Questions

Question 1

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.

Answer 1

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.

Question 2

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.

Answer 2

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.

Question 3

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.

Answer 3

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.

Question 4

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.

Answer 4

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.

Question 5

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

Answer 5

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.

Question 6

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 6

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 7

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 and buttox
4. Arm and chest
5. Hands and nails
6. Back
7. 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

Answer 7

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

Question 8

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.

Answer 8

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.

Question 9

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 9

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.

Question 10

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 10

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.

Question 11

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 11

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.

Question 12

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 12

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.

Question 13

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 13

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 14

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 14

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 15

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 15

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.

Question 16

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 16

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.

Question 17

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 17

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 18

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 18

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 19

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

a. Providing nail care
b. Teaching foot care
c. Making an occupied bed
d. Determining aspiration risk

Answer 19

ANS: C
The skill of making an occupied bed can be delegated to nursing assistive personnel. Nail care, teaching foot care, and assessing aspiration risk of a patient with diabetes must be performed by the RN; these skills cannot be delegated.

Question 20

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 20

ANS: B
Halitosis is the term for “bad breath.” Cheilitis is the term for cracked lips. Dental caries are cavities in the teeth and could be a cause of the halitosis. Glossitis is the term for inflamed tongue

Question 21

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 21

ANS: C
Oral care is provided in the following sequence: Clean chewing and inner tooth surfaces first. Clean outer tooth surfaces. Moisten brush with chlorhexidine rinse to rinse. Use toothette to clean roof of mouth, gums, and inside cheeks. Gently brush tongue but avoid stimulating gag reflex. Rinse.

Question 22

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

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 22

ANS: D
When providing oral hygiene to an unconscious patient, the nurse needs to protect him or her from choking and aspiration. Have two nurses provide care; one nurse does the actual cleaning, and the other caregiver removes secretions with suction equipment. The nurse can delegate nursing assistive personnel to participate. Some agencies use equipment that combines a mouth swab with the suction device. This device can be used safely by one nurse to provide oral care. Commercially made foam swabs are ineffective in removing plaque. Do not use lemon-glycerin sponges because they dry mucous membranes and erode tooth enamel. While cleansing the oral cavity, use a small oral airway or a padded tongue blade to hold the mouth open. Never use your fingers to hold the patient’s mouth open. A human bite contains multiple pathogenic microorganisms.

Question 23

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 23

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 24

The nurse is caring for an older-adult patient 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 24

ANS: A
Edentulous means without teeth; therefore, the nurse needs to assess the oral cavity. While older adults may want the room warmer and drafts should be avoided, this does not help with being edentulous. Edentulous does not mean the patient has edema. While older-adult patients can have reduced sensations, this is not the meaning of edentulous.

Question 25

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 25

ANS: A
In community health and home care settings, it is particularly important to inspect the hair for lice so appropriate hygienic treatment can be provided. If pediculosis capitis (head lice) is suspected, the nurse must protect self against self-infestations by handwashing and by using gloves or tongue blades to inspect the patient’s hair. Suspicions cannot be ignored. Shaving hair off affected areas is the treatment for pediculosis pubis (crab lice) and is rarely used for head lice. Caution against use of products containing lindane because the ingredient is toxic and known to cause adverse reactions.

Question 26

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 26

ANS: A
Dandruff is scaling of the scalp that is accompanied by itching. Pediculosis (lice infestation) resides on scalp attached to hair strands; eggs look like oval particles, similar to dandruff. Alopecia is hair loss or balding. Xerostomia is dry mouth.

Question 27

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 27

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 28

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 28

ANS: C
If a patient is able to perform perineal self-care, encourage this independence. Patients most in need of perineal care are those at greatest risk for acquiring an infection such as uncircumcised males; perineal care is necessary. Embarrassment should not cause the nurse to overlook the patient’s hygiene needs. The nurse should provide this care only if the patient is unable to do so.

Question 29

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 29

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 30

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 30

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 31

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 31

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 32

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

a. Back to front
b. In a circular motion
c. From pubic area to rectum
d. Upward from rectum to pubic area

Answer 32

ANS: C
Cleansing from pubic area to rectum (front to back) reduces the transfer of microorganisms to the urinary meatus and decreases the risk of urinary tract infection. Cleansing from rectum to pubic area or back to front increases the risk of urinary tract infection. Circular motions are used in male perineal care.

Question 33

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 33

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 34

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 34

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 35

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 35

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 36

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

Answer 36

ANS: B
Thoroughly wash and rinse lens storage case on a daily basis. Clean periodically with soap or liquid detergent, rinse thoroughly with warm water, and air-dry. Do not use tap water to clean soft lenses. Lenses should be kept moist or wet when not worn. Use fresh solution daily when storing and disinfecting lenses.

Question 37

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 37

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 38

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 38

ANS: B
Adjust volume to a comfortable level for talking at a distance of 1 yard. Initially, wear a hearing aid for 15 to 20 minutes; then gradually increase wear time to 10 to 12 hours per day. Batteries last 1 week with daily wearing of 10 to 12 hours. Avoid the use of hairspray and perfume while wearing hearing aids. Residue from the spray can cause the aid to become oily and greasy.

Question 39

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 39

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 40

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 40

ANS: B
With this type of model (in-the-canal), cerumen tends to plug this model more than others. There are three popular types of hearing aids. An in-the-canal (ITC) aid is the newest, smallest, and least visible and fits entirely in the ear canal. It has cosmetic appeal, is easy to manipulate and place in the ear, and does not interfere with wearing eyeglasses or using the telephone, and the patient can wear it during most physical exercise. An in-the-ear aid (ITE, or intra-aural) is more noticeable than the ITC aid and is not for people with moisture or skin problems in the ear canal. The larger size of this type of aid (behind-the-ear, BTE, or post-aural) can make use of eyeglasses and phones difficult; it is more difficult to keep in place during physical exercise.

Question 41

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 41

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 42

A nurse is providing hygiene care to a bariatric patient using chlorhexidine gluconate (CHG) wipes. Which actions will the nurse take? (Select all that apply.)

a. Do not rinse.
b. Clean under breasts.
c. Inform that the skin will feel sticky.
d. Dry thoroughly between skin folds.
e. Use two wipes for each area of the body.

Answer 42

ANS: A, B, C
CHG wipes are easy to use and accessible for older patients and bariatric patients, offering a no-rinse or -drying procedure. For a bariatric patient or a patient who is diaphoretic, provide special attention to body areas such as beneath the woman’s breasts, in the groin, skin folds, and perineal area, where moisture collects and irritates skin surfaces. Use wipes as directed on package—one wipe per each area of the body. CHG can leave the skin feeling sticky. If patients complain about its use, you need to explain their vulnerability to infection and how CHG helps reduce occurrence of health care–associated infection.

Question 43

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 43

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 44

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 44

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.