Nursing Fundamentals: Module 2(Hygiene, Moving and Positioning, Activity and Exercise)

A nurse cares for four patients in an intensive care unit. Which patients should be prioritized for providing perineal care? 1. Dialysis patients 2. Bariatric patients 3. Patients with diabetes mellitus 4. Patients receiving chemotherapy treatment for cancer

2 Rationale Bariatric patients may not be able to perform self-hygiene activities. Because of the location of the perineum, morbidly obese patients may need assistance reaching the perineum for effective cleaning. Patients on dialysis, patients with diabetes mellitus, and patients receiving chemotherapy treatment for cancer are typically able to care for their perineum themselves. p. 831

A 43-year-old women who is obese reports frequent burning and numbness of the feet. The patient also has foot pain when standing for a long time. Which condition would the nurse suspect? Diabetes Morton's neuroma Rheumatoid arthritis Congenital deformities

2 Rationale Burning, numbness, and pain in the feet when standing for a long period of time are symptoms of Morton's neuroma. It is a common condition in middle-aged women who are overweight. Foot pain alone is associated with diabetes, rheumatoid arthritis, and congenital deformities. p. 824

Which action is contraindicated in a patient with peripheral vascular disease? 1. Filing the fingernails 2. Clipping the toenails 3. Using a soft cuticle brush 4. Applying lotion to the feet

2 Rationale Clipping the toenails is contraindicated in patients with peripheral vascular disease. Filing the nails is preferred to clipping. Applying lotion prevents the skin from becoming too dry. Using a soft cuticle brush reduces the incidence of inflamed cuticles. p. 864

The nurse observes impaired oral mucous membranes in a patient. Which of the nurse's instructions indicates that the cause of this condition is malnutrition? 1. "Use bland rinses." 2. "Consult a dietitian." 3. "Use unwaxed floss." 4. "Limit your diet to soft foods."

2 Rationale Impaired oral mucous membranes may be due to malnutrition or chemical trauma. Making dietary changes by consulting a dietitian may help to avoid the risk of impairment of oral mucosa due to malnutrition. Using bland rinses, using unwaxed floss, and limiting the diet to soft foods may reduce impairment due to chemical trauma. p. 832

Which nursing intervention is contraindicated for treating corns? 1. Wide shoes 2. Oval corn pads 3. Warm water soaks 4. Proper nail trimming

2 Rationale Oval corn pads should be avoided because these pads increase pressure on the toes and reduce circulation. Wearing wide and soft shoes helps treat corns. Warm water soaks soften corns before rubbing them with a pumice stone. Proper nail trimming is recommended for ingrown nails. pp. 830, 862

A registered nurse teaches a nursing student about the characteristics of hair. Which statement if made by the nursing 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 Rationale Physiological factors do not directly affect the hair shaft. The hair shaft itself is lifeless. Hormonal changes, nutrition, and certain illnesses affect the hair's characteristics, and nutrient deficiencies of the hair follicle may change hair color. p. 823

Which trouble areas should be assessed for correction when the patient is placed in the position depicted in the image? 1. Ears 2. Knees 3. Sacrum 4. Humerus

3 Rationale The image depicts the supported Fowler's position. The trouble areas in this position include the sacrum and heels. Unprotected pressure points at the ears are the trouble areas in side-lying position. Unprotected pressure points at the knees and humerus are the trouble points in Sims' position. p. 430

Which positioning of the patient by the nurse will help prevent flexion contracture of the cervical vertebrae? 1. Prone position 2. Semi-prone position 3. 30-degree lateral position 4. Supported Fowler's position

4 Rationale The supported Fowler's position prevents the flexion contracture of the cervical vertebrae. The prone position would be beneficial for patients with acute respiratory distress. The 30-degree lateral position, or side-lying position, prevents pressure from bony prominences on the back. The semi-prone position prevents foot drop. p. 435

A nurse bathes an older adult 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 Rationale A bag bath involves using several soft, nonwoven cotton cloths that are premoistened in a solution of no-rinse surfactant cleanser and emollient to clean a patient. A tub bath involves immersion of the patient in a tub of water. A sponge bath sink involves bathing the patient using a sponge along with a bath basin or sink with the patient sitting in a chair. In a shower bath, the patient sits or stands under a continuous stream of water. p. 836

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

1 Rationale A stroke frequently causes leg weakness or paralysis. This commonly results in altered walking patterns. Heart failure and renal diseases increase the risk of tissue edema, particularly in dependent areas such as the feet, but do not typically result in a significantly altered gait. Neuropathic changes associated with diabetes mellitus may cause altered sensation in the feet, but the gait is most likely unaffected until the late stage of the disease. p. 863

A registered nurse supervises a nursing student who is performing oral care for an unconscious patient. Which action indicates the need for correction? 1. Brushing the tongue to stimulate the gag reflex 2. Using topical chlorhexidine gluconate for rinsing 3. Placing the bed in the semi-Fowler's position before performing oral care 4. Holding the patient's mouth open with a small oral airway or a padded tongue blade

1 Rationale An unconscious patient should not have his or her gag reflex stimulated because the patient may aspirate. Using topical chlorhexidine gluconate for rinsing enhances oral hygiene and prevents infections. Placing the patient in the semi-Fowler's position while performing oral care prevents the risk of aspiration. The patient's mouth should be opened with a small oral airway or a padded tongue blade. If the fingers are used to hold the mouth open, the patient may bite and microorganisms may be transferred to the patient's mouth. p. 840

A registered nurse teaching a nursing student about bath and perineal care for older adult patients. Which statement made by the nursing student indicates the need for further teaching? 1. "I should bathe older adult patients in the afternoon." 2. "I should provide perineal care to the patient after breakfast." 3. "I should provide a sitz bath to a patient with an inflamed perineal region." 4. "I should suggest an Aveeno bath to a patient receiving home care nursing."

1 Rationale Bath care should be provided as part of a routine morning schedule. Perineal care should also be provided to the patient during the routine morning care schedule. A sitz bath cleans and reduces pain and inflammation in the perineal and anal regions. Aveeno baths, oatmeal baths, and cornstarch baths are types of medicated baths recommended in home care settings. p. 836

A registered nurse evaluates a nursing student who is assisting a patient with a shower. Which nursing action indicates a need for further teaching? 1. Asking the patient to use bath oils 2. Cleaning the shower area before and after a bath 3. Instructing the patient to take a shower with warm water for 6 minutes 4. Asking the patient to test the water and then adjusting the temperature as needed

1 Rationale Bath oils may make bathtub surfaces slippery and put the patient at risk of falling. Therefore, the nurse should caution the patient against using bath oils. Cleaning the shower area before and after a bath helps to prevent transmission of infections. Prolonged exposure to warm water during a shower may lead to vasodilation; therefore, the nurse should instruct the patient to shower for less than 10 minutes. The nurse should ask the patient to test the water and then adjust the temperature accordingly to prevent accidental burns. p. 861

While caring for a patient, the nurse suspects improper turning. Which condition does the nurse suspect? Scraping of the skin Maceration of the skin Accidental injuring of the skin Mechanical irritation of the skin

1 Rationale Improper turning or positioning techniques can lead to scraping or stripping of the skin surface. Maceration occurs from continuous exposure to moisture. Accidental injury can occur if finger rings are not removed. Mechanical irritation of the skin can occur if smooth linen cloths are not used. p. 822

While assessing a patient, the nurse observes that the patient has a dry cornea. What may be the cause of this condition? Paralysis of the trigeminal nerve Hormonal and nutrient deficiencies Ulcerations and trauma of the head region Strong stimulation of the sympathetic nervous system

1 Rationale Paralysis of the trigeminal nerve eliminates the blink reflex, which causes corneal drying. Hormonal changes and nutritional deficiencies may affect the patient's hair characteristics. Ulcerations and trauma of the head region can cause significant bleeding in the oral cavity. Strong stimulation of the sympathetic nervous system may cause xerostomia. p. 822

Which position may lead to plantar flexion of the feet? 1. Prone position 2. Supine position 3. Side-lying position 4. Supported Fowler's position

1 Rationale Placing the patient in the prone position may lead to plantar flexion of the feet. The supine position may increase cervical flexion if a thick pillow is placed below the head. The side-lying position may lead to excessive lateral flexion of the spine. The supported Fowler's position may lead to increased cervical flexion. p. 430

The nurse observes fecal secretions in the skin folds of the buttocks and anus. What is the appropriate nursing action in this situation? 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 patient's side and keep him or her covered with a blanket.

1 Rationale Skinfolds near the buttocks and anus may contain fecal secretions that cause the growth of microorganisms. In this situation, the nurse should enclose the fecal material in an underpad or toilet tissue and remove the waste with disposable wipes. An absorbent pad is placed under the patient's buttocks only after cleaning the anus and buttocks, but not when the fecal matter is present. This cleaning motion prevents any contamination. The nurse should help the patient into a prone or side-lying position to expose the back and buttocks for bathing while limiting exposure. The nurse should place a towel lengthwise along the patient's side and keep the patient covered with a blanket as standard procedure. p. 859

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

1 Rationale The nurse observes range of motion (ROM) during a bath to measure a patient's joint mobility. The nurse should use the Braden scale to measure the risk of pressure ulcers. To maintain proper body alignment, the nurse should lower the side rail closest to the nurse and help the patient to comfortably lie down in the supine position. The nurse should assess the patient's level of comfort and fatigue to determine the patient's tolerance of bathing activities. p. 861

In a long-term health care facility, the nurse is evaluating the condition of a patient with immobility. Which assessment should the nurse perform to determine if the patient has developed joint contracture? Measure range of motion Determine the level of comfort Evaluate the patient's body alignment Observe the skin for areas of erythema/breakdown

1 Rationale The nurse should assess range of motion to determine if joint contracture is developing. The nurse should determine the patient's level of comfort and evaluate the patient's body alignment to determine the level of comfort. Observing the skin for areas of erythema or breakdown, especially under bony prominences, determines if there is need to increase the frequency of repositioning. p. 439

An elderly patient complains of itching. On examination, the nurse finds that the patient's skin is dry and flaky. The patient bathes frequently. The patient has no other complaints. What should the nurse tell the patient to do? 1. Decrease bathing frequency with soap. 2. Bathe with hot water frequently without soap. 3. Bathe with cool water frequently without soap. 5. Apply talcum powder on the body after bathing.

1 Rationale The skin of old people is prone to dryness due to decreased production of protective lubricating substances. The nurse should advise this patient to avoid taking frequent baths with soap to prevent excessive dryness and itching. Taking frequent baths with cool or hot water with or without soap erodes the protective lubricating substances of the skin. This results in excessive dryness. Talcum powder absorbs water and keeps the skin dry, so the patient should be advised not to use talcum powder after bathing. p. 823

A group of nursing personnel plan to take an unstable and weak patient out of a tub. Which equipment is beneficial in this situation? 1. Lift equipment 2. Linen bag 3. Nail clippers 4. Disposable bath mat

1 Rationale Weak or unstable patients need extra assistance in getting out of a tub. The nursing staff should have lift equipment handy to transfer the patient from a bathtub. A linen bag, nail clippers, and a disposal bath mat are equipment used to perform nail and foot care. p. 861

A nurse helps an unsteady patient out of the bathtub. What should the nurse do to ensure the patient's safety? Drain the bathtub before the patient gets out Apply lotion to the patient's freshly dried skin Drape a bath towel over the patient's shoulders Teach the patient how to use the call light for assistance

1 Rationale While assisting an unsteady patient out of the bathtub, the nurse should drain the bathtub before the patient gets out to prevent accidental falls. Applying lotion to the freshly dried skin moisturizes, but may not ensure safety. The nurse should place a bath towel over the patient's shoulders to prevent the patient from becoming cold. When a patient is about to get out of the bathtub, the patient should not be taught how to use the call light for assistance. p. 861

While logrolling a patient, the nurse crosses the patient's arms on the chest. What is the reason for the nurse's action? 1. Prevent injury to arms 2. Maintain alignment of the body 3. Prevent tension on spinal column 4. Prepare patient for turning onto one side

1 Rationale While logrolling, the patient's arm should be crossed on the chest to prevent injuries to the arms. When one nurse grasps a drawsheet at the lower hips and thighs, and the other nurse grasps the drawsheet at the patient's shoulder and lower back, this maintains proper alignment of all body parts. Placing a small pillow between the patient's knees prevents tension on the spinal column and adduction of the hip. Placing the patient in supine position on the side of the bed opposite the direction to be turned prepares the patient for turning onto the side. p. 438

A registered nurse (RN) is evaluating the actions of a nursing student who is performing foot and nail care. Which of the nursing student's actions indicates the need for further learning? 1. Rewarming the water after 3 minutes 2. Placing the basin on a bathmat or towel 3. Allowing the patient's feet and fingernails to soak for 10 to 20 minutes 4. Cleaning under the fingernails with a plastic stick while the fingers immersed in water

1 Rationale While performing nail and foot care, the nurse should fill the wash basin with warm water and test the water temperature. After soaking the patient's feet and fingernails, the nurse should rewarm the water after 10 minutes. The basin is placed on the bath mat or towel. The patient's feet and fingernails should be soaked for 10 to 20 minutes. While the fingers are immersed in the basin, the fingernails are gently cleaned with a plastic stick. p. 864

Which statements are true regarding implication of cultural aspects of hygiene practice? Select all that apply. 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 his or her 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 Rationale The cultural aspects of hygiene practice include allowing the family members to participate in care, if desired, by adapting the schedule of hygiene activities. It also includes providing gender-congruent caregivers if requested or needed. The patient's hair should not be shaved without first obtaining consent from the patient, or his or her family. Privacy should be maintained, especially for women from cultures that value female modesty, such as Asian, Muslim, Hispanic, and Nigerian cultures. Uncovering the lower torso and exposing the arms should be avoided in women of Middle Eastern and Asian descent. p. 824

The nurse covers the patient's chest and abdomen and places a bath towel under the patient's leg to wash the lower extremities. What are the rationales behind this action? Select all that apply. 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 Rationale The nurse places a bath towel under the patient's leg to prevent the soiling of the bed linen. The nurse should keep the patient's other leg and perineum draped to prevent unnecessary exposure. The nurse should wash the patient's leg using firm strokes from ankle to knee and from knee to thigh to promote circulation and venous return. The nurse wipes the genital areas from front the back using clean water to reduce microorganism transmission to perineal structures. Placing a bath towel is not associated with manipulating a patient's gown. p. 857

A nurse provides nail care to a patient. Which nursing action indicates that the nurse is skilled in providing cuticle care? 1. The nurse uses a plastic stick for cleaning. 2. The nurse uses a nail brush for cleaning. 3. The nurse pushes the cuticles back while cleaning. 4. The nurse puts the patient's fingers in hot water while cleaning.

2 Rationale A nail brush should be used for cleaning the cuticles and the area around it. An orange plastic stick is used to clean under the fingernails gently. Cuticles should never be pushed back or cut. While cleaning the cuticles, the patient's fingers should not be soaked in hot water. p. 864

The nurse is assessing a patient's visual status, ability to sit without support, and hand grasp abilities. What are the rationales behind this nursing action? Select all that apply. To determine the degree of assistance the patient needs for bathing To determine how to bathe and position the patient To determine if the range of motion may be delegated to assistive personnel To provide a baseline for comparison over time if bathing improves the skin condition To provide information related to the skin and genitalia during bathing

1&3 Rationale The nurse should assess a patient's visual status, ability to sit without support, and hand grasp abilities to determine the degree of assistance the patient needs for bathing. Range of motion (ROM) may be delegated to nursing assistive personnel depending on the patient's visual status, ability to sit without support, and hand grasp abilities. Bathing and positioning the patient may need to be altered with the presence of intravenous lines, oxygen tubing, and urinary catheters. To assess the patient's skin the nurse should note the dryness, scaling, and redness. This provides a baseline in determining if bathing improves the skin condition. The nurse should ask the patient about any problems such as excess moisture, inflammation, drainage, rashes, or skin lesions to find out any information related to the patient's skin and genitalia during bathing. p. 854

Which areas of the patient would bear weight when placed in the side-lying position? Select all that apply. 1. Hip 2. Heel 3. Ileum 4. Shoulder 5. Humerus

1&4 Rationale In the side-lying position, most of the patient's body weight rests on the hip and shoulder. In supported Fowler's position, the pressure would be on the heels. In Sims' position, the major portion of the body weight rests on the ileum, humerus, and clavicle. p. 430

Which complications would the nurse have to monitor for when using the supported Fowler's position? Select all that apply. 1. Pressure on the posterior aspect of the knees 2. Excessive lateral flexion of the spine 3. Hyperextension of the lumbar spine 4. Increased shearing force on the back 5. Unprotected pressure points at the ileum

1&4 Rationale In the supported Fowler's position, pressure is applied on the posterior aspect of the knees, decreasing circulation to the feet. Increased shearing force on the back may be due to the supported Fowler's position. Excessive lateral flexion on the spine is due to the side-lying position. Hyperextension of the lumbar spine may be due to the prone position. Lack of protection for pressure point at the ileum is due to the Sims' position. p. 430

A registered nurse teaches a nursing student about performing foot and nail care for a patient with diabetes mellitus. Which of the nursing student's statements indicate the need for further teaching? Select all that apply. 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 Rationale The nursing student should avoid soaking a diabetic patient's feet because this action may cause maceration and drying of the skin, which could lead to tissue breakdowns and infections. The patient's fingers should be soaked in warm water because hot water may cause burns. Patients with diabetes should not get their nails clipped because this action may increase the risk of infection if the skin is accidentally cut. A soft cuticle brush should be used for diabetic patients to prevent inflammation. Lotion is use to moisten the skin. pp. 863, 864

The nurse provides dietary instructions to a patient to help to prevent tooth decay. Which of the patient's statements indicate effective learning? Select all that apply. 1. "I will eat apples regularly." 2. "I will eat cakes frequently." 3. "I will drink coffee regularly." 4. "I will eat candies frequently." 5. "I will minimize carbohydrate intake."

1&5 Rationale Minimizing carbohydrates decreases the amount of sugar that is exposed to the teeth. Apples are rich in fiber and do not promote tooth decay. Cakes, coffee, and candies are rich in artificial sugars and/or are corrosive, so they increase the risk of tooth decay. p. 839

While caring for a patient, a nurse finds that the patient is untidy and is uninterested in hygiene. What should the nurse do in this situation? Select all that apply. 1. Educate the patient about hygiene. 2. Help the patient develop new hygiene practices. 3. Force the patient to change the hygiene practices. 4. Assess the patient's personal preferences regarding hygiene. 5. Assess the patient's ability to perform daily hygiene practices.

1&5 Rationale Patients who appear untidy or uninterested in hygiene should be educated about the importance of hygiene. The nurse should also determine the patient's ability to perform daily hygiene. New hygiene practices should be developed for patients who are unable to perform regular hygiene practices due to illness or impairment. Patients should not be forced to change hygiene practices unless the practice affects the patient's health. Knowing the patient's personal preferences promotes individualized care. p. 823

What are the common trouble areas for patients in the supine position? Select all that apply. 1. Extended elbows 2. Unsupported feet 3. Externally rotated hips 4. Decreased circulation to the feet 5. Increased shearing force on the back and knees

1,2&3 Rationale Patients in the supine position rest on their backs and may experience extended elbows, unsupported feet, and externally rotated hips. Pressure on the posterior aspects of the feet leads to decreased circulation, observed in patients positioned in the supported Fowler's position. There is an increase in shear on the back of the knees when the head of the bed is raised greater than 60 degrees in the supported Fowler's position. p. 430

The nurse is caring for patients on a medical-surgical unit. The nurse plans the patients' care and instructs the nursing assistant to assist in repositioning patients every 2 hours. Which patients are at the greatest risk for complications if not repositioned properly? Select all that apply. 1. A 20-year-old unconscious patient 2. A 90-year-old frail patient 3. A 65-year-old patient who is visually impaired 4. A 40-year-old patient who has paraplegia 5. A 30-year old patient who has cholecystitis

1,2&4 Rationale Patients who are at the greatest risk for complications if not properly repositioned are those who are unconscious, frail, or paralyzed. The 20-year-old unconscious patient is at risk for pulmonary and cardiac complications, and at risk for deteriorated skin condition. The 90-year-old frail patient would be unable to change position independently. The 40-year-old paraplegia patient would be unable to move independently and is at risk of complications. The 65-year-old patient with visual impairment and the 30-year-old patient with cholecystitis can move by themselves. These patients are not at risk for developing complications. pp. 413, 420, 428

After assessing the patient's foot, the primary health care provider concludes that the patient has Morton's neuroma. Which symptoms are associated with this condition? Select all that apply. 1. Pain in the foot 2. Burning of the foot 3. Swelling of the foot 4. Thickness of the foot 5. Numbness of the foot

1,2&5 Rationale Morton's neuroma is a common condition that affects middle-aged women. Symptoms include foot pain and numbness and a burning sensation in the foot. Foot swelling, which is known as bunions, is a common problem that affects older adults. The thickness of the foot, which is known as calluses, is a common problem that affects older adults. p. 824

Which statements are correct regarding the perineal care of a male patient? Select all that apply. 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 Rationale The shaft of the penis must be cleaned gently because vigorous cleaning may cause an erection. The abduction of the legs provides easier access to the scrotal tissues. If the patient is uncircumcised, the nurse should retract the foreskin. The urethral meatus should be cleaned in a circular motion to prevent microorganisms from entering the urethra. The anus and buttocks area must be cleaned using a front to back motion to prevent infection. p. 859

The nurse is monitoring an older adult patient who has undergone coronary artery bypass graft (CABG) for blocked blood vessels of the heart. Which dermatological findings in the patient indicate healthy skin? Select all that apply. 1. Pink color 2. Symmetry 3. Supple skin 4. Warm skin 5. Hair follicle density

1,3&4 Rationale Changes in color, thickness, temperature, and hydration of the skin are various dermatological presentations that help the nurse to differentiate between healthy and unhealthy skin. A pink color indicates healthy skin. Suppleness of the skin indicates that the skin is well hydrated, and warm skin indicates adequate circulation. Symmetry and hair follicle density do not indicate significant pathological change in postoperative patients. p. 822

What are common foot problems in older adults? Select all that apply. 1. Corns 2. Bruises 3.Calluses 4. Bunions 5. Resiliency

1,3&4 Rationale Corns, calluses, and bunions are common foot problems in older adults. Bruises are seen on the skin of older adults. Resiliency is the loosening of the shape of the skin; this condition is observed in older adults. p. 824

The nurse is caring for a patient with acute respiratory distress syndrome. While positioning the patient, the nurse observes hyperextension of the lumbar spine. Which patient positioning would likely have caused this condition? 1. Sims' position 2. Prone position 3. Side-lying position 4. Supported Flower's position

2 Rationale Prone positioning is most suitable for patients with acute respiratory distress syndrome and acute lung injury. The potential trouble points with patients in the prone position include hyperextension of the lumbar spine and neck hyperextension. The trouble points of the Sims' position and the side-lying position are lateral flexion of the neck and lack of foot support. The trouble points of the supported Fowler's position are increased cervical flexion and pressure on the posterior aspects of the knee. p. 430

What is the name of the crescent-shaped white area present in the nail body? 1. Cuticle 2. Lunula 3. Nail bed 4. Nail groove

2 Rationale The crescent-shaped white area of the nail body is called the lunula. The nail groove is hidden by the cuticle. The nail bed is a thin layer of the epithelium under the nail. The root of the nail is located in the skin at the nail groove. p. 822

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 Rationale The dermis is a layer of skin formed by bundles of collagen and elastic fibers. It is thick and underlies the epidermis. The epidermis is comprised of several thin layers of epithelial cells. Dead cells are replaced by new cells generated by the innermost layer of the epidermis. Hair follicles, sebaceous glands, and sweat glands are present in the dermal layer of the skin. p. 822

Which nursing action is most appropriate when making a bed for a patient who has draining wounds? 1. Checking whether the wheels of the bed are locked 2. Frequently inspecting the bed for soiled or wet linens 3. Checking the bed linens for food particles after meals 4. Performing bed making while the patient is out of the room for tests

2 Rationale The nurse should frequently check the linens of patients who have draining wounds to see whether they are soiled or wet due to the exudates that have drained from the wound. Checking whether the wheels of the bed are locked helps prevent the patient from accidentally falling from the bed. This intervention is appropriate with all patients. Checking the bed linen for food particles after meals helps maintain hygiene; this intervention may not be the most appropriate while performing bed making for a patient with draining wounds. Making a bed is generally performed while the patient is out of the room for tests. This intervention is appropriate with all patients. p. 848

A registered nurse delegates perineal care of a male patient to the nursing assistive person. Which action of the nursing assistive person requires the registered nurse's follow-up? 1. Assisting the patient into a supine position in the bed 2. Cleaning the tip of penis as the final step in perineal care 3. Cleaning the tip of the penis with a circular motion, starting at the meatus 4. Using a gloved hand to grasp the shaft of the penis in order to retract the foreskin

2 Rationale The nurse should wash the tip of penis first to prevent contaminants from the perineum or anus from entering the urethra. A male patient should be assisted into supine position while being provided perineal care. The nurse should clean the tip of the penis with a circular motion, starting at the meatus. This direction of cleaning moves from an area of least contamination to an area of most contamination. The nurse should use gloves while providing perineal care to the patient to prevent the transmission of infections and to ensure safety. p. 859

Which action performed by the nurse is inappropriate while implementing care to patients in a health care facility? Providing care with a flexible attitude Being judgmental and confident while providing care Planning rest periods while caring for a patient who is tired Developing new ways of providing care to patients with impaired self-care ability

2 Rationale While providing hygienic care, the nurse should be nonjudgmental and confident. The nurse should provide care with an attitude of flexibility because of variations in the patient's physical status and hygiene practices. The nurse should pace activities and plan rest periods while caring for a patient who is tired to prevent exhaustion. The nurse should also develop new ways of providing care to patients with impaired self-care ability. p. 826

Which suggestion made by the nurse is appropriate for reducing mechanical irritation? 1. "You should use alkaline soap." 2. "You should use smooth linen cloths." 3. "You should avoid the use of dry razors." 4. "You should avoid the use of deodorants."

2 The use of smooth linen cloths can reduce mechanical irritation. Alkaline soaps neutralize the protective acid condition of the skin. The use of deodorants can cause chemical irritation. The use of dry razors can cause scraping or stripping of the epidermal surface. p. 822

The nurse evaluates the knowledge of the nursing assistive person after teaching the process of washing a patient's abdomen. Which statements of the nursing assistive person need correction? Select all that apply. 1. A towel maintains warmth and privacy. 2. Draping causes the exposure of body parts. 3. Keeping the skin folds clean and dry prevents skin irritations. 4. Dressing the affected side causes a decreased range of motion. 5. Moisture that collects in the skin folds predisposes the patient to skin maceration.

2&4 Rationale Draping involves covering or wrapping loosely; this action prevents the unnecessary exposure of body parts. Dressing the affected side first allows for easier manipulation of the gown above the body part with reduced range of motion (ROM). A towel maintains warmth and privacy, in addition to preventing the soiling of bed linen. Keeping the skin folds clean and dry prevents skin irritation or allergic reactions. Moisture and sediment that collect in the skin folds predispose the patient to skin maceration. p. 857

The nurse is caring for different patients. Which patient's condition may benefit from logrolling? 1. Head injury 2. Hand fracture 3. Spinal cord injury 4. Abdominal surgery

3 Rationale Patients with a spinal cord injury often need to keep the spinal column in straight alignment to prevent further injury. Therefore, logrolling would be beneficial for this patient to prevent further injury. A patient with head injury would benefit from the semi-Fowler's position. A patient with a hand injury and a patient with an abdominal surgery are placed in the supine position. p. 438

The nurse is making an occupied bed. Which actions would help in reducing the transmission of microorganisms? Select all that apply. 1. Pull room curtains around the bed while making the bed. 2. Perform hand hygiene and apply clean gloves. 3. Wipe off any moisture on exposed mattress with a towel. 4. If the bedspread and linens are soiled, place them in a linen bag. 5. Position the patient on the far side of the bed, turned onto the side, facing away.

2,3&4 Rationale Performing hand hygiene and using clean gloves [1] [2] [3] prevent the spread of infection from the nurse to the patient. Any moisture on the bed should be wiped off to prevent the transmission of infection. The soiled bedspread and bed linens should be disposed of in the linen bag to reduce transmission of microorganisms. Pulling room curtains around the bed maintains the patient's privacy but does not prevent the spread of microorganisms. Turning the patient onto the side provides space for the placement of clean linens. p. 849

A patient is being transferred from bed to stretcher. Which precautions should the nurse take to ensure patient safety during transfer? Select all that apply. 1. Release the brakes of the bed to allow movement. 2. Raise the bed to the level of the stretcher. 3. Cross the patient's arms on chest while transferring. 4. Involve multiple caregivers for safe transfer. 5. Unlock the stretcher's wheels once it is in place alongside the bed.

2,3&4 Rationale The bed should be raised to the level of the stretcher to allow the patient to slide from the bed to the stretcher. Keep the patient's arms crossed when transferring to prevent any injury to the arm. Three caregivers are needed to transfer a patient safely and are positioned specifically to minimize caregivers stretching. The bed brakes should be locked to prevent it from moving. Once the stretcher is placed alongside the bed, the wheels should be locked to prevent further movement. p. 431

What tasks should be done when the nurse makes a patient's bed? Select all that apply. 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 5. Placing soiled linens in special linen bags before placing them in a hamper

2,4&5 Rationale The nurse should always raise the patient's bed to an appropriate height before changing linens. Linens should be straightened throughout the day. Soiled linens should be placed in a special linen bag to avoid transmitting infections. Top sheets and spreads should not be tucked or mitered at the corners. Shaking the soiled linens will transmit infections; therefore, this action should be avoided.

The nurse is giving a patient a bath. Which nursing intervention is beneficial for the patient 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 Rationale Before washing the patient's hands and fingernails, the nurse should soak the patient's hands in water for 2 to 3 minutes. This softens cuticles and calluses of the hand, loosens debris beneath the nails, and enhances the feeling of cleanliness. The nurse should cut the patient's fingernails after soaking them in water because the soak softens the nails and helps in the easy removal of nails. Alkaline soap residue is irritating to the skin and can decrease the normal protectiveness of acid pH. Moisturizing the patient's hands should not be done right before washing. p. 857

Which action may increase the risk of amputation in a patient who has diabetes mellitus? 1. Avoiding garters 2. Wearing dry socks 3. Wearing tight shoes 4. Avoiding knee-high nylons

3 Rationale Diabetic patients should avoid wearing tight shoes because the patient may develop poor circulation in the feet and be at a higher risk for amputation. Wearing garters may also result in amputation. The use of knee-high nylons should also be avoided. Dry socks should be worn to preventing the risk of infection. p. 863

Which action made by the patient may result in excessive skin dryness? 1. Using adhesive tape 2. Using oval corn pads daily 3. Using nail polish remover frequently 4. Using over-the-counter liquid preparations for removing corns

3 Rationale Excessive drying is associated with the frequent use of nail polish removers. In older adults, removing adhesive tape causes skin tearing. Using oval corn pads exerts pressure on the toes and decreases circulation in the feet. The use of over-the-counter liquid preparations should be avoided for removing corns because of the risk of burning and ulceration. p. 863

The nurse instructs a chlorhexidine gluconate (CHG)-sensitive patient to limit complete baths. What is an unexpected outcome in a patient who is using CHG cloths? 1. The patient is unable to cooperate in bathing 2. The patient is excessively tired and is unable to participate in bathing 3. The patient has excessive dryness, rashes, or pressure ulcers appear on the skin 4. The patient's rectum, perineum, or genital area is inflamed or has a foul-smelling odor

3 Rationale Excessive dryness, rashes, or pressure ulcers appearing on the skin is an unexpected outcome of hygiene care that can occur in the patient. The nurse should suggest that the patient limit complete baths if the patient has an increased sensitivity to chlorhexidine gluconate (CHG). The nurse should reschedule bathing to a time when the patient is more rested, and notify the primary health care provider if the patient is unable to cooperate or is too tired to participate in bathing. If the patient's rectum, perineum, or genital areas are inflamed or have a foul-smelling odor, this may indicate an infection. p. 862

Which condition is observed by placing the patient in the Sims' position? 1. Excessive lateral flexion 2. Increased cervical flexion 3. Lateral flexion of the neck 4. Plantar flexion of the ankles

3 Rationale Patients positioned in the Sims' position may suffer from lateral flexion of the neck. Excessive lateral flexion of the spine may occur if a patient is positioned in a side-lying position. Patients positioned in the prone position may experience plantar flexion of the ankles. Increased cervical flexion is observed in patients positioned in the supported Fowler's position. p. 430

The nursing student is performing range-of-motion (ROM) exercises for a patient who has been immobile for an extended period. Which action performed by the nursing student needs correction? 1. Performing ROM exercises when the pain score is 2 2. Performing ROM exercises 5 times during a session 3. Performing ROM exercises from smaller joints to larger joints 4. Performing ROM exercises by extending the joint as much as possible

3 Rationale The nurse should perform the ROM exercises from larger joints to smaller joints. Because a pain score of 0 is not possible, a pain score 2 is considered as a minimum in which ROM exercises can be performed. The movements should be repeated 5 times during each session. The joint can be extended as much as possible, but it should not be extended beyond resistance, and force should not be applied to perform the ROM exercises. p. 431

After teaching a female patient about perineal care, a registered nurse evaluates the patient's understanding. Which action of the patient indicates effective learning? The patient washes her perineum by wiping with warm water. The patient washes her perineum from back to front using long, firm strokes. The patient washes her perineum from front to back using a clean washcloth. The patient washes her perineum with a circular motion beginning at the urinary meatus.

3 Rationale The patient should clean her perineum from front to back with a clean washcloth to reduce the chance of transmitting fecal organisms to the urinary meatus. The patient should wash her perineum by rinsing it with warm water because rinsing removes soap and microorganisms more effectively than wiping. The patient should not wash the perineum with long, firm strokes, because it may create discomfort tissue irritation. The patient should not wash from back to front. p. 858

While caring for a postoperative patient, the nurse spreads trochanter rolls on the bed before positioning the patient. In which position is the nurse preparing to place the patient? 1. Sims' position 2. Prone position 3. Supine position 4. Supported Fowler's Position

3 Rationale Trochanter rolls are used to increase comfort for the patient and to reduce the risk of injury to the skin and musculoskeletal system when the patient is placed in the supine position. In the Sims' position, the patient places the weight on the anterior ileum, humerus, and clavicle. Trochanter rolls would not be used in this position. In the prone position, the nurse uses pillows under the lower extremities to reduce the risk of foot drop. In the supported Fowler's position, the knees are supported to reduce the risk of deep vein thrombosis. p. 429

The registered nurse is teaching a nursing student about positioning techniques. Which statement made by the nursing student indicates effective learning? 1. "I can use a thick pillow, because it decreases cervical flexion." 2. "I can use pillows of any size to position the patient." 3. "I can use folded sheets when additional pillows are unavailable." 4. "I can use a thin pillow to protect the skin from pressure ulcers."

3 Rationale When additional pillows are unavailable, or if they are an improper size, the nurse can use folded sheets, blankets, or towels as positioning aids. A thick pillow under a patient's head increases cervical flexion, which would not be desirable. Therefore, a thick pillow should not be used. Pillows of a particular size should be used depending on the position and the patient to prevent discomfort. A thin pillow under bony prominences does not protect the skin and tissue from damage caused by pressure ulcers. p. 429

Which type of bath is beneficial to patients with skin disorders? 1. Tub bath 2. Partial bed bath 3. Therapeutic bath 4. Complete bed bath

3 Therapeutic baths are used for the promotion of healing or soothing effects; they are effective in soothing itching or skin disorders. Tub baths are commonly used for long-term care. Partial bed baths involve washing selected areas such as the head, axillae, hands, and perineal areas. Complete bed baths are provided to patients who are completely dependent; these baths are performed in the bed. p. 855

The registered nurse is teaching a student nurse about restorative and continuing care for a patient who underwent hip replacement. Which statements by the nursing student indicate effective learning? Select all that apply. 1. "I will provide a cane to facilitate walking." 2. "I will assist the patient while bathing." 3. "I will ensure that the patient can eat by him- or herself." 4. "I will ensure that the patient can take medication by himself or herself." 5. "I will ensure that the caregiver is assisting the patient during meal preparation."

3&4 Rationale The goal and focus of restorative care is on activities of daily living (ADLs) and also on instrumental activities of daily living (IADLs), such as shopping, preparing meals, and taking medications. Eating independently and taking medication by himself or herself are outcome measures of restorative care. Using a cane while walking may indicate the inability to walk without support. Bathing is an example of an ADL, and the goal of restorative care is for the patient to perform this activity without assistance. p. 431

A registered nurse teaches a nursing student about patient-centered care in hygiene practice. Which statements, if made by the nursing student, indicates the need for further learning? Select all that apply. 1. "I should recognize that some cultures prohibit touching." 2. "I should maintain privacy while caring, especially for female patients." 3. "I can uncover the lower torso of women of Middle Eastern or East Asian descent." 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."

3&4 Rationale The nurse should avoid uncovering the lower torso of patients of Middle Eastern and East Asian descent. The nurse should understand that toileting practices differ by culture. The nurse should understand that certain cultures prohibit touching. The nurse should maintain privacy while caring for female patients because some cultures are particular about female modesty. The nurse should allow the patient's family members to participate in hygiene activities to help the patient feel more comfortable. p. 824

The nurse teaching a family member caregiver how to bathe the patient explains the importance of using long strokes on the patient's extremities, moving from distal to proximal. Why is this bathing technique used? 1. To decrease the chance of infection 2. To help remove dry, flaky skin 3. To prevent skin trauma 4. To promote venous return

4 Rationale The pressure from long, smooth strokes moving from distal to proximal areas presses on the veins, which promotes venous return. This bathing technique does not decrease the chance of infection, necessarily remove dry, flaky skin or prevent skin trauma. p. 856

Which statements are true regarding the oral cavity? Select all that apply. 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.

3&4 Rationale The saliva moistens food and thereby facilitates bolus formation. Medications, exposure to radiation, dehydration, and mouth breathing impair saliva secretion in the mouth. The mucous membrane, continuous with the skin, lines the oral cavity. The floor of the mouth and the undersurface of the tongue are richly supplied with blood vessels. Strong sympathetic nervous stimulation completely inhibits the release of saliva leading to xerostomia, or dry mouth. p. 823

Which patient is more prone to ulcer formation on the skin? 1. A patient using dry razors 2. A patient using deodorants 3. A patient using depilatories 4. A patient using moisturizers

4 Rationale A patient using moisturizers is more prone to ulcer formation on the skin. Constant exposure of the skin to moisture causes maceration, which promotes ulcer formation. Scraping or stripping on the surface of the skin can occur due to the use of dry razors. Using deodorants and depilatories may cause chemical irritation of the skin. p. 822

Which nursing intervention is contraindicated while performing oral hygiene for a patient who is at a risk of oral mucositis due to chemotherapy? 1. Rinsing with a bland rinse 2. Flossing with unwaxed floss 3. Brushing gently with a soft toothbrush 4. Applying oil-based moisturizer to the lips

4 Rationale Chemotherapy may injure the oral mucosa and the patient may be at risk of oral mucositis. Therefore, the nurse should apply water-based moisturizer to the patient's lips. The nurse should not apply oil-based moisturizers. The patient should use a bland rinse. The patient should also use unwaxed floss and gently brush the teeth with a soft toothbrush. p. 832

Which site is at risk for skin breakdown when the patient is in the side-lying position? 1. Knees 2. Clavicle 3. Humerus 4. Trochanter

4 Rationale In the side-lying position, lack of protection for the pressure point at the trochanter may result in skin breakdown and pressure ulcers. Lack of protection for pressure points at the ileum, humerus,clavicle, knees, and ankles may lead to skin breakdown in the Sims' position. p. 430

Increased cervical flexion is observed when the patient is placed in which position? 1. Sims' position 2. Prone position 3. Side-lying position 4. Supported Fowler's position

4 Rationale Increased cervical flexion may occur if a patient is placed in the supported Fowler's position, because the pillow at the head is too thick and the head thrusts forward. Patients positioned in the Sims' position may experience lack of foot support. Patients positioned in the prone position may suffer from neck hyperextension. Patients positioned in the side-lying position may suffer from lateral flexion of the neck. p. 430

The nurse is caring for four different patients with immobility. Which patient should the nurse place in the supine position? 1. Patient with pressure ulcers 2. Patient with respiratory distress 3. Patient with deep vein thrombosis 4. Patient with musculoskeletal complications

4 Rationale Patients with musculoskeletal complications would benefit from being placed in the supine position. Patients with pressure ulcers would benefit from being placed in the lateral side-lying position. Patients with deep vein thrombosis should be placed in supported Fowler's position. Patients with respiratory distress would benefit from being placed in the prone position because it helps improve oxygenation. p. 430

The nurse is ordered to perform bath and perineal care for a patient. After a bath, the patient reports dizziness. Which nursing intervention during bath and perineal care may be responsible for the patient's condition? 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 very warm water for 20 minutes

4 Rationale Prolonged exposure to warm water may cause vasodilation and pooling of the patient's blood, leading to light-headedness and dizziness. Placing a disposable towel on the floor prevents slipping and falling. The nurse should fill the tub halfway with warm water and adjust the temperature per the patient's requirement to prevent accidental burns. Drying skin for 30 minutes helps to prevent chilling. p. 861

The nurse is preparing to clean the neck, back, and buttocks of an unconscious patient. Which type of chlorhexidine gluconate (CHG) cloth should the nurse use? 1. Cloth 3 2. Cloth 4 3. Cloth 5 4. Cloth 6

4 Rationale The nurse should use chlorhexidine gluconate (CHG) cloth 6 to clean the back of the neck, back, and buttocks of an unconscious patient. CHG cloth 3 is useful to clean the patient's abdomen and perineum. CHG cloth 4 is used to clean the right leg, right foot, and web spaces. CHG cloth 5 is used to clean the left leg, left foot, and web spaces. p. 860

The registered nurse is teaching a nursing student about the safety guidelines for nursing skills. Which statement by the nursing student indicates the need for further learning? 1. "I should raise the side rail on the opposite side of the bed from where I'm standing." 2. "I should evaluate the patient for correct body alignment." 3. "I should determine the type of assistance required for safe positioning." 4. "I should arrange the positioning equipment as close as possible to the patient's bed."

4 Rationale The positioning equipment should be arranged in such a way that it does not interfere with the positioning process; therefore, the equipment should not always be placed next to or too far away from the bed, but should be placed appropriately. The side rails on the side of the bed should be raised on the opposite side where the nurse stands to prevent the patient from falling out of the bed. The nurse should evaluate the patient for correct body alignment and pressure risks after repositioning. The nurse should determine the amount and type of assistance required for safe positioning, including any transfer equipment and the number of personnel to safely transfer the patient. p. 433

The nurse is making an occupied bed for a patient.. The soiled bedspread and blanket are removed and discarded in a linen bag. Then the patient is positioned on the far side of the bed with the patient facing away from the nurse. The nurse finds that the mattress is wet and covers it with linen. Which step followed by the nurse 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 nurse 4. Applying the linen over the wet mattress

4 Rationale When making an occupied bed[1] [2][3], the nurse should assess the requirements of the patient and take measures to reduce the transmission of microorganisms. Applying the linen on a wet mattress increases the risk for transmission of microorganisms to the patient. Therefore, the nurse should wipe off the moisture with a towel and clean the mattress with disinfectant before applying the fresh linen. The soiled blanket and bedspread should be discarded in the linen bag to prevent the spread of infection. Positioning the patient away from the nurse makes the linen change easier. p. 851

The nurse is evaluating the patient's condition after providing care for immobility. The nurse observes the condition of the patient and places the patient on a pressure-relieving mattress. Why did the nurse implement this intervention? 1. The patient avoids moving. 2. Joint contractures are worsening 3. The patient has difficulty moving. 4. The skin is showing areas of erythema and breakdown.

4 Rationale When the skin shows erythema and breakdown, the nurse should place the patient on a pressure-relieving mattress. When the patient avoids moving, the nurse administers analgesia as ordered by the health care provider. When worsening joint contractures are observed, the nurse ensures that activity and range of motion are implemented consistently. When the patient has difficulty moving, the nurse consults the physical or occupational therapist. p. 428

While positioning a hemiplegic patient in the supported Fowler's position, the nurse positions the head of the patient against a small pillow with the chin slightly forward. What is the rationale behind this nursing action? 1. Promote circulation 2. Support lumbar vertebrae 3. Prevent shoulder dislocation 4. Prevent flexion contractures

4 Rationale While positioning a hemiplegic patient who is unable to control head movement in the supported Fowler's position, the nurse should position the head on a small pillow with the chin slightly forward to prevent hyperextension of the neck. Using pillows to support the arms and hands of a patient who does not have voluntary control promotes circulation by preventing venous pooling. Positioning a small pillow at the lower back of a hemiplegic patient helps support the lumbar vertebrae and decreases flexion of the vertebrae. Use of pillows to support arms and hands may help prevent shoulder dislocation from the effect of a downward pull of unsupported arms. p. 435

The nurse is assisting a patient in the supported supine position. Which nursing action should the nurse implement to reduce the rotation of the hip? 1. Placing pillows under the upper shoulders 2. Placing pillows under the pronated forearms 3. Placing small rolled towel under the lumbar area of back 4. Placing trochanter rolls parallel to the lateral surface of the thighs

4 Rationale While positioning the patient in the supine position, the nurse should place trochanter rolls or sandbags parallel to the lateral surface of the patient's thighs if the patient is immobile. Placing pillows under the upper shoulders, neck, or head helps in maintaining the correct body alignment and prevents flexion contractures of the cervical spine. The nurse places pillows under the pronated forearms and keeps the upper arms parallel to the patient's body to reduce the internal rotation of the shoulder and prevent extension of the elbows. Placing a small rolled towel under the lumbar area of the back provides support to the lumbar region. p. 436

While caring for a patient with immobility, the nurse positions the patient in the supported supine position. The nurse places pillows under the pronated forearms keeping the upper arms parallel to the patient's body. What is the reason for this nursing action? 1. To reduce extension of fingers 2. To maintain correct body alignment 3. To provide support to the lumbar spine 4. To reduce the internal rotation of shoulders

4 Rationale While positioning the patient in the supported supine position, the nurse places pillows under the pronated forearms, and keeps the upper arms parallel to the patient's body to reduce the internal rotation of the shoulder and prevent extension of the elbows. Placing the hand rolls in the patient's arms helps reduce the extension of the fingers and abduction of the thumb. Placing pillows under the upper shoulders, neck, or head helps in maintaining the correct body alignment and prevents flexion contractures of the cervical spine. Placing a small rolled towel under the lumbar area of the back provides support to the lumbar spine. p. 436

The nurse reviews the data of four patients who are at a risk of developing feet and nail problems. Which patient may be at a risk of increased friction and pressure on the feet? Patient A- Stroke Patient B- Heart Failure Patient C- Diabetes mellitus Patient D- Peripheral vascular disease

Patient A Rationale A patient with a stroke or cerebrovascular accident may have residual foot or leg weakness or paralysis, resulting in altered mobility. An altered gait may ultimately lead to increased friction and pressure on the feet. A patient with heart failure may be at a risk of increased tissue edema, particularly in dependent areas such as the feet. A patient with diabetes is at a high risk for skin infections. A patient with peripheral vascular disease may develop a break in skin integrity due to reduced blood flow to peripheral tissues. p. 863