課本裡的題目.docx

**PRACTICING FOR NCLEX (Hygiene & activity)** 1\. A nurse is scheduling hygiene for patients on the unit. What is the priority the nurse uses to guide planning for patient's personal hygiene? a\. When the patient had their most recent bath b\. The patient's usual hygiene practices and preference...

**PRACTICING FOR NCLEX (Hygiene & activity)** 1\. A nurse is scheduling hygiene for patients on the unit. What is the priority the nurse uses to guide planning for patient's personal hygiene? a\. When the patient had their most recent bath b\. The patient's usual hygiene practices and preferences c\. Where the bathing fits in the nurse's schedule d\. The time that is convenient for the AP 2\. A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential to good patient outcomes, especially for those receiving mechanical ventilation. What are positive outcomes expected from this care? Select all that apply. a\. Promoting the patient's sense of well-being b\. Preventing deterioration of the oral cavity c\. Contributing to decreased incidence of aspiration pneumonia d\. Eliminating the need for flossing e\. Decreasing oropharyngeal secretions f\. Compensating for an inadequate diet 3\. A nurse assisting a patient with a bed bath observes the older adult has dry skin, which the patient states is "itchy." Which intervention is appropriate? a\. Bathe the patient more frequently. b\. Use an emollient on the dry skin. c\. Explain that this is expected as people age. d\. Limit the patient's fluid intake. 4\. A charge nurse in a skilled nursing facility is working to reduce patients' foot and nail problems. The charge nurse reminds the nurses and APs to closely observe which of these patients at higher risk? Select all that apply. a\. Patient taking antibiotics for chronic bronchitis b\. Patient with type 2 diabetes c\. Patient who has obesity d\. Patient who frequently bites their nails e\. Patient with prostate cancer f\. Patient who frequently washes their hands 5\. When assessing the skin, nurses use techniques to provide complete data and correct documentation. Which actions are appropriate during the skin assessment? Select all that apply. a\. Comparing bilateral parts for symmetry b\. Proceeding in a toe-to-head, systematic manner c\. Using standard terminology to communicate and document findings d\. Avoiding using data from the nursing history to direct the assessment e\. Documenting only skin abnormalities on the health record f\. When risk factors are identified, following up with a related skin assessment 6\. A nurse is caring for an adolescent with severe acne. Which recommendations would be most appropriate to include in the teaching plan for this patient? Select all that apply. a\. Wash the skin twice a day with a mild cleanser and warm water. b\. Use cosmetics liberally to cover blackheads. c\. Apply emollients on the area. d\. Squeeze blackheads as they appear. e\. Keep hair off the face and wash hair daily. f\. Avoid tanning booth exposure and use sunscreen. 7\. A nurse is performing oral care on a patient who has advanced dementia. The nurse notes that the mouth is extremely dry with crusts remaining after the oral care. What action will the nurse take next? a\. Recommend a consultation with an oral surgeon. b\. Communicate the condition to the health care team. c\. Gently scrape the oral cavity with a tongue depressor. d\. Increase the frequency of the oral hygiene and apply mouth moisturizer to oral mucosa. 8\. A nursing student asks an experienced nurse why they provide massage for their patients. Which of these would be reflected in the nurse's response? a\. To help with pain management b\. To provide comfort c\. To communicate to patients through touch d\. To energize patients, especially those with dementia e\. To facilitate healing after back or spinal surgery f\. To help increase circulation 9\. A nurse is caring for a patient with an eye infection with a moderate amount of discharge. What is the most appropriate technique for the nurse to use when cleansing this patient's eyes? a\. Using diluted hydrogen peroxide on a clean washcloth to wipe the eyes b\. Wiping the eye from the outer canthus toward the inner canthus c\. Positioning the patient on the opposite side of the eye to be cleansed d\. Cleansing the eye using a different section of the cloth for each stroke until clean 10\. A nurse in a long-term care facility observes the AP providing foot care for patients. Which actions by the AP require the nurse to intervene? Select all that apply. a\. Bathing the feet thoroughly in a mild soap and tepid water solution b\. Soaking the resident's feet in warm water and bath oil c\. Drying the feet and area between the toes thoroughly d\. Applying an alcohol rub for odor and dryness to the feet e\. Applying an antifungal foot powder f\. Cutting the toenails at the lateral corners when trimming the nail 11\. A nurse in a memory care unit is assisting a patient with dementia with bathing. Which nursing action will enhance patient comfort and prevent anxiety? a\. Shifting the focus of the interaction to the "process of bathing" b\. Washing the face and hair at the beginning of the bath c\. Using music to soothe anxiety and agitation for more ebook/ testbank/ solution manuals requests: email 960126734\@qq.com d\. Avoiding towel baths or forms of bathing with which the patient is unfamiliar 12\. A nurse is teaching a nursing student how to perform perineal care for patients. What actions are appropriate when performing this procedure? Select all that apply. a\. For male and female patients, wash the groin area with a small amount of soap and water and rinse. b\. For a female patient, spread the labia and move the washcloth from the anal area toward the pubic area. c\. For male and female patients, always proceed from the most contaminated area to the least contaminated area. d\. For male and female patients, use a clean portion of the washcloth for each stroke. e\. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. f\. In an uncircumcised male patient, avoid retracting the foreskin (prepuce) while washing the penis. 13\. A home care nurse is assisting an older adult with an unsteady gait with a tub bath. Which action is recommended in this procedure? a\. Adding bath oil to the water to prevent dry skin b\. Allowing the patient to lock the door to guarantee privacy c\. Assisting the patient in and out of the tub to prevent falling d\. Keeping the water temperature very warm because older adults chill easily 14\. A nurse is about to bathe a female patient who has an IV in the forearm. The patient's gown, which does not have snaps on the sleeves, needs to be removed prior to bathing. How will the nurse proceed? a\. Quickly disconnecting the IV tubing closest to the patient and thread it through the gown sleeve b\. Cutting the gown with scissors to allow arm movement c\. Threading the bag and tubing through the gown sleeve, keeping the line intact d\. Temporarily disconnecting the tubing from the IV container, threading it through the gown 15\. A nurse is caring for a 25-year-old patient who is unresponsive following a head injury. The patient has several piercings in the ears and nose that appear crusted and slightly inflamed. What is the most appropriate action to care for this patient's piercings? a\. Avoiding removing or washing the piercings until the patient is responsive b\. Rinsing the sites with warm water and remove crusts with a cotton swab c\. Washing the sites with alcohol and apply an antibiotic ointment d\. Removing the jewelry and allow the sites to heal over 16\. An RN in a long-term care facility supervises APs as they provide hygiene to older adults. What action by the AP will the nurse correct? a\. When providing perineal care, washing the area from front to back b\. Insisting the older adult must take a bath or shower each day c\. Telling the patient to avoid soaking feet, helps the patient dry between the toes d\. Covering areas not being bathed with a bath blanket **ANSWERS WITH RATIONALES** **1. b.** The patient's preferences, practices, and rituals should always be taken into consideration, unless there is a clear threat to health. The patient and nurse should work together to come to a mutually agreeable time and method to accomplish the patient's personal hygiene. The availability of staff to assist may be important, but the patient's preferences are a higher priority. **2. a, b, c.** Adequate oral hygiene is essential for promoting the patient's sense of well-being and preventing deterioration of the oral cavity. Diligent oral hygiene and use of chlorhexidine gluconate (CHG) in critical care areas, can limit the growth of pathogens in oropharyngeal secretions, decreasing the incidence of ventilator-associated pneumonia, aspiration pneumonia, and other systemic diseases. Oral care does not eliminate the need for flossing, decrease oropharyngeal secretions, or compensate for poor nutrition. **3. b.** An emollient soothes dry skin, whereas frequent bathing increases dryness. Telling the patient this is normal with aging and does not help resolve the issue. Limiting fluid intake can promote dehydration and exacerbate dry skin. **4. b, c, d, f.** Variables known to cause nail and foot problems include deficient self-care abilities, vascular disease, arthritis, diabetes mellitus, history of biting nails or trimming them improperly, frequent or prolonged exposure to chemicals or water, trauma, ill-fitting shoes, and obesity. Antibiotic use and prostate cancer do not predispose to foot or nail problems. **5. a, b, c, f.** During skin assessment, the nurse should compare bilateral parts for symmetry, use standard terminology to communicate and document findings, and perform the appropriate skin assessment when risk factors are identified. The nurse should proceed in a head-to-toe systematic manner, using cues/data from the nursing history to direct the assessment. When documenting a physical assessment of the skin, the nurse should describe exactly what is observed or palpated, including appearance, texture, size, location or distribution, and characteristics of any findings. **6. a, e, f.** Washing the skin removes oil and debris, hair should be kept off the face and washed daily to keep oil from the hair off the face. Exposure to UV light should be avoided, especially when using acne treatments. Liberal use of cosmetics and emollients can clog the pores, worsening acne. Squeezing blackheads is discouraged because it may lead to infection. **7. d.** If initial oral care results in continued dryness of the oral cavity with crusting, the nurse should increase frequency of oral hygiene, apply mouth moisturizer to oral mucosa, and monitor fluid intake and output to ensure adequate intake of fluid. It is not necessary to report this condition prior to providing the interventions mentioned above; however, mouth care and re-evaluation of the oral cavity is documented. The crusts should not be scraped with a tongue depressor. **8. a, b, c, f.** The benefits of massage include general relaxation and increased circulation, pain relief, sleep promotion, and increased patient comfort and well-being. Massage also provides an opportunity for the nurse to communicate and connect with the patient through touch. Back massage is contraindicated if the patient has had back surgery or has fractured ribs. **9. d.** The nurse applies gloves for the cleaning procedure, uses water or normal saline, and a clean washcloth or gauze to cleanse the eyes. After dampening a cleaning cloth with the solution of choice, the nurse wipes once while moving from the inner canthus to the outer canthus of the eye to reduce forcing debris into the area drained by the nasolacrimal duct. The nurse should turn the cleansing cloth and use a different section for each stroke until the eye is clean. **10. b, d, f.** The nurse corrects the AP for soaking the feet or using alcohol and reminds them to use moisturizer if the feet are dry. Digging into or cutting the toenails at the lateral corners when trimming the nails requires correction; toenails should be trimmed straight across. Guidelines for foot care include bathing the feet thoroughly in a mild soap and tepid water solution; drying feet thoroughly, including the area between the toes; and applying an antifungal foot powder when requested. **11. c.** The nurse use music to soothe anxiety and agitation. The nurse should also shift the focus of the interaction from the "task of bathing" to the needs and abilities of the patient, and focus on comfort, safety, autonomy, and self-esteem, in addition to cleanliness. Wash the face and hair at the end of the bath or at a separate time. Water dripping in the face and having a wet head are often the most upsetting parts of the bathing process for people with dementia. The nurse should also consider methods for bathing aside from showers and tub baths. Towel baths, washing under clothes, and bathing "body sections" one day at a time, as well as dry shampoo or "shower cap" shampoos, are additional options. **12. a, d, e.** Wash and rinse the groin area (both male and female patients) with a small amount of soap and water, and rinse. For male and female patients, always proceed from the least contaminated area to the most contaminated area and use a clean portion of the washcloth for each stroke. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. For a female patient, spread the labia and move the washcloth from the pubic area toward the anal area. In an uncircumcised male patient (teenage or older), retract the foreskin (prepuce) while washing the penis and return it to its original position when finished. **13. c.** Safe nursing practice requires that the nurse assists a patient with an unsteady gait in and out of the tub. Adding bath oil to the bath water poses a safety risk because it makes the patient and tub slippery. Although privacy is important, if the patient locks the door, the nurse cannot help if there is an emergency. The water should be comfortably warm at 43° to 46°C. Older adults have an increased susceptibility to burns due to diminished sensitivity. **14. c.** Threading the bag and tubing through the gown sleeve maintains a closed system and prevents contamination. No matter how quickly performed, any disconnection of IV tubing results in a breach of the sterile system, creating risk for infection. Cutting a gown is not an alternative except in an emergency. **15. b.** When providing care for piercings, the nurse performs hand hygiene, applies gloves, then cleanses the site of all crusts and debris by rinsing the site with warm water and removing the crusts with a cotton swab. The nurse should then apply a dab of liquid-medicated cleanser, per policy, to the area, turn the jewelry back and forth to work the cleanser around the opening, rinse well, remove gloves, and perform hand hygiene. The nurse should not use alcohol, peroxide, or ointments at the site and should avoid removing piercings unless it is absolutely necessary (e.g., when an MRI is ordered.) **16. b.** Older adults tend to develop dry skin; bathing frequency will change accordingly. Soaking adults' feet is not recommended. It is appropriate to keep a patient warm with bath blankets and provide perineal care washing from front to back.