Deck 31: Hygiene

Question 1

Which assessment finding leads the nurse to question the physician's order for irrigation of the patient's ear?

A) The patient has some short soft hairs present on the pinna.
B) A large amount of cerumen is noted in the patient's ear canal.
C) The patient has ear pain with purulent drainage in the ear canal.
D) The patient's tympanic membrane is a translucent pearl-gray color.

Answer 1

The patient has ear pain with purulent drainage in the ear canal.

Question 2

Which nursing intervention is appropriate when bathing older adult patients?

A) Use warm water,mild skin cleanser,and moisturizing lotion.
B) Apply a topical steroid cream to dry skin areas after bathing.
C) Assist the patient to take relaxing,long hot showers twice weekly.
D) Wash the patient's skin using plain water and dry with a soft towel.

Answer 2

Use warm water,mild skin cleanser,and moisturizing lotion.

Question 3

Which intervention is appropriate to prevent the patient from reinfection after recovery from oral thrush?

A) The teeth should be flossed after each meal.
B) The patient's toothbrush should be replaced.
C) Lip balm should be applied to prevent chapping.
D) An antiseptic mouthwash should be used twice daily.

Answer 3

The patient's toothbrush should be replaced.

Question 4

Which is the priority nursing intervention for a patient with confusion and the diagnosis impaired dentition related to inability to perform oral care?

A) Assess the patient's preferred methods for oral hygiene.
B) Brush the patient's teeth twice daily with a soft toothbrush.
C) Use foam swab sticks to clean the oral cavity every morning.
D) Encourage the patient to chew sugarless gum during the day.

Question 5

Which is the highest priority nursing diagnosis for a patient who is frequently incontinent of stool and urine?

A) Risk for impaired skin integrity related to exposure to urine and stool
B) Powerlessness related to inability to control release of bowel and bladder
C) Readiness for enhanced comfort related to expressed desire to smell fresh
D) Social isolation related to unpleasant odor from stool and urine

Question 6

Which patient would benefit from the use of lubricant eye ointment?

A) A patient with chronic viral conjunctivitis
B) A stroke patient whose right eye does not close fully
C) A patient who has extended-wear contact lenses in place
D) A patient with an eye infection after swimming in a pond

Question 7

The nurse is caring for a bedridden patient with long straight hair.Which is the appropriate intervention to prevent the hair from becoming matted?

A) Apply no-tangle conditioner to the hair.
B) Cut the matted hair.
C) Braid the patient's hair into several pigtails.
D) Wash the patient's hair daily with baby shampoo.

Question 8

The nurse is caring for a patient who has just undergone shoulder replacement surgery.Which is the best option for washing the patient's hair?

A) Utilize a no-rinse shampoo cap.
B) Use a handheld shower sprayer.
C) Have the patient lean back into the sink.
D) Have the patient lean over the wash basin.

Question 9

What will the nurse do with extra clean linens that were left over after the patient's bath?

A) Place them back in the linen closet.
B) Place them on the patient's bedside table.
C) Use them to bathe the patient's roommate.
D) Place them in a laundry bag to be laundered.

Question 10

Which is the best approach to change nasogastric tube tape that has become crusted with secretions?

A) Soften the secretions using a warm moist washcloth.
B) Use blunt-edged scissors to loosen the tape from the skin.
C) Saturate the tape with a denatured alcohol solution.
D) Soak the crusted areas of tape with adhesive remover.

Question 11

How can the nurse best respect the patient's cultural preferences for hygiene?

A) Shave the patient's facial hair every morning after the bath.
B) Add scented bath oils to the water before bathing the patient.
C) Ensure that a staff member of the same sex bathes the patient.
D) Accommodate the patient's wish to wash before morning prayers.

Question 12

Which interventions are appropriate for a patient with the nursing diagnosis impaired oral mucus membranes related to immunosuppression,thrush,and ulceration?

A) Rinse the mouth with warm saline solution every few hours.
B) Rinse the mouth with half strength hydrogen peroxide twice daily.
C) Use cotton swabs soaked in lemon-glycerin solution to clean the oral mucosa.
D) Use a tongue scraper to remove the thick coating from the oral mucosa.
E) Encourage the patient to have soft foods such as yogurt,ice cream,and pudding.

Question 13

Which hygiene interventions are appropriate for a patient with the nursing diagnosis ineffective protection related to impaired blood clotting?

A) Use an emery board to file the patient's nails.
B) Use a soft toothbrush and avoid flossing the teeth.
C) Rinse with a chlorhexidine mouthwash after meals.
D) Use antibacterial soap for showering each morning.
E) Use an electric razor to shave the patient's facial hair.

Question 14

Which interventions are appropriate when providing oral care to an intubated patient receiving mechanical ventilation?

A) Floss the gums gently after brushing the teeth each morning.
B) Rinse the mouth with a solution of peroxide and baking soda.
C) Suction the patient's mouth throughout the cleaning procedure.
D) Keep the head of the patient's bed elevated at least 30 degrees.
E) Clean the oral mucosa using a chlorhexidine-based mouthwash.

Question 15

The nurse notes red,moist patches on the skin under the female patient's breasts.What is the appropriate action of the nurse when caring for this area?

A) Gently clean and dry the area and obtain an order for antifungal powder.
B) Apply a rich moisturizer cream to the area after washing with soap and water.
C) Apply a topical antibiotic cream to the area after rinsing with peroxide and water.
D) Wash the area with moisturizing soap and apply a lanolin-based cream to the area.

Question 16

Which assessment finding leads the nurse to lightly wash the patient's legs rather than using long,firm strokes?

A) The patient's platelet count was 40,000/mm³ this morning.
B) The patient is taking ciprofloxacin for a bladder infection.
C) The patient is taking levothyroxine for hypothyroidism.
D) The patient's urinalysis was positive for protein and white blood cells.

Question 17

Which bath time assessment of the diabetic patient is most important?

A) Presence of fingernail clubbing
B) Presence of any petechiae or bruises
C) Presence of abdominal rebound tenderness
D) Presence of pedal pulses and intact sensation

Question 18

Which patient outcome is most important for the patient with the nursing diagnosis bathing/hygiene self-care deficit related to neuromuscular impairment and fatigue?

A) The patient's skin will remain intact and free of body odor.
B) The patient will report feeling of cleanliness after morning care.
C) The patient's privacy and dignity will be maintained during the bath.
D) The patient will verbalize understanding of need for bathing assistance.

Question 19

The nurse is caring for a diabetic patient who has rough skin on the feet and thick,overgrown toenails.Which is the best intervention of the nurse?

A) Liberally apply lotion to the patient's feet,especially between the toes.
B) Use a pumice stone to smooth roughened areas of skin on the patient's feet.
C) Gently trim the patient's toenails after soaking the feet in warm soapy water.
D) Obtain a consultation for a podiatrist to assess the feet and provide nail care.