Chapter 9

Question 1

The nurse is preparing to bathe a patient. What should the room temperature be set at?
a. No warmer than 67°F (19.4°C)
b. No cooler than 68°F (20°C)
c. No cooler than 70°F (21.1°C)
d. 75°F or warmer (23.8°C)

Answer 1

b. No cooler than 68°F (20°C)

Question 2

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? (The
wording of this is unclear)
a. 10 to 15 minutes
b. 20 to 30 minutes
c. 30 to 40 minutes
d. 1 hour

Answer 2

b. 20 to 30 minutes

Question 3

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.

Answer 3

c. Remove the patient from the sitz bath and return to bed.

Question 4

What should the water temperature be when preparing a tepid bath for a patient?
a. 98.6°F (37°C)
b. 100.2°F (37.8°C)
c. 104.8°F (40.4°C)
d. 110.4°F (43.5°C)

Answer 4

a. 98.6°F (37°C)

Question 5

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 injury
d. Infection

Answer 5

c. Pressure injury

Question 6

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

Answer 6

b. Collapse of blood vessels

Question 7

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

Answer 7

c. Every 120 minutes

Question 8

The nurse assesses a red blister over the right superior iliac area of a patient. What stage is
this decubitus injury?
a. 1
b. 2
c. 3
d. 4

Answer 8

b. 2

Question 9

The nursing assessment of a pressure injury 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

Answer 9

c. Whether improvement is occurring

Question 10

The nurse attempts to avoid a pressure injury 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 10

c. 30-degree lateral

Question 11

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

Answer 11

b. To stimulate appetite

Question 12

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 denturestogether
d. Inserting the upper denture first

Answer 12

d. Inserting the upper denture first

Question 13

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 (38.3°C)
b. 105°F (40.5°C)
c. 110°F (43.3°C)
d. 120°F (48.8°C)

Answer 13

c. 110°F (43.3°C)

Question 14

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

Answer 14

a. When a bleeding tendency is present

Question 15

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

Answer 15

c. Gently washing the leg and patting dry with a towel

Question 16

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. Health care provider
b. RN
c. CNA
d. Podiatrist

Answer 16

d. Podiatrist

Question 17

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 17

b. At least twice a day

Question 18

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

Answer 18

c. Diamond position

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

Answer 19

d. From the inner toward the outer canthus

Question 20

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 20

c. At least every 8 hours

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 soiledlinens?
a. Place on the floor
b. Fan in the air
c. Hold away from the uniform
d. Place at the end of the bed

Answer 21

c. Hold away from the uniform

Question 22

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

Answer 22

a. From the meatus outward

Question 23

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.

Answer 23

d. 30 degrees.

Question 24

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. Health care provider’s orders
c. Patient’s preferences
d. Outcome goals

Answer 24

c. Patient’s preferences

Question 25

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

Answer 25

c. Give a daily bath

Question 26

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

Answer 26

b. Independence

Question 27

The nurse discovers a reddened area over a patient’s hip. What should be the nurse’sfirst
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.

Answer 27

c. Press the area gently to assess for blanching.

Question 28

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

Answer 28

b. 10 to 20 minutes

Question 29

Where should a nurse performing a backrub begin?
a. Shoulder
b. Base of the neck
c. Sacral area
d. Lumbar area

Answer 29

c. Sacral area

Question 30

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.

Answer 30

c. Speak slowly and clearly to the patient.

Question 31

A health care provider orders a patient to be placed in the Trendelenburg’s 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

Answer 31

c. Tilted with the head of the bed down

Question 32

The health care provider orders a patient to be placed in the reverse Trendelenburg’s
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

Answer 32

d. Tilted with the foot of the bed down

Question 33

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

Answer 33

a. Observing the skin for abnormalities