Deck 9: Hygiene and Care of the Patient’s Environment

Question 1

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?

A) Back-lying
B) Full lateral
C) 30-degree lateral
D) Full prone

Answer 1

30-degree lateral

Question 2

How frequently should the nurse clean the nares of patients who have a nasogastric tube or are receiving oxygen by nasal cannula?

A) At least every 2 hours
B) At least every 6 hours
C) At least every 8 hours
D) At least every 10 hours

Answer 2

At least every 8 hours

Question 3

How often should the nurse cleanse the meatal-catheter junction of a patient with an indwelling catheter?

A) At least once a day
B) At least twice a day
C) At bedtime
D) Each shift

Answer 3

At least twice a day

Question 4

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?

A) Every 30 minutes
B) Every 60 minutes
C) Every 120 minutes
D) Every 180 minutes

Question 5

The nurse is preparing to bathe a patient. What should the room temperature be set at?

A) No warmer than 67° F
B) No cooler than 68° F
C) No cooler than 70° F
D) 75° F or warmer

Question 6

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?

A) Square position
B) Long position
C) Diamond position
D) Rectangular position

Question 7

Proper hair care is important for the patient's self-image. What is the proper water temperature when shampooing a patient's hair?

A) 101° F
B) 105° F
C) 110° F
D) 120° F

Question 8

The nurse is assessing a patient's skin for signs of impaired skin integrity. Which finding by the nurse is considered a major manifestation?

A) Burn
B) Laceration
C) Pressure ulcer
D) Infection

Question 9

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?

A) 10 to 15 minutes
B) 20 to 30 minutes
C) 30 to 40 minutes
D) 1 hour

Question 10

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?

A) Washing the leg with long, firm strokes and drying with a towel
B) Omitting washing the leg at all
C) Gently washing the leg and patting dry with a towel
D) Applying lotion in long, smooth strokes

Question 11

What should the water temperature be when preparing a tepid bath for a patient?

A) 98.6° F
B) 100.2° F
C) 104.8° F
D) 110.4° F

Question 12

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?

A) To improve self-esteem
B) To stimulate appetite
C) To restore tooth destruction
D) To assist with periodontitis

Question 13

A patient is recovering from a hemorrhoidectomy and experiences dizziness within 5 minutes when taking a sitz bath. What action should the nurse implement?

A) Cover the patient to prevent chilling
B) Stay with the patient until the full time for the bath has elapsed
C) Remove the patient from the sitz bath and return to bed
D) Assess vital signs every 5 minutes during the remainder of the sitz bath

Question 14

The nurse assesses a red blister over the right superior iliac area of a patient. What stage is this decubitus ulcer?

A) I
B) II
C) III
D) IV

Question 15

When must the nurse remember to use an electric razor when shaving a patient?

A) When a bleeding tendency is present
B) When there is a risk for suicide
C) When the facial hair is fine
D) When speed is essential

Question 16

The nursing assessment of a pressure ulcer includes size, depth, pain, odor, and color of tissue. What does this evaluate?

A) Treatment needed
B) Effectiveness of implementation
C) Whether improvement is occurring
D) Need for additional interventions

Question 17

How will the nurse correctly replace a patient's dentures after cleaning?

A) Inserting the lower denture first
B) Asking the patient to insert them
C) Inserting both dentures together
D) Inserting the upper denture first

Question 18

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?

A) Heat from pressure
B) Collapse of blood vessels
C) Friction from pressure
D) Collapse of skin tissue

Question 19

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?

A) Upward toward the forehead
B) Downward toward the chin
C) From the outer toward the inner canthus
D) From the inner toward the outer canthus

Question 20

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?

A) Physician
B) RN
C) CNA
D) Podiatrist

Question 21

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?

A) Place on the floor
B) Fan in the air
C) Hold away from the uniform
D) Place at the end of the bed

Question 22

The nurse is preparing to make an occupied bed. What procedure will the nurse follow to correctly complete this task? (Select all that apply.)

A) Remove spread and blanket separately
B) Place soiled sheet at end of bed
C) Place bath blanket over patient on top sheet
D) Slide mattress to bottom of bed
E) Position patient to far side of bed

Question 23

How should the nurse cleanse the meatal opening when performing male perineal care?

A) From the meatus outward
B) With an alcohol swab
C) In a circular motion
D) With a cotton-tipped applicator

Question 24

The physician orders a patient to be placed in the reverse Trendelenburg position. How should the nurse place the bed?

A) On the floor
B) Parallel with the floor
C) Tilted with the head of the bed down
D) Tilted with the foot of the bed down

Question 25

Where should a nurse performing a backrub begin?

A) Shoulder
B) Base of the neck
C) Sacral area
D) Lumbar area

Question 26

A physician orders a patient to be placed in the Trendelenburg position. How will the nurse position the bed?

A) On the floor
B) Parallel with the floor
C) Tilted with the head of the bed down
D) Tilted with the foot of the bed down

Question 27

Which guideline should be followed when giving a backrub?

A) Observing the skin for abnormalities
B) Massaging for at least 10 minutes
C) Following massage with a brisk alcohol rub
D) Conversing with patient continually throughout the backrub
E) Using alcohol-based lotion for disinfection

Question 28

The nurse lowers the bed to place the patient on the bedpan. The angle of the head of the bed should be raised to:

A) 20 degrees.
B) 45 degrees.
C) 90 degrees.
D) 30 degrees.

Question 29

The nurse is assisting a patient to perform personal hygiene. What is the most important focus of the nurse when assisting this patient?

A) Nursing care
B) Independence
C) Repetition
D) Performance

Question 30

The nurse avoids dragging the patient across the bed linen to decrease the potential risk of skin injury by _________.

Question 31

The nurse is caring for a patient experiencing presbycusis. What intervention should the nursing personnel be instructed to implement?

A) Speak quickly to the patient
B) Speak in loud tones to the patient
C) Speak slowly and clearly to the patient
D) Tell the patient they must purchase a hearing aid

Question 32

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?

A) 5 to 10 minutes
B) 10 to 20 minutes
C) 20 to 30 minutes
D) 30 to 40 minutes

Question 33

To prevent skin breakdown in a wheelchair-bound patient, the nurse teaches the patient to shift the patient's weight every _______ minutes.

Question 34

As a safety precaution against breakage of dentures, the nurse should place __________ in the emesis basin before cleaning the dentures.

Question 35

The nurse discovers a reddened area over a patient's hip. What should be the nurse's first intervention?

A) Cover the area with an occlusive dressing
B) Apply mild ointment with a cotton-tipped applicator
C) Press the area gently to assess for blanching
D) Rub gently to increase circulation

Question 36

What does the nurse recognize is important to consider when using the nursing process to plan hygiene care of the patient?

A) Nurse's orders
B) Physician's orders
C) Patient's preferences
D) Outcome goals

Question 37

Because of its effect on epithelization, the LPN/LVN should confirm the order to use ____________ or _____________ on a stage III pressure ulcer.

Question 38

The nurse is providing personal hygiene for a Hindu patient from India. What intervention should the nurse implement?

A) Not serve meat
B) Shampoo the patient's hair weekly
C) Give a daily bath
D) Cut nails monthly