Hygiene

A patient who is wearing partial dentures reports painful red sores on the roof of the mouth. The nurse suspects that the patient has denture-induced stomatitis. Which patient statement supports the nurse's conclusion? 1 "I clean my dentures once a day." 2 "I visit the dentist every 6 months." 3 "I soak the dentures in water overnight." 4 "I rinse my mouth with chlorhexidine mouthwash."

1

An older patient tells the nurse, "My skin is dry and flaky. I take a bath every day. How can I prevent my skin from being so itchy?" Which recommendation does the nurse make? Correct1 "Decrease the number of times that a bath with soap is taken." 2 "Bathe with hot water each day, without using soap." 3 "Bathe with cool water instead of warm water." 4 "Apply talcum powder on the body after bathing."

1

Assessment findings of a patient's feet include scaling and cracking of the skin between the toes and soles and small blisters containing liquid. The nurse anticipates which treatment plan? 1 Application of griseofulvin 2 Application of salicylic acid 3 Burning with an electrical spark 4 Freezing with solid carbon dioxide

1

The nurse is caring for four older patients and identifies that which patient should be bathed twice a week? 1 A patient with dry skin 2 A patient with bowel incontinence 3 A patient with urinary incontinence 4 A bariatric patient

1

The nurse observes a caregiver providing a patient with a bath. The nurse intervenes when the caregiver performs which action? 1 Massages the reddened skin areas 2 Performs range-of-motion exercises for the patient 3 Reports skin changes or early signs of skin integrity 4 Positions a patient with musculoskeletal limitations with caution

1

The nurse observes an assistive personnel (AP) providing oral care for an unconscious patient. The nurse intervenes when the AP takes which action? 1 Stimulates the gag reflex 2 Swabs to clean the outer tooth surfaces 3 Brushes with a soft-bristled toothbrush 4 Moistens a clean brush with chlorhexidine gluconate to rinse

1

The nurse observes fecal secretions in the skinfolds of the buttocks and anus. Which action does the nurse take? 1 Enclose the secretions in an underpad or toilet tissue. 2 Place a clean absorbent pad under the patient's buttocks. 3 Help place the patient in a prone or side-lying position. 4 Place a towel lengthwise along the patient's side and keep the patient covered with a blanket.

1

Which nursing action is being depicted in the image? 1 Rinsing the teeth 2 Removing secretions 3 Irrigating the oral cavity 4 Performing the tracheal bronchial suctioning

1

Which nail change can occur when a patient experiences disease or inflammation? Select all that apply. One, some, or all responses may be correct. Correct1 Change in the shape of the nail Correct2 Change in the thickness of the nail Correct3 Change in the curvature of the nail 4 The nail becomes pink in color. 5 The tip of the nail is translucent white.

1,2,3

The registered nurse educates a nursing student about patient-centered care in hygiene practice. Which statement made by the nursing student indicates understanding of the teaching? Select all that apply. One, some, or all responses may be correct. 1 "I need to recognize that culture plays a role in sensitivity to personal space and gender." 2 "I should maintain privacy, especially for women from cultures that value female modesty." 3 "I need to consider that a patient's economic status influences the ability to regularly maintain hygiene." 4 "I should understand that toileting practices are equal in all cultures." 5 "I can allow the patient's family members to participate in hygiene activities."

1,2,3,5

Which statement is correct about a type of baths? Select all that apply. One, some, or all responses may be correct. 1 A partial bed bath is indicated in a patient with pain. 2 A sponge bath is indicated in a patient sitting in a chair. 3 A complete bed bath is given to patients who are very ill. 4 A complete bed bath offers a reduction in bathing time. 5 A tub bath is given to remove infected tissue from wounds.

1,2,4

Which technique does the nurse use when providing perineal care for a male patient? Select all that apply. One, some, or all responses may be correct. 1 Gently clean the shaft of the penis. 2 Clean the scrotum by having the patient abduct his legs. 3 Clean the urethral meatus using a back to front motion. 4 Clean the anus and buttocks area using a back to front motion. 5 Retract the foreskin of the patient if the penis is uncircumcised.

1,2,5

A debilitated patient is admitted to the hospital with hematemesis. When performing oral hygiene, the nurse finds that the patient is suddenly unable to breathe, and there is a large amount of blood in the patient's mouth. Which action does the nurse take? Select all that apply. One, some, or all responses may be correct. 1 Suction the oral airway of the patient. 2 Place the patient in Trendelenburg's position. 3 Perform tracheal bronchial suctioning. 4 Initiate emergency protocol. 5 Perform chest compressions.

1,3,4

The nurse is preparing to administer oral care to a patient who is unconscious. The nurse identifies that which bed position is appropriate when performing this activity? Select all that apply. One, some, or all responses may be correct. 1 Sims' position 2 Prone position 3 Supine position 4 Semi-Fowler's position 5 Trendelenburg's position

1,4

The nurse provides information to a nursing student about foot and nail care for a patient with diabetes mellitus. Which statement made by the nursing student indicates the need for further teaching? Select all that apply. One, some, or all responses may be correct. 1 "I should soak the patient's feet in warm water." 2 "I should refrain from clipping the patient's toenails." 3 "I should use a soft cuticle nail brush around the patient's cuticles." 4 "I should soak the patient's fingernails in hot water for 10 minutes." 5 "I should apply lotion to the feet and hands after proper drying."

1,4

Before beginning a bed bath, the nurse offers the patient a bedpan for which primary reasons? Select all that apply. One, some, or all responses may be correct. 1 To help the patient feel more comfortable during the bath 2 To promote patient safety 3 To promote proper body alignment 4 To decrease the chances of interruption of the bath 5 To reduce the transmission of microorganisms

1,4,5

While caring for a patient, the nurse instructs the patient to perform oral hygiene at least twice a day to prevent which condition? Select all that apply. One, some, or all responses may be correct. 1 Gingivitis 2 Xerostomia 3 Ulcerations 4 Dental caries 5 Periodontal disease

1,4,5

The nurse assesses the feet of a patient whose bed is tilted with the head end down. The nurse recalls which purpose of this bed positioning? Select all that apply. One, some, or all responses may be correct. 1 To facilitate venous return 2 To promote lung expansion 3 To promote gastric emptying 4 To prevent esophageal reflux 5 To perform postural drainage

1,5

The nurse supervises a nursing student who is performing oral care for a patient who is receiving anticoagulant therapy. Which action by the student indicates the need for further education? Select all that apply. One, some, or all responses may be correct. 1 Flossing vigorously near the gum line 2 Brushing with fluoride toothpaste 3 Using a rounded, soft-bristled toothbrush 4 Rinsing with chlorhexidine gluconate liquid 5 Using a lemon-glycerin sponge to clean after brushing

1,5

Before providing bath care, the nurse asks the patient about preferred personal hygiene and grooming practices. The nurse recognizes that the exploration of the patient's preferences is important for which primary reason? 1 To identify the patient's learning needs 2 To enable the patient to participate in the plan of care 3 To coordinate bathing with other scheduled activities 4 To determine the degree of assistance needed by the patient

2

The nurse caring for a male patient observes an assistive personnel (AP) performing perineal care. Which action by the AP indicates the need for the nurse to intervene? 1 The AP uses clean gloves. 2 The AP does not retract the foreskin before cleansing. 3 The AP uses the clean portion of a washcloth for each cleansing wipe. 4 The AP uses a circular motion to cleanse from the urinary meatus outward.

2

The nurse delegates perineal care of a male patient to an assistive personnel (AP). The nurse intervenes when the AP performs which action? 1 Assists the patient into a supine position in the bed 2 Cleans the tip of penis as the final step in perineal care 3 Cleans the tip of the penis with a circular motion, starting at the meatus 4 Uses a gloved hand to grasp the shaft of the penis to retract the foreskin

2

The nurse evaluates the needs of four patients and determines that which patient is the priority for receiving perineal care? 1 A patient receiving dialysis 2 A bariatric patient 3 A patient with diabetes mellitus 4 A patient receiving chemotherapy treatment for cancer

2

To reduce mechanical irritation of the skin, the nurse makes which suggestion to a patient? 1 "Use alkaline soap." Correct2 "Use smooth linen cloths." 3 "Avoid the use of dry razors." Incorrect4 "Avoid the use of deodorants."

2

While performing foot and nail care, the nurse observes tissue edema on the patient's feet. Which predisposing condition might have contributed to the assessment finding? Select all that apply. One, some, or all responses may be correct. 1 Stroke 2 Heart failure 3 Renal disease 4 Diabetes mellitus 5 Peripheral vascular disease

2,3

The nurse observes a caregiver making the bed of a postoperative patient. The nurse identifies that which action needs to be corrected? Select all that apply. One, some, or all responses may be correct. 1 Makes the bed when it is unoccupied 2 Places extra linens in the patient's room 3 Folds the top covers back as in a modified open bed 4 Tucks or miters the top sheets and spread 5 Folds the bedspread to one side or to the bottom third of the bed

2,4

The nurse provides education to a nursing student about bathing a patient with limited mobility. Which statement made by the student indicates the need for further teaching? Select all that apply. One, some, or all responses may be correct. 1 A towel maintains warmth and privacy. 2 Draping causes the exposure of body parts. 3 Keeping the skinfolds clean and dry prevents skin irritation. 4 If the patient uses a regular gown, remove the gown from the affected side first. 5 Moisture that collects in the skinfolds predisposes the patient to skin maceration.

2,4

The nurse is performing oral hygiene for a critically ill patient with an artificial airway and who is on mechanical ventilation. Which action reduces the risk of ventilator-associated pneumonia? 1 Using lemon-glycerin sponges 2 Using a toothbrush with hard bristles 3 Using chlorhexidine mouthwash 4 Using commercially made foam swabs

3

The nurse is preparing to bathe a patient with limited upper extremity range of motion (ROM). Considering the patient's condition, which specific intervention does the nurse perform? 1 Bathing the patient with warm water 2 Explaining the bath procedure to the patient 3 Removing the patient's gown from the unaffected side first 4 Using chlorhexidine gluconate (CHG) wipes

3

The nurse observes a caregiver bathing a patient with peripheral vascular disease. The nurse identifies that which action by the caregiver may predispose the patient to infection? 1 Using a nail brush to clean around the cuticles 2 Drying the patient's skin and applying moisturizer 3 Placing the patient's feet in the bath basin for soaking 4 Using short, light strokes from ankle to knee

3

The nurse provides mouth care for an unconscious patient. How does the nurse test the presence of the patient's gag reflex? 1 Using an oral suction catheter 2 Placing the fingers in the patient's mouth 3 Placing a tongue blade on the back half of the patient's tongue 4 Placing the patient in a position that lessens the risk of aspiration

3

Which intervention is the priority in a patient experiencing a low body temperature? 1 Add extra blankets. 2 Put socks on the patient. 3 Remove wet linen. 4 Educate the patient about heat conservation.

3

The nurse educates a nursing student about bathing patients. Which statement made by the student indicates the need for further teaching? Select all that apply. One, some, or all responses may be correct. 1 "I should place an 'occupied' sign on the bathroom door." 2 "I should drain the tub before mobilizing an unsteady patient." 3 "I should instruct the patient to remain in the warm bath water for 20 minutes." 4 "I should assist the patient into the tub, then collaborate with the patient to determine the correct temperature." 5 "I should instruct the patient to hold the safety bars while getting in and out of the bathtub."

3,4

The nurse prepares a bed for a patient who is being admitted to the hospital. Which action does the nurse take? Select all that apply. One, some, or all responses may be correct. 1 Places the soiled linen on the floor 2 Places soiled linen directly in the linen bag 3 Keeps the linen away from the nurse's uniform 4 Leans over the mattress while placing the linen 5 Places the clean linen in a dirty-linen container if it touches the floor

3,5

The nurse is preparing to bathe an unconscious patient using a chlorhexidine gluconate (CHG) cleansing pack, which contains six premoistened towels for cleaning. The nurse selects which cloth to clean the patient's neck, back, and buttocks? 1 Cloth three 2 Cloth four 3 Cloth five

4

The nurse provides education for a patient's family member about bathing techniques. The family member asks, "Why do I need to use long strokes on the extremities, moving from distal to proximal areas?" Which explanation does the nurse give? 1 It decreases the chance of infection. 2 It helps remove dry, flaky skin. 3 It prevents skin trauma. 4 It promotes venous return.

4

The nurse provides information for a nursing student about the implications of skin care. Which statement made by the student indicates the need for further teaching? 1 "I should smooth the bed linens out regularly." 2 "I should remove rings from the patient's fingers." 3 "I should check that the patient's bath water is not excessively hot or cold." 4 "I should maximize friction by moving the patient frequently."

4

The nurse recognizes that hygiene practices may be need to be altered when indicated by an illness or condition. Which specific practice does the nurse implement for a bariatric patient who underwent surgery? 1 Keeping the bed linens dry 2 Wearing smooth linen clothes 3 Maintaining proper foot hygiene 4 Using adaptive bathing methods

4

The nurse reviews a patient's medical record and identifies that the patient is at risk of ulcer formation related to which history finding? 1 The daily use of a dry razor 2 The application of deodorant twice a day 3 Frequent use of depilatories to remove hair 4 Constant exposure of skin to moisture

4

The nurse reviews the procedure for performing oral care for an unconscious patient and questions which step of the procedure? 1 Unless contraindicated, position the patient in Sims' or side-lying position. 2 Turn the patient's head toward the mattress in a dependent position. 3 Elevate the head of the bed (HOB) at least 30 degrees. 4 Insert an oral airway to keep the mouth open.

4

When assessing a patient's mouth, the nurse recognizes that the patient is at risk of an opportunistic infection because the patient's normal mouth flora is disrupted. The nurse reviews the patient's medication history and suspects that which type of medication is the cause for this condition? 1 Antipyretic drug 2 Hypoglycemic drug 3 Antihypertensive drug 4 Broad-spectrum antibiotic

4

Which foot problem does the nurse anticipate if a patient reports using oval corn pads to treat corns? 1 Burns 2 Infection 3 Abrasions 4 Ulceration

4

Arrange in sequential order the steps involved in performing oral care for an unconscious patient. 1. Remove the partial plate or dentures, if present. 2. Apply clean gloves. 3. Clean the mouth, cleaning the inner and outer tooth surfaces and gently brushing the tongue. 4. Place a towel under the patient's head and an emesis basin under the patient's chin. 5. Identify the patient with at least two identifiers.

5,2,4,1,3

Which action may increase the risk of amputation in a patient who has diabetes mellitus? Select all that apply. One, some, or all responses may be correct. 1 Wearing garters 2 Wearing dry socks 3 Wearing tight shoes 4 Wearing knee-high nylons 5 Wearing cotton socks

1,3,4

The nurse observes another caregiver bathing a patient and intervenes when the caregiver takes which action? 1 Rubs the patient's skin 2 Removes finger rings 3 Bathes the patient with warm water 4 Gives the patient a blanket

1

The nurse provides education about skin care to a group of patient caregivers and includes which instruction? Select all that apply. One, some, or all responses may be correct. 1 Use emollients. 2 Use alkaline soaps. 3 Bathe patients regularly. 4 Keep the patient's bed and linens dry. 5 Use several blankets or bed coverings.

1,3,4

The nurse presents education to a group of nursing students about pediculosis capitis and includes which information about lice and infection? 1 The lice cause tularemia. 2 The lice cause Lyme disease. 3 The lice cause Rocky Mountain spotted fever. 4 The lice do not cause an infection.

4

Which oral care activity is ineffective at removing plaque on the teeth? 1 Using waxed floss 2 Using fluoride toothpaste 3 Using electric toothbrushes 4 Using commercially made foam swabs

4

The nurse provides education to a group of nursing students about the use of chlorhexidine gluconate (CHG) and includes which information? 1 CHG makes the skin feel smooth and supple. 2 CHG helps reduce the occurrence of health care-associated infection. 3 The CHG that is used is a 10% solution. 4 Carefully rinse the skin after using CHG to reduce irritation.

2

The nurse reviews the plan for foot care of a patient with corns and questions which intervention? 1 Wider, softer shoes 2 Oval corn pads 3 Warm water soaks 4 Referral to a podiatrist

2

The nurse is preparing to provide perineal care to a female patient and places the patient in which position? 1 Supine position 2 Semi-Fowler's position 3 Dorsal recumbent position 4 Reverse Trendelenburg's position

3

The nurse is assessing the skin of four patients. Which patient's findings indicate acne? 1 Patient A 2 Patient B 3 Patient C 4 Patient D

1

When caring for a patient with altered consciousness, the nurse performs which test to help determine whether the patient is at risk of aspiration? 1 Gag reflex 2 Corneal reflex 3 Rinne's test 4 Weber's test

1

While assessing a patient, the nurse notes cracks in the skin and makes which recommendation to the patient? 1 "Use emollients." 2 "Use alkaline soaps." 3 "Clean the skin daily." 4 "Minimize exposure to moisture."

1

While assessing a patient, the nurse notes inflamed gums and documents which condition in the patient's medical record? 1 Gingivitis 2 Xerostomia 3 Dental caries 4 Periodontitis

1

While caring for a patient, the nurse suspects that improper turning is the cause of which assessment finding? 1 Scraping of the skin 2 Maceration of the skin 3 Chemical irritation of the skin 4 Mechanical irritation of the skin

1

The nurse provides care for a patient who is admitted to the emergency department after a head injury. The nursing team leader observes the nurse providing care and intervenes when the nurse performs which action? 1 Turns the patient to the side 2 Applies a cervical collar to the patient 3 Notifies the health care provider immediately of the patient's arrival 4 Assesses the patient in the absence of the health care provider

1

The nurse reviews the medical record of a patient with dementia and notes that the patient cries, hits, and shouts while receiving a bath. Which suggestion does the nurse make? 1 Giving a bag bath 2 Taking the patient to the shower which is located down the hallway 3 Asking a family member to give the patient the bath 4 Postponing the bath for 2 days

1

The nurse identifies that which patient is at risk of foot problems related to increased friction and altered mobility? 1 Patient A 2 Patient B 3 Patient C 4 Patient D

1

The nurse observes an altered gait while ambulating a patient. Which condition is most likely associated with this assessment finding? 1 Stroke 2 Heart failure 3 Renal disease 4 Diabetes mellitus

1

Which type of bath is most appropriate for a patient with an inflamed and swollen rectum, perineum, and genital area? 1 Sitz bath 2 Tub bath 3 Therapeutic bath 4 Complete bed bath

1

Which type of equipment does the nurse obtain before attempting to take an unstable and weak patient out of a bathtub? 1 Lift equipment 2 Linen bag 3 Nail clippers 4 Disposable bath mat

1

he nurse reviews a patient's medical record and notes a history of Morton's neuroma. The nurse expects which symptom? Select all that apply. One, some, or all responses may be correct. 1 Pain in the foot on weight bearing 2 Burning of the foot 3 Swelling of the foot 4 Thickness of the foot 5 Numbness of the foot

1,2,5

Which factor impairs salivary secretions? Select all that apply. One, some, or all responses may be correct. 1 Dehydration 2 Glistening of the mucosa 3 Significant bleeding 4 Effects of medication 5 Exposure to radiation

1,4,5

Which concern is priority 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

2

Which condition impairs the healing function of skin? 1 Brain injury 2 Diabetes mellitus 3 Paralysis of the trigeminal nerve 4 Acquired immunodeficiency syndrome

2

When providing care for a patient with diabetes, the nurse pays particular attention to the patient's gait to determine the presence of which condition? 1 Pain during ambulation 2 Foot problems because of ill-fitting shoes 3 Loss of cutaneous sensation in the feet 4 Self-care deficit related to limited mobility

3

The nurse identifies that a patient is at risk of corneal drying based on which history finding? 1 Paralysis of the trigeminal nerve 2 Hormonal changes and nutrient deficiencies 3 Ulcerations and trauma of the head region 4 Strong stimulation of the sympathetic nervous system

1

The nurse provides education to a group of nursing students about complete hygiene care that may be needed when a chronic illness exhausts or incapacitates patients. Which example does the nurse include? Select all that apply. One, some, or all responses may be correct. 1 Cancer 2 Arthritis 3 Pulmonary disease 4 Neurological disease 5 Muscular disorders

1,3,4

n which part of the skin do the normal flora reside? 1 Dermis 2 Epidermis 3 Collagen fibers 4 Subcutaneous tissue

2

A patient experiences athlete's foot. Which treatment instruction does the nurse provide to the patient? Select all that apply. One, some, or all responses may be correct. 1 Soak the feet in warm water. 2 Keep the feet well ventilated. 3 Keep the nails trimmed. 4 Dry the feet well after bathing. 5 Wear clean socks or stockings.

2,4,5

The nurse helps an unsteady patient out of the bathtub and takes which action to provide for patient safety? 1 Drains the bathtub before the patient gets out 2 Applies lotion to the patient's freshly dried skin 3 Drapes a bath towel over the patient's shoulders 4 Teaches the patient how to use the nurse call system for assistance

1

The nurse is bathing a patient who experiences burning in the perineal area. As the nurse is preparing to perform perineal care, the patient says, "I want to finish my bath without help." How does the nurse respond? 1 "Because of your symptoms, I need to observe your perineal area." 2 "Please inspect your perineal area and report the findings to me." 3 "You can finish your bath without my assistance." 4 "Do you have a family member that can help you complete the care?"

1

The nurse supervises a nursing student who is performing oral care for an unconscious patient. The nurse intervenes when the student takes which action? 1 Brushes the tongue to stimulate the gag reflex 2 Uses topical chlorhexidine gluconate for rinsing 3 Places the bed in the semi-Fowler's position before performing oral care 4 Holds the patient's mouth open with a small oral airway or a padded tongue blade

1

When planning a patient's bathing and perineal care, which action does the nurse take to prevent fatigue? 1 Schedule the use of a shower or tub. 2 Have the patient wear a bath robe and slippers. 3 Place a disposable towel on the floor in front of the tub or shower. 4 Review the prescriptions concerning the patient's movement and positioning.

1

Which assessment may help the nurse determine how to position a patient for bathing? 1 Assessment for the presence of external medical equipment 2 Assessment of the patient's bathing preferences 3 Assessment of the patient's sensitivity or allergy to chlorhexidine gluconate (CHG) 4 Assessment of the patient's visual status and ability to sit without support

1

n which order does the nurse complete the steps of a complete or partial bed bath? 1. Check the room for spills. 2. Close the room doors and windows. 3. Remove the patient's gown or pajamas. 4. Place a bath blanket over the patient, loosen and remove the top covers. 5. Verify that bed is in a locked position and raised to a comfortable height.

1,2,5,4,3

A patient with dementia often screams and hits while receiving hygiene care. Which technique does the nurse use to reduce stress during the bathing experiencing? Select all that apply. One, some, or all responses may be correct. 1 Give the patient options for making decisions. 2 Administer any prescribed analgesic 30 minutes before the bath. 3 Consider an alternative to traditional bathing, such as the bag bath. 4 Use restraints to prevent the patient from injuring self or the nurse. 5 Act quickly to keep the bath as short as possible.

1,3

The nurse determines that which type of bath is most appropriate for a patient with dementia who becomes agitated and aggressive during bathing? 1 Tub bath 2 Bag wipes 3 Therapeutic bath 4 Complete bed bath

2

The nurse discusses treatment of acne with a group of teenagers and recalls that the condition is caused by active inflammation of which glands? 1 Sweat Correct2 Sebaceous 3 Pituitary 4 Thyroid

2

The nurse educates a nursing student about bed making. Which statement made by the nursing student indicates the need for further teaching? 1 "I should raise the bed before changing the linen." 2 "I should shake soiled linens before replacing them." 3 "I should straighten any linen that is loose or wrinkled throughout the day." 4 "I should place soiled linens in special linen bags before placing them in a hamper."

2

The nurse explains the use of chlorhexidine gluconate (CHG) wipes to a group of nursing students. Which statement made by a student indicates the need for further teaching? 1 "Chlorhexidine gluconate wipes decrease the time for bathing." 2 "Chlorhexidine gluconate wipes are contraindicated in bariatric patients." 3 "Chlorhexidine gluconate wipes are indicated for providing bathing care for older-adult patients." 4 "Chlorhexidine gluconate wipes are found to reduce the incidence of hospital-acquired infections."

2

The nurse is assisting a patient to bathe at the sink. During the procedure, the patient experiences fatigue, rapid breathing, and tachycardia. Which action does the nurse take first? 1 Apply oxygen via nasal cannula. 2 Assist the patient into a sitting or lying position. 3 Notify the health care provider. 4 Assess the patient's oxygen saturation.

2

The nurse reviews the oral and foot care being provided to a patient who is receiving anticoagulant therapy and questions which intervention? 1 Flossing gently near the gum line 2 Shaping the corners of the toenails 3 Brushing the teeth with a soft brush 4 Rinsing the dentures after every meal

2

The registered nurse provides education to a group of nursing students about critical thinking. Which statement by a student indicates the need for further teaching? Incorrect1 "All factors should be considered during assessment." Correct2 "Anticipating information is not part of making clinical judgments." 3 "The nursing knowledge should be integrated with the knowledge from other disciplines." 4 "It requires the synthesis of knowledge, experience, and information gathered from the patients."

2

The registered nurse provides information to a nursing student about cultural beliefs and personal values that may influence hygiene. Which statement by the student indicates the need for further teaching? 1 "North Americans use deodorant to prevent body odors." 2 "All socioeconomic groups are sensitive to body odors." 3 "Homeless people may be reluctant to remove their shoes to bathe." 4 "People from diverse backgrounds frequently follow different self-care practices."

2

Which technique does the nurse use while bathing a patient? 1 Uncovering the patient's entire body during the bath 2 Washing the patient's extremities in a distal-to-proximal motion 3 Washing the dirtiest areas first and then the cleanest areas 4 Covering the patient with a small lightweight blanket during the bath

2

The nurse plans hygiene care for four patients and determines that which patient should be bathed first? 1 A patient who just returned to the nursing unit from surgery and is experiencing pain at a level of 7 on a scale of 0 to 10 2 A patient who prefers a bath in the evening when family members visit and can assist 3 A patient who is experiencing frequent, incontinent diarrheal stools 4 A patient who has just returned from diagnostic testing and reports extreme fatigue

3

The nurse provides an older patient with education related to skin care. Which patient statement indicates the need for further teaching? 1 "I should bathe twice a week." 2 "I should rinse well after using soap." 3 "I should use hot water for bathing." 4 "I should drink plenty of fluids."

3

The nurse reviews the at-home foot care history of a patient and recognizes that which activity may result in excessive skin dryness? 1 Use of adhesive tape 2 Use of oval corn pads daily 3 Use of nail polish remover frequently 4 Use of over-the-counter liquid preparations for removing corns

3

The registered nurse provides information to a nursing student about different developmental stages of the skin. Which statement made by the nursing student indicates the need for further teaching? Select all that apply. One, some, or all responses may be correct. 1 "Toddlers have greater resistance to infections and skin irritation." 2 "Older adults have an increased risk of bruising, dry skin, and itching." 3 "The epidermis and dermis of neonates are tightly bound together." 4 "The growth and maturation of the integument increase during adolescence." 5 "Sweat glands become fully functional when the individual becomes an adult."

3,5

When assessing an older patient, the nurse notes dry feet and identifies which cause of this condition? Select all that apply. One, some, or all responses may be correct. 1 Improper fit of footwear Incorrect2 Presence of systemic disease Correct3 Dehydration of epidermal cells Incorrect4 Continued exposure to trauma Correct5 Decrease in sebaceous gland secretions

3,5

In which order does the nurse complete the steps of bathing a female patient with an indwelling urinary catheter? 1. Provide catheter care. 2. Clean the labia majora. 3. Clean the upper thighs. 4. Place the patient in a dorsal recumbent position. 5. Expose the urethral meatus and vaginal orifice. 6. Clean the labia minora, clitoris, and vaginal orifice.

4,3,2,5,6,1

The nurse assesses a patient and identifies that which foot problem is most likely to change the patient's gait? 1 Pain 2 Burning 3 Swelling 4 Numbness

1

The nurse educates a nursing student about ear irrigation for a 4-year-old. Which statement by the student indicates the need for further teaching? 1 "I should pull the pinna down and back." 2 "I should wash the ear canal with warm solution (37° C [98.6° F])." 3 "I should direct the fluid toward the superior aspect of the ear canal." 4 "I should assist the patient into a side-lying position with the affected ear up."

1

The nurse is giving a patient a bath. While washing the extremities, the nurse uses firm strokes from distal to proximal areas. Which rationale explains this action? 1 To promote circulation 2 To measure joint mobility 3 To prevent venous return 4 To prevent contamination of clean areas

1

The nurse observes a caregiver providing bathing and perineal care to a patient with pruritus. Which action by the caregiver indicates the need for further learning? 1 Cleansing the patient with soap 2 Reporting any skin changes to the nurse 3 Notifying the health care provider if the patient has pain and shortness of breath 4 Encouraging the patient to perform range-of-motion (ROM) exercises

1

When providing perineal care to a male patient, the nurse places the patient in which position? 1 Supine position 2 Fowler's position 3 Trendelenburg position 4 Dorsal recumbent position

1

Which action does the nurse take to prevent skin breakdown in a drowsy patient who is incontinent of stools? 1 Checking frequently for soiling 2 Washing the perineal area with strong soap and water 3 Placing the nurse call system within easy reach 4 Keeping a pad under the patient

1

Which assessment finding would the nurse expect in a healthy 78-year-old male patient when performing routine foot care? 1 Dry feet 2 Fungal infection 3 Presence of ulcers 4 Morton's neuroma

1

While performing hygiene, which nursing action reduces skin inflammation and promotes circulation? 1 Washing the feet in warm water 2 Using a hard brush around the cuticles 3 Applying lotion after proper drying 4 Placing the fingers and arms in a comfortable position

1

Which factor influences a patient's hygiene practices? Select all that apply. One, some, or all responses may be correct. 1 Cultural beliefs 2 Personal values 3 Functional ability 4 Religious practices 5 Available resources

1,2,3,4,5

A patient who wears dentures is diagnosed with stomatitis. Which information does the nurse include in the patient's discharge instructions related to denture care? Select all that apply. One, some, or all responses may be correct. 1 Clean the mouth and dentures after meals. 2 Wearing dentures while sleeping contributes to stomatitis. 3 Prevent the dentures from becoming warped; keep them covered in water when not being worn. 4 After removing dentures, place them on a soft tissue or cloth. 5 Ensure that the dentures fit well; poorly fitting dentures contribute to stomatitis.

1,2,3,5

Which assessment will the nurse perform to determine a patient's ability to perform foot care? Select all that apply. One, some, or all responses may be correct. 1 Balance 2 Visual acuity 3 Cultural background 4 Muscle strength and flexibility 5 Orientation and cognitive function

1,2,4,5

Which patient is at risk for poor hygiene practices? Select all that apply. One, some, or all responses may be correct. 1 A patient diagnosed with dementia 2 A patient experiencing acute psychosis 3 A patient who had influenza 1 month ago 4 A patient who had a cerebrovascular accident 5 A patient who suffered from a traumatic brain injury

1,2,4,5

The nurse is teaching a group of nursing students about different bathing techniques. Which information about bag baths does the nurse include? Select all that apply. One, some, or all responses may be correct. 1 Bag baths take less time. 2 Bag baths provide patient comfort. 3 Bag baths can increase the dryness of the patient's skin. 4 The risk of nosocomial infections is greater with bag baths. 5 Bag baths are suitable for patients in long-term care.

1,2,5

The nurse provides instruction about the oral cavity for a group of nursing students and includes which information? Select all that apply. One, some, or all responses may be correct. 1 The saliva facilitates bolus formation. 2 Mouth breathing may impair saliva secretion in the mouth. 3 The dorsal surface of the tongue is richly supplied with blood vessels. 4 Strong sympathetic system stimulation enhances the release of saliva. 5 The mucous membrane, continuous with the skin, lines the oral cavity.

1,2,5

The nurse is assisting an elderly patient with a bath and performs which intervention? 1 Ensures that the water is soapy 2 Applies lotion to chapped skin 3 Uses hot water to bathe the patient 4 Applies the maximum amount of mild soap

2

The nurse places a disposable bath mat on the floor of the bathtub while assisting a patient with a shower. Which reason explains this intervention? 1 To prevent accidental burns 2 To prevent the patient from falling 3 To prevent light-headedness and dizziness 4 To protect the patient from becoming chilled

2

The nurse teaches a nursing student about oral hygiene. Which statement made by the nursing student indicates effective learning? 1 "Flossing removes excess toothpaste." 2 "Oral hygiene prevents plaque-associated oral diseases." 3 "Rinsing massages the gums and relieves discomfort." 4 "Brushing removes tartar that collects at the gum line."

2

Which statement is true regarding the skin? 1 The epidermis is made up of a thin layer of epithelial cells. 2 The dermis is formed by bundles of collagen and elastic fibers. 3 Dead cells are replaced by new cells generated by the dermis. 4 Hair follicles, sebaceous glands, and sweat glands run through the epidermal layer.

2

A teenager asks the nurse for advice on how to treat acne. Which recommendation does the nurse make? Select all that apply. One, some, or all responses may be correct. 1 "Oil your hair frequently." 2 "Topical antibiotics may be prescribed for severe forms of acne." 3 "Use a good soap to wash your face." 4 "Wash skin and hair thoroughly with warm water." 5 "Use cosmetics sparingly."

2,3,4,5

The nurse identifies that which principle should be followed when performing hygiene for a patient? Select all that apply. One, some, or all responses may be correct. 1 Implementing techniques to impair healing of the skin 2 Conveying respect 3 Initiating actions to prevent injury to sensitive tissue 4 Fostering patient comfort 5 Promoting normal structure and function of tissues

2,3,4,5

The nurse is caring for a patient with acne and provides which instruction for skin care? Select all that apply. One, some, or all responses may be correct. 1 Avoid washing the hair each day. 2 Avoid squeezing the acne. 3 Use cosmetics sparingly. 4 Use prescribed topical applications. 5 Eliminate foods that aggravate the condition from diet.

2,3,4,5

The nurse is caring for a patient who is receiving immunosuppressive agents and who reports a burning sensation and pain in the mouth. The nurse suspects a diagnosis of stomatitis and provides which education to the patient? 1 Recommend that the patient use the commercially available mouthwashes to clean the mouth. 2 Instruct the patient to refrain from brushing the teeth until the problem subsides. 3 Advise the patient to limit alcohol consumption and stop smoking. 4 Recommend that the patient apply lemon-glycerin swabs every 2 hours to keep the mouth clean.

3

The nurse identifies that which physiological effect may be associated with using oval corn pads under the feet? 1 Excessive dryness 2 Increased risk of tearing 3 Increased risk of amputation 4 Decreased circulation to surrounding tissues

4

The nurse inserts an oral airway in an unconscious patient while performing oral care. Which is the rationale behind this action? 1 To prevent aspiration 2 To provide drainage for oral secretions 3 To prevent the transfer of microorganisms 4 To prevent the patient from biting down on the fingers

4

The nurse observes a caregiver making an occupied 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 caregiver. The caregiver finds that the mattress is wet and covers it with linen. The nurse identifies that which action by the caregiver may lead to the spread of infection? 1 Placing the soiled blanket in a linen bag 2 Placing the soiled bedspread in linen bag 3 Positioning the patient facing away from the caregiver 4 Applying the linen over the wet mattress

4

The nurse provides information about oral hygiene to a patient for the purpose of preventing infection. Which statement made by the patient indicates the need for further teaching? 1 "I will use a battery-powered toothbrush." 2 "I will change my toothbrush every 3 months." 3 "I will use a small brush to reach all areas of the mouth." 4 "I will use lemon-glycerin sponges to clean my mouth."

4

Which information regarding foot care in the patient with diabetes is accurate? 1 Use only cold water to wash the feet. 2 Feet should be soaked to soften the cuticles. 3 Apply emollient lotion between the toes. 4 Feet should be dried thoroughly after washing.

4

Which instruction is beneficial to a patient with dry skin? 1 Use topical antibiotics. 2 Bathe more frequently. 3 Apply antiseptic lotion or spray. 4 Add moisture to the air by using a humidifier.

4

The nurse observes a patient brushing the teeth. The patient holds the toothbrush bristles at a 45-degree angle when brushing the gum line and brushes the teeth from the crown to the gum line. The mucous membranes of the patient's mouth are dry. Which instruction does the nurse provide to the patient? 1 Use lemon-glycerin preparations. 2 Brush the teeth from the gum line to the crown. 3 Hold the toothbrush bristles at a 90-degree angle to the gum line. 4 Use an alcohol-based mouthwash rather than flossing.

2

Arrange the steps for applying the bottom sheet to an unoccupied bed in correct order. 1. Apply all of the bottom linen on one side of the bed before moving to the opposite side. 2. Remove the soiled linen and place it in a laundry bag. 3. Reposition the mattress and wipe off any moisture with a washcloth moistened in antiseptic solution. 4. While standing at the head of the bed, miter the top corner of the bottom sheet. 5. Ensure that the fitted sheet is smooth over the mattress.

2,3,1,5,4

Which condition is observed in a patient who has gingivitis? 1 Dry mouth 2 Tooth decay 3 Inflammation of the gums 4 Inflammation of sebaceous glands

3

A patient has begun wearing full dentures. Which instruction does the nurse provide in the patient's education? Select all that apply. One, some, or all responses may be correct. 1 Clean the dentures on a regular basis to avoid gingival infection. 2 Except for cleaning, wear them continuously for the first 6 months, so the gums can adjust to them. 3 Observe mouth for reddened areas under the dentures and small red sores on the roof of the mouth. 4 Schedule regular dentist appointments. 5 Keep the dentures covered in water when they are not worn. 6 Rinse the dentures and mouth after every meal.

1,3,4,5,6

Arrange in the correct order the steps the nurse takes to wash a patient's face. 1. Move the mitt from the inner to outer canthus. 2. Soak the crusts on the eyelids for 2 to 3 minutes. 3. Immerse the mitt in water and wringing it thoroughly. 4. Ask whether the patient is wearing contact lenses. 5. Document any abnormal findings.

4,3,1,2,5

The nurse observes a caregiver who is performing foot care on an older patient. Which action by the caregiver may lead to decreased peripheral circulation? 1 Using oval corn pads 2 Applying adhesive tape 3 Cutting corns with a razor blade 4 Applying liquid preparations to remove corns

1

What is a significant cause of bleeding in the oral cavity? Correct1 Trauma Incorrect2 Gingivitis 3 Xerostomia 4 Dental caries

1

The nurse is caring for an immobile patient. Which action does the nurse perform as a part of evening care to promote sleep? Select all that apply. One, some, or all responses may be correct. 1 Change soiled linens. 2 Provide oral hygiene. 3 Provide a bath or shower. 4 Help the patient wash the face and hands. 5 Prepare the patient for scheduled tests.

1,2,4

The nurse provides postoperative care to a patient and identifies that which dermatological finding indicates healthy skin? Select all that apply. One, some, or all responses may be correct. Correct1 Smooth skin Incorrect2 Skin flaking Correct3 Supple skin Correct4 Warm skin 5 Scaling of the skin

1,3,4

The nurse provides instructions about making an occupied bed for an assistive personnel (AP) and includes which information? Select all that apply. One, some, or all responses may be correct. 1 Clean, disinfect, and dry the mattress surface if it is soiled or has moisture. 2 Add a waterproof pad (absorbent side up) over the drawsheet with the seam side up. 3 If a flat bottom sheet is used, miter the top corner of the sheet. 4 Stress to the patient the need to roll while staying aligned. 5 Avoid lifting the mattress during tucking of bottom flat sheet.

1,3,4,5

The nurse teaches a patient with diabetes mellitus about the importance of foot care and includes which instruction to prevent infection while performing the care? Select all that apply. One, some, or all responses may be correct. 1 "Apply lotion to the feet daily." 2 "Clean the feet with hot water." 3 "Cut the nails close to the nail bed." 4 "Soak the feet in water at least 10 minutes before nail care." 5 "Assess the skin for redness, abrasions, and open areas daily."

1,5

Which assessment question does the nurse ask when providing mouth care? 1 "What kind of lotion do you use?" 2 "Do you enjoy going to the dentist?" 3 "How often and when do you usually bathe?" 4 "Do you have any mouth pain or toothaches?"

4

A patient experiences impaired oral mucous membranes. Which nursing instruction indicates that the cause of the condition is malnutrition? 1 "Use bland rinses." 2 "Consult a dietitian." 3 "Use unwaxed floss." 4 "Limit your diet to soft foods."

2

Which statement is true about the development stage of adolescents? 1 Sebaceous glands become less active, resulting in acne. 2 In girls, the skin becomes soft with increased vascularity. 3 The growth and maturation of the integument decreases. 4 In boys, the skin becomes darker because of decreased thickness.

2

A patient with diabetes presents for a routine physical examination. Which assessment does the nurse perform when evaluating the patient's feet? Select all that apply. One, some, or all responses may be correct. 1 Palpate the brachial pulse. 2 Palpate the posterior tibial pulse. 3 Assess intact sensation. 4 Inspect the feet for areas of blistering. 5 Assess the range of motion of the foot and ankle.

2,3,4

In which order does the nurse complete the steps of perineal care for a male patient with an uncircumcised penis? 1. Cover the thighs. 2. Retract the foreskin. 3. Place the patient in a supine position. 4. Clean the shaft of the penis and scrotum. 5. Clean the tip of the penis at the urethral meatus. 6. Return the foreskin to its natural position.

3,1,2,5,6,4

A 25-year-old patient reports an infection caused by a break in skin integrity after using home remedies for foot corns. The nurse suspects that which foot care practice caused this condition? 1 Using oval corn pads 2 Applying adhesive tape 3 Using over-the-counter liquid preparations 4 Cutting corns or calluses with a razor blade

4

A nursing student bathes a patient with paresthesia. The nurse intervenes when the nursing student performs which action? 1 Drains the tub of water before the patient tries to get out 2 Cleans the shower area before and after the bath 3 Instructs the patient to take a shower with warm water for no more than 10 minutes 4 Asks the patient to test the water and then adjusts the temperature as needed

4

A patient is receiving chemotherapy. Which advice does the nurse give to the patient regarding oral hygiene? 1 Apply firm pressure of the toothbrush while brushing the teeth and gums. 2 Lemon-glycerin sponges remove plaque and tartar from tooth enamel. 3 Flossing after every meal is recommended by the American Dental Association. 4 Fluoride toothpastes should be applied to the teeth before flossing.

4

The nurse provides care for an adolescent with acne and recalls which primary reason for the condition? 1 Increased skin vascularity 2 Increased thickness of the skin 3 Increased maturation of integument 4 Increased inflammation of sebaceous glands

4

The nurse provides teaching about foot care to a patient. To prevent ulceration and burning, the nurse provides which instruction? 1 Avoid garters. 2 Avoid using adhesive tape on the skin. 3 Avoid soaking the feet in warm water. 4 Avoid using over-the-counter liquid preparations to remove corns.

4

The nurse assesses the mouth of a patient with partial dentures and notes that the gums have lost vascularity and tissue elasticity. The nurse identifies that the patient's condition will likely result in which occurrence? 1 Ill-fitting dentures 2 Significant bleeding 3 Difficulty with chewing food 4 Periodontal disease

1

The nurse bathes an older patient using a pack of cotton cloths that are premoistened with a surfactant cleaner and an emollient. Which bath is being given to the patient? 1 Bag bath 2 Tub bath 3 Sponge bath 4 Shower bath

1

The nurse observes a caregiver giving a bath to a patient with deep vein thrombosis. Which action by the caregiver requires immediate intervention by the nurse? 1 Massages the leg using long, firm strokes from ankle to knee 2 Allows the patient to stay in the bathtub for 20 minutes 3 Uses the same part of the wash mitt to cleanse both eyes 4 Fails to dry the toes and feet completely

1

The nurse observes a patient's range of motion (ROM) while providing a complete bed bath to the patient. Which is the reason behind this nursing action? 1 To evaluate joint mobility 2 To measure risk of pressure ulcers 3 To ensure proper body alignment of the patient 4 To determine the patient's tolerance of bathing activities

1

The registered nurse provides education for a nursing student about factors that influence patient hygiene. Which statement made by the student indicates the need for further teaching? Correct1 "Family customs have little effect on hygiene practices as an adult." Incorrect2 "In some cases touch is considered magical and healing; others view it as evil or anxiety-producing." 3 "Different cultures have preferences about hot and cold water and their effects on healing or diseases." 4 "I should allow family members to participate in care if desired by adapting the schedule of hygiene activities."

1

The nurses identifies that an older patient is at risk of which common foot problem? Select all that apply. One, some, or all responses may be correct. 1 Corns 2 Hammertoes 3 Calluses 4 Bunions 5 Morton's neuroma

1,2,3,4

The nurse recalls that which assessment is included when evaluating a patient's oral cavity? Select all that apply. One, some, or all responses may be correct. 1 Observing for cleanliness 2 Using olfaction to assess halitosis 3 Palpating any tender areas while wearing sterile gloves 4 Inspecting the mouth for color, hydration, texture, and lesions 5 Informing the health care provider of abnormalities

1,2,4

The home-health nurse provides care for a patient with diabetes. The patient states, "To get ready for a pedicure, I just soaked my feet in hot sudsy water." Which action does the nurse take? Select all that apply. One, some, or all responses may be correct. 1 Instruct the patient to avoid soaking the feet, to decrease the risk of tissue ulceration. 2 Apply moisturizer to both feet. 3 Instruct the patient to walk barefoot at home to ensure complete drying of the feet. 4 Advise the patient to sit with legs crossed for a minimal amount of time. 5 Check sensations in both feet.

1,2,5

To prevent contamination of a patient's clean areas during bathing, which guideline does the nurse follow? Select all that apply. One, some, or all responses may be correct. 1 Stroking the abdomen from top to bottom 2 Washing from the cleanest areas to the dirtiest areas 3 Uncovering the patient's entire body 4 Folding the washcloth into a mitt around the nurse's hand 5 Using a proximal-to-distal motion to wash a patient's extremities

2,4

The nurse identifies that which patient condition may increase the risk of tissue ulceration because of excessive soaking of the feet? 1 Renal calculi 2 Cirrhosis of the liver 3 Peripheral vascular disease 4 Congestive heart failure

3

Which mouth condition is caused by tooth decay? 1 Gingivitis 2 Xerostomia 3 Dental caries 4 Periodontal disease

3

The nurse teaches a patient who is receiving radiation therapy to the neck about ways to reduce the risk of stomatitis. Which patient statement indicates effective learning? Select all that apply. One, some, or all responses may be correct. 1 "I will use a hard toothbrush." 2 "I will limit the intake of alcohol." 3 "I will use normal saline for rinsing." 4 "I will rinse my mouth every 2 hours." 5 "I will use lemon-glycerin sponges to clean the oral cavity."

3,4

Which intervention is appropriate when bathing a patient who cannot move from the bed? Select all that apply. One, some, or all responses may be correct. 1 Washing the patient's face with soap 2 Filling the bath basin with cool water 3 Washing the patient from front to back when cleaning the buttocks 4 Folding the bath blanket back to the patient's waist 5 Disconnecting the intravenous tube while changing the patient's gown

3,4

Arrange in the correct order the steps the nurse takes to remove a gown with no snaps from a patient who has an intravenous (IV) line in place. 1. Remove the IV tubing from the pump. 2. Slide the IV bag and tubing though the arm of the patient's new gown. 3. Remove the gown from the arm without the IV line. 4. Remove the gown from the arm with the IV line. 5. Restart the IV fluid infusion.

3,4,1,2,5

A patient reports heartburn and a bitter-tasting fluid regurgitating into the mouth during sleep. The nurse suggests which bed position? 1 Prone 2 Supine 3 Lateral recumbent 4 Reverse Trendelenburg's

4

The nurse advises a patient to avoid the use of dry razors. Which condition is the nurse trying to prevent? 1 Chemical irritation Incorrect2 Mechanical irritation 3 Loss of stratum corneum Correct4 Weakening of the epidermis

4

The nurse observes a nursing student who is assisting a patient with shaving with a razor. Which action by the student indicates the need for further learning? 1 Checking the razor for clean blade 2 Moistening the skin with lukewarm water 3 Using long, firm razor strokes in the direction the hair grows 4 Using short, upward strokes to remove hair on the chin

4

The nurse plans perineal care for four patients. The nurse identifies that which patient is considered least in need of the care and will be scheduled last? 1 A patient who underwent rectal surgery 2 A patient with an indwelling urinary catheter 3 A patient who gave birth to a child one day ago 4 A patient who underwent penile circumcision six months ago

4

Which foot problem is common in middle-aged women? 1 Corns 2 Calluses 3 Fungal infections 4 Morton's neuroma

4

Which information regarding bed making is accurate? 1 Place soiled linen directly in the hamper. 2 Place clean linen on the floor next to the bed. 3 Place the bed in the lowest position before bed making. 4 Organize bed-making activities to conserve time and energy.

4

Which part of the tooth weakens with aging, causing the patient to be more prone to infection? 1 Neck 2 Enamel 3 Mandible 4 Periodontal membrane

4

While assessing a patient, the nurse finds maceration on the skin and suspects which reason for this condition? 1 Use of dry razors Incorrect2 Excessive use of soap 3 Trauma Correct4 Constant exposure to moisture

4

While bathing, a patient with dyspnea reports feeling extremely tired. Which action does the nurse take? 1 Notify the health care provider. 2 Obtain a special bed surface. 3 Suggest the administration of a sitz bath. 4 Elevate the head of the patient's bed.

4

While providing care, the nurse finds that a patient is untidy and is uninterested in hygiene. Which action does the nurse take first? 1 Educate the patient about hygiene. 2 Help the patient develop new hygiene practices. 3 Observe the patient performing hygiene care activities. 4 Assess the patient's ability to perform daily hygiene practices.

4

While providing perineal care to a female patient, the nurse wipes the perineal region from the perineum to the rectum. Which rationale explains this technique? 1 To reduce discomfort of the patient 2 To provide full exposure of genitalia 3 To prevent the soiling of surrounding skin surfaces 4 To prevent the urinary tract from being contaminated

4

Which nursing intervention is represented in the figure? 1 Cleaning the cuticles 2 Clipping the fingernails 3 Cleaning under the fingernails 4 Filing the corners of the fingernails

3

Which patient activity places the patient at risk of loss of the protective acid condition of the skin? 1 The patient uses emollients. 2 The patient uses depilatories. Correct3 The patient uses alkaline soaps. 4 The patient uses cosmetics and deodorants.

3

Which statement is true regarding the implications of skin care? 1 Constant exposure of the skin to moisture causes chemical irritation. 2 Cosmetics, deodorants, and depilatories cause maceration or softening of the skin. 3 Weakening of the epidermis occurs because of scraping or stripping of the skin's surface. 4 Improper positioning techniques result in the development of pressure ulcers.

3

While assessing the patient's foot, the nurse notes lesions on the sole of the foot. The diagnostic test results reveal a papillomavirus infection. The nurse recognizes that the findings are indicative of which condition? 1 Corn 2 Callus 3 Plantar warts 4 Athlete's foot

3

While bathing a patient, the nurse recalls that excessive massaging of the patient's calf could create which patient response? 1 Chilling 2 Anxiety 3 Loosening of a deep vein thrombosis 4 Strain on the musculoskeletal structures

3

While teaching a patient about denture care, the nurse instructs the patient to avoid wearing dentures while sleeping to prevent which problem? 1 Warping of the dentures 2 Irritation of the gums 3 Stomatitis 4 Gingival infection

3

A sitz bath is an example of which type of bath? 1 Medicated bath 2 Partial bed bath 3 Therapeutic bath 4 Complete bed bath

3

A nursing student lists questions to ask to assess a patient's tolerance of hygiene activities. The nurse educator reviews the list and explains to the student that which question is not part of the assessment? 1 "Which type of bath do you prefer?" 2 "What can I do to minimize shortness of breath, pain, or fatigue?" 3 "Which aspects of bathing or brushing your teeth cause discomfort or fatigue?" 4 "Does bathing cause any symptoms such as shortness of breath, pain, or fatigue?"

1

The nurse gives a bed bath to a patient and takes which measure to provide comfort to the patient? 1 Uses warm water for the bath 2 Uses alkaline soap for the bath 3 Uses a mitt to clean the eyes, wiping from outer to inner canthus 4 Uses chlorhexidine gluconate (CHG) solution to the clean face

1

The nurse delegates the task of providing a patient with oral care to an assistive personnel (AP). Which instruction does the nurse give to the AP? Select all that apply. One, some, or all responses may be correct. 1 "Report any pain the patient experiences." 2 "Position the patient to avoid aspiration." 3 "Report excessive coughing in the patient." 4 "Consider bleeding of the gums to be a normal reaction." 5 "Choking is common after oral hygiene."

1,2,3

The nurse covers the patient's chest and abdomen and places a bath towel under the patient's leg to wash the lower extremities. For which reason is this technique is used? Select all that apply. One, some, or all responses may be correct. 1 To prevent the soiling of bed linen 2 To prevent unnecessary exposure 3 To promote circulation and venous return 4 To reduce microorganism transmission to perineal structures 5 To allow the manipulation of the gown with reduced range of motion

1,2

The nurse educator provides teaching to a group of nurses about cultural aspects of hygiene practice and would include which implication for patient-centered care? Select all that apply. One, some, or all responses may be correct. 1 Family members are allowed to participate in care. 2 Gender-congruent caregivers should be provided if requested. 3 The patient's hair can be shaved without prior discussion with the patient or the patient's family. 4 Privacy should be maintained only for women from Middle Eastern cultures. 5 Hispanic patients should not have their lower torso exposed.

1,2

The nurse explains how to provide eye care to a nursing student. Which statement made by the nursing student indicates effective learning? 1 "I should gently apply pressure over the eyeball." 2 "I should wash the eye with a small amount of soap." 3 "I should clean the eye from the outer canthus to the inner canthus." 4 "I should avoid chlorhexidine gluconate (CHG) solution for cleaning the eyes."

4

The nurse provides home care instruction regarding foot care to a patient with diabetes mellitus and includes which information? Select all that apply. One, some, or all responses may be correct. 1 "Dry your feet thoroughly after cleaning them." 2 "Wrap small pieces of lamb's wool around your toes." 3 "Apply moleskin to any parts of your feet that are under friction." 4 "Use spot adhesive bandages to protect against pressure." 5 "Soak your feet in warm water for at least 10 to 15 minutes."

1,2,3

Which assessment finding indicates to the nurse that a patient may have difficulty performing activities of self-care independently? Select all that apply. One, some, or all responses may be correct. 1 The patient experiences frequent shortness of breath 2 Postoperative incisional pain 3 Confusion 4 The patient is nothing by mouth (NPO) for a surgical procedure 5 Moderate hypertension

1,2,3

A child has pediculosis capitis, and the nurse provides the parent with instructions related to appropriate hygiene care. Which information does the nurse include in the education? Select all that apply. One, some, or all responses may be correct. 1 "Clean and boil the comb." 2 "Use tweezers to catch live lice." 3 "Screen for lice twice a week." 4 "Clean the child's clothes in warm water." 5 "Dip the comb in a cup of water to remove lice between each passing."

1,2,5

The nurse is caring for a patient with diabetes and observes for which sign of peripheral neuropathy? Select all that apply. One, some, or all responses may be correct. 1 Foot deformities 2 Abnormal gait 3 Shiny appearance of the skin 4 Absent or decreased pulses 5 Muscle wasting of the lower extremities

1,2,5

Recognizing that a patient with diabetes may be susceptible to oral health problems, the nurse provides the patient with which oral hygiene instruction? Select all that apply. One, some, or all responses may be correct. 1 "Use a soft-bristled toothbrush." 2 "Replace dentures frequently." 3 "Brush your teeth at least twice a day." 4 "Brush your teeth for a minimum of 90 seconds." 5 "Rinse your mouth at least 4 times a day with saline water." 6 "Floss your teeth twice a day."

1,3,4,5

A male nurse is preparing to bathe a female patient. The patient states, "I don't want a man to give me a bath." Which action does the nurse take? Select all that apply. One, some, or all responses may be correct. 1 Identify a female nurse that can assist the patient with bathing. 2 Convince the patient that he will work quickly and provide as much privacy as possible. 3 Allow the patient to complete as much hygiene care without assistance and omit the remaining components. 4 Ask the patient if she prefers to have a family member assist with the care. 5 Ask the patient why she has concerns about his care.

1,4

A patient asks the nurse about reasons for dry and flaky skin and loss of protective oils from the skin. The nurse includes which possible cause for the condition? Select all that apply. One, some, or all responses may be correct. Correct1 Bathing frequently 2 Using alkaline soaps Incorrect3 Perspiring excessively Correct4 Bathing with hot water 5 Using excessive deodorants

1,4

The nurse discusses mouth care with a group of older community members and lists which benefit of complete oral hygiene? Select all that apply. One, some, or all responses may be correct. 1 Stimulates the appetite 2 Promotes weight loss 3 Reduces the incidence of acid reflux 4 Enhances well-being 5 Improves systemic circulation

1,4

The nurse provides dietary instructions to a patient to help prevent tooth decay. Which patient statement indicates effective learning? Select all that apply. One, some, or all responses may be correct. 1 "I will eat apples regularly." 2 "I will eat cake frequently." 3 "I will drink coffee regularly." 4 "I will eat candies frequently." 5 "I will minimize carbohydrate intake."

1,5

The nurse prepares a bath care plan for a patient with diabetes and includes which intervention? Select all that apply. One, some, or all responses may be correct. 1 Cut and clean the patient's nails. 2 Avoid massaging the back of the patient's calf. 3 Soak the patient's feet in a bath basin while washing and rinsing. 4 Wash the patient's leg using long, firm strokes from the ankle to the knee. 5 Wash the patient's arm using long, firm strokes from the axilla to the fingers.

2

The nurse provides care for a 45-year-old woman who reports frequent burning and numbness of the feet and foot pain when standing for a long time. The nurse suspects which condition? 1 Diabetes 2 Morton's neuroma 3 Rheumatoid arthritis 4 Congenital deformity

2

A nursing student cares for a patient who is dehydrated and experiencing xerostomia. The nurse intervenes when the nursing student performs which action? 1 Offers ice chips 2 Uses lemon-glycerin sponges 3 Uses chlorhexidine mouthwash 4 Applies water-based moisturizer to the lips

2

The nurse provides education to a group of nursing students related to hygiene care. Which statement made by a student indicates the need for further teaching? 1 "I should provide care with a flexible attitude." Correct2 "I should be confident and judgmental while providing care." 3 "I should plan rest periods while caring for a patient who is tired." 4 "I should develop new ways of providing care to patients with impaired self-care ability."

2

The nurse provides nail cuticle care for a patient and uses which technique? 1 Uses a plastic stick for cleaning 2 Uses a nailbrush for cleaning 3 Pushes the cuticles back while cleaning 4 Soaks the patient's fingers in hot water while cleaning

2

The nurse reviews the plan for foot care of a patient with peripheral vascular disease and questions which intervention? 1 Filing the fingernails 2 Clipping the toenails 3 Using a soft cuticle brush 4 Applying lotion to the feet

2

The nurse suspects that a patient with diabetes is experiencing peripheral neuropathy based on which assessment finding? 1 Thickened toenails 2 Low vibratory sensation 3 Decreased hair growth on the feet 4 Paleness of the skin on limb elevation

2

The nurse teaches a nursing student about bathing and perineal care for older patients. Which statement made by the student indicates the need for further teaching? 1 "The term a.m. care includes washing the patient's hands and face, and helping with oral care." 2 "I should bathe older patients in the afternoon when they are more alert." 3 "A sitz bath may be recommended for a patient with an inflamed perineal region." 4 "A medicated bath, such as Aveeno, may be recommended in the home setting."

2

Which instruction does the nurse give to the assistive personnel (AP) who is providing a complete bed bath to a patient? 1 Expect patient fatigue during bathing. 2 Avoid massaging the reddened area under the skinfolds. 3 Wash the patient's face with chlorhexidine gluconate solution. 4 Disconnect the intravenous pump tubing while removing the patient's gown.

2

The nurse cares for a patient who has arthritis. Which question does the nurse ask to determine the patient's religious and cultural practices? Select all that apply. One, some, or all responses may be correct. 1 "Does bathing cause shortness of breath?" 2 "How can I best help you with hair care?" 3 "Do you have any preferences for how you bathe?" 4 "Which bathing activities may cause discomfort?" 5 "How comfortable are you with my care?"

2,3,5

The nurse is caring for a patient who has reduced sensation in both feet. Which action does the nurse take? Select all that apply. One, some, or all responses may be correct. 1 Avoid cleaning the feet until a prescription from the health care provider is received. 2 Wash the feet with lukewarm water and then dry well. 3 Apply moisturizing lotion to the feet, especially between the toes. 4 File the toenails straight across. 5 Advise the patient that going barefoot will help keep skin on the feet dry and healthy.

2,4

The nurse creates a step-by-step procedure for making a patient's bed and includes which information? Select all that apply. One, some, or all responses may be correct. 1 Tucking the top sheets in at the corners 2 Raising the bed before changing the linen 3 Shaking soiled linens 4 Straightening the linen if it becomes loose or wrinkled

2,4,5

The nurse provides teaching to a female patient about perineal care. Which method of washing the perineum indicates effective learning by the patient? 1 Wiping with toilet paper 2 From back to front using long, firm strokes 3 From front to back using a clean washcloth 4 In a circular motion beginning at the urinary meatus

3

The registered nurse provides education to a nursing student about the characteristics of hair. Which statement made by the student indicates a need for further teaching? 1 "The hair shaft is lifeless." 2 "Hormonal changes affect the hair's characteristics." 3 "Physiological factors directly affect the hair shaft." 4 "Nutrient deficiencies of the hair follicle cause changes in hair color."

3

The registered nurse teaches a patient about skin protection. Which statement by the patient indicates the need for further teaching? 1 "I should use emollients." 2 "Alkaline soaps neutralize the protective acid condition of skin." 3 "Wet bed linen or gowns decrease heat loss." 4 "I should minimize the exposure of skin to moisture."

3

A patient reports pain between the toes of one foot. The nurse assesses the patient's foot and notes a cone-shaped, round, and raised lesion between the toes. Which treatment recommendation does the nurse make? 1 Wear oval corn pads. 2 Apply salicylic acid. 3 Soak the foot in warm water. 4 Soak the foot in antiseptic solution.

3

The nurse cares for a patient with impaired circulation to the lower extremities. Which action helps reduce the risk of infection? 1 Clipping the toenails 2 Soaking the feet in hot water 3 Cutting the nails straight across 4 Using knee-high nylons to cover the legs

3

The nurse educates a nursing student on how to bathe patients with altered cognition. Which statement made by the student indicates the need for further teaching? 1 "I should ensure that bath mats are available." 2 "I should administer prescribed analgesics half an hour before a bath." 3 "I should use only cool water when bathing patients with altered cognition." 4 "I should be aware that patients with impaired cognition may behave aggressively during bathing."

3

The nurse instructs a patient to use safety bars when getting in and out of the tub. Which rationale explains this intervention? 1 To maintain privacy 2 To prevent accidental burns 3 To prevent slipping and falling 4 To provide immediate assistance in case the patient feels weak or giddy

3

The nurse is giving a patient a bath. Which nursing intervention is beneficial while washing the hands and nails? 1 Cutting the patient's nails before washing 2 Using alkaline soap to clean the fingernails and hands 3 Soaking the patient's hands in water for 2 to 3 minutes before washing 4 Moisturizing the patient's hands before washing

3

The nurse identifies that which intervention is appropriate to include in a plan for foot care for an older patient with diabetes? Select all that apply. One, some, or all responses may be correct. 1 Use oval corn pads. 2 Cut the calluses using scissors. 3 Avoid use of adhesive tape. 4 Do not soak the patient's feet. 5 Use over-the-counter liquid preparation to remove corns.

3,4

The nurse is teaching a group of nursing students about bathing and perineal care. Which instruction does the nurse include? Select all that apply. One, some, or all responses may be correct. 1 Wash the eye from outer to inner canthus. 2 Bathe the arm using long, firm strokes from axilla to fingers. 3 Raise and support the arm above the head to wash, rinse, and dry axilla thoroughly. 4 Soak any crusts on the eyelids for 2 to 3 minutes with a damp cloth before attempting removal. 5 Wash, rinse, and dry the forehead, cheeks, nose, neck, and ears without soap, if the patient prefers.

3,4,5

When assessing an older patient, the nurse notes dry feet and identifies which cause of this condition? Select all that apply. One, some, or all responses may be correct. 1 Improper fit of footwear 2 Presence of systemic disease 3 Dehydration of epidermal cells 4 Continued exposure to trauma 5 Decrease in sebaceous gland secretions

3,5

A teenager tells the nurse, "For the past few weeks, I have been perspiring a lot, especially in the underarm area." How does the nurse respond? 1 "Consult your health care provider." 2 "Use talcum powder in the underarm area 3 to 4 times a day." 3 "It is likely that you have an infection; you will need treatment with an antibiotic." 4 "This is typical for people who are your age; you should begin using an antiperspirant daily."

4

After receiving a bath, a patient reports dizziness. The nurse suspects that which intervention during the bath may have caused this condition to occur? 1 Placing a disposable towel on the floor 2 Filling the bathtub halfway with warm water 3 Allowing the patient's skin to air dry for 30 seconds 4 Exposing the patient to warm water for 20 minutes

4

An elderly patient reports dry and itchy skin. The nurse identifies that the condition is associated with which physiological change that occurs in the older population? 1 Loss of resiliency of the skin 2 Exposure to an environment with a high humidity 3 Decreased production of epidermal cells 4 Decreased production of lubricating substances

4

The nurse reviews a patient's medical record and notes that the patient often becomes afraid or fights while being bathed. Which condition may be responsible for this type of reaction? 1 Obsessive-compulsive disorder Incorrect2 Cancer 3 Asthma Correct4 Dementia

4

The nurse reviews the plan for oral care for a patient who is at a risk of oral mucositis because of chemotherapy. The nurse questions which item listed on the plan? 1 Rinse with a bland rinse. 2 Floss with unwaxed floss. 3 Brush gently with a soft toothbrush. 4 Apply oil-based moisturizer to the lips.

4

Which assessment finding would the nurse expect when performing hygiene care for a patient with diabetes mellitus? 1 Dry flakes on the scalp 2 Excessive salivation 3 Presence of plantar warts 4 Skin breakdown on the feet

4

In which order does the nurse complete the steps of washing a patient's abdomen? 1. Fold the bath blanket down to just above the pubic region. 2. Lift the bath towel with one hand. 3. Keep the abdomen covered between washing and rinsing. 4. Place the bath towel lengthwise over the chest and abdomen. 5. Stroke from side to side, giving special attention to the skin folds of the abdomen.

4,1,2,5,3

The nurse observes excessive dryness in a patient's toenails. The nurse asks which question to determine a factor that contributed to the dryness? Select all that apply. One, some, or all responses may be correct. 1 "Do you wear clean socks daily?" 2 "Do you wear tight-fitting shoes?" 3 "How often do you trim your nails?" 4 "Do you change your nail polish regularly?" 5 "How often do you apply moisturizer to your feet?"

4,5

A patient presents to the health care provider's office with a tick in the scalp. The nurse removes the tick carefully by pulling upward with blunt tweezers, placing it in a sealed bag, and disposing of it. The health department nurse reviewed the process that was used and makes which determination? 1 The nurse followed the correct procedure. 2 The tick should have been placed on a petri dish in an autoclave. 3 The tick should have been sent to the health department. 4 The nurse should have twisted the tick to remove it.

1

A patient who is receiving chemotherapy experiences inflamed gums and oral mucosa and painful sores in the mouth. The nurse performs which intervention when providing oral care? Select all that apply. One, some, or all responses may be correct. 1 Decreasing frequency of oral hygiene 2 Applying water-soluble moisturizing gel on the oral mucosa 3 Encouraging intake of soft foods 4 Using commercial mouthwash 5 Using normal saline rinses

2,3,5

The nurse obtains a prescription for a sitz bath to address which patient need? 1 To help the patient to cooperate during bathing 2 To reduce the foul-smelling odor of an inflamed genital area 3 To soothe the patient whose perineum is inflamed 4 To provide comfort to the patient who is unable to participate in bathing

3

A patient with pediculosis corporis receives a prescription for pediculicide lotion. The nurse reviews the medication education that is prepared for the patient and questions which instruction? 1 Wash the infested clothing in hot water. 2 Take a second shower 12 to 24 hours after the initial dose of lotion is applied. 3 Vacuum rooms thoroughly and throw away debris. 4 Apply pediculicide lotion after showering when the skin is wet.

4

The nurse educator provides teaching to a group of nursing staff members about the oral cavity and includes which information? 1 The periodontal membrane lies above the gum margins. 2 Saliva is only secreted by glands present inside the oral cavity. 3 The undersurface of the tongue and the floor of the mouth are supplied with a few blood vessels. 4 Exposure to radiation can impair salivary secretion in the mouth.

4

The nurse uses a bath basin to bathe a patient who is sitting in a chair. The nurse documents that which type of bath was given? 1 Sitz bath 2 Tub bath 3 Partial bed bath 4 Sponge bath

4