Questions Flashcards
The nurse is providing an educational session for a group of preschool workers. The nurse reminds the group about the most important thing to do to prevent the spread of infection. Which information did the nurse share with the preschool workers?
a. Encourage preschool children to eat a nutritious diet.
b. Suggest that parents provide a multivitamin to the children.
c. Clean the toys every afternoon before putting them away.
d. Wash their hands between each interaction with children.
ANS: D
The single most important thing that individuals can do to prevent the spread of infection is to wash their hands before and after eating, going to the bathroom, changing a diaper, and wiping a nose and between touching each individual child. It is important for preschool children to have a nutritious diet; a healthy individual can fight infection more effectively. A health care provider, along with the parent, makes decisions about dietary supplements. Cleaning the toys can decrease the number of pathogens but is not the most important thing to do in this scenario.
The nurse is caring for a patient in the hospital. The nurse observes the nursing assistive personnel (NAP) turning off the handle faucet with bare hands. Which professional practice principle supports the need for follow-up with the NAP?
a. The nurse is responsible for providing a safe environment for the patient.
b. Different scopes of practice allow modification of procedures.
c. Allowing the water to run is a waste of resources and money.
d. This is a key step in the procedure for washing hands.
ANS: A
The nurse is responsible for providing a safe environment for the patient. The effectiveness of infection control practices depends on conscientiousness and consistency in using effective aseptic technique by all health care providers. After washing hands, turn off a handle faucet with a dry paper towel, and avoid touching the handles with your hands to assist in preventing the transfer of microorganisms. Wet towels and hands allow the transfer of pathogens from faucet to hands. The principles and procedures for washing hands are universal and apply to all members of health care teams. Being resourceful and aware of the cost of health care is important, but taking shortcuts that may endanger an individual’s health is not a prudent practice.
The nurse is caring for a patient who becomes nauseated and vomits without warning. The nurse has contaminated hands. Which action is best for the nurse to take next?
a. Wash hands with an antimicrobial soap and water.
b. Clean hands with wipes from the bedside table.
c. Use an alcohol-based waterless hand gel.
d. Wipe hands with a dry paper towel.
ANS: A
The Centers for Disease Control and Prevention (CDC) recommends that when hands are visibly soiled, one should wash with a non-antimicrobial soap or with antimicrobial soap. Cleaning hands with wipes or using waterless hand gel does not meet this standard. If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely decontaminating hands. Wiping hands with a dry paper towel will occur after the nurse has washed both hands.
The nurse is performing hand hygiene before assisting a health care provider with insertion of a chest tube. While washing hands, the nurse touches the sink. Which action will the nurse take next?
a. Inform the health care provider and recruit another nurse to assist.
b. Rinse and dry hands, and begin assisting the health care provider.
c. Extend the handwashing procedure to 5 minutes.
d. Repeat handwashing using antiseptic soap.
ANS: D
The inside of the sink and the edges of the sink, faucet, and handles are considered contaminated areas. If the hands touch any of these areas during handwashing, repeat the handwashing procedure utilizing antiseptic soap. There is no need to inform the health care provider or be relieved of this assignment. If the hands are contaminated when touching the sink, drying hands and proceeding with the procedure could possibly contaminate and contribute to increased microbial counts during the procedure, resulting in infection for the patient. Extending the time for washing the hands (although this is what will happen when the procedure is repeated) is not the focus. The focus is to repeat the whole hand hygiene procedure utilizing antiseptic soap.
The home health nurse is teaching a patient and family about hand hygiene in the home. Which situation will cause the nurse to emphasize washing hands before and after?
a. Shaking hands
b. Performing treatments
c. Opening the refrigerator
d. Working on a computer
ANS: B
Patients and family members should perform hand hygiene before and after treatments and when coming in contact with body fluids. Shaking hands does not require washing of hands before and after. Washing hands before and after opening the refrigerator and using the computer is not required.
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
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.
A nurse is providing a bath. In which order will the nurse clean the body, beginning with the first area?
- Face
- Eyes
- Perineum and buttox
- Arm and chest
- Hands and nails
- Back
- Abdomen and legs
a. 1, 2, 5, 4, 7, 6, 3
b. 2, 1, 4, 5, 7, 6, 3
c. 2, 1, 5, 4, 6, 7, 3
d. 1, 2, 4, 5, 3, 7, 6
ANS: B
The sequence for giving a bath is as follows: eyes, face, both arms, chest, hands/nails, abdomen, both legs, back, perineal hygiene, and buttocks/anus
The nurse is caring for a patient in an intensive care unit who needs a bath. Which priority action will the nurse take to decrease the potential for a health care–associated infection?
a. Use local anesthetic on reddened areas.
b. Use nonallergenic tape on dressings.
c. Use a chlorhexidine wash.
d. Use filtered water.
ANS: C
The Centers for Disease Control and Prevention (CDC) recommends the use of chlorhexidine (CHG) bathing for patients in intensive care units, patients who are scheduled for surgery, and all patients with invasive central line catheters as part of MRSA reduction efforts. Using local anesthetics, nonallergenic tape, and filtered water does not affect the cause of a health care–associated infection by, for example, decreasing microbial counts like a CHG bath.
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.
ANS: B
No two individuals perform hygiene in the same manner; it is important to individualize the patient’s care based on knowing about the patient’s unique hygiene practices and preferences. Hygiene care is never routine; this care requires intimate contact with the patient and communication skills to promote the therapeutic relationship. In addition, during hygiene, the nurse should take time to learn about the patient’s health promotion practices and needs, emotional needs, and health care education needs.
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
ANS: B
Family customs play a major role during childhood in determining hygiene practices such as the frequency of bathing, the time of day bathing is performed, and even whether certain hygiene practices such as brushing of the teeth or flossing are performed. As children enter adolescence, peer groups and media often influence hygiene practices. During the adult years involvement with friends and work groups shape the expectations that people have about personal appearance. Some older adults’ hygiene practices change because of changes in living conditions and available resources.
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.
ANS: A
Allow the patient to follow normal hygiene practices; change the bath to evening. Patients have individual preferences about when to perform hygiene and grooming care. Knowing the patient’s personal preferences promotes individualized care for the patient. Hygiene care is never routine. Maintaining individual personal preferences is important unless new hygiene practices are indicated by an illness or condition. Cancelling hygiene and trying again is not an option since the nurse already knows the reason for refusal. Adapting practices to meet individual needs is required.
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.
ANS: B
In older adults, daily bathing as well as bathing with water that is too hot or soap that is harsh causes the skin to become excessively dry. As the patient ages, the skin thins and loses its resiliency and moisture, and lubricating skin glands become less active, making the skin fragile and prone to bruising and breaking.
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
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.
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.
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.
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.
ANS: D
During a bath, assess the status of sensory nerve function by checking for touch, pain, heat, cold, and pressure. When restricted from moving freely, dependent body parts are exposed to pressure that reduces circulation. However, this patient is mobile and therefore is able to change positions. Limiting caloric and protein intake may result in impaired or delayed wound healing. A mobile patient can use bathroom facilities or a urinal and does not need a urinary catheter.
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.
ANS: C
The nurse must assist the patient in developing new hygiene practices when indicated by an illness or condition. For example, the nurse will need to teach a patient with diabetes proper foot hygiene. Patients who appear unkempt often need further assessment regarding their ability to participate in daily hygiene. Patients with certain types of physical limitations or disabilities often lack the physical energy and dexterity to perform hygienic care. Culturally, maintaining cleanliness does not hold the same importance for some ethnic groups as it does for others.
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
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.
