Hygiene

Question 1

Its 11pm. Mr Denner is admitted to your unit during the nifht and started on IV fluids and antibiotics. Although, he is usually able to eat with assistance, he is ordered NPO. His lethargy and weakness, combined with underlying dysphagia, have put him at greater risk for aspiration. When you meet Mr. Denner, he is lethargic and weak.

While providing ORAL care, it is important to take steps to prevent infection.

What steps will you take to prevent infection? Choose all that apply.

a. Put on googles and mask
b. put on sterile gloves
c. put on a gown
d. put on clean gloves
e. PErform hand hygiene
f. Maintain surgical asepsis

Answer 1

D. Put on clean gloves
E Perform hand hygiene

The rest of the choices are not usually needed to provide oral care for the DEPENDENT patient.

Question 2

You’ve idenrified steps to prevent infection. Now, you must assess Mr. Denner before performing oral care.

Which of the foloowing should be included in your ASSESSMENT of Mr. Denner? Choose all that apply.

a. level of consciousness
b. inspect his oral cavity or any cases, sores, or white patches
c. inquire as to when his last dental visit was.
d. determine whether Mr. Denner wears dentures.
e. After determining that Mr. Denner’s oral health is good, postpone oral care.

Answer 2

a. level of consciousness
b. inspect his oral cavity or any cases, sores, or white patches
d. determine whether Mr. Denner wears dentures.

Question 3

Youve identified the equipment you must have ready to prevent ASPIRATION of cleaning fluids. Now you must raise the bed to a comfortable working height and help Mr. Denner to an appropriate position to provide oral care.

Can you identify which position to place Mr. Denner to provide oral care?

a. lying on his back with head tilted sideways
b. lying on his side with his head tilted backward.
c. Lying on his side with his head tilted forward
d. Fowler’s position
e. Semi-Fowler’s position

Answer 3

c. Lying on his side with his head tilted forward

Question 4

Youve assisted Mr. Denner into an appropriate position to reveive oral care. You must now also lower the rail of the bed on the side that hes facing, place a towel across his chest. put on clean gloves, and an emesis basin in position under his chin before you begin the procedure for providing oral care. The steps in the procedure to provide oral care to Mr. Denner are given on the screen. Place in order.

1. Gently clean Mr. Denners gums, mucous membrane, and tongue.
2. Position Mr. Denners head to allow water to return to the emesis basin.
3. Brush Mr. Denners teeth carefully with a toothbrush and paste.
4. Rinse. Mr. Denners oral cavity with a gauze-padded tongue blade.
5. Apply lubricant or oral moisturizer to his lips.

Answer 4

in order:

1. Brush Mr. Denners teeth carefully with a toothbrush and paste.
2. Gently clean Mr. Denners gums, mucous membrane, and tongue.
3. Rinse. Mr. Denners oral cavity with a gauze-padded tongue blade.
4. Position Mr. Denners head to allow water to return to the emesis basin.
5. Apply lubricant or oral moisturizer to his lips.

Question 5

You have finished cleaning Mr. Denners mouth. Now you must take the last few steps to complete the oral care procedure. The last few steps are listed here, but they’re out of order:

1. Performe hand hygiene.
2. lower the bed and raise the side rail.
3. Remove your gloves.
4. Document your assessment and interventions.
5. Ensure that Mr. Denner is comfortable and has the call light at hand.

Answer 5

in order:

1. Remove your gloves.
2. lower the bed and raise the side rail.
3. Ensure that Mr. Denner is comfortable and has the call light at hand.
4. Document your assessment and interventions
5. Performe hand hygiene.

Question 6

Research is supporting Chlorohexadine in baths to prevent _____________.

Especially in patients with ____________ or patient in the __________ unit.

Answer 6

Infections
Central lines
Intensive care unit

Question 7

Chlorhexidine (CHG) baths may be performed with __________ or by adding chlorhexidine liquid to _______ water.

Answer 7

pre-moistened wipes
warm water

Question 8

the use of disposable wipes decreases the risk of _____ contamination and are ______ balanced and do not require rinsing and contain skin _____.

Answer 8

bacterial
ph balanced
emollients.

Question 9

before you start a bed bath on a patient what should you review first?

Answer 9

pts medical records
any physical activity limitations

Question 10

Before taking gown off of a patient for a bed bath, what should you check for FIRST?

Answer 10

their IV LINE.

Question 11

What should you do when placing lotion on patient?

Answer 11

Rub hands together so lotion can be warm BEFORE applying on patients skin.

Question 12

A towel under the patient when bed bathing provides. _______, ___________, and protects bed from __________.

Answer 12

warmth
comfort
moisture

Question 13

In the bed bath video, what was placed in the butt crack for protection?

Answer 13

moisture barrier cream

Question 14

Providing Oral Care for the DEPENDENT PATIENT:

Always __________ to patient what you are doing every step of the way.

Answer 14

explain - even if patient is unconscious.

Question 15

Providing Oral Care for the DEPENDENT PATIENT:

Have HEAD tilted ______ and body on their ______. This prevents ___________ into the lungs.

Answer 15

forward
side
aspiration

Question 16

The major cause of tooth loss in adults OLDER THAN 35 years of age is _______.

Answer 16

gum disease.

Question 17

VOCAB:

Measures for maintianing a level of personal cleanliness and grooming which promotes PHYSICAL and PSYCHOLOGICAL well-being.

Answer 17

personal hygiene

Question 18

VOCAB:

hair loss or baldness

Answer 18

ALOPECIA

Question 19

VOCAB:

Caries of the teeth

Answer 19

Cavities

Question 20

VOCAB:

wax in the EXTERNAL ear canals, consisting of a heavy oil and brown pigment

Answer 20

CERUMEN

Question 21

VOCAB:

ulceration of the lips

Answer 21

cheilosis

Question 22

VOCAB:

Inflammation of the gingivae or gums

Answer 22

gingivitis

Question 23

VOCAB:

inflammation of the tongue

Answer 23

glossitis

Question 24

VOCAB:

offensive BREATH

Answer 24

halitosis

Question 25

VOCAB:

infestation with lice

Answer 25

Pediculosis

Question 26

VOCAB:

extensive inflammation of the gums and alveolar tissues; synonym for PERIODONTITIS

Answer 26

Periodontitis

Question 27

VOCAB:

Invisible, destructive, bacterial film that builds up on teeth and eventually leads to the destruction of tooth enamel.

Answer 27

plaque

Question 28

VOCAB:

inflammation of the oral mucosa

Answer 28

stomatitis

Question 29

VOCAB:

HARD deposit on the teeth near the gum line formed by plaque buildup and dead bacteria.

Answer 29

tartar

Question 30

Hygienic practices include caring for the:

(9 things total)

Answer 30

skin
hair
nails
eyes
ears
nose
mouth
feet
perineal area.

Question 31

An important first line of defense preventing the entry of pathogens, minimizes absorption of harmful substnces and preventing excessive water loss.

Answer 31

maintaining SKIN condition and integrity.

Question 32

Changes in the color or condition of the ___ are related to changes in hormonal activity or to changes in the blood supply to hair follicles.

Answer 32

hair shaft.

Question 33

Nails are an accessory structure of the skin composed of _____ tissue.
Healthy nail BEDS are ___, ___, and evenly __.

Answer 33

epitheleal
pink, convex, evenly curved.

Question 34

Type of therapy done by sitting in warm, shallow water. It can help soothe pain, itching and other symptoms in the anal and genital areas.

Answer 34

sitz bath

Question 35

what is a bedside commode?

Answer 35

its a portable toilet. can be easily moved around for convenience. Great for patients who cant walk to the bathroom due to frailty ro illness.

Question 36

what is a trochanter roll?

Answer 36

a cylindrical prop such as a rolled-up towel, foam roll, cylindrical cushion/pillow or rolled- up blanket/linen.

Question 37

define paraplegic

Answer 37

a person affected by paralysis of the legs and lower body.

Question 38

define incontinent

Answer 38

having no or insufficient voluntary control over urination or defecation.

Question 39

Medical term for the outer ear is the _____ or ____.
made of cartilage and skin.

Answer 39

auricle or pinna.

Question 40

what does warfarin medication do?

Answer 40

it is a blood thinner. treats and prevents blood clots.

Question 41

A nurse is taking care of a client who needs a bed bath. Which action can the nurse delegate to an uNLICENSED ASSISTIVE PERSONEL (UAP)

1. assesments during bath
2. back massage
3. wound care.

Answer 41

2. back massage

can be delegated to a UAP
but assessments and wound care MUST BE DONE BY THE RN.

Question 42

A client is undergoing chemotherapy for ovarian cancer which has metastasized (spread). She has been experiencing increased nausea and vomiting associated with treatment. Which is an internal resource that the client has to help her attain her self-care goals?

1. She has family and friends who help with self-care
2. She has motivation to participate in self-care

Answer 42

2. she has motivation to participate in self-care

Question 43

The nurse is caring for 4 clients. For which client is a sitz bath most appropriate?
1. 42 yr old recovering from ac- section
2. 51 year old with hemorrhoids
3. 73- yr old with pneumonia who can get up to bedside commode.
4. 60 yr old who is 1 day postop from a knee replacement.

Answer 43

2. patient with hemorrhoids.

Question 44

Which clients are most at risk for foot difficulties?

Answer 44

older patients with type 2 diabetes.

Question 45

A female nurse is assisting an older man who has dementia with a bath in his hospital room. Which approach should the nurse take?
1. call a male nurse to bath the patient
2. call a family member to help bathe the patient.
3. nurse should bathe patient, since he has dementia.
4. client should be allowed to complete as much as the bath as he can.

Answer 45

4. client should be allowed to complete as much as the bath as he can.

Question 46

define analgesia

Answer 46

the inability to feel pain.

Question 47

wash the face and hair at the ______ of the bath or seperate time since these parts could be most upsetting of the bathing process for people with DEMENTIA.

Answer 47

end

Question 48

The nurse is caring for the client with diabetes who has THICK toenails.. What is the appropriate nursing intervention?

1. file, rather than cut the nails.
2. use large nail clippers
3. use a handheld electric rotary file to reduce the length of the toenails.
4. use scissors.
5. clean under the toenails with a wooden orange stick.

Answer 48

1. file, rather than cut the nails.

using scissors or nail clippers may slip and injure tissue.

Question 49

which nursing action is appropriate when providing foot care for a client?
1. rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms.
2. for diabetic clients, trim the nails with nail clippers.
3. cuto off any corns or calluses.
4. soak the feet in a solution of mild soap and tepid water.

Answer 49

1. rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms.

dont soak the feet. splitting and peeling of the nails can be caused by repeated or prolonged contact with water.

Question 50

a client is undergoing chemotherapy for ovarian cancer which has metastasized. She has been experiencing increased nausea and comiting associated with tx. Which is an internal resource that the client has to help her attain her self-care goals.
1. she has family and friends who help her with self-care
2. she has good mobility around her home.
3. she has hot water to bathe in.
4. she has motivation to participate in self-care

Answer 50

4.

Question 51

The parents of 3 young children have discussed the dental health needs of their children with the nurse. Which statement indicates the need for further instruction.
1. fluoride tx are needed until my children reach the age of 14
2. if my children do not have cavities by the age of 10, fluoride tx can be discontinured.
3. tartar cannot be brushed or flossed away.
4. brushing is important to remove bacteria from the mouth and teeth.

Answer 51

2. if my children do not have cavities by the age of 10, fluoride tx can be discontinured.

Question 52

a nurse caring for the sking of clients of different age groups should consider which accurately described condition?
1. secretions from skin glands are at their maximum from age 3 months on.
2. an infants skin and mucous membranes are protexted from infection by a natural immunity.
3. The skin becomes thicker and more leathery with aging and is prone to wrinkles and dryness.
4. An adolescents skin ordinarily has enlarged sebaceous glands and increased glandular secretions.

Answer 52

——-

Question 53

which action (s) is appropriate to safely bathe an older adult client? Select all that apply.
1. use tub/shower seat if balance problems are present.
2. Pour scented bath oils into the tub to improve dryness of the skin and decrease odors.
3. Use viourous rubbing motions when drying the skin to increase circulation.
4. Provide the client a long-handled shower brush or attachement if experiencing limited mobility.
5. carefully monitor water temperature.

Answer 53

1, 4, & 5

Question 54

A kindergarten student is sent to the school nurse bc they have been vigorously scratching their scalp for a few hrs. What is the nurse’s priority action.
1. assess for dandruff.
2. assess for possible pediculosis.
3. check for fleas.
4. Assess for the presence of alopecia.

Answer 54

2. pediculosis= lice

Question 55

A nurse is preparing the environment in a hospital room for a newly admitted client. Which actions are recommended? Select all that apply.
1. avoid carrying out conversations immediatly outside the client’s room
2. Do not store clients personal items in the bedside stand bc nurses need to open and close the stand to obtain bath basin, lotion, and other items.
3. Do not place soiled dressings or anything with a strong odor in the WASTE receptacle in the clients rooom.
4. Position client beds at the appropriate height with the wheels unlcoked. Follow principles of surgical asepsis at the bedsie.
5. In general, keep the room temperature between 20 degree and 23 degrees C (68 degrees and 74 degrees F)

Answer 55

1, 3, & 5

**soiled dressings or items with strong odors should be disposed of in the SOILED UTILITY ROOM in order to prevent causing an unpleasant environment in the clients room or possibly causing the client to feel nauseous.

Question 56

A nurse is caring for a client who has had difficulty sleeping. What nursing intervention may facilitate the client’s rest?
1. providing multiple stimuli to make the client tired.
2. Engaging in a therapeutic conversation
3. Giving the client something to drink.
4. Providing a back rub before bed.

Answer 56

4.

Question 57

A nurse is assisting an older, continent client with dry skin who is hospitalized. Which approach to hygiene should the nurse take with this client?

1. use skin lotion daily and avoid giving the bed baths.
2. alternate b/t a full bed bath on one day and use of skin lotion or bath oil on the next.
3. provide a tub bath with bath oil every day.
4. provide a full bed bath with soap and water every day.

Answer 57

—-

Question 58

a nurse is providing nail care for feet to clients admitted to a health care facility. What should the nurse look for while performing nail care for a client with long history of diabetes?
1. cold feet.
2. Bony bump on the joint at the base of the big toe.
3. breaks in skin integrity and fungal nail infection
4. Redness and swelling in the joint of the big toe with reports of pain.

Answer 58

3.

Question 59

The nurse is providing hygiene education for a family who will soon take an older adult client home from the hospital. WHich statement by a family member requires further nursing instruction?

1. i should install grab bars in the shower or tub at arm level of my loved one
2. i chould provide soap for daily bathing to remove debris and keep my loved ones skin moist.
3. i should obrain a tub or shower seat bc my loved one has mobility issues
4. i should chek the bath water temp before allowing my loved one to bathe.

Answer 59

3.