ch. 40 hygiene

Question 1

A nurse is preparing to provide hygiene care. Which principle should the nurse consider when planning hygiene care?

a. Hygiene care is always routine and expected.

b. No two individuals perform hygiene in the same manner.

c. It is important to standardize a patient’s hygienic practices.

d. During hygiene care do not take the time to learn about patient needs.

Answer 1

B. No two individuals perform hygiene in the same manner.

Question 2

A patient’s hygiene schedule of bathing and brushing teeth is largely influenced by family
customs. For which age group is the nurse most likely providing care?

a. Adolescent

b. Preschooler

c. Older adult

d. Adult

Answer 2

B. Preschooler

Question 3

The patient has been diagnosed with diabetes. When admitted, the patient is unkempt and is in
need of a bath and foot care. When questioned about hygiene habits, the nurse learns the
patient takes a bath once a week and a sponge bath every other day. To provide ultimate care
for this patient, which principle should the nurse keep in mind?

a. Patients who appear unkempt place little importance on hygiene practices.

b. Personal preferences determine hygiene practices and are unchangeable.

c. The patient’s illness may require teaching of new hygiene practices.

d. All cultures value cleanliness with the same degree of importance.

Answer 3

C. The patient’s illness may require teaching of new hygiene practices.

Question 4

The nurse is caring for a patient who refuses to bathe in the morning. When asked why, the
patient says, ―I always bathe in the evening.‖ Which action by the nurse is best?

a. Defer the bath until evening and pass on the information to the next shift.

b. Tell the patient that daily morning baths are the ―normal‖ routine.

c. Explain the importance of maintaining morning hygiene practices.

d. Cancel hygiene for the day and attempt again in the morning.

Answer 4

A. Defer the bath until evening and pass on the information to the next shift.

Question 5

A nurse is completing an assessment of the patient. Which principle is a priority?

a. Foot care will always be important.

b. Daily bathing will always be important.

c. Hygiene needs will always be important.

d. Critical thinking will always be important.

Answer 5

D. Critical thinking will always be important.

Question 6

When providing hygiene for an older-adult patient, the nurse closely assesses the skin. What
is the rationale for the nurse’s action?

a. Outer skin layer becomes more resilient.

b. Less frequent bathing may be required.

c. Skin becomes less subject to bruising.

d. Sweat glands become more active.

Answer 6

B. Less frequent bathing may be required.

Question 7

The nurse is bathing a patient and notices movement in the patient’s hair. Which action will
the nurse take?

a. Use gloves to inspect the hair.

b. Apply a lindane-based shampoo immediately.

c. Shave the hair off of the patient’s head.

d. Ignore the movement and continue.

Answer 7

A. Use gloves to inspect the hair.

Question 8

The patient has been brought to the emergency department following a motor vehicle
accident. The patient is unresponsive. The driver’s license states that glasses are needed to
operate a motor vehicle, but no glasses were brought in with the patient. Which action should
the nurse take next?

a. Stand to the side of the patient’s eye and observe the cornea.

b. Conclude that the glasses were lost during the accident.

c. Notify the ambulance personnel for missing glasses.

d. Ask the patient where the glasses are.

Answer 8

A. Stand to the side of the patient’s eye and observe the cornea.

Question 9

A nurse is assessing a patient’s skin. Which patient is most at risk for impaired skin integrity?

a. A patient who is afebrile

b. A patient who is diaphoretic

c. A patient with strong pedal pulses

d. A patient with adequate skin turgor

Answer 9

B. A patient who is diaphoretic

Question 10

The nurse caring for a patient who is immobile frequently checks for impaired skin integrity.
What is the rationale for the nurse’s action?

a. Inadequate blood flow leads to decreased tissue ischemia.

b. Patients with limited caloric intake develop thicker skin.

c. Pressure reduces circulation to affected tissue.

d. Verbalization of skin care needs is decreased.

Answer 10

C. Pressure reduces circulation to affected tissue.

Question 11

The nurse is caring for a patient diagnosed with diabetes mellitus and circulatory
insufficiency, who is also experiencing peripheral neuropathy and urinary incontinence. On
which areas does the nurse focus care?

a. Decreased pain sensation and increased risk of skin impairment

b. Decreased caloric intake and accelerated wound healing

c. High risk for skin infection and low saliva pH level

d. High risk for impaired venous return and dementia

Answer 11

A. Decreased pain sensation and increased risk of skin impairment

Question 12

Which action by the nurse will be the most important for preventing skin impairment in a
mobile patient with local nerve damage?

a. Insert an indwelling urinary catheter.

b. Limit caloric and protein intake.

c. Turn the patient every 2 hours.

d. Assess for pain during a bath.

Answer 12

D. Assess for pain during a bath.

Question 12

The nurse is caring for a patient who has undergone surgery for a broken leg and has a cast in
place. What should the nurse do to prevent skin impairment?

a. Assess surfaces exposed to the edges of the cast for pressure areas.

b. Keep the patient’s blood pressure low to prevent overperfusion of tissue.

c. Do not allow turning in bed because that may lead to re-dislocation of the leg.

d. Restrict the patient’s dietary intake to reduce the number of times on the bedpan.

Answer 12

A. Assess surfaces exposed to the edges of the cast for pressure areas.

Question 13

After performing foot care, the nurse checks the medical record and discovers that the patient
has a lesion on the sole of the foot caused by a virus. Which condition did the nurse most
likely observe?

a. Corns

b. A callus

c. Plantar warts

d. Athlete’s foot

Answer 13

C. Plantar warts

Question 14

The nurse is caring for a patient diagnosed with diabetes who is reporting severe foot pain due
to corns. The patient has been using oval corn pads to self-treat the corns. Which information
will the nurse share with the patient?

a. Corn pads are an adequate treatment and should be continued.

b. The patient should avoid soaking the feet before using a pumice stone.

c. The current self-treatment is likely impeding with circulation to the toes.

d. Tighter shoes would help to compress the corns and make them smaller.

Answer 14

C. The current self-treatment is likely impeding with circulation to the toes.

Question 15

The patient diagnosed with athlete’s foot (tinea pedis) states being relieved because it is only
athlete’s foot, and it can be treated easily. Which information about this condition should the
nurse consider when formulating a response to the patient?

a. It is contagious with frequent recurrences.

b. It is most helpful to air-dry feet after bathing.

c. It is treated with salicylic acid.

d. It is caused by lice.

Answer 15

A. It is contagious with frequent recurrences.

Question 16

When assessing a patient’s feet, the nurse notices that the toenails are thick and separated
from the nail bed. What does the nurse most likely suspect is the cause of this condition?

a. Fungi

b. Friction

c. Nail polish

d. Nail polish remover

Answer 16

A. Fungi

Question 17

The nurse is providing education about the importance of proper foot care to a patient
diagnosed with diabetes mellitus. Which primary goal is the nurse trying to achieve?

a. Prevention of plantar warts

b. Prevention of foot fungus

c. Prevention of neuropathy

d. Prevention of amputation

Answer 17

D. Prevention of amputation

Question 18

The nurse is providing oral care to an unconscious patient and notes that the patient has
extremely bad breath. Which term will the nurse use when reporting to the oncoming shift?

a. Cheilitis

b. Halitosis

c. Glossitis

d. Dental caries

Answer 18

B. Halitosis

Question 19

The nurse is caring for a patient diagnosed with diabetes. Which task will the nurse assign to
the nursing assistive personnel?

a. Providing nail care

b. Teaching foot care

c. Making the patient’s bed

d. Determining aspiration risk

Answer 19

C. Making the patient’s bed

Question 20

The patient is being treated for cancer with weekly radiation therapy to the head and
intravenous chemotherapy treatments. Which assessment is the priority?

a. Feet

b. Nail beds

c. Perineum

d. Oral cavity

Answer 20

D. Oral cavity

Question 21

The nurse is providing oral care to an unconscious patient. Which action should the nurse take
to protect the patient from injury?

a. Moisten the mouth using lemon-glycerin sponges.

b. Hold the patient’s mouth open with gloved fingers.

c. Use foam swabs to help remove plaque.

d. Suction the oral cavity.

Answer 21

D. Suction the oral cavity.

Question 22

The nurse is teaching the patient about flossing and oral hygiene. Which instruction will the
nurse include in the teaching session?

a. Using waxed floss prevents bleeding

b. Flossing removes plaque and tartar from the teeth

c. Performing flossing at least 3 times a day is beneficial

d. Applying toothpaste to the teeth before flossing is harmful

Answer 22

B. Flossing removes plaque and tartar from the teeth

Question 23

The nurse is teaching the parents of a child who has head lice (pediculosis capitis). Which
information will the nurse include in the teaching session?

a. Treatment is use of regular shampoo.

b. Products containing lindane are most effective.

c. Head lice may spread to furniture and other people.

d. Manual removal is not a realistic option as treatment.

Answer 23

C. Head lice may spread to furniture and other people.

Question 24

A patient has scaling of the scalp. Which term will the nurse use to report this finding to the
oncoming staff?

a. Dandruff

b. Alopecia

c. Pediculosis

d. Xerostomia

Answer 24

A. Dandruff

Question 25

A nurse is providing a bath. In which order will the nurse clean the body, beginning with the
first area?

1. Face
2. Eyes
3. Perineum
4. Arm and chest
5. Hands and nails
6. Back and buttocks
7. Abdomen and legs

a. 1, 2, 5, 4, 7, 6, 3
b. 2, 1, 4, 5, 7, 3, 6
c. 2, 1, 5, 4, 6, 7, 3
d. 1, 2, 4, 5, 3, 7, 6

Answer 25

B. 2, 1, 4, 5, 7, 3, 6

Question 26

The nurse is caring for a patient who has multiple ticks on lower legs and body. What should
the nurse do to rid the patient of ticks?

a. Use tweezers and pull upward with steady pressure.

b. Burn the ticks with a match or small lighter.

c. Allow the ticks to drop off by themselves.

d. Apply miconazole and cover with plastic.

Answer 26

A. Use tweezers and pull upward with steady pressure.

Question 27

The nurse is providing oral care to a patient. In which order will the nurse clean the oral
cavity, starting with the first area?

1. Roof of mouth, gums, and inside cheek
2. Chewing and inner tooth surfaces
3. Outer tooth surfaces
4. Tongue

a. 4, 1, 3, 2
b. 3, 2, 4, 1
c. 2, 3, 1, 4
d. 1, 4, 2, 3

Answer 27

C. 2, 3, 1, 4

Question 28

The nurse is caring for an older-adult patient diagnosed with Alzheimer’s disease who is
ambulatory but requires total assistance with activities of daily living (ADLs). The nurse
notices that the patient is edentulous. Which area should the nurse assess?

a. Assess oral cavity.

b. Assess room for drafts.

c. Assess ankles for edema.

d. Assess for reduced sensations.

Answer 28

A. Assess oral cavity.

Question 29

A self-sufficient bedridden patient is unable to reach all body parts. Which type of bath will
the nurse assign to the nursing assistive personnel?

a. Bag bath

b. Sponge bath

c. Partial bed bath

d. Complete bed bath

Answer 29

c. Partial bed bath

Question 30

The nurse is preparing to provide a complete bed bath to an unconscious patient. The nurse
decides to use a bag bath. In which order will the nurse clean the body, starting with the first
area?

1. Neck, shoulders, and chest
2. Abdomen and groin/perineum
3. Legs, feet, and web spaces
4. Back of neck, back, and then buttocks
5. Both arms, both hands, web spaces, and axilla

a. 5, 1, 2, 3, 4
b. 1, 5, 2, 3, 4
c. 1, 5, 2, 4, 3
d. 5, 1, 2, 4, 3

Answer 30

B. 1, 5, 2, 3, 4

Question 31

The female nurse is caring for a male patient who is uncircumcised but not ambulatory and
has full function of all extremities. The nurse is providing the patient with a partial bed bath.
How should perineal care be performed for this patient?

a. Should be postponed because it may cause embarrassment.

b. Should be unnecessary because the patient is uncircumcised.

c. Should be done by the patient.

d. Should be done by the nurse.

Answer 31

C. Should be done by the patient.

Question 32

A nursing assistive personnel (AP) is providing AM care to patients. Which action by the AP
will require the nurse to intervene?

a. Not offering a backrub to a patient with fractured ribs

b. Not offering to wash the hair of a patient with neck trauma

c. Turning off the television while giving a backrub to the patient

d. Turning patient’s head with neck injury to side when giving oral care

Answer 32

D. Turning patient’s head with neck injury to side when giving oral care

Question 33

A nurse is providing AM care to patients. Which action will the nurse take?

a. Soaks feet of patient with peripheral vascular disease.

b. Applies CHG solution to wash perineum of patient with a stroke.

c. Cleanses eye from outer canthus to inner canthus of patient with diabetes.

d. Uses long, firm stroke to wash legs of patient with blood-clotting disorder.

Answer 33

B. Applies CHG solution to wash perineum of patient with a stroke.

Question 34

The nurse is providing a complete bed bath to a patient using a commercial bath cleansing
pack (bag bath). What should the nurse do?

a. Rinse the skin thoroughly.

b. Allow the skin to air-dry.

c. Avoid using a bath towel.

d. Dry the skin with a towel.

Answer 34

B. Allow the skin to air-dry.

Question 35

A nurse is providing perineal care to a female patient. Which washing technique will the nurse
use?

a. Cleansing from back to front

b. Washing using a circular motion

c. Cleansing from pubic area to rectum

d. Cleansing upward from rectum to pubic area

Answer 35

C. Cleansing from pubic area to rectum

Question 36

The nurse is providing perineal care to an uncircumcised male patient. Which action will the
nurse take?

a. Leave the foreskin alone because there is little chance of infection.

b. Retract the foreskin for cleansing and allow it to return on its own.

c. Retract the foreskin and return it to its natural position when done.

d. Leave the foreskin retracted after cleansing the penis.

Answer 36

C. Retract the foreskin and return it to its natural position when done.

Question 37

Which instruction will the nurse provide to the nursing assistive personnel when providing
foot care for a patient with diabetes?

a. Do not place slippers on the patient’s feet.

b. Trim the patient’s toenails daily.

c. Report sores on the patient’s toes.

d. Check the brachial artery.

Answer 37

C. Report sores on the patient’s toes.

Question 38

The debilitated patient is resisting attempts by the nurse to provide oral hygiene. Which action
will the nurse take next?

a. Insert an oral airway.

b. Place the patient in a flat, supine position.

c. Use undiluted hydrogen peroxide as a cleaner.

d. Quickly proceed while not talking to the patient.

Answer 38

A. Insert an oral airway.

Question 39

A nurse is providing oral care education to a patient with stomatitis. Which instructions will
the nurse provide?

a. Avoid commercial mouthwashes.

b. Avoid normal saline rinses.

c. Brush with a hard toothbrush.

d. Brush with an alcohol-based toothpaste.

Answer 39

A. Avoid commercial mouthwashes.

Question 40

The nurse is teaching a patient about contact lens care. Which instructions will the nurse
include in the teaching session?

a. Use tap water to clean soft lenses.

b. Wash and rinse lens storage case daily.

c. Reuse storage solution for no longer than a week.

d. Keep the lenses is a cool dry place when not being used.

Answer 40

B. Wash and rinse lens storage case daily.

Question 41

The patient reports to the nurse about a perceived decrease in hearing. When the nurse
examines the patient’s ear, a large amount of cerumen buildup at the entrance to the ear canal
is observed. Which action will the nurse take next?

a. Teach the patient how to use cotton-tipped applicators.

b. Tell the patient to use a bobby pin to extract earwax.

c. Apply gentle, downward retraction of the ear canal.

d. Instill hot water into the ear canal to melt the wax.

Answer 41

C. Apply gentle, downward retraction of the ear canal.

Question 42

The patient is being fitted with a hearing aid. In teaching the patient how to care for the
hearing aid, which instructions will the nurse provide?

a. Change the battery every day or as needed.

b. Adjust the volume for a talking distance of 1 yard.

c. Wear the hearing aid 24 hours per day except when sleeping.

d. Avoid the use of hairspray, but aerosol perfumes are allowed.

Answer 42

B. Adjust the volume for a talking distance of 1 yard.

Question 43

The patient is reporting an inability to clear nasal passages. Which action will the nurse take?

a. Use gentle suction to prevent tissue damage.

b. Instruct patient to blow nose forcefully to clear the passage.

c. Place a dry washcloth under the nose to absorb secretions.

d. Insert a cotton-tipped applicator to the back of the nose.

Answer 43

A. Use gentle suction to prevent tissue damage.

Question 44

A patient uses an in-the-canal hearing aid. Which assessment is a priority?

a. Eyeglass usage

b. Cerumen buildup

c. Type of physical exercise

d. Excessive moisture problems

Answer 44

B. Cerumen buildup