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Fundamental Chapter 9
Terms in this set (38)
The nurse is preparing to bathe a patient. What should the room temperature be set at?
No cooler than 68°The recommended room temperature is 68° to 74° F.
.The nurse explains that the purpose of a sitz bath is to reduce inflammation in the perineal and anal area. What is the least amount of time the nurse will instruct for a sitz bath?
20 to 30 minutes
A patient is recovering from a hemorrhoidectomy and experiences dizziness within 5 minutes when taking a sitz bath. What action should the nurse implement?
Remove the patient from the sitz bath and return to bedThe patient may become dizzy during a sitz bath due to dilation of the large vessels in the abdomen. If this occurs, the patient should be removed from the sitz bath and returned to bed. Vital signs should be assessed until they return to normal.
What should the water temperature be when preparing a tepid bath for a patient?
The nurse is assessing a patient's skin for signs of impaired skin integrity. Which finding by the nurse is considered a major manifestation?
Pressure ulcer A major manifestation of impaired skin integrity is a pressure ulcer.
A nurse assesses an area of sustained redness on the coccyx area of a resident in long-term care. What is the most likely cause of this pressure area?
Collapse of blood vessels.A pressure ulcer occurs when there is sufficient pressure to collapse the blood vessels
The nurse is caring for an unconscious patient with a risk for skin impairment. How often will the nurse plan to change the position of this patient?
Every 120 minutes
The nurse assesses a red blister over the right superior iliac area of a patient. What stage is this decubitus ulcer?
A pressure ulcer demonstrating blisters is a stage II decubitus ulcer.
.The nursing assessment of a pressure ulcer includes size, depth, pain, odor, and color of tissue. What does this evaluate?
Whether improvement is occurring
.The nurse attempts to avoid a pressure ulcer for a bedridden patient by turning the patient frequently. What is the most favorable position for the nurse to move this patient into?
One reason the nurse focuses on oral hygiene is to maintain a healthy state of the oral cavity. What is another reason to promote oral hygiene?
To stimulate appetite
A sense of well-being can stimulate appetite.
How will the nurse correctly replace a patient's dentures after cleaning?
Inserting the upper denture first
Proper hair care is important for the patient's self-image. What is the proper water temperature when shampooing a patient's hair?
Water at 110° F should be used to shampoo a patient's hair.
When must the nurse remember to use an electric razor when shaving a patient?
When a bleeding tendency is present
The nurse is bathing a patient with a deep vein thrombosis in the left leg. What modification will the nurse make when attending to the left leg?
Gently washing the leg and patting dry with a towel
The nurse is providing hand and foot care to a patient and notices the patient has extremely hard nails. Who is the person best prepared to provide nail care for patients with extremely hard nails?
How often should the nurse cleanse the meatal-catheter junction of a patient with an indwelling catheter?
At least twice a day
.The nurse is preparing to perform perineal care for the female patient. What is the best method for using a bath blanket to drape the patient?
Clear water is used to cleanse the eyes. It is important to use proper technique when cleansing the eyes to prevent infection. What direction will the water flow when cleansing a patient's eyes?
From the inner toward the outer canthus
How frequently should the nurse clean the nares of patients who have a nasogastric tube or are receiving oxygen by nasal cannula?
At least every 8 hours
The nurse must follow the principles of medical asepsis while making a patient's bed, including procedures for handling linens. How should the nurse handle soiled linens?
Hold away from the uniform
How should the nurse cleanse the meatal opening when performing male perineal care?
From the meatus outward
The nurse lowers the bed to place the patient on the bedpan. The angle of the head of the bed should be raised to:
.What does the nurse recognize is important to consider when using the nursing process to plan hygiene care of the patient?
The nurse is providing personal hygiene for a Hindu patient from India. What intervention should the nurse implement?
Give a daily bath
The nurse is assisting a patient to perform personal hygiene. What is the most important focus of the nurse when assisting this patient?
.The nurse discovers a reddened area over a patient's hip. What should be the nurse's first intervention?
Press the area gently to assess for blanching
The nurse is educating a patient regarding a tub bath. What is the maximum length of time the nurse should instruct the patient to remain in the water?
10 to 20 minutes
A patient should not stay in the water for more than 20 minutes.
Where should a nurse performing a backrub begin?
The nurse is caring for a patient experiencing presbycusis. What intervention should the nursing personnel be instructed to implement?
Speak slowly and clearly to the patient
A physician orders a patient to be placed in the Trendelenburg position. How will the nurse position the bed?
Tilted with the head of the bed down
The physician orders a patient to be placed in the reverse Trendelenburg position. How should the nurse place the bed?
Tilted with the foot of the bed down
Which guideline should be followed when giving a backrub?
Observing the skin for abnormalities
The nurse is preparing to make an occupied bed. What procedure will the nurse follow to correctly complete this task? (Select all that apply.)
Remove spread and blanket separately
Place bath blanket over patient on top sheet
Position patient to far side of bed
.The nurse avoids dragging the patient across the bed linen to decrease the potential risk of skin injury by _________.
Because of its effect on epithelization, the LPN/LVN should confirm the order to use ____________ or _____________ on a stage III pressure ulcer.
To prevent skin breakdown in a wheelchair-bound patient, the nurse teaches the patient to shift the patient's weight every _______ minutes.
As a safety precaution against breakage of dentures, the nurse should place __________ in the emesis basin before cleaning the dentures.
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