Terms in this set (35)
Excoriation(red, scaly areas with surface loss of skin tissue) occurs in patients whose skin is exposed to bodily fluids such as stool, urine, or gastric juicesPediculosisinfestation with liceGingivitisSores anywhere in the oral cavity, (inflammation of the gums),Halitosisfoul-smelling breathMacerationbreakdown of the skin caused by fluidAn ambulatory diabetic patient states that she is unable to reach her feet to clip her toenails. The patient's toenails are long and thick. What is the next step the nurse should take? a. Soak the patient's feet, and trim her toenails using clippers. b. Delegate foot care of this patient to the unlicensed assistive personnel (UAP). c. Assess the patient's self-care status. d. Ask for a referral to a podiatrist.d. Ask for a referral to a podiatrist.An alert and oriented elderly male patient has been admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). He is unshaven, has unkempt hair, and has a foul body odor. Asking which hygiene-related assessment question is a priority for the nurse? a. "Do you have friends or family nearby?" b. "Can you raise your arms up to brush your teeth?" c. "Do you become short of breath during your shower?" d. "Are you able to get in and out of your bed at home?"c. "Do you become short of breath during your shower?"Which action by a female patient lets the nurse know that the patient has understood perineal care teaching? a. The patient washes her perineum with a circular motion beginning at the urinary meatus. b. The patient washes her perineum from front to back using a clean washcloth. c. The patient washes her perineum from back to front with long, firm strokes. d. The patient washes her perineum lightly to prevent tissue damage.a. The patient washes her perineum from front to back using a clean washcloth.What should the nurse do before leaving a patient's room after giving a complete bed bath? a. Place the call light within reach, and leave the bed as it was during the bath. b. Lower the bed to its lowest position, raise all four side rails so that the patient does not fall out of bed, and place the call light within reach. c. Lower the bed to its lowest position, raise the top two side rails to assist the patient in turning and positioning, and place the call light within reach. d. Leave the bed in a position that is comfortable for the caregiver because more care will be needed, raise the top two side rails, and place the call light within reach.c. Lower the bed to its lowest position, raise the top two side rails to assist the patient in turning and positioning, and place the call light within reach.Which actions by the nurse concerning oral care on an unconscious patient are considered safe? (Select all that apply.) a. Performing oral care with the patient in a supine position b. Performing oral care with the patient turned to the side c. Installing suction equipment at the bedside d. Providing oral care every 2 hours e. Using a hard-bristle toothbrushb.Performing oral care with the patient turned to the side c.Installing suction equipment at the bedside d.Providing oral care every 2 hoursWhich safety precaution is a priority for the nurse when bathing a patient with peripheral neuropathy? a. Keeping the top two side rails up during the bath b. Checking the bath water temperature before the bath c. Encouraging independence with perineal care during the bath d. Facilitating range-of-motion exercises and dangling before the bathb. Checking the bath water temperature before the bathWhich nursing diagnosis is a priority for a patient who needs assistance with activities of daily living? a. Self-Care Deficit b. Deficient Knowledge c. Risk for Activity Intolerance d. Readiness for Enhanced Self-Carea. Self-Care DeficitWhich statements are true regarding back massage? (Select all that apply.) a. Only a licensed massage therapist can perform back massage. b. Back massage may stimulate the deep muscles. c. Massage provides relaxation and comfort. d. Tapotement stimulates the skin. e. A massage may promote sleep.b.Back massage may stimulate the deep muscles. c.Massage provides relaxation and comfort. d.Tapotement stimulates the skin. e.A massage may promote sleep.A patient diagnosed with head lice has an order for pediculicidal shampoo. Which statement is true about this shampoo? a. It can be used only on patients with the ability to stand in the shower. b. It can cause central nervous system side effects, including dizziness. c. It is used by pregnant women and young children. d. It is safe for patients with seizures.b. It can cause central nervous system side effects, including dizziness.Which statement indicates an understanding by the UAP of eye care during a patient's bath using washcloths and a bath basin? a. "The eyes are washed with soap and water from the inner canthus to the outer canthus." b. "The eyes should always be washed using sterile normal saline and a gauze sponge." c. "The eyes are washed from the outer canthus to the inner canthus using water only." d. "The eyes are washed with water using a clean part of the washcloth for each eye."d. "The eyes are washed with water using a clean part of the washcloth for each eye."1. Which area of the body is most likely to be excoriated? a. Elbows b. Facial skin c. Cervical spine d. Perineumd. Perineum Areas of the body that are prone to excoriation are those exposed to bodily fluids such as stool, urine, gastric juices, or sweat, as well as where skin touches skin.2. Which nursing action is necessary for patient safety during a bed bath? a. All four side rails are always kept in the raised position during the bath. b. The bed is always in the low and locked position while bathing the patient. c. The top side rail is raised opposite the side where the nurse is standing. d. The bed is always kept in a flat position with a pillow under the patient's head.c. The top side rail is raised opposite the side where the nurse is standing. The bed is raised to a comfortable working position and the side rail is lowered on the side where the nurse is standing. It is important to leave the bed in the low and locked position with the top side rails up when the bath is finished and the nurse is leaving the room. The position of the bed and the patient during the bath is dependent on the patient's condition and comfort level.3. Which statement accurately describes proper technique for performing male perineal care? The nurse a. washes the patient from the back of the perineum toward the penis. b. washes with a circular motion starting with the urinary meatus. c. places the patient in the prone position with supporting pillows. d. places the patient in the dorsal recumbent position.b. washes with a circular motion starting with the urinary meatus. During male perineal care the penis is cleansed with soap and water using a circular motion starting at the urinary meatus in order to keep pathogens away from the urinary tract. The shaft of the penis is then cleansed using firm downward strokes. The patient is usually in the supine position with the bed either flat or the head of the bed raised.4. The nurse has delegated care of a patient's dentures to unlicensed assistive personnel. Which statement by the assistive personnel indicates an understanding of denture care? a. "It is not necessary to use a toothbrush in the patient's mouth since the patient does not have teeth." b. "I will wrap the dentures in a tissue so that they will not get damaged and place them on the bedside table within reach of the patient." c. "I will put on clean gloves and brush the dentures gently with a toothbrush and toothpaste." d. "I will soak the dentures in the sink and then place them in a denture cup labeled with the patient's name."c. "I will put on clean gloves and brush the dentures gently with a toothbrush and toothpaste." Dentures are brushed with a regular toothbrush and toothpaste over a sink that has been padded with a washcloth to prevent breakage if they are accidentally dropped. The patient's mouth should be cleansed with a soft brush or toothette after the dentures are removed and before they are reinserted. Never wrap dentures in a tissue because they may accidently be discarded. Soaking dentures in a sink where nurses and patients wash their hands is contraindicated because pathogens may be present in the sink.5. Which assessment finding by the nurse indicates a complication from oxygen via nasal cannula? a. Dry nasal passages b. Inability to speak clearly c. Increased nasal drainage d. Skin breakdown on the china. Dry nasal passages Oxygen via nasal cannula can be drying to the nares. Use of a nasal cannula does not affect the patient's ability to speak and should not increase drainage. Pressure areas from a nasal cannula may include the nares, the cheeks, and the top front crease of the auricle of the ear but not the chin.6. Which statement is most accurate about hearing aid and ear care for hospitalized patients who are hard of hearing? a. Hard of hearing patients should wear hearing aids at all times while hospitalized. b. Hearing aids should be cleansed daily with soap and water before reinsertion. c. Cerumen is removed with a cotton-tipped applicator before inserting hearing aids. d. Hearing aids are cleansed with a dry cloth and stored in a labeled container.d. Hearing aids are cleansed with a dry cloth and stored in a labeled container. Hearing aids are an electronic device and therefore are cleansed with only a dry cloth. Some patients prefer to remove their hearing aids while sleeping. Using cotton-tipped applicators is contraindicated in any patient because the cerumen may be pushed further into the ear canal. When not in use, hearing aids are stored in a container labeled with the patient's name to prevent misplacement.7. Which procedure is correct when making an occupied bed? a. The bed is left in the low and locked position for patient safety. b. The bed is made starting at the head and working toward the feet. c. Soiled linen is loosened on one side of the bed and rolled under the patient. d. Making an occupied bed cannot be delegated to unlicensed assistive personnel.c. Soiled linen is loosened on one side of the bed and rolled under the patient. When making an occupied bed, one side of the bed is stripped and made first while the patient is rolled to the opposite side. The patient is then rolled over the linens and the second side is made. Bed making may be delegated to unlicensed assistive personnel after reviewing specific patient limitations.8. Which statement by a patient with the nursing diagnosis of Self-Care Deficit would indicate attainment of the goal: Patient will actively participate in bathing within 24 hours after surgery? a. "I need help with my bath." b. "I was able to wash my own feet today." c. "I am going to need assistance at home." d. "Could you help me brush my teeth this morning?"b. "I was able to wash my own feet today." An increase in the patient's ability to care for his or her own hygienic needs indicates achievement of goals related to Self-Care Deficit. The other statements indicate continued dependence with activities of daily living.9. Which statements are correct concerning bathing a hospitalized patient? (Select all that apply.) a. A complete bed bath is for patients who are bedridden. b. All hospitalized patients need a complete bed bath. c. Bathing removes dead skin, bacteria, and body fluids. d. Male personnel must always perform male perineal care. e. Keeping skin clean and dry helps prevent breakdown.a. A complete bed bath is for patients who are bedridden. c. Bathing removes dead skin, bacteria, and body fluids. e. Keeping skin clean and dry helps prevent breakdown. Bedridden patients need complete bed baths. Bathing keeps skin clean and helps prevent breakdown while removing skin, bacteria, and bodily fluids. Each patient is assessed to determine the level of care and bathing assistance needed. Personnel can perform perineal care on patients of the opposite sex, treating the patient with dignity and professionalism.10. Which hygienic care instructions by the nurse should be given to a patient who is being discharged on an anticoagulant? (Select all that apply.) a. Use an electric razor for shaving. b. Brush teeth with a soft toothbrush. c. Trim beard with double blade safety razor. d. Use caution when trimming nails with clippers. e. Deeply massage unused muscles while bathing.a. Use an electric razor for shaving. b. Brush teeth with a soft toothbrush. d. Use caution when trimming nails with clippers. Due to the risk of bleeding, only electric razors should be used by patients on anticoagulants for trimming facial hair and shaving. A soft toothbrush reduces the risk of damage to the gums. Other sharp instruments such as nail clippers are used with caution to avoid cutting skin. Deep massage may cause bruising in patients on anticoagulants.
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