Hygiene

Question 1

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 1

ANS: B

Excessive moisture (diaphoretic) on the surface of the skin serves as a medium for bacterial growth and causes irritation, softens epidermal cells, and leads to skin maceration. A patient who is afebrile is not a high risk; however, a patient who is febrile (fever) is prone to skin breakdown. A patient with strong pedal pulses is not a high risk; however, a patient with vascular insufficiency is. A patient with adequate skin turgor is not a high risk; however, a patient with poor skin turgor is.

Question 2

The nurse is caring for a patient who is immobile. The nurse frequently checks the patient 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 2

ANS: C

Body parts exposed to pressure have reduced circulation to affected tissue. Patients with limited caloric and protein intake develop thinner, less elastic skin with loss of subcutaneous tissue. Inadequate blood flow causes ischemia and breakdown. Verbalization is affected when altered cognition occurs from dementia, psychological disorders, or temporary delirium, not from immobility.

Question 3

The nurse is caring for a patient who has diabetes mellitus and circulatory insufficiency, with 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 3

ANS: A

Patients with paralysis, circulatory insufficiency, or peripheral neuropathy (nerve damage) are unable to sense an injury to the skin (decreased pain sensation). The presence of urinary incontinence, circulatory insufficiency, and neuropathy can combine to result in breakdown, so the patient has an increased risk of skin impairment. While the patient may have decreased caloric intake, the patient will not have accelerated wound healing with circulatory insufficiency, neuropathy, and incontinence. While the patient is at high risk for skin infection, the low salivary pH level is not an issue. While the patient may have a high risk for impaired venous return from the circulatory insufficiency, there is no indication the patient has dementia.

Question 4

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

Answer 4

ANS: A

Assess surfaces exposed to casts, cloth restraints, bandages and dressings, tubing, or orthopedic devices. An external device applied to or around the skin exerts pressure or friction on the skin, leading to skin impairment. When restricted from moving, dependent body parts are exposed to pressure that reduces circulation to affected tissues, promoting pressure ulcers. Patients with limited caloric and protein intake develop impaired or delayed wound healing. Keeping the blood pressure artificially low may decrease arterial blood supply, leading to ischemia and breakdown.

Question 5

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

a. Contagious with frequent recurrences
b. Helpful to air-dry feet after bathing
c. Treated with salicylic acid
d. Caused by lice

Answer 5

ANS: A

Athlete’s foot spreads to other body parts, especially the hands. It is contagious and frequently recurs. Drying feet well after bathing and applying powder help prevent infection. It is caused by a fungus, not lice, and is treated with applications of griseofulvin, miconazole, or tolnaftate. Plantar wars are treated with salicylic acid or electrodesiccation.

Question 6

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 6

ANS: A

Inflammatory lesions and fungus of the nail bed cause thickened, horny nails that separate from the nail bed. Ask women whether they frequently polish their nails and use polish remover because chemicals in these products cause excessive nail dryness. Friction and pressure from ill-fitting or loose shoes causes keratosis (corns). It is seen mainly on or between toes, over bony prominences.

Question 7

. The nurse is providing education about the importance of proper foot care to a patient who has 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 7

ANS: D

Foot ulceration is the most common single precursor to lower extremity amputations among persons with diabetes. Prevention of plantar warts and foot fungus are important but not the primary goal. Neuropathy is a degeneration of the peripheral nerves usually due to poor control of blood glucose levels; it is not a direct result of foot care.

Question 8

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

a. Feet
b. Nail beds
c. Perineum
d. Oral cavity

Answer 8

ANS: D

The oral cavity is the priority. Radiation to the head reduces salivary flow and lowers pH of saliva, leading to stomatitis and tooth decay, while chemotherapy drugs kill the normal cells lining the oral cavity, leading to ulcers and inflammation. While the feet, nail beds, and perineum are important, they are not as affected as the oral cavity with head or neck radiation and chemotherapy.

Question 9

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 9

ANS: B

Dental flossing removes plaque and tartar between teeth. To prevent bleeding, the patient should use unwaxed floss. Flossing once a day is sufficient. If toothpaste is applied to the teeth before flossing, fluoride will come in direct contact with tooth surfaces, aiding in cavity prevention.

Question 10

. 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 10

ANS: C

Head lice are difficult to remove and spread to furniture and other people if not treated. Caution against use of products containing lindane because the ingredient is toxic and is known to cause adverse reactions. Treatments use medicated shampoo for eliminating lice. Manual removal is the best option when treatment has failed.

Question 11

. 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 11

ANS: B

The sequence for giving a bath is as follows: eyes, face, both arms, chest, hands/nails, abdomen, both legs, perineal hygiene, back, and buttocks/anus.

Question 12

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 blunt 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 12

ANS: A

Using blunt tweezers, grasp the tick as close to the head as possible and pull upward with even, steady pressure. Hold until the tick pulls out, usually for about 3 to 4 minutes. Save the tick in a plastic bag, and put it in the freezer if necessary to identify the type of tick. Because ticks transmit several diseases to people, they must be removed. Allowing them to drop off by themselves is not an option. Do not burn ticks off with a match or lighter. Miconazole is used to treat athlete’s foot; it is a fungal medication. Covering ticks with plastic does not remove ticks.

Question 13

. 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 13

ANS: C

A partial bath consists of washing body parts that the patient cannot reach, including the back, and providing a backrub. Dependent patients in need of partial hygiene or self-sufficient bedridden patients who are unable to reach all body parts receive a partial bed bath. Complete bed baths are administered to totally dependent patients in bed. The bag bath contains several soft, nonwoven cotton cloths that are premoistened in a solution of no-rinse surfactant cleanser and emollient. The sponge bath involves bathing from a bath basin or a sink with the patient sitting in a chair.

Question 14

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 14

ANS: B

Use all six chlorhexidene gluconate (CHG) cloths in the following order:

1. Cloth 1: Neck, shoulders, and chest
2. Cloth 2: Both arms, both hands, web spaces, and axilla
3. Cloth 3: Abdomen and then groin/perineum
4. Cloth 4: Right leg, right foot, and web spaces
5. Cloth 5: Left leg, left foot, and web spaces
6. Cloth 6: Back of neck, back, and then buttocks

Question 15

A nursing assistive personnel (NAP) is providing AM care to patients. Which action by the NAP 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 15

ANS: D

The nurse must intervene if the NAP turns the patient’s head with a neck injury; this is contraindicated and must be stopped to prevent further injury. All the other actions are appropriate and do not need follow-up. Consult the medical record for any contraindications to a massage (e.g., fractured ribs, burns, and heart surgery). Before washing a patient’s hair, determine that there are no contraindications to procedure (e.g., neck injury). When providing a backrub, enhance relaxation by reducing noise (turning off the television) and ensuring that the patient is comfortable.

Question 16

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 16

ANS: B

CHG is safe to use on the perineum and external mucosa. If patient has diabetes or peripheral vascular disease with impaired circulation and/or sensation, do not soak feet. Maceration of skin may predispose to infection. Do not use long, firm strokes to wash the lower extremities of patients with history of deep vein thrombosis or blood-clotting disorders. Use short, light strokes instead. Eye should be cleansed from the inner to outer canthus on all patients.

Question 17

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 thoroughly.
b. Allow the skin to air-dry.
c. Do not use a bath towel.
d. Dry the skin with a towel.

Answer 17

ANS: B

The nurse should allow the skin to air-dry for 30 seconds. Drying the skin with a towel removes the emollient that is left behind after the water/cleanser solution evaporates. It is permissible to lightly cover the patient with a bath blanket or towel to prevent chilling. Do not rinse when using a bag bath.

Question 18

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.

Answer 18

ANS: C

Return the foreskin to its natural position. Keeping the foreskin retracted leads to tightening of the foreskin around the shaft of the penis, causing local edema and discomfort. The foreskin may not return to its natural position on its own. Patients at greatest risk for infection are uncircumcised males.

Question 19

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 19

ANS: C

Report any changes that may indicate inflammation or injury to tissue. Do not allow the diabetic patient to go barefoot; injury can lead to amputations. Clipping toenails is not allowed. Patients with peripheral vascular disease or diabetes mellitus often require nail care from a specialist to reduce the risk of infection. When assessing the patient’s feet, the nurse palpates the dorsalis pedis of the foot, not the brachial artery.

Question 20

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 20

ANS: A

If the patient is uncooperative, or is having difficulty keeping the mouth open, insert an oral airway. Insert it upside down, and then turn the airway sideways and over the tongue to keep the teeth apart. Do not use force. Position the patient on his or her side or turn the head to allow for drainage. Placing the patient in a flat, supine position could lead to aspiration. Hydrogen peroxide is irritating to mucosa. Even though the patient is debilitated, explain the steps of mouth care and the sensations that he or she will feel. Also tell the patient when the procedure is completed.

Question 21

A nurse is providing oral care to a patient with stomatitis. Which technique will the nurse use?

a. Avoid commercial mouthwashes.
b. Avoid normal saline rinses.
c. Brush with a hard toothbrush.
d. Brush with an alcohol-based toothpaste.

Answer 21

ANS: A

Stomatitis causes burning, pain, and change in food and fluid tolerance. Advise patients to avoid alcohol and commercial mouthwash and stop smoking. When caring for patients with stomatitis, brush with a soft toothbrush and floss gently to prevent bleeding of the gums. In some cases, flossing needs to be temporarily omitted from oral care. Normal saline rinses (approximately 30 mL) on awaking in the morning, after each meal, and at bedtime help clean the oral cavity.

Question 22

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 22

ANS: C

When cerumen is visible, gentle, downward retraction at the entrance to the ear canal causes the wax to loosen and slip out. Instruct the patient never to use sharp objects such as bobby pins or paper clips to remove earwax. Use of such objects can traumatize the ear canal and ruptures the tympanic membrane. Avoid the use of cotton-tipped applicators as well because they cause earwax to become impacted within the canal. Instilling cold or hot water causes nausea or vomiting.

Question 23

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 23

ANS: A

Excessive nasal secretions can be removed using gentle suctioning. However, patients usually remove secretions from the nose by gentle blowing into a soft tissue. Caution the patient against harsh blowing that creates pressure capable of injuring the eardrum, the nasal mucosa, and even sensitive eye structures. If the patient is unable to remove nasal secretions, assist by using a wet washcloth or a cotton-tipped applicator moistened in water or saline. Never insert the applicator beyond the length of the cotton tip.

Question 24

The nurse is caring for a patient with cognitive impairments. Which actions will the nurse take during AM care? (Select all that apply.)

a. Administer ordered analgesic 1 hour before bath time.
b. Increase the frequency of skin assessment.
c. Reduce triggers in the environment.
d. Keep the room temperature cool.
e. Be as quick as possible.

Answer 24

ANS: B, C

If a patient is physically dependent or cognitively impaired, increase the frequency of skin assessment. Adapt your bathing procedures and the environment to reduce the triggers. For example, administer any ordered analgesic 30 minutes before a bath and be gentle in your approach. Keep the patient’s body as warm as possible with warm towels and be sure the room temperature is comfortable.

Question 25

The nurse is caring for a patient who has peripheral neuropathy. Which clinical manifestations does the nurse expect to find upon assessment? (Select all that apply.)

a. Abnormal gait
b. Foot deformities
c. Absent or decreased pedal pulses
d. Muscle wasting of lower extremities
e. Decreased hair growth on legs and feet

Answer 25

ANS: A, B, D

A patient with peripheral neuropathy has muscle wasting of lower extremities, foot deformities, and abnormal gait. A patient with vascular insufficiency will have decreased hair growth on legs and feet, absent or decreased pulses, and thickened nails.

Question 26

Which patients will the nurse determine are in need of perineal care? (Select all that apply.)

a. A patient with rectal and genital surgical dressings
b. A patient with urinary and fecal incontinence
c. A circumcised male who is ambulatory
d. A patient who has an indwelling catheter
e. A bariatric patient

Answer 26

ANS: A, B, D, E

Patients most in need of perineal care include those at greatest risk for acquiring an infection (e.g., uncircumcised males, patients who have indwelling urinary catheters, or those who are recovering from rectal or genital surgery or childbirth). A patient with urinary and bowel incontinence needs perineal cleaning with each episode of soiling. Bariatric patients need special attention to body areas such as skin folds and the perineal area. In addition, women who are having a menstrual period require perineal care. Circumcised males are not at high risk for acquiring infection, and ambulatory patients can usually provide perineal self-care.

Question 27

The patient must stay in bed for a bed change. Which actions will the nurse implement? (Select all that apply.)

a. Apply sterile gloves.
b. Keep soiled linen close to uniform.
c. Advise patient will feel a lump when rolling over.
d. Turn clean pillowcase inside out over the hand holding it.
e. Make a modified mitered corner with sheet, blanket, and spread.

Answer 27

ANS: C, D, E

When making an occupied bed, advise patients they will feel a lump when turning, turn clean pillowcase inside out, and make a modified mitered corner. Clean gloves are used. Keep soiled linen away from uniform.