Question 1

The nurse is shampooing a client's hair.Which assessment finding should the nurse consider as expected?

Accepted Answer

It is expected for the client's hair to have a smooth texture and not be oily or dry following a shampoo. Dry, dark, and thin hair may indicate damage or poor quality of hair. Smooth, taut, and shiny hair may indicate excessive oiliness from overproduction of sebum. A tender, warm scalp may indicate inflammation or infection.

Question 2

The nurse is preparing to bath a client on the first postoperative day.Which nursing intervention should take priority?

Accepted Answer

Raising the side rails is the priority to ensure the safety of the postoperative client during the bath. This will prevent falls or injuries from occurring while the nurse is gathering supplies. Other options such as applying lotion, changing the water, or removing soiled dressings during the bath can be done after ensuring the client's safety.

Question 3

A client's hearing aid needs to be cleaned.What action should the nurse take to complete this task?

Accepted Answer

The best choice is to clean with a dry, soft cloth. Using alcohol or other liquids could damage the hearing aid. It is also important to keep the battery out when the aid is not in use to preserve battery life, and to store it in a dry, cool place like a bedroom drawer instead of a humid location like a bathroom cabinet.

Question 4

The nurse is preparing to provide hygienic care to a client.On what will the nurse focus this care?

Accepted Answer

Hygienic care typically focuses on the client's personal hygiene, including bathing and cleaning the hair. Clothes, family, and nutrition are important considerations for overall client care but do not necessarily fall under hygienic care.

Question 5

During the morning bath of a client,the nurse identifies areas of erythema below the client's breasts.What should the nurse do to enhance comfort and healing for the client?

Accepted Answer

Washing the skin carefully will remove any dirt or debris that could irritate the skin and promote healing.

Question 6

A client tells the nurse that bathing is done at the sink in the bathroom at home because it is difficult to physically lift the legs to get into the shower.The nurse identifies which factor as influencing this client's hygienic practice?

Accepted Answer

The client's physical ability, or lack thereof, to lift their legs to get into the shower is an example of health and energy influencing their hygienic practice.

Question 7

The nurse is preparing to shave a client.Which action step should the nurse consider when providing this care?

Accepted Answer

The nurse should rinse the razor after each stroke to remove hair and shaving cream, ensuring a clean and effective shave.

Question 8

The nurse is preparing to provide a client with mouth care.What should the nurse do to ensure safe handling of the client's dentures?

Accepted Answer

Placing a washcloth in the bowl of the sink helps prevent the dentures from breaking if they are dropped during cleaning.

Question 9

The nurse is making a client's bed.What safety measure should the nurse implement at this time?

Accepted Answer

Placing the soiled sheet in a laundry bag is the appropriate safety measure for the nurse when making a client's bed. This prevents the transmission of infection or contamination to other surfaces in the room. Beginning at the head and moving toward the foot or mitering corners at the head of the bed are proper techniques for making a bed, but they are not specific safety measures. Preparing the client is not related to the safety of the nurse.

Question 10

The nurse is preparing to remove ticks from a client's scalp.Which actions should the nurse perform to safely remove these pathogens from the client?
(Select all that apply)

Accepted Answer

A) Using blunt tweezers to grasp the tick close to the skin's surface is the recommended method to avoid leaving tick parts in the skin. C) Washing the area with antibacterial soap before and after removal helps prevent infection. D) Pulling the tick away in a steady, perpendicular motion to the skin's surface ensures complete removal without squeezing the tick's body, which can reduce the risk of transmitting pathogens. B and E (applying heat with a match and applying petroleum jelly) are not recommended methods as they can cause the tick to release more saliva or regurgitate its stomach contents into the bite wound, increasing the risk of disease transmission.

Question 11

A client needs to have soft contact lenses removed.What should the nurse do when removing the lenses?

Accepted Answer

Gently pinching the lens and lifting it out is the proper technique for removing soft contact lenses. This helps avoid damage or irritation to the eye. Having the client look up or pulling the lower eyelid upward can also be helpful in removing the lenses, but gently pinching is the primary technique. Using the pad of the ring finger is not recommended as it can lead to damage to the eye or contact lens.

Question 12

The nurse is preparing to provide morning care to a client.What should the nurse explain to the client as the reason for a daily bath?

Accepted Answer

A daily bath helps to stimulate circulation, which is beneficial for the client's overall health and well-being.

Question 13

The nurse is making an occupied bed.Which step will provide comfort for the client during this linen change?

Accepted Answer

Allowing for a toe pleat prevents pressure on the client's toes, enhancing comfort during the linen change.

Question 14

The nurse identifies the diagnosis Self-Care Deficit related to cognitive impairment as appropriate for a client.What should the nurse select as an expected outcome for this client?

Accepted Answer

The expected outcome for Self-Care Deficit related to cognitive impairment would involve a goal specific to improving the client's ability to perform self-care activities. Option C, “The client, with supervision, will brush her teeth,” is the most appropriate goal for this diagnosis as it focuses on improving the client's ability to perform a specific self-care activity. Options A, B, and D may be related to the client's overall care and well-being, but they are not specific to improving self-care abilities.

Question 15

A client has the nursing diagnosis Risk for Impaired Skin Integrity related to immobility.Which nursing intervention should be identified for this client's problem?

Accepted Answer

Keeping linens dry and wrinkle-free helps prevent pressure ulcers and skin breakdown, which is crucial for clients at risk of impaired skin integrity due to immobility.

Question 16

A client who is ambulatory is able to get out of bed for morning care.What should the nurse assess before assisting the client out of the bed to change the linen?
(Select all that apply)

Accepted Answer

The answer of A client who is ambulatory is able...

Question 17

Unlicensed assistive personnel are caring for a client's ears.What information should be reported to the nurse?

Accepted Answer

The presence of any drainage should be reported to the nurse as it could indicate an infection or other ear-related issue that requires medical attention. Excessive earwax may not necessarily be a concern and can often be addressed through routine cleaning. The presence of a hearing aid is important information but does not necessarily require immediate attention from the nurse. Loud talking may be a preference or habit of the client and does not necessarily impact their care or require nursing intervention.

Question 18

A client's hearing aid needs to be removed.What action should the nurse perform?

Accepted Answer

The nurse should assist the client with removal when necessary to ensure proper removal without causing discomfort or injury to the client's ear.

Question 19

The nurse is reviewing assigned clients for morning care needs.Which situation could pose a threat to one client's personal hygiene?

Accepted Answer

A newly formed ileostomy can pose a threat to a client's personal hygiene due to the potential for leakage or odor, requiring special care and attention.

Question 20

A connection on a client's intravenous solution was dislodged and solution saturated the client's gown and bed linens.The nurse will provide which type of hygienic care to the client?

Accepted Answer

As-needed care (PRN care) is provided in response to an incident or client's needs, such as when a client's gown and bed linens are saturated and need to be changed outside the routine schedule.

Quiz 33: Hygiene