Deck 6: Client Hygiene

Question 1

The nurse prepares to delegate bathing a client to the assistive personnel (AP). Which actions are appropriate prior to delegating this task to the AP? Select all that apply.

A) Informing the AP what type of bath is appropriate
B) Describing precautions specific to the needs of the client
C) Telling the AP who to notify if there are any concerns
D) Informing the AP to encourage the client to perform as much self-care as appropriate
E) Having the AP document the bathing experience for the nurse to read later

Answer 1

A, B, D
Explanation:1. The nurse would inform the AP what type of bath and what precautions are appropriate for that specific client's needs. Although it is often faster to perform the entire bath without encouraging client participation, the AP should take the time needed and encourage the client to perform as much self-care as possible to promote the client's autonomy. The nurse does not need to tell the AP to whom to report concerns, because they should be reported to the nurse. The nurse should instruct the AP to report about the bathing experience as soon as it is completed, and the nurse would not wait to read the AP's documentation.
2. The nurse would inform the AP what type of bath and what precautions are appropriate for that specific client's needs. Although it is often faster to perform the entire bath without encouraging client participation, the AP should take the time needed and encourage the client to perform as much self-care as possible to promote the client's autonomy. The nurse does not need to tell the AP to whom to report concerns, because they should be reported to the nurse. The nurse should instruct the AP to report about the bathing experience as soon as it is completed, and the nurse would not wait to read the AP's documentation.
3. The nurse would inform the AP what type of bath and what precautions are appropriate for that specific client's needs. Although it is often faster to perform the entire bath without encouraging client participation, the AP should take the time needed and encourage the client to perform as much self-care as possible to promote the client's autonomy. The nurse does not need to tell the AP to whom to report concerns, because they should be reported to the nurse. The nurse should instruct the AP to report about the bathing experience as soon as it is completed, and the nurse would not wait to read the AP's documentation.
4. The nurse would inform the AP what type of bath and what precautions are appropriate for that specific client's needs. Although it is often faster to perform the entire bath without encouraging client participation, the AP should take the time needed and encourage the client to perform as much self-care as possible to promote the client's autonomy. The nurse does not need to tell the AP to whom to report concerns, because they should be reported to the nurse. The nurse should instruct the AP to report about the bathing experience as soon as it is completed, and the nurse would not wait to read the AP's documentation.
5. The nurse would inform the AP what type of bath and what precautions are appropriate for that specific client's needs. Although it is often faster to perform the entire bath without encouraging client participation, the AP should take the time needed and encourage the client to perform as much self-care as possible to promote the client's autonomy. The nurse does not need to tell the AP to whom to report concerns, because they should be reported to the nurse. The nurse should instruct the AP to report about the bathing experience as soon as it is completed, and the nurse would not wait to read the AP's documentation.

Question 2

Place the steps of providing perineal-genital care for a female in the appropriate order
Response 1. Apply gloves.
Response 2. Wipe from the pubis to the rectum.
Response 3. Place a towel under the client's hips.
Response 4. Clean the labia minora.
Response 5. Position and drape the client.

Answer 2

3, 5, 1, 4, 2
Explanation:The nurse first places a towel under the client's hips to protect the bed. The female client should be positioned in a back-lying position with the knees flexed and spread well apart. Cover the body and legs with the bath blanket to minimize exposure. Apply gloves and clean the labia majora, then open the labia to clean the labia minora using separate quarters of the washcloth for each stroke. After cleaning the genitalia, wipe from the pubis to the rectum in order to avoid bringing bacteria from the rectum toward the urethra, which could result in a urinary tract infection.

Question 3

Place the steps of providing special oral care for an unconscious client in the correct order.
Response 1. Prepare the client by positioning in a side-lying position with the head of the bed lowered.
Response 2. Clean the teeth and rinse the mouth. Brush the teeth gently to prevent irritating the gums.
Response 3. Ensure client comfort and document procedure per policy.
Response 4. Perform hand hygiene and observe other appropriate infection control procedures.
Response 5. Place a towel under the client's chin. Place the curved basin against the client's chin and lower cheek to collect fluid.
Response 6. Provide for client privacy by drawing curtains around bed or closing the door to the room.

Answer 3

4 ,6, 1, 5, 2, 3
Explanation:Rationale 1: The third step of providing oral care for an unconscious client is to position the client in a side-lying position with the head of the bed lowered.
Rationale 2: The fifth step in providing oral care for an unconscious client is to clean the teeth and rinse the mouth. The nurse will gently brush the teeth to prevent irritating the gums.
Rationale 3: Ensuring client comfort and documenting the procedure, per policy, is the final step.
Rationale 4: The first step is to perform hand hygiene and observe other appropriate infection control procedures.
Rationale 5: The fourth step is to place a towel and the curved basin under the client's chin and lower cheek to collect fluid.
Rationale 6: The second step is to provide the client privacy by drawing the curtains around the bed and closing the door to the room.

Question 4

Place the steps of assisting with the cleaning of a client's hearing aid in the appropriate order
Response 1. Perform hand hygiene and wear appropriate personal protective equipment.
Response 2. Remove the hearing aid and turn off and lower the volume.
Response 3. Remove the earmold and soak in mild soap solution.
Response 4. After thoroughly drying, insert hearing aid into the client's ear.
Response 5. Prior to performing procedure, introduce self and identify the client.
Response 6. Provide for client privacy by drawing curtains or closing the door.

Question 5

Place the steps of providing foot care to a diabetic client in the appropriate order.
Response 1. Provide for privacy by pulling curtain or closing door to room.
Response 2. Fill washbasin with warm water and test temperature of water.
Response 3. File toenails straight across and even with tops of toes. Use nail clippers to clip nails straight across, then shape with nail file.
Response 4. Assist client to sitting position. Help bedridden client to supine position with head of bed elevated. Place disposable bath mat on floor under client's feet, or place towel on mattress.
Response 5. Perform hand hygiene. Arrange equipment on over-bed table.
Response 6. Help client place feet in basin. Fill basin with warm water, and soak for 10 minutes.

Question 6

The nurse notes that a client has significant body odor despite having clean hair, skin, nails, and clothes. Which should the nurse consider about the client regarding this assessment finding?

A) The use of deodorant is against the client's religion.
B) The client is unaware of how deodorant is to be used.
C) The client has a disorder that affects the sense of smell.
D) The client may have limited financial resources to purchase deodorant,

Question 7

The nurse is assigning tasks to assistive personnel (AP) after receiving handoff communication. For which client should the nurse complete hair care?

A) Client with arthritis
B) Client with heart failure
C) Client with a cervical spine injury
D) Client with chronic obstructive pulmonary disease (COPD)