Nursing Fundamentals Ch 17 TTE Hygiene
A nurse is caring for a client with a decreased level of consciousness (LOC). When performing mouth care, what action by the nurse will decrease complications of oral care?
The client should be placed in a side-lying position to prevent aspiration.
A nurse is providing oral care for a client who has been in a coma for 2 weeks. For what oral hygiene alteration might this client be at risk?
White patches may be present that indicate a fungal infection called thrush.
An 80-year-old woman tells the nurse that she just itches all the time and her skin seems very dry. How do these symptoms relate to aging skin?
activity of the glands in the skin lessens
A nurse is educating a client on how to care for dentures. What is a recommended teaching guideline?
Store dentures in cold water when not in use.
The nurse is caring for an older adult client who has refused a bath for several days, and has now developed a rash on the buttocks. Which statement by the nurse should be made first?
"Getting a bath helps to remove the bacteria from your skin, which is what is causing the rash on your buttocks."
The nurse has completed teaching regarding pediculosis. Which client statement requires further nursing teaching?
"I will use conditioner so that the lice eggs will slide off my hair."
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."
Which statement made by the client, regarding flat patches of brown skin on the face, demonstrates understanding?
"These brown spots are senile lentigines and are common when you get older."
A nurse is caring for a client with long hair. The client asks if something could be done about her hair to be more comfortable. How would the nurse respond?
"Yes, I can braid it for you if you want me to."
A nurse is reviewing proper toothbrushing procedures with a family. At what angle would the nurse advise to hold a manual toothbrush when cleaning the teeth? Record your answer using a whole number.
45
Which client is most at risk for foot difficulties?
45-year-old woman with type 2 diabetes
A nurse on an acute medical unit is responsible for providing assistance with hygiene for clients who are unable to do so independently. The nurse should be aware that the use of a safety razor for shaving is contraindicated from which client?
A man who is receiving an intravenous infusion of an anticoagulant for the treatment of a pulmonary embolism
A nurse is assisting a client to shave his beard. What should the nurse do while providing this aspect of hygiene?
Apply cream to area to be shaved in a layer about 0.5 in (1.25-cm) thick.
An older adult client with Parkinson's disease is unable to take care of himself. The client frequently soils his bed and is unable to clean himself independently. How should the nurse in this case ensure the client's perineal care?
Cleanse to remove secretions from less-soiled to more-soiled areas.
A nurse is providing oral care to a client with dentures. What action would the nurse perform first?
Don gloves
The nurse is caring for an older adult client who has refused a bath for several days, and has now developed a rash on the buttocks. What is the priority nursing intervention?
Explain that cleanliness helps to remove bacteria from skin, which can prevent infection.
Bathing should be performed in an orderly, head-to-toe manner. True/False
False
Older, continent clients who are hospitalized should receive a full bed bath with soap and water every day. True/ False
False
The student nurse is providing a bed bath to a client with limited mobility. Which action should the student perform during this task?
Fold the washcloth like a mitt on your hand so that there are no loose ends.
The unlicensed assistive personnel (UAP) is re-making the bed in a hospital room where the client was just discharged. The nurse observes the UAP performing the action pictured above. What initial instruction should the nurse provide to the UAP?
Inform the UAP that she should be wearing gloves
The nurse assists the client to the bathroom sink to perform morning care. The nurse observes the client wash his face, arms, abdomen, and legs. The nurse washes the client's back and rectal area and applies soap to the back. The client brushes his teeth and ambulates to a chair in his room with assistance. How will the nurse describe the morning care on the client's chart?
Partial Care
A kindergarten student is sent to the school nurse because they have been vigorously scratching her scalp for a few hours. The nurse's first action will be to assess the child for the presence of:
Pediculosis
Which health problem is most clearly suggestive of a history of inadequate dental care?
Periodontitis
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.
A nurse is preparing to provide oral care to a client who is unconscious. The nurse would place the client in which position?
Side-lying
A 35-year-old woman is 1 day postpartum. She is reporting moderate perineal pain after giving birth and would like to clean the area. Which method of bathing is most appropriate for this client?
Sitz bath
What type of bath is preferred to decrease the inflammation after rectal surgery?
Sitz bath
A client who has been admitted in the health care facility has had surgery and is unconscious. The nurse needs to take care of the client's hygiene and oral care daily. The client's teeth and lips show dry crusts when there is a day's gap in the oral hygiene. What can best describe the client's oral condition?
Sordes
The nurse is caring for a client who is on warfarin therapy. Which teaching will the nurse provide?
Use electric razor for shaving purposes
A nurse providing hygiene and bathing for older adult clients knows that additional safety measures may be necessary in their care. The nurse delegates some aspects of care to an unlicensed assistive personnel (UAP). Which of the following are true regarding safety of the older adult while bathing? Select all that apply.
Use of a tub/shower seat may be necessary if balance problems are present. Water temperature should be monitored carefully due to decreased temperature sensation. Use a long-handled shower brush or attachment to help with limited mobility.
The nurse is caring for a client that is comatose. What action by the nurse will prevent complications related to the provision of oral care?
Use small amounts of water and oral suction device.
An older adult resident of a long-term care facility has recurring problems with dry skin. Which strategy should the nursing staff utilize in order to help meet the resident's hygiene needs while preventing skin dryness?
Using a non cleansing soap agent
A nurse is brushing the hair of a client admitted to the health care facility following a fracture in the hand. The nurse implements this action based on the understanding that brushing the hair:
facilitates oil distribution.
When the nurse cleanses the client's leg during a bed bath, it will allow for:
increased circulation
A 55-year-old client has just undergone surgery for a knee replacement. He asks the nurse if he can shave because his face is itching from the stubble. What information is a priority for the nurse to verify prior to shaving the client?
medications listed on the client's medication administration record (MAR)
The nurse is observing a student who is using a safety razor to shave a client. Which action would require intervention by the nurse?
pulling the razor against the direction of hair growth
The nurse is preparing to delegate a bath for a 90-year-old client who is nonresponsive and has mild skin breakdown. Which type of bath will the nurse delegate to the unlicensed assistive personnel (UAP)?
traditional bed bath with linen change
