Question 1

The nurse knows that routine hygienic care does not include:

Accepted Answer

A)  massage with lotion. 
B)  oral care with a toothbrush. 
C)  shaving with a disposable razor. 
D)  ear hygiene with cotton-tipped applicators. 
A)  massage with lotion. 
B)  oral care with a toothbrush. 
C)  shaving with a disposable razor. 
D)  ear hygiene with cotton-tipped applicators. D

Question 2

The nurse is assisting a patient to insert contacts and a contact is dropped. What action should occur next?

Accepted Answer

A)  Moisten the finger with lens solution and gently touch it to pick it up. 
B)  Moisten the contact lens with tap water and pick it up. 
C)  Pick it up and insert the contact lens. 
D)  Discard the contact lens. 
A)  Moisten the finger with lens solution and gently touch it to pick it up. 
B)  Moisten the contact lens with tap water and pick it up. 
C)  Pick it up and insert the contact lens. 
D)  Discard the contact lens. A

Question 3

The nurse should avoid soaking the feet of which patient population? (Select all that apply.)

Accepted Answer

A)  Patients with peripheral vascular disease 
B)  Patients with a stroke 
C)  Patients with diabetes 
D)  Patients with arthritis 
A)  Patients with peripheral vascular disease 
B)  Patients with a stroke 
C)  Patients with diabetes 
D)  Patients with arthritis A, B, C

Question 4

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

Accepted Answer

A)  The nurse has the opportunity to assess the respiratory, gastrointestinal, and genitourinary systems during the bath. 
B)  UAPs perform hygiene because there is no benefit of nurses doing it. 
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 odor. 
A)  The nurse has the opportunity to assess the respiratory, gastrointestinal, and genitourinary systems during the bath. 
B)  UAPs perform hygiene because there is no benefit of nurses doing it. 
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 odor.

Question 5

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

Question 6

The nurse is bathing a patient and notes reddened skin above the coccyx. Which action by the nurse is appropriate? (Select all that apply.)

Accepted Answer

A)  Apply a barrier cream and massage the area. 
B)  Document and describe the area and report to the physician. 
C)  Wash and dry the area and position patient without pressure on coccyx. 
D)  Report the area to the charge nurse. 
A)  Apply a barrier cream and massage the area. 
B)  Document and describe the area and report to the physician. 
C)  Wash and dry the area and position patient without pressure on coccyx. 
D)  Report the area to the charge nurse.

Question 7

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 8

The UAP asks why the arms are washed from distal to proximal. Which response by the nurse is appropriate?

Accepted Answer

A)  To promote circulation 
B)  To maintain asepsis 
C)  To maintain comfort 
D)  To maintain tradition 
A)  To promote circulation 
B)  To maintain asepsis 
C)  To maintain comfort 
D)  To maintain tradition

Question 9

Regarding perineal care, which nursing action is appropriate? (Select all that apply.)

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 
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

Question 10

The patient expresses a desire to learn methods to be independent regarding self-care. Based on this, the most appropriate nursing diagnosis would be:

Accepted Answer

A)  ineffective health maintenance. 
B)  readiness for enhanced self-care. 
C)  hygiene self-care deficit. 
D)  disturbed body image. 
A)  ineffective health maintenance. 
B)  readiness for enhanced self-care. 
C)  hygiene self-care deficit. 
D)  disturbed body image.

Question 11

The nurse has assisted the patient to wash his hands, face, axillae, and perineal area. What type of bath should 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 12

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 13

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 14

The nurse is assisting her patients with hygiene care. She knows that this includes the following: (Select all that apply.)

Accepted Answer

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

Question 15

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.

Question 16

The nurse is performing perineal care for the uncircumcised patient. Which of the following is true?

Accepted Answer

A)  The foreskin should not be moved. 
B)  The foreskin should be retracted, pulling it away from the body. 
C)  The foreskin should be left retracted and allowed to return to position naturally after care. 
D)  The foreskin should be retracted and returned to position by the nurse after cleaning, rinsing, and drying. 
A)  The foreskin should not be moved. 
B)  The foreskin should be retracted, pulling it away from the body. 
C)  The foreskin should be left retracted and allowed to return to position naturally after care. 
D)  The foreskin should be retracted and returned to position by the nurse after cleaning, rinsing, and drying.

Question 17

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)  Imbalanced Nutrition: Less than body requirements 
B)  Deficient fluid volume 
C)  Risk for infection 
D)  Acute pain 
A)  Imbalanced Nutrition: Less than body requirements 
B)  Deficient fluid volume 
C)  Risk for infection 
D)  Acute pain

Question 18

The nurse is asked to shave a patient that is taking 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 19

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

Accepted Answer

A)  Patient will ambulate independently twice a day. 
B)  Patient will perform all of own ADLs. 
C)  Patient will consume 75% of all meals. 
D)  Patient will begin to perform 50% of own ADLs. 
A)  Patient will ambulate independently twice a day. 
B)  Patient will perform all of own ADLs. 
C)  Patient will consume 75% of all meals. 
D)  Patient will begin to perform 50% of own ADLs.

Question 20

What statement 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.

Exam 27: Hygiene and Personal Care

The nurse knows that routine hygienic care does not include:

The nurse is assisting a patient to insert contacts and a contact is dropped. What action should occur next?

The nurse should avoid soaking the feet of which patient population? (Select all that apply.)

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

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

The nurse is bathing a patient and notes reddened skin above the coccyx. Which action by the nurse is appropriate? (Select all that apply.)

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

The UAP asks why the arms are washed from distal to proximal. Which response by the nurse is appropriate?

Regarding perineal care, which nursing action is appropriate? (Select all that apply.)

The patient expresses a desire to learn methods to be independent regarding self-care. Based on this, the most appropriate nursing diagnosis would be:

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

Which statement by the patient indicates a teaching need?

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 is assisting her patients with hygiene care. She knows that this includes the following: (Select all that apply.)

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 of the following is true?

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?

The nurse is asked to shave a patient that is taking Coumadin. What is the most appropriate action?

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

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

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 to Older Adult

Vital Signs

Health History and Physical Assessment

Ethnicity and Cultural Assessment

Spiritual Health

Public Health, Community Base, 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

Urinary Elimination

Death and Loss

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