Upgrade to remove ads
Ch 9 studyguide
Terms in this set (55)
Only the rules of touch are typically unspoken and Unwritten there are usually visible to the Observer
Urinary incontinence is
Is not based on age
Medicare and Medicaid will not
Cover the cost of treating pressure ulcers that developed during the patient's hospitalization
When the external pressure against the skin is greater then the pressure in the capillary bed blood flow ________ to the adjacent tissues
Assisting a patient with hygiene give the nurse an opportunity to perform a complete and thorough
The recommended room temperature for most adults is
68° to 74° F (20° to 23°C)
If external pressure on the skin or tissues continues without relief for more than _____ our sales in the involve layers of skin tend to undergo necrosis
Inserting objects into the internal auditory canal can damage the _____ or cause _____ to become impacted in the canal
Tympanic membrane(ear drum)
Patients who are in mobilize, poorly nerves, and have reduced sensation are at risk for impaired ______
The nurse is teaching a patient who has diabetes about foot care. What should be included in the self care instructions?
Inspect feet daily for breaks in the skin
An older adult patient wears dentures, and the nurse will delegate the denture care to the UAP. What instruction should the nurse give to the UAP about the patient's dentures?
Brush Dentures with a soft toothbrush
Andela getting the early morning care that should occur before breakfast, what does the nurse remind the UAP to do for the patient?
Help the patient wash hands and face
A patient who is paralyzed from the waist down is at risk for developing a pressure ulcer on the sacral area. Which intervention would the nurse use for this patient?
Teach to shift way every 15 minutes
Well completing the bath a nurse notices a red area on the patient's sacrum. What should the nurse do first?
Assess for other areas of erythema
The nurse is assessing the oral cavity of an unconscious patient and she's tenacious, Drive exudate on the tongue, teeth and gums. What instructions should be given to the UAP?
Use a moisten sponge applicator and gently clean crust several times for shift
The nurse is evaluating that I care that has been delegated to and is being provided by a new staff member. Which action is appropriate?
Removing dried secretions with moist guaze
The nurse observes a patient performing ear care. Identify which behavior indicates a need for additional teaching?
Leaves hearing aid by Sunny window
The nurse is caring for a postpartum patient. Which assessment should the nurse perform first before starting perineal care?
Assess ability to perform own care
A nurse is caring for an elderly patient he requires assistance with elimination. He can walk very slowly but it's frequently incontinent Fern before he can get to the toilet. What should the nurse do to help the patient with elimination?
Instruct the UAP to be alert for the call signal and answer promptly
Show the patient how to use a urinal and place it within his reach
Obtain an order for a commode chair and place it close to the bed
Make a plan with the patient to call sooner rather than delaying
The nurse student is told to observe the bounding and 7 adult patient and Report any abnormalities to the nurse. What should the student report as an unexpected finding?
Stool was a dull clay color
The nurse is caring for a new patient who needs assessment skin and self-care abilities perineal care partial bath in the bed linen change. The patient is very obese. What is the best strategy to meet the needs of the patient?
Assess skin and self-care abilities while working with the UAP to Complete Care
Which patient is most likely to request that the room temperature be turned down?
Has chronic pulmonary disease
The nurse is caring for elderly residents in an assisted living facility. What is the best strategy to prevent skin breakdown among this vulnerable group?
Instruct UAP to help residents out of bed as much as possible
A family member tells the nurse that the staff is spending too much time laughing and chatting at the nurses station and it's disturbing the patients rest and comfort. What should the nurse do first?
Assess the patient's discomfort and ask what other things are interfering with rest
The nurse is supervising a nursing student he was giving a patient bed bath. The nurse would intervene if the student performs which action?
Pets up all four side rails after completing the bath
The nurse instructed the UAP to encourage the patients Independence in accomplishing adl's which behavior best indicates that the UAP understood what to do?
The nurse observe the patient is brushing his own teeth
Unconscious patient Oral Care what instruction should the nurse give to the UAP to ensure the safety of the patient?
Position the patient upright use pillows for support as needed
Report bleeding sores in the mouth or obvious problems with teeth or gums
Use a soft toothbrush and brush teeth as for any other patient
Have an oral suction device ready and check function prior to starting.
Perform hand hygiene before donning clean gloves
And never tells the nurse that he has muscle soreness and stiffness after performing a new exercise program. What was a nurse recommend?
A tub bath with the proper temperature of 113° to 115° F (45° to 46° C)
A patient with dementia and need assistance with bathing. What strategies are best to use to help the patient accomplish this task?
Maintain a relaxed demeanor smell frequently and use a calm tone of voice
Reassure frequently and say things such as you are doing well we are almost done
Use destructions rather than trying to negotiate or making demands
Attempt to have the same caregivers as often as possible for hygienic care
How bathing may be affected or altered if the patient is extremely fatigued
Perform only the care that is absolutely necessary for comfort and safety
How bathing may be affected or altered if the patient is on complete bed rest
Assist with bath and Oral Care Etc while patient is in bed
How bathing may be affected or altered if the patient has right-sided paralysis following a CVA
Encourage them to do as much hygiene care as possible with left-arm assisting when necessary
How baby may be affected or altered it there is inflammation of the perianal tissue
How bathing may be affected or altered if the patient is an eastern Indian Hindu
Hygiene is very important daily baths as part of their religious Duty bathing after meal or water is too hot may be avoided
How baby may be affected or altered if the patient is an older adult who is incontinent
Special Care given to plans and dry the skin carefully perineal care may be more frequent and Skin Barrier cream can be applied
What is the bass that aids in reduction of inflammation of the perineal and anal area
The LPN is giving a bed bath to a patient with diabetes Well assessing the skin which area of the body needs special attention?
A patient is noted with a pressure ulcer on his sacrum. The pressure ulcer has full thickness skin loss with necrosis of the subcutaneous tissue which classification is this pressure ulcer?
A bed fast patient has a sacral pressure ulcer. How often does the nurse instruct staff to reposition the patient?
Every 2 hours
The nurse is doing discharge teaching with a female patient who is going home with a Foley catheter. Which statement by the patient indicates a need for further teaching?
I will wash my perineum from Back to Front
The nurse is caring for a immobile patient with in continuance and poor nutrition. What nursing diagnosis best describes patients problem?
Impaired skin integrity
What is the purpose of positioning a patient at the 30 degree lateral position
Reduction of pressure points
Patient is hard of hearing your makes his hearing aid before going to bed. What is an important step for the patient to remember?
Turn off the battery
A patient receiving anticoagulant therapy is requesting touche. What is the nurses most appropriate response the patient?
You will be able to shave with only an electric razor
Nurses set an example for patients regarding hygiene. What personal hygiene measures should the nurse display?
Wear clean uniform everyday
Keep fingernails clean short and manicure
Use breath mints
Which is not a factor affecting personal hygiene
What room temperature is good for a patient hospital room?
68° to 74° F
A sitz bath cleanses which area?
Perineal and rectal areas
Which is a type of substance used for a medicated bath?
Which condition contraindicates a massage?
Which type of patient is prone to develop a pressure sore?
Confused female with a diagnosis of pneumonia who is lethargic and unable to utilize the call light for assistance
Which skin integrity problem can occur when improperly lifting or pulling a patient up in bed?
Which type of physician should be consulted for a diabetic patient with thick long yellow toenails?
Which type of perineal care should be performed at least twice a day?
Urinary catheter care
When cleansing this area the nurse should use Clear clean water only.
You might also like...
NURS 112: NCLEX questions - Taylor Ch 31
Sherpath wk 5
Assessment Related to Hygiene and Personal Care
ch 19 fundies
Other sets by this creator
PN Management A
PN Management B
Leadership and Management