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Foundation prepch.31
| Question | Answer |
|---|---|
| A nurse is providing perineal care for a female client who has a decreased level of consciousness. Which technique should the nurse employ when providing this care? | Wipe from the pubic area toward the anal area. |
| A pediatric nurse is providing a health promotional education program to a group of preschool parents. One parent asks the nurse the following question: “I have started buying bottled water. How will this affect my children?” | there is a need to determine if the bottled water has fluoride. |
| Which modification to bathing should be implemented for a client who is incontinent? | Use special perineal skin cleaners and moisture barriers. |
| The nurse is providing perineal care for clients in a hospital setting. What is an appropriate nursing action when providing this type of care? | Dry the cleaned areas and apply an emollient as indicated. |
| A nurse is taking care of a client who needs a bed bath. Which action can the nurse delegate to an unlicensed assistive personnel (UAP)? | a massage |
| The nurse is caring for a client with diabetes who has thick toenails. What is the appropriate nursing intervention? | Contact a podiatrist to care for toenails. |
| A nurse is caring for a client with limited physical mobility. The nurse has completed bathing the client and a student nurse asks, "Why are you making a trochanter roll?" After reviewing the image, which response | "I am placing the new linens under the rolled, soiled lines to avoid contamination." |
| Which aspect of denture care is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? | Brushing the dentures |
| A nurse is shampooing a client’s hair while the client is in bed. Which intervention should the nurse make to reduce back strain while performing the procedure? | Raise the bed to elbow height. |
| When the nurse observes slight bruising on the client's left thigh during the bed bath, he takes a closer look and palpates a lump on the anterior surface of the thigh. The nurse has used the bath activity for: | assessment of tissues. |
| Which statement made by the client, regarding flat patches of brown skin on the face, demonstrates understanding? | “These brown spots are senile lentigines and are common when you get older.” |
| The nurse is providing care for a client and observes that the eyeglasses are cloudy and soiled. What action should the nurse take to be sure the lenses are clean and not damaged during cleaning? | Use a special cleaning solution for eye glass lenses |
| The unlicensed assistive personnel (UAP) is remaking the bed in a hospital room where the client was just discharged. The nurse observes the UAP performing the action pictured above. What initial instruction | Inform the UAP that she should be wearing gloves. |
| When providing oral care, what does the nurse recognize as the most important component of the oral care process? | a thorough, mechanical cleaning |
| When a black adolescent client asks the nurse how to care for long hair, which is braided into small braids, the nurse should instruct the client that: | hair should be washed as often as necessary. |
| A client has a diagnosis of Bathing/Hygiene Self-care Deficit due to recent surgery and decreased strength. An appropriate goal to include in the client’s plan of care would be: | client will participate in self-care measures by the end of the week. |
| The nurse has completed teaching regarding pediculosis. Which client statement requires further nursing teaching? | “I will use conditioner so that the lice eggs will slide off my hair.” |
| The nurse is preparing to provide hygiene for a client with obesity who has bed rest ordered for 3 days. What is the priority nursing intervention that will be performed to deliver hygiene care? | Check the order within the plan of care for hygiene. |
| A kindergarten student is sent to the school nurse because she has been vigorously scratching her scalp for a few hours. The nurse's first action will be to assess the child for the presence of: | pediculosis. |
| Which health problem is most clearly suggestive of a history of inadequate dental care? | periodontitis |
| The first line of defense against microorganisms and infection entering the body is the person's: | skin. |
| When an adult client from Indonesia refuses a complete bath on the day after abdominal surgery, the nurse should: | understand that his culture may influence his hygiene and ask him his preference. |
| A nurse is assessing the client’s ability to perform ear care. Which statement by the client requires further education by the nurse? | “I use cotton-tipped applicators daily to remove cerumen.” |
| A nurse is caring for a client who has had difficulty sleeping. What nursing intervention may facilitate the client's rest? | Providing a back rub before bed |
| The nurse has completed teaching regarding pediculosis. Which client statement requires further nursing teaching? | “I will use conditioner so that the lice eggs will slide off my hair.” |
| A nurse is caring for a client with limited physical mobility. The nurse has completed bathing the client and a student nurse asks, "Why are you making a trochanter roll?" which response by the nurse to the student would be most accurate? | "I am placing the new linens under the rolled, soiled lines to avoid contamination." |
| Which aspect of denture care is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? | Brushing the dentures |
| The acute care nurse is talking with an older client who had a complete bed bath earlier in the day.client says "I like to be scrubbed clean during my bath and the person who bathed me today didn't even use soap and water, | "That person probably used special bathing products and deliberately avoided scrubbing to help keep your skin intact." |
| A nurse is delegating shaving of a client who is prescribed anticoagulant therapy to the unlicensed assistive personnel (UAP). What information is most important for the nurse to include for this client? | The client should use an electric razor. |
| A client is undergoing chemotherapy for ovarian cancer which has metastasized. She has been experiencing increased nausea and vomiting associated with treatment. Which is an internal resource | She has motivation to participate in self-care. |
| The nurse is caring for a client who is on warfarin therapy. Which teaching will the nurse provide? | Use an electric razor for shaving purposes. |
| The nurse is teaching a client about hearing aid care. Which teaching is appropriate? | Store the hearing aid in a cool environment. |
| A nurse is providing oral care to a client and observes that a significant amount of blood is coming from the client's gums. Which actions are appropriate responses? Select all that apply. | Encourage the client to rinse his or her mouth and spit. Check the client's most recent platelet level after providing care. |
| A nurse is shampooing a client’s hair while the client is in bed. Which intervention should the nurse make to reduce back strain while performing the procedure? | Raise the bed to elbow height. |
| The nurse is providing perineal care for clients in a hospital setting. What is an appropriate nursing action when providing this type of care? | Dry the cleaned areas and apply an emollient as indicated. |
| A female nurse is assisting an older man who has dementia with a bath in his hospital room. Which approach should the nurse take? | The client should be allowed to complete as much of the bath as he can. |
| A new mother has brought her infant into the pediatric clinic. The infant has an excoriation on the buttocks. What should the nurse instruct the mother? | Keep the diaper and buttocks clean and dry and apply zinc oxide. |
| A woman is being treated for breast cancer with 5-FU and cisplatin in large doses. She should expect: | alopecia. |
| A nurse is washing a client's hair using a shampoo cap. Which step should the nurse use? | Remove and discard the cap after one use and dry the client's hair with a towel. |
| Which client is most at risk for foot difficulties? | 45-year-old woman with type 2 diabetes |
| Which statement made by the client, regarding flat patches of brown skin on the face, demonstrates understanding? | “These brown spots are senile lentigines and are common when you get older.” |
| The nurse is caring for four clients. For which client is a sitz bath most appropriate? | 51-year old with hemorrhoids |
| The nurse is caring for a client who has been diagnosed with pediculosis. What intervention will the nurse provide? | Launder gowns, linens, and towels separate from other clients' items. |
| The nurse is planning hygiene care for a client with self-care bathing deficit related to weakness. Which nursing intervention is appropriate? | Encourage the client to wash own face and hands. |
| Which aspect of denture care is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? | Brushing the dentures |
| A nurse is shampooing a client’s hair while the client is in bed. Which intervention should the nurse make to reduce back strain while performing the procedure? | Raise the bed to elbow height. |
| Which nursing action is appropriate when providing foot care for a client? | Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms. |
| A school nurse is dealing with an outbreak of pediculosis in an elementary school. Which education points should the nurse prioritize when educating the parents of students who have lice and nits? | the importance of completely finishing the prescribed treatment |
| A nurse is preparing to help a client with a skin infection have a tub bath. In which way can the nurse ensure the client's safety? | Check that the bathroom has a nonskid floor. |
| A nurse is caring for a client who cannot swallow or expectorate. What interventions to keep the mouth and throat free of accumulating secretions should the nurse perform when caring for this client? Select all that apply. | Provide frequent mouth care. Arrange for suctioning to remove mucus. Assist the client to a lateral position. |
| A nurse providing hygiene and bathing for older adult clients knows that additional safety measures may be necessary in their care. The nurse delegates some aspects of care to an unlicensed assistive personnel (UAP). Which of the following are true | Use of a tub/shower seat may be necessary if balance problems are present. Water temperature should be monitored carefully due to decreased temperature sensation. Use a long-handled shower brush or attachment to help with limited mobility. |
| A client is hospitalized with orthostatic hypotension from dehydration. A nurse must delegate the task of hygiene and morning care to an (UAP). What type of bath should the nurse instruct the UAP to provide to the client? | partial bath |
| The nurse is teaching a nursing student about caring for a client with dentures. Which education will the nurse provide? | “Hold dentures over a plastic basin or towel when cleaning them.” |
| A nurse is assisting an older, continent client with dry skin who is hospitalized. Which approach to hygiene should the nurse take with this client? | Alternate between a full bed bath on one day and use of skin lotion or bath oil on the next. |
| A nurse caring for the skin of clients of different age groups should consider which accurately described condition? | An adolescent’s skin ordinarily has enlarged sebaceous glands and increased glandular secretions. |
| A 55-year-old client has just undergone surgery for a knee replacement. He asks the nurse if he can shave because his face is itching from the stubble. What information is a priority for the nurse to verify prior to shaving the client? | medications listed on the client's medication administration record (MAR) |
| A client has a nursing diagnosis of Self-Care Deficit: Bathing. What would an appropriate "related/to (r/t)" statement include? | R/t right-sided weakness |
| A nurse is evaluating the effectiveness of health promotion teaching related to hygiene at a community workshop. Which statements by one of the participants requires further teaching to ensure understanding? Select all that apply. | "It is important to brush your teeth regularly but flossing is not necessary since it can damage the gums." "Hygiene does not contribute to my well-being so I can choose to not perform hygiene." "Hygiene measures have no affect on skin." |
| An older adult client is reporting dry, itching skin. The nurse should assess: | how often the client is bathing. |
| A 71-year-old client is concerned about brown patches of skin on their face and forearm. What is the appropriate nursing statement? | “Those are senile lentigines and are common in older adults.” |
| The nurse is teaching a nursing student about caring for a client with dentures. Which education will the nurse provide? | “Hold dentures over a plastic basin or towel when cleaning them.” |
| Which group of individuals is most likely to show increasing concern regarding their personal appearance and adopt new hygiene measures, such as more frequent showers? | Adolescents |
| A nurse is taking care of a client with schizophrenia who only recently started taking her medications again. When she is off of her medications she often forgets to bathe and does not wear clothing that is appropriate for the weather. | "What are your expectations about bathing at this time?” |
| A nurse is caring for a client with a decreased level of consciousness (LOC). When performing mouth care, what action by the nurse will decrease complications of oral care? | The client should be placed in a side-lying position to prevent aspiration. |
| The parents of 3 young children have discussed the dental health needs of their children with the nurse. Which statement indicates the need for further instruction? | "If my children do not have cavities by the age of 10, fluoride treatments can be discontinued." |
| A client has been diagnosed with pediculosis corporis. Which medication is the most appropriate treatment? | Lindane |
| A 35-year-old woman is 1 day postpartum. She is reporting moderate perineal pain after giving birth and would like to clean the area. Which method of bathing is most appropriate for this client? | sitz bath |
| There are many problems that can occur on the feet that, if found, need to be assessed further. Which common foot problem is a cone-shaped lesion, which is usually found on the fourth or fifth toe over a toe joint? | corn |
| In which situation would it be appropriate to shave the beard of an unconscious client without his permission? | When inserting an endotracheal tube |
| A registered nurse is overseeing the care of several residents of a long-term care facility. Which task would be inappropriate to delegate to unlicensed assistive personnel (UAP)? | Using a tool to remove a contact lens that has adhered to the resident's eye |
| The nurse is observing a student who is using a safety razor to shave a client. Which action would require intervention by the nurse? | pulling the razor against the direction of hair growth |
| The nurse is preparing to bathe a client using a self-contained bathing system that has premoistened, disposable washcloths. Which method for warming the premoistened cloths is correct? | Heat the entire package in the microwave, following the manufacturer's recommendation. |
| When caring for a client with dentures, what should the nurse teach the client? | Keeping dentures out for long periods of time permits the gum line to change, affecting denture fit. |
| A nursing student is caring for a client with dentures. Which action by the nursing student would require intervention by the nurse? | using ungloved hands to remove an unconscious client’s dentures |
| A nurse is providing oral care to children on a pediatric unit. Which guideline should the nurse follow for providing care in special situations? | Water should be used to clean an infant's teeth. |
| A client is receiving radiation treatments for thyroid cancer and has stomatitis. When planning care, the nurse identifies which priority nursing diagnosis? | Imbalanced Nutrition: Less than Body Requirements |
Created by:
briannagrace