Question 1

The nurse and UAP are making an occupied bed together. Which action by the nurse is incorrect?

Accepted Answer

A)  The nurse asks and assists the patient to turn toward the UAP and loosens the fitted sheet and rolls it in toward the patient. 
B)  The nurse rolls dirty linens to the side then places the linens on the floor while finishing. 
C)  The nurse tucks the clean bottom sheet under the cleaner underside of the dirty linens. 
D)  The nurse wears gloves to remove dirty linens. 
A)  The nurse asks and assists the patient to turn toward the UAP and loosens the fitted sheet and rolls it in toward the patient. 
B)  The nurse rolls dirty linens to the side then places the linens on the floor while finishing. 
C)  The nurse tucks the clean bottom sheet under the cleaner underside of the dirty linens. 
D)  The nurse wears gloves to remove dirty linens. B

Question 2

The nurse is performing perineal care for the uncircumcised patient. Which action does the nurse take?

Accepted Answer

A)  Does not move the foreskin. 
B)  Retracts the foreskin, pulling it away from the body. 
C)  Leaves the foreskin retracted, allowing it to return to position naturally after care. 
D)  Retracts the foreskin and returns it to its natural position after cleaning, rinsing, and drying. 
A)  Does not move the foreskin. 
B)  Retracts the foreskin, pulling it away from the body. 
C)  Leaves the foreskin retracted, allowing it to return to position naturally after care. 
D)  Retracts the foreskin and returns it to its natural position after cleaning, rinsing, and drying. D

Question 3

Which tool is used by the nurse to determine risk for impaired skin integrity?

Accepted Answer

A)  Braden scale 
B)  Glasgow scale 
C)  Vanderbilt scale 
D)  MMSE scale 
A)  Braden scale 
B)  Glasgow scale 
C)  Vanderbilt scale 
D)  MMSE scale A

Question 4

The nurse is caring for a patient with swallowing concerns and decreased level of consciousness. The nurse knows to put the patient in what position for oral care?

Accepted Answer

A)  High Fowler's 
B)  Prone 
C)  Side-lying 
D)  Low Fowler's 
A)  High Fowler's 
B)  Prone 
C)  Side-lying 
D)  Low Fowler's

Question 5

The nurse notes that a trauma patient has multiple tangles in the hair. Which actions taken by the nurse are appropriate?

Accepted Answer

A)  Work the tangles to the ends of the hair, then trim with scissors. 
B)  Apply warm water and conditioner. 
C)  Apply detangler as available. 
D)  Use a comb or fingers to work through tangles. 
E)  Cut the tangles out if working on them agitates the patient. 
A)  Work the tangles to the ends of the hair, then trim with scissors. 
B)  Apply warm water and conditioner. 
C)  Apply detangler as available. 
D)  Use a comb or fingers to work through tangles. 
E)  Cut the tangles out if working on them agitates the patient.

Question 6

The nurse is providing care to a post-stroke patient on the rehabilitation floor with a nursing diagnosis of Impaired health maintenance. Which goal is most appropriate on day one?

Accepted Answer

A)  Patient will ambulate independently twice a day. 
B)  Patient will perform all own ADLs. 
C)  Patient will consume 75% of all meals. 
D)  Patient will begin to perform 25% of own ADLs. 
A)  Patient will ambulate independently twice a day. 
B)  Patient will perform all own ADLs. 
C)  Patient will consume 75% of all meals. 
D)  Patient will begin to perform 25% of own ADLs.

Question 7

The nurse is demonstrating cultural sensitivity in performing perineal care when carrying out which actions?

Accepted Answer

A)  The male nurse delegates perineal care of a female patient to the female UAP. 
B)  The male nurse asks a female patient if she would prefer a female to perform care. 
C)  The nurse approaches the care in a sensitive, professional manner. 
D)  The nurse assesses cultural preferences of the patient prior to care. 
E)  The nurse provides care quickly and in a matter of fact manner. 
A)  The male nurse delegates perineal care of a female patient to the female UAP. 
B)  The male nurse asks a female patient if she would prefer a female to perform care. 
C)  The nurse approaches the care in a sensitive, professional manner. 
D)  The nurse assesses cultural preferences of the patient prior to care. 
E)  The nurse provides care quickly and in a matter of fact manner.

Question 8

The nurse is asked to shave a patient who is taking warfarin (Coumadin). What is the most appropriate action?

Accepted Answer

A)  Refuse to shave the patient because he is on an anticoagulant. 
B)  Shave as usual with a safety razor. 
C)  Offer to wax rather than shave the patient. 
D)  Use an electric razor. 
A)  Refuse to shave the patient because he is on an anticoagulant. 
B)  Shave as usual with a safety razor. 
C)  Offer to wax rather than shave the patient. 
D)  Use an electric razor.

Question 9

The nurse recognizes which statement by the patient indicates a teaching need?

Accepted Answer

A)  "I use bobby pins to remove excessive ear wax." 
B)  "I use soap and a warm cloth to clean the outside of my ear." 
C)  "My doctor sometimes gives me oil drops for my ears." 
D)  "I never use Q-Tips." 
A)  "I use bobby pins to remove excessive ear wax." 
B)  "I use soap and a warm cloth to clean the outside of my ear." 
C)  "My doctor sometimes gives me oil drops for my ears." 
D)  "I never use Q-Tips."

Question 10

The nurse knows that which statement is true regarding the importance of hygiene?

Accepted Answer

A)  The nurse can assess other body systems during the bath. 
B)  UAPs perform hygiene because there is no benefit of nurses doing this care. 
C)  The mucous membranes of the lips, nostrils, anus, vagina, and urethra are not a part of the integumentary system when providing hygiene. 
D)  The main purpose of bathing is to decrease the patient's body odor. 
A)  The nurse can assess other body systems during the bath. 
B)  UAPs perform hygiene because there is no benefit of nurses doing this care. 
C)  The mucous membranes of the lips, nostrils, anus, vagina, and urethra are not a part of the integumentary system when providing hygiene. 
D)  The main purpose of bathing is to decrease the patient's body odor.

Question 11

Excessively dry skin can lead to cracks and openings in the integumentary system. Based on this, what is the most applicable Nursing diagnosis for a patient with excessively dry skin?

Accepted Answer

A)  Impaired Health Maintenance 
B)  Risk for Injury 
C)  Risk for infection 
D)  Acute pain 
A)  Impaired Health Maintenance 
B)  Risk for Injury 
C)  Risk for infection 
D)  Acute pain

Question 12

When providing the patient with routine hygienic care, which action would the nurse omit?

Accepted Answer

A)  Massage the back with lotion 
B)  Oral care with a toothbrush 
C)  Shaving with a disposable razor 
D)  Ear hygiene with cotton-tipped applicators 
A)  Massage the back with lotion 
B)  Oral care with a toothbrush 
C)  Shaving with a disposable razor 
D)  Ear hygiene with cotton-tipped applicators

Question 13

Regarding perineal care, which nursing actions are appropriate?

Accepted Answer

A)  The nurse applies gloves prior to performing perineal care. 
B)  The nurse ignores the erection of a male patient during perineal care. 
C)  The nurse documents the perineal care. 
D)  The nurse only completes perineal care with daily bathing. 
E)  The nurse can delegate perineal care. 
A)  The nurse applies gloves prior to performing perineal care. 
B)  The nurse ignores the erection of a male patient during perineal care. 
C)  The nurse documents the perineal care. 
D)  The nurse only completes perineal care with daily bathing. 
E)  The nurse can delegate perineal care.

Question 14

The nurse knows that which areas of the patient's body are at increased risk of excoriation?

Accepted Answer

A)  Exposed areas such as the face 
B)  Areas exposed to stool 
C)  Skin on skin areas 
D)  Area under pendulous breasts 
E)  Under an abdominal fold 
A)  Exposed areas such as the face 
B)  Areas exposed to stool 
C)  Skin on skin areas 
D)  Area under pendulous breasts 
E)  Under an abdominal fold

Question 15

The nurse correctly identifies which patient as having the highest risk for injury related to temperature of water when bathing?

Accepted Answer

A)  Patient with asthma 
B)  Patient with attention deficit hyperactivity disorder 
C)  Patient with a stroke 
D)  Patient with diabetes 
A)  Patient with asthma 
B)  Patient with attention deficit hyperactivity disorder 
C)  Patient with a stroke 
D)  Patient with diabetes

Question 16

When the nurse is assisting patients with hygiene care, which tasks should be included?

Accepted Answer

A)  Bathing 
B)  Oral care 
C)  Perineal care 
D)  Foot care 
E)  Patient communication
F) None of above 
A)  Bathing 
B)  Oral care 
C)  Perineal care 
D)  Foot care 
E)  Patient communication
F) None of above

Question 17

The nurse has assisted the patient to wash the hands, face, axillae, and perineal area. What type of bath does the nurse chart?

Accepted Answer

A)  Sink bath 
B)  Complete bed bath 
C)  Partial bed bath 
D)  Shower 
A)  Sink bath 
B)  Complete bed bath 
C)  Partial bed bath 
D)  Shower

Question 18

What statement by the nurse is true regarding oral care of patients on anticoagulants?

Accepted Answer

A)  Use an electric toothbrush daily. 
B)  Avoid oral care. 
C)  Use mouthwash only. 
D)  Use a soft-bristled toothbrush. 
A)  Use an electric toothbrush daily. 
B)  Avoid oral care. 
C)  Use mouthwash only. 
D)  Use a soft-bristled toothbrush.

Question 19

Which member of the collaborative team is most appropriate to cut the toenails of a diabetic patient?

Accepted Answer

A)  Nurse 
B)  Physical therapist 
C)  Occupational therapist 
D)  Podiatrist 
A)  Nurse 
B)  Physical therapist 
C)  Occupational therapist 
D)  Podiatrist

Question 20

The nurse is preparing to give a patient a complete bed bath. What area of the body should be bathed first?

Accepted Answer

A)  Hands 
B)  Eyes 
C)  Face 
D)  Arms 
A)  Hands 
B)  Eyes 
C)  Face 
D)  Arms

Exam 27: Hygiene and Personal Care

The nurse and UAP are making an occupied bed together. Which action by the nurse is incorrect?

The nurse is performing perineal care for the uncircumcised patient. Which action does the nurse take?

Which tool is used by the nurse to determine risk for impaired skin integrity?

The nurse is caring for a patient with swallowing concerns and decreased level of consciousness. The nurse knows to put the patient in what position for oral care?

The nurse notes that a trauma patient has multiple tangles in the hair. Which actions taken by the nurse are appropriate?

The nurse is providing care to a post-stroke patient on the rehabilitation floor with a nursing diagnosis of Impaired health maintenance. Which goal is most appropriate on day one?

The nurse is demonstrating cultural sensitivity in performing perineal care when carrying out which actions?

The nurse is asked to shave a patient who is taking warfarin (Coumadin). What is the most appropriate action?

The nurse recognizes which statement by the patient indicates a teaching need?

The nurse knows that which statement is true regarding the importance of hygiene?

Excessively dry skin can lead to cracks and openings in the integumentary system. Based on this, what is the most applicable Nursing diagnosis for a patient with excessively dry skin?

When providing the patient with routine hygienic care, which action would the nurse omit?

Regarding perineal care, which nursing actions are appropriate?

The nurse knows that which areas of the patient's body are at increased risk of excoriation?

The nurse correctly identifies which patient as having the highest risk for injury related to temperature of water when bathing?

When the nurse is assisting patients with hygiene care, which tasks should be included?

The nurse has assisted the patient to wash the hands, face, axillae, and perineal area. What type of bath does the nurse chart?

What statement by the nurse is true regarding oral care of patients on anticoagulants?

Which member of the collaborative team is most appropriate to cut the toenails of a diabetic patient?

The nurse is preparing to give a patient a complete bed bath. What area of the body should be bathed first?

Nursing, Theory, and Professional Practice

Values, Beliefs, and Caring

Communication

Critical Thinking in Nursing

Introduction to the Nursing Process

Assessment

Nursing Diagnosis

Planning

Implementation and Evaluation

Documentation, Electronic Health Records, and Reporting

Ethical and Legal Considerations

Leadership and Management

Evidence-Based Practice and Nursing Research

Health Literacy and Patient Education

Nursing Informatics

Health and Wellness

Human Development: Conception Through Adolescence

Human Development: Young Adult Through Older Adult

Vital Signs

Health History and Physical Assessment

Ethnicity and Cultural Assessment

Spiritual Health

Public Health, Community-Based, and Home Health Care

Human Sexuality

Safety

Asepsis and Infection Control

Activity, Immobility, and Safe Movement

Skin Integrity and Wound Care

Nutrition

Cognitive and Sensory Alterations

Stress and Coping

Sleep

Diagnostic Testing

Medication Administration

Pain Management

Perioperative Nursing Care

Oxygenation and Tissue Perfusion

Fluid, Electrolytes, and Acid-Base Balance

Bowel Elimination

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