department is caring for a client who has been hit in the eye with a baseball. The client reports that wearing contact lenses. What is the priority action by the nurse?

Notify the emergency department health care provider the client is wearing contact lenses

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

A nurse is delegating shaving of a client who is prescribed anticoagulant therapy to the unlicensed assistive personnel (UAP). What information is most important for the nurse to include for this client?

The client should use an electric razor

A client with diabetes asks the nurse what should be done for a large callus on the right great toe. What is the best response by the nurse?

"I encourage you to see your podiatrist to get a recommendation for your callus"

The nurse is teaching a client about shaving the face. Which statement made by the client indicates a need for additional teaching?

"I will pull the skin taut to reduce the risk for ingrown hairs"

The nurse is performing perineal care for a female client when the client asks the nurse to use baby powder to help keep her perineum dry. What is the best response by the nurse?

"It is recommended to avoid the use of baby powder in the perineal area because it creates a place for bacteria to grow"

The acute care nurse is talking with a client who just finished performing oral care. The client states, "I have some whitish-yellow patches on my tongue. Should I be concerned?" Which response by the nurse is most appropriate?

"Let me assess the patches. They may indicate the development of a fungal infection."

The nurse observes a staff member performing perineal care on a female client. The staff member washes the client's rectal area and then washes the client's urinary meatus. What is the most useful instruction for the nurse to give the staff member?

"Microbial contamination can occur when cleaning the anal area first"

The unresponsive client's spouse at bedside asks the nurse about oral care. The spouse states, "If my spouse is not eating, why do you still brush the teeth?" How does the nurse best respond?

"Mouth care during this time helps prevent complications"

The client requests powder to be applied to the genitalia after perineal care. Which explanation from the nurse to the client is best?

"Powder in the genital area can create a medium for bacterial growth"

The acute care nurse is talking with an older adult client who had a complete bed bath earlier in the day. The client states, "I like to be scrubbed clean during my bath, and the person who bathed me today didn't even use soap and water and barely rubbed my skin to dry it" Which response by the nurse is most appropriate?

"Use the special bathing products and avoidance of scrubbing help keep your skin intact"

The nurse is teaching a client about denture care. Which statement from the client indicates a need for further teaching?

"When I eat, I will remove my dentures and place them in a napkin"

A nurse is preparing to shampoo a client's hair while the client is in bed. Place the steps below in the order that the nurse would perform them?

1) Place a protective pad under the client's head and shoulders after removing the pillow 2) Fill the pitcher with water at an appropriate temperature 3) Place the shampoo board under the client's head 4) Position a drain container underneath the drain of the shampoo board 5) Put on gloves and give the client a folded washcloth to hold over the forehead 6) Saturate the client's hair with water from the pitcher

A nurse is assisting a 72-year-old client with a tub bath. The nurse fills the tub halfway with water and checks the temperature of the bath water. Which temperature would the nurse identify as appropriate for this client?

100oF (38oC)

A nurse is preparing to shampoo a client's hair while the client is in bed and gathers the water in a pitcher. The nurse checks the temperature of the water and decides to continue based on which water temperature reading?

105oF (40.6oC)

A nurse is providing care to several clients who are extremely weak and need to have their hair shampooed while remaining in bed. When gathering the necessary supplies, the nurse would anticipate needing to adapt the shampoo board for the client with which condition?

Acute spinal cord injury

A nurse is assisting an older, continent client with dry skin who is hospitalized. Which approach to hygiene should the nurse take with this client?

Alternate between a full bed bath on one day and use of skin lotion or bath oil on the next

The nurse is performing perineal care on an adult male client who was incontinent of stool. After cleansing the perineal area, what is the most appropriate intervention by the nurse?

Apply a thin barrier of skin protectant to the perineal area

A nurse is assisting a client with denture care. What is the best way to remove the client's dentures?

Apply gentle pressure with a 4 x 4 gauze to grasp the denture plate

The nurse is providing denture care for a client who is too sedated to assist. Which is a recommended guideline for this procedure?

Apply gentle pressure with a piece of gauze to remove the upper dentures.

A client is shaving and calls for the nurse when he cuts his face and is bleeding. What is the best action by the nurse?

Apply pressure with a gauze pad for 2 to 3 minutes.

The nurse provides care to a sedated client with soiled sheets. Which action does the nurse take to move the client?

Ask for help from a staff member

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?

Assess both eyes for contact lenses

After assisting a bed-bound client with oral care, what action does the nurse take?

Assist the client to a comfortable position in the bed.

A client who is wearing soft contact lenses is unable to remove the lenses before bedtime. What action should the nurse take?

Assist the client to remove the lenses using a small pair of rubber grippers.

Which aspect of denture care is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

Brushing the dentures

The acute care nurse is preparing to bathe a client and notices that the client is wearing a regular hospital gown and has continuous intravenous (IV) fluids infusing. Which action by the nurse is appropriate?

Carefully thread the IV bag and tubing through the arm of the regular gown, and then replace it with a snap-arm gown at the end of the bath.

The nurse cleans the clients after a bowel movement and notes stool on the gloves. The nurse has not finished cleaning the client. What action should the nurse take?

Change into a new pair of gloves

The nurse is changing the linens for a client who could not be turned on the side due to a surgical incision on the right hip and pain from a fall in the left hip. What nursing intervention would be appropriate for this client?

Change the bed linens from the top to the bottom

The nurse uses perineal cleansing wipes for the client who has had a bowel movement. Which action does the nurse take?

Change to a clean wipe after each stroke

The nurse is preparing to make a bed occupied by a client who is on bedrest. What is the first action the nurse would take in this procedure?

Check the client's chart

A nurse is providing nail care for an older adult client. Which action should the nurse take?

Cut the nail straight across; File the nail straight across; Gently clean under the nails using an orangewood stick; Round the tips of the nails in a gentle curve using a file.

How should the nurse open the bottom sheet when making an unoccupied bed?

Fanfold to the center

The nurse is providing oral care to a hospitalized client. Which outcome of this intervention is the priority?

Decreasing the incidence of hospital-acquired pneumonia

When a client cannot be turned on the side, what recommended nursing action would the nurse perform, with assistance from another nurse, to replace the soiled linens once they have been removed?

Ease the clean linens under the client, from the top to the bottom of the bed

A client has requested assistance with tooth brushing. What necessary supplies will the nurse gather?

Emesis basin; Toothbrush; Disposable gloves; Toothpaste; Towel

When providing oral care to an unconscious client, the nurse takes which action?

Ensure there is a towel and basin positioned for drainage

The nurse is changing a client's bedding while the client is out of the room getting an X-ray. What would the nurse do with the reusable linens?

Fold the linens in fourths on the bed and then hang them over a clean chair

How would the nurse remove the top linens when making an occupied bed?

Have the client hold onto the bath blanket and reach under it to remove the linens

The nurse is preparing to bathe a client using a self-contained bathing system that has premoistened, disposable washcloths. Which method for warming the premoistened cloths is correct?

Heat the entire package in the microwave, following the manufacturer's recommendation

A nurse must change the linens on a bed while it is occupied. Which actions should the nurse take?

Help the client turn towards the opposite side of the bed and fan-fold soiled linens as close to the client as possible; Put on gloves before removing soiled linens; Place a bath blanket over the client

Where should the nurse roll soiled linens when removing them from an unoccupied bed?

Inside the bottom sheet

The nurse is preparing to change the linens from the top to the bottom for a client who cannot be turned on the side. Which accurately describes a recommended step in this procedure when removing the soiled linens?

Keep the blanket in place over the client to provide privacy and remove the top sheet.

The nurse is making a bed occupied by a client. How would the nurse position the client when loosening bottom bed linens?

Lying on one side

The nurse making an occupied bed. Under which body part of the client would the nurse place the draw sheet?

Midsection

The nurse is preparing to give a bed bath to a client. Which supplies would the nurse need to gather before entering the client's room?

Protective pads; gown; bath blanket; towels; linen

The nurse is changing the lines on a client's bed. What is the nurse's primary objective for this nursing action?

Provide client comfort

A nurse is shaving a male client's face. Which should the nurse do?

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

A nurse is shampooing a client's hair while the client is in bed. Which intervention should the nurse make to reduce back strain while performing the procedure?

Raise the bed to elbow height.

When making an occupied bed, the nurse positions and tucks in the bottom linens on one side of the bed. What would be the nurse's next action?

Raise the side rails.

The nurse has placed the rolled, soiled linens in the laundry hamper. What should be the nurse's next action?

Remove gloves, unless indicated for transmission precautions.

The nurse is planning to bathe a client who has thigh-high anti-embolism stockings in place. Which action is correct?

Remove the anti-embolism stockings before the bath.

The nurse is providing perineal care for an uncircumcised adult male client. What is a recommended guideline for this action?

Retract the foreskin when washing the prepuce of adolescents and older.

The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. What is the correct technique for cleaning the penis?

Retract the foreskin while washing the penis then, immediately pull the foreskin back into place

The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. Which technique for cleaning the penis is correct?

Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place.

When performing perineal care for the male client, the nurse should be particularly gentle and avoid pressure when cleansing which area?

Scrotum

The nurse is providing oral care for a client who has suffered head trauma. The client is unresponsive. How will the nurse best position the client?

Side-lying

The nurse is assisting a hospitalized client with oral care. How will the nurse position the client?

Sitting at the edge of the bed

A nurse is preparing to give a bed bath to a client. What approach should the nurse take?

Start with cleanest areas and end with most soiled areas

The nurse is providing oral care to an unconscious client. Which piece of equipment would be important use to individualize care for this client?

Suction toothbrush

What would be most important to document after shaving a client?

That the chin was nicked with the razor

An unlicensed assistive personal (UAP) is performing perineal care for a female client. Which action by the UAP requires intervention by the nurse?

The UAP begins cleansing from the anus toward the pubic bone.

The nurse has delegated contact lens removal to the unlicensed assistive personnel (UAP) for a client in the preoperative area. Which action by the UAP requires intervention by the nurse?

The UAP has placed the client in a side-lying position.

A nurse must provide oral care for an older adult client who cannot effectively manipulate a toothbrush. How often should the nurse brush and floss the client's teeth?

Twice a day

A nurse is performing perineal care for a female client. Which action would most be important to maintain the client's privacy?

Uncover only the area being cleaned

The nurse is providing a bed bath for a female client who is unconscious. The nurse should pay special attention to cleaning which areas of the body?

Underneath the breasts and in between skin folds

The nurse is preparing to perform oral care for a client who has full dentures. Which action should the nurse take?

Use a toothbrush and paste to gently brush all surfaces; Place paper towels or a washcloth in the sink to prevent damage if the dentures are dropped during cleaning; Provide privacy while the client removes dentures from the mouth.

Which modification to bathing should be implemented for a client who is incontinent?

Use special perineal skin cleansers and moisture barriers.

Which methods can be used to remove a client's soft contact lenses?

Use the pads of the index finger and thumb to gently pinch and remove the lens; Ask the client to remove them, if able

A client with a history of diabetes is demonstrating nail care to the nurse. Which action by the client requires teaching by the nurse?

Using a nail clipper to cut the nail straight across

A nurse is preparing to wash the hair of a client who is confined to bed. The nurse plans on using a shampoo cap. Which action would the nurse do first?

Warm the cap in the microwave

The nurse is teaching a client with peripheral vascular disease about foot care. What will be included in the teaching plan?

Wear appropriate footwear; See a podiatrist for treatment for bunions; Schedule foot exams with podiatrist at least once per year

The nurse is performing perineal care for a male client. What part of the perineum would the nurse clean first?

tip of the penis