Question 1

A nurse is providing perineal care to a female patient. Which washing technique will the nurse use?

Accepted Answer

Cleansing from pubic area to rectum (front to back) reduces the transfer of microorganisms to the urinary meatus and decreases the risk of urinary tract infection. Cleansing from rectum to pubic area or back to front increases the risk of urinary tract infection. Circular motions are used in male perineal care.

Question 2

The nurse is caring for a patient who has multiple ticks on lower legs and body. What should the nurse do to rid the patient of ticks?

Accepted Answer

Using blunt tweezers, grasp the tick as close to the head as possible and pull upward with even, steady pressure. Hold until the tick pulls out, usually for about 3 to 4 minutes. Save the tick in a plastic bag, and put it in the freezer if necessary to identify the type of tick. Because ticks transmit several diseases to people, they must be removed. Allowing them to drop off by themselves is not an option. Do not burn ticks off with a match or lighter. Miconazole is used to treat athlete's foot; it is a fungal medication. Covering ticks with plastic does not remove ticks.

Question 3

The female nurse is caring for a male patient who is uncircumcised but not ambulatory and has full function of all extremities. The nurse is providing the patient with a partial bed bath. How should perineal care be performed for this patient?

Accepted Answer

If a patient is able to perform perineal self-care, encourage this independence. Patients most in need of perineal care are those at greatest risk for acquiring an infection such as uncircumcised males; perineal care is necessary. Embarrassment should not cause the nurse to overlook the patient's hygiene needs. The nurse should provide this care only if the patient is unable to do so.

Question 4

The nurse is teaching the patient about flossing and oral hygiene. Which instruction will the nurse include in the teaching session?

Accepted Answer

Dental flossing removes plaque and tartar between teeth. To prevent bleeding, the patient should use unwaxed floss. Flossing once a day is sufficient. If toothpaste is applied to the teeth before flossing, fluoride will come in direct contact with tooth surfaces, aiding in cavity prevention.

Question 5

The nurse is providing oral care to a patient. In which order will the nurse clean the oral cavity, starting with the first area?
1) Roof of mouth, gums, and inside cheek
2) Chewing and inner tooth surfaces
3) Outer tooth surfaces
4) Tongue

Accepted Answer

Oral care is provided in the following sequence: Clean chewing and inner tooth surfaces first. Clean outer tooth surfaces. Moisten brush with chlorhexidine rinse to rinse. Use toothette to clean roof of mouth, gums, and inside cheeks. Gently brush tongue but avoid stimulating gag reflex. Rinse.

Question 6

Which instruction will the nurse provide to the nursing assistive personnel when providing foot care for a patient with diabetes?

Accepted Answer

Report any changes that may indicate inflammation or injury to tissue. Do not allow the diabetic patient to go barefoot; injury can lead to amputations. Clipping toenails is not allowed. Patients with peripheral vascular disease or diabetes mellitus often require nail care from a specialist to reduce the risk of infection. When assessing the patient's feet, the nurse palpates the dorsalis pedis of the foot, not the brachial artery.

Question 7

A self-sufficient bedridden patient is unable to reach all body parts. Which type of bath will the nurse assign to the nursing assistive personnel?

Accepted Answer

A partial bath consists of washing body parts that the patient cannot reach, including the back, and providing a backrub. Dependent patients in need of partial hygiene or self-sufficient bedridden patients who are unable to reach all body parts receive a partial bed bath. Complete bed baths are administered to totally dependent patients in bed. The bag bath contains several soft, nonwoven cotton cloths that are premoistened in a solution of no-rinse surfactant cleanser and emollient. The sponge bath involves bathing from a bath basin or a sink with the patient sitting in a chair.

Question 8

The nurse is preparing to provide a complete bed bath to an unconscious patient. The nurse decides to use a bag bath. In which order will the nurse clean the body, starting with the first area?
1) Neck, shoulders, and chest
2) Abdomen and groin/perineum
3) Legs, feet, and web spaces
4) Back of neck, back, and then buttocks
5) Both arms, both hands, web spaces, and axilla

Accepted Answer

Use all six chlorhexidene gluconate (CHG) cloths in the following order:
1. Cloth 1: Neck, shoulders, and chest
2. Cloth 2: Both arms, both hands, web spaces, and axilla
3. Cloth 3: Abdomen and then groin/perineum
4. Cloth 4: Right leg, right foot, and web spaces
5. Cloth 5: Left leg, left foot, and web spaces
6. Cloth 6: Back of neck, back, and then buttocks

Question 9

The nurse is providing oral care to an unconscious patient. Which action should the nurse take?

Accepted Answer

When providing oral hygiene to an unconscious patient, the nurse needs to protect him or her from choking and aspiration. Have two nurses provide care; one nurse does the actual cleaning, and the other caregiver removes secretions with suction equipment. The nurse can delegate nursing assistive personnel to participate. Some agencies use equipment that combines a mouth swab with the suction device. This device can be used safely by one nurse to provide oral care. Commercially made foam swabs are ineffective in removing plaque. Do not use lemon-glycerin sponges because they dry mucous membranes and erode tooth enamel. While cleansing the oral cavity, use a small oral airway or a padded tongue blade to hold the mouth open. Never use your fingers to hold the patient's mouth open. A human bite contains multiple pathogenic microorganisms.

Question 10

A nurse is providing oral care to a patient with stomatitis. Which technique will the nurse use?

Accepted Answer

Stomatitis causes burning, pain, and change in food and fluid tolerance. Advise patients to avoid alcohol and commercial mouthwash and stop smoking. When caring for patients with stomatitis, brush with a soft toothbrush and floss gently to prevent bleeding of the gums. In some cases, flossing needs to be temporarily omitted from oral care. Normal saline rinses (approximately 30 mL) on awaking in the morning, after each meal, and at bedtime help clean the oral cavity.

Question 11

The debilitated patient is resisting attempts by the nurse to provide oral hygiene. Which action will the nurse take $\bold{next}$?

Accepted Answer

If the patient is uncooperative, or is having difficulty keeping the mouth open, insert an oral airway. Insert it upside down, and then turn the airway sideways and over the tongue to keep the teeth apart. Do not use force. Position the patient on his or her side or turn the head to allow for drainage. Placing the patient in a flat, supine position could lead to aspiration. Hydrogen peroxide is irritating to mucosa. Even though the patient is debilitated, explain the steps of mouth care and the sensations that he or she will feel. Also tell the patient when the procedure is completed.

Question 12

A nurse is providing AM care to patients. Which action will the nurse take?

Accepted Answer

CHG is safe to use on the perineum and external mucosa. If patient has diabetes or peripheral vascular disease with impaired circulation and/or sensation, do not soak feet. Maceration of skin may predispose to infection. Do not use long, firm strokes to wash the lower extremities of patients with history of deep vein thrombosis or blood-clotting disorders. Use short, light strokes instead. Eye should be cleansed from the inner to outer canthus on all patients.

Question 13

A nurse is providing a bath. In which order will the nurse clean the body, beginning with the first area?
1) Face
2) Eyes
3) Perineum
4) Arm and chest
5) Hands and nails
6) Back and buttocks
7) Abdomen and legs

Accepted Answer

The sequence for giving a bath is as follows: eyes, face, both arms, chest, hands/nails, abdomen, both legs, perineal hygiene, back, and buttocks/anus.

Question 14

The patient is being treated for cancer with weekly radiation therapy to the head and chemotherapy treatments. Which assessment is the priority?

Accepted Answer

The oral cavity is the priority. Radiation to the head reduces salivary flow and lowers pH of saliva, leading to stomatitis and tooth decay, while chemotherapy drugs kill the normal cells lining the oral cavity, leading to ulcers and inflammation. While the feet, nail beds, and perineum are important, they are not as affected as the oral cavity with head or neck radiation and chemotherapy.

Question 15

A patient has scaling of the scalp. Which term will the nurse use to report this finding to the oncoming staff?

Accepted Answer

Dandruff is scaling of the scalp that is accompanied by itching. Pediculosis (lice infestation) resides on scalp attached to hair strands; eggs look like oval particles, similar to dandruff. Alopecia is hair loss or balding. Xerostomia is dry mouth.

Question 16

The nurse is caring for an older-adult patient with Alzheimer's disease who is ambulatory but requires total assistance with activities of daily living (ADLs). The nurse notices that the patient is edentulous. Which area should the nurse assess?

Accepted Answer

Edentulous means without teeth; therefore, the nurse needs to assess the oral cavity. While older adults may want the room warmer and drafts should be avoided, this does not help with being edentulous. Edentulous does not mean the patient has edema. While older-adult patients can have reduced sensations, this is not the meaning of edentulous.

Question 17

A nursing assistive personnel (NAP) is providing AM care to patients. Which action by the NAP will require the nurse to intervene?

Accepted Answer

The nurse must intervene if the NAP turns the patient's head with a neck injury; this is contraindicated and must be stopped to prevent further injury. All the other actions are appropriate and do not need follow-up. Consult the medical record for any contraindications to a massage (e.g., fractured ribs, burns, and heart surgery). Before washing a patient's hair, determine that there are no contraindications to procedure (e.g., neck injury). When providing a backrub, enhance relaxation by reducing noise (turning off the television) and ensuring that the patient is comfortable.

Question 18

The nurse is providing a complete bed bath to a patient using a commercial bath cleansing pack (bag bath). What should the nurse do?

Accepted Answer

The nurse should allow the skin to air-dry for 30 seconds. Drying the skin with a towel removes the emollient that is left behind after the water/cleanser solution evaporates. It is permissible to lightly cover the patient with a bath blanket or towel to prevent chilling. Do not rinse when using a bag bath.

Question 19

The nurse is providing perineal care to an uncircumcised male patient. Which action will the nurse take?

Accepted Answer

Return the foreskin to its natural position. Keeping the foreskin retracted leads to tightening of the foreskin around the shaft of the penis, causing local edema and discomfort. The foreskin may not return to its natural position on its own. Patients at greatest risk for infection are uncircumcised males.

Question 20

The nurse is teaching the parents of a child who has head lice (pediculosis capitis). Which information will the nurse include in the teaching session?

Accepted Answer

Head lice are difficult to remove and spread to furniture and other people if not treated. Caution against use of products containing lindane because the ingredient is toxic and is known to cause adverse reactions. Treatments use medicated shampoo for eliminating lice. Manual removal is the best option when treatment has failed.

Quiz 40: Hygiene

A nurse is providing perineal care to a female patient. Which washing technique will the nurse use?

The nurse is caring for a patient who has multiple ticks on lower legs and body. What should the nurse do to rid the patient of ticks?

The female nurse is caring for a male patient who is uncircumcised but not ambulatory and has full function of all extremities. The nurse is providing the patient with a partial bed bath. How should perineal care be performed for this patient?

The nurse is teaching the patient about flossing and oral hygiene. Which instruction will the nurse include in the teaching session?

The nurse is providing oral care to a patient. In which order will the nurse clean the oral cavity, starting with the first area? 1) Roof of mouth, gums, and inside cheek 2) Chewing and inner tooth surfaces 3) Outer tooth surfaces 4) Tongue

Which instruction will the nurse provide to the nursing assistive personnel when providing foot care for a patient with diabetes?

A self-sufficient bedridden patient is unable to reach all body parts. Which type of bath will the nurse assign to the nursing assistive personnel?

The nurse is providing oral care to an unconscious patient. Which action should the nurse take?

A nurse is providing oral care to a patient with stomatitis. Which technique will the nurse use?

The debilitated patient is resisting attempts by the nurse to provide oral hygiene. Which action will the nurse take $\bold{next}$ ?

A nurse is providing AM care to patients. Which action will the nurse take?

A nurse is providing a bath. In which order will the nurse clean the body, beginning with the first area? 1) Face 2) Eyes 3) Perineum 4) Arm and chest 5) Hands and nails 6) Back and buttocks 7) Abdomen and legs

The patient is being treated for cancer with weekly radiation therapy to the head and chemotherapy treatments. Which assessment is the priority?

A patient has scaling of the scalp. Which term will the nurse use to report this finding to the oncoming staff?

The nurse is caring for an older-adult patient with Alzheimer's disease who is ambulatory but requires total assistance with activities of daily living (ADLs) . The nurse notices that the patient is edentulous. Which area should the nurse assess?

A nursing assistive personnel (NAP) is providing AM care to patients. Which action by the NAP will require the nurse to intervene?

The nurse is providing a complete bed bath to a patient using a commercial bath cleansing pack (bag bath) . What should the nurse do?

The nurse is providing perineal care to an uncircumcised male patient. Which action will the nurse take?

The nurse is teaching the parents of a child who has head lice (pediculosis capitis) . Which information will the nurse include in the teaching session?

Quiz 40: Hygiene

A nurse is providing perineal care to a female patient. Which washing technique will the nurse use?

The nurse is caring for a patient who has multiple ticks on lower legs and body. What should the nurse do to rid the patient of ticks?

The female nurse is caring for a male patient who is uncircumcised but not ambulatory and has full function of all extremities. The nurse is providing the patient with a partial bed bath. How should perineal care be performed for this patient?

The nurse is teaching the patient about flossing and oral hygiene. Which instruction will the nurse include in the teaching session?

The nurse is providing oral care to a patient. In which order will the nurse clean the oral cavity, starting with the first area? 1) Roof of mouth, gums, and inside cheek 2) Chewing and inner tooth surfaces 3) Outer tooth surfaces 4) Tongue

Which instruction will the nurse provide to the nursing assistive personnel when providing foot care for a patient with diabetes?

A self-sufficient bedridden patient is unable to reach all body parts. Which type of bath will the nurse assign to the nursing assistive personnel?

The nurse is providing oral care to an unconscious patient. Which action should the nurse take?

A nurse is providing oral care to a patient with stomatitis. Which technique will the nurse use?

The debilitated patient is resisting attempts by the nurse to provide oral hygiene. Which action will the nurse take next\bold{next}next ?

A nurse is providing AM care to patients. Which action will the nurse take?

A nurse is providing a bath. In which order will the nurse clean the body, beginning with the first area? 1) Face 2) Eyes 3) Perineum 4) Arm and chest 5) Hands and nails 6) Back and buttocks 7) Abdomen and legs

The patient is being treated for cancer with weekly radiation therapy to the head and chemotherapy treatments. Which assessment is the priority?

A patient has scaling of the scalp. Which term will the nurse use to report this finding to the oncoming staff?

The nurse is caring for an older-adult patient with Alzheimer's disease who is ambulatory but requires total assistance with activities of daily living (ADLs) . The nurse notices that the patient is edentulous. Which area should the nurse assess?

A nursing assistive personnel (NAP) is providing AM care to patients. Which action by the NAP will require the nurse to intervene?

The nurse is providing a complete bed bath to a patient using a commercial bath cleansing pack (bag bath) . What should the nurse do?

The nurse is providing perineal care to an uncircumcised male patient. Which action will the nurse take?

The nurse is teaching the parents of a child who has head lice (pediculosis capitis) . Which information will the nurse include in the teaching session?

The debilitated patient is resisting attempts by the nurse to provide oral hygiene. Which action will the nurse take $\bold{next}$ ?