Chapter 33 My Nursing Test Banks

 

Kozier & Erbs Fundamentals of Nursing, 9/E
Chapter 33

Question 1

Type: MCSA

What would the nurse explain to a client the reason for a daily bath?

1. To assess skin integrity

2. To develop a nurse-client relationship

3. To moisturize the skin

4. To stimulate circulation

Correct Answer: 4

Rationale 1: Giving a bath to a client will allow the nurse to assess the skin but this is not the most important purpose.

Rationale 2: Giving a bath to a client will allow the nurse to develop a nurse-client relationship but this is not the most important purpose.

Rationale 3: Giving a bath to a client will allow the nurse to moisturize the skin but this is not the most important purpose.

Rationale 4: The three major reasons for a bath are to remove waste products like perspiration, stimulate circulation, and refresh the client.

Global Rationale: Page Reference: 750

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 05 Identify the purposes of bathing.

Question 2

Type: MCSA

Which nursing intervention should take priority when giving a bath to a surgical client on the first post-op day?

1. Apply lotion to the extremities.

2. Change the water when it becomes cold.

3. Raise side rails when gathering supplies.

4. Remove the soiled dressing during the bath.

Correct Answer: 3

Rationale 1: Applying lotion to the skin would be performed before or after, not during, the bath.

Rationale 2: Changing the water needs to be done before it becomes cold, but it is not a priority.

Rationale 3: Raising the side rails would take priority when planning care. This is a safety issue, and safety is second on Maslows hierarchy of needs. The client is only 1 day postop and may still be sedated, posing a risk for a potential fall.

Rationale 4: A dressing change would be performed before or after, not during, the bath and only with a doctors order.

Global Rationale: Page Reference: 758

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 07 Compare and contrast the task-centered approach and the person-centered approach to bathing.

Question 3

Type: MCSA

A client has had a hemorrhoidectomy and has been ordered a sitz bath BID. Which of the following interventions is appropriate in assisting the client with his bath?

1. Flatten the reservoir bag on a hard surface and press on it to expel air.

2. Have the client use the clamp on the tubing to regulate the flow of water.

3. Leave the client sitting on the basin for 45 minutes.

4. Place the sitz bath on the commode seat, and fill the reservoir with warm water at 110F to 115F.

Correct Answer: 2

Rationale 1: Having the client use the clamp on the tubing to regulate the flow of water is a correct intervention. Flattening the reservoir is performed when an ice bag or hot water bottle is filled. The time for a sitz bath usually ranges from 15 to 20 minutes, not 45 minutes. The water in the reservoir should be about 105F, not 110F to 115F, which would be too hot.

Rationale 2: Having the client use the clamp on the tubing to regulate the flow of water is a correct intervention. Flattening the reservoir is performed when an ice bag or hot water bottle is filled. The time for a sitz bath usually ranges from 15 to 20 minutes, not 45 minutes. The water in the reservoir should be about 105F, not 110F to 115F, which would be too hot.

Rationale 3: Having the client use the clamp on the tubing to regulate the flow of water is a correct intervention. Flattening the reservoir is performed when an ice bag or hot water bottle is filled. The time for a sitz bath usually ranges from 15 to 20 minutes, not 45 minutes. The water in the reservoir should be about 105F, not 110F to 115F, which would be too hot.

Rationale 4: Having the client use the clamp on the tubing to regulate the flow of water is a correct intervention. Flattening the reservoir is performed when an ice bag or hot water bottle is filled. The time for a sitz bath usually ranges from 15 to 20 minutes, not 45 minutes. The water in the reservoir should be about 105F, not 110F to 115F, which would be too hot.

Global Rationale: Page Reference: 751-755

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 15 Verbalize the steps used in:
b. Providing perineal-genital care.

Question 4

Type: MCSA

Which assessment finding would be normal with a clients hair when giving a shampoo?

1. Dry, dark, thin

2. Smooth, taut, shiny

3. Smooth texture and not oily or dry

4. Tender, warm scalp

Correct Answer: 3

Rationale 1: The hair should not be dry or thin. This could be a sign of alopecia. Darkness would depend on hair color through the gene pool.

Rationale 2: Skin is assessed as being smooth, taut, or shiny, not hair.

Rationale 3: The hair should be smooth in texture and neither oily nor dry.

Rationale 4: A tender, warm scalp could indicate a problem, so this would not be normal.

Global Rationale: Page Reference: 783

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Identify normal and abnormal assessment findings while providing hygiene care.

Question 5

Type: MCSA

Which would be an expected outcome for a client with the nursing diagnosis Self-Care Deficit related to cognitive impairment?

1. The client will be able to name the staff that works on the day shift.

2. The client will eliminate safety hazards in her environment.

3. The client, with supervision, will brush her teeth.

4. The nurse will stress the importance of adequate fluid intake.

Correct Answer: 3

Rationale 1: Cognitive impairment limits the clients ability to understand and comprehend; therefore naming the staff is not within the clients realm of understanding.

Rationale 2: Cognitive impairment limits the clients ability to understand and comprehend; therefore eliminating safety hazards is not within the clients realm of understanding.

Rationale 3: A client with cognitive impairment would be able to brush her teeth but only with supervision. The client would not voluntarily brush their teeth without prompting from the staff.

Rationale 4: Cognitive impairment limits the clients ability to understand and comprehend; therefore stressing adequate fluid intake is not within the clients realm of understanding.

Global Rationale: Page Reference: 775

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 04 Apply the nursing process to common problems related to hygienic care of the:
Skin.
Feet.
Nails.
Mouth.
Hair.
Eyes.
Ears.

Question 6

Type: MCSA

Which situation could pose a threat to a clients personal hygiene?

1. A client has a newly formed ileostomy.

2. A client performs meticulous foot care.

3. A German client refuses to bathe everyday.

4. The room temperature is set at 72F.

Correct Answer: 1

Rationale 1: Some of the factors that influence ones personal hygiene are social practices, body image, knowledge of physical condition, and cultural variables. A client who has had an ileostomy has had a body image change which can greatly influence whether he will care for it or rely on others. This can pose a threat if the client chooses not to care for it.

Rationale 2: Performing meticulous foot care does not pose a threat to ones hygiene.

Rationale 3: Bathing every other day does not pose a threat to ones hygiene.

Rationale 4: Room temperature of 72F does not pose a threat to ones hygiene.

Global Rationale: Page Reference: 750

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 02 Identify factors influencing personal hygiene.

Question 7

Type: MCSA

When providing hygienic care to a client, the nurse will provide care to the clients:

1. Clothes

2. Family

3. Hair

4. Nutritional

Correct Answer: 3

Rationale 1: Hygienic care does not include care of the clients clothes.

Rationale 2: Hygienic care does not include care to the clients family.

Rationale 3: Hygiene care consists of skin, hair, hands, feet, eyes, nose, mouth, back, and perineum.

Rationale 4: Hygienic care does not include the clients nutritional status.

Global Rationale: Page Reference: 750

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 Describe hygienic care that nurses provide to clients.

Question 8

Type: MCSA

Which steps will the nurse perform to remove a clients soft contact lens?

1. Gently pinch the lens and lift it out.

2. Have the client look up.

3. Pull the lower eyelid upward.

4. Use the pad of the ring finger.

Correct Answer: 1

Rationale 1: Gently pinching the lens and lifting it out is one of the correct steps for removing a clients soft contact lens.

Rationale 2: The nurse should have the client look straight ahead, not up.

Rationale 3: The upper eyelid is pulled down gently.

Rationale 4: The nurse would use the pad of the index finger, not the ring finger.

Global Rationale: Page Reference: 791

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10 Identify the steps in removing contact lenses.

Question 9

Type: MCSA

What should the nurse include as foot care for the client who is newly diagnosed with diabetes?

1. Cut toenails around and file.

2. Dry toes thoroughly.

3. Wash feet with water at a temperature of 90F to 98.6F.

4. Inspect feet thoroughly once a week.

Correct Answer: 2

Rationale 1: Toenails should be cut straight across, and nurses do not cut diabetic clients toenails. Only a podiatrist should handle this task.

Rationale 2: Toes should be dried thoroughly after being washed to impede fungal growth and prevent maceration.

Rationale 3: The water to wash the feet should be 100F to 110F.

Rationale 4: Feet should be inspected each day, not once a week, for early detection of any problems.

Global Rationale: Page Reference: 768

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 15 Verbalize the steps used in:
c. Providing foot care.

Question 10

Type: MCSA

Which nursing intervention should be applied to a client with a nursing diagnosis of Risk for Skin Integrity Impairment related to immobility?

1. Encourage client to eat at least 40% of meals.

2. Keep linens dry and wrinkle-free.

3. Restrict fluid intake.

4. Turn client every 3 hours.

Correct Answer: 2

Rationale 1: For nutritional support to promote healthy tissue, clients should consume more than 40% of their meals.

Rationale 2: Keeping linens dry and wrinkle-free will prevent pressure areas.

Rationale 3: Fluids should not be restricted unless some other physical condition dictates. The skin should be kept hydrated.

Rationale 4: To relieve pressure, the client should be turned every 2 hours, not every 3.

Global Rationale: Page Reference: 753

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts:

Learning Outcome: 04 Apply the nursing process to common problems related to hygienic care of the:
Skin.
Feet.
Nails.
Mouth.
Hair.
Eyes.
Ears.

Question 11

Type: MCSA

What should the unlicensed assistive personnel report to the nurse when caring for a clients ears?

1. Excessive earwax

2. Loud talking

3. Presence of a hearing aid

4. Presence of any drainage

Correct Answer: 4

Rationale 1: Excess earwax is not an immediate problem.

Rationale 2: Loud talking could be an indication the client is hard of hearing, which is not an immediate threat.

Rationale 3: The presence of a hearing aid should already be noted on the clients admission assessment.

Rationale 4: The health care provider should report any drainage from the ears to the nurse.

Global Rationale: Page Reference: 793

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Identify normal and abnormal assessment findings while providing hygiene care.
16 Recognize when it is appropriate to delegate hygiene skills for clients to unlicensed assistive personnel.

Question 12

Type: MCSA

Which step is essential when removing a clients hearing aid?

1. Assist the client with removal when necessary.

2. Instruct the client to remove the aid in the sunroom.

3. Leave the aid in place when bathing.

4. Send the aid home with the family.

Correct Answer: 1

Rationale 1: The small size of hearing aids may make it difficult for older adults to manipulate, so they may need assistance in the aids removal.

Rationale 2: Clients are instructed not to remove their aids in common rooms like a sunroom.

Rationale 3: The removal of the aid is necessary before bathing so it is not damaged.

Rationale 4: The aid should always be stored in the clients bedside table-not sent home with the family-so it is available for later use.

Global Rationale: Page Reference: 793-794

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12 Describe the steps for removing, cleaning, and inserting hearing aids.

Question 13

Type: MCSA

When cleaning a clients hearing aid, the nurse should:

1. Clean with a dry, soft cloth.

2. Leave the battery in place when not in use.

3. Store the aid in the bathroom cabinet.

4. Use alcohol to remove any earwax.

Correct Answer: 1

Rationale 1: It is recommended by the manufacturers to clean the aid with a dry, soft cloth to prevent any damage to the aid.

Rationale 2: The aid should be turned off and the battery removed to preserve the life of the battery.

Rationale 3: The aid should be stored in a safe place where it will not get damaged. It should not be stored in the bathroom cabinet.

Rationale 4: Alcohol is not recommended to be used on an aid because it could damage the aid.

Global Rationale: Page Reference: 793-794

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12 Describe the steps for removing, cleaning, and inserting hearing aids.

Question 14

Type: MCSA

When making a clients bed, the nurse will implement which safety measure?

1. Begin at the head and move toward the foot, loosening bottom linens.

2. Miter corners at the head of the bed.

3. Place the soiled sheet in a laundry bag.

4. Prepare the client.

Correct Answer: 3

Rationale 1: Beginning at the head and moving toward the foot, loosening the bottom linens, provides maximum work space.

Rationale 2: Mitering the corners at the head of the bed prevents linens from becoming easily loosened.

Rationale 3: Placing the soiled sheet in the laundry bag reduces the spread of microorganisms, which is a safety measure for both the nurse and client.

Rationale 4: Preparing the client readies the client for the procedure.

Global Rationale: Page Reference: 797

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14 Identify safety and comfort measures underlying bed-making procedures.

Question 15

Type: MCSA

What should the nurse instruct a client about a hearing aid?

1. Do not buy extra batteries.

2. Marking the aid is not necessary when living in a long-term facility.

3. Do not use hair spray when wearing a hearing aid.

4. Use a hair dryer while wearing a hearing aid.

Correct Answer: 3

Rationale 1: Extra batteries are needed to keep on hand because a battery only lasts 1 1/2 to 2 weeks.

Rationale 2: Marking the aid is necessary for a client living in a long-term facility because of the potentially high number of hearing aids.

Rationale 3: Hair spray can clog a hearing aid, and clients are encouraged not to use it when the aid is in use.

Rationale 4: A hair dryer should not be used around the aid as heat can damage the aid.

Global Rationale: Page Reference: 794-795

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12 Describe the steps for removing, cleaning, and inserting hearing aids.

Question 16

Type: MCSA

Which step will provide comfort for the client during occupied bed change of linens?

1. Allow for a toe pleat.

2. Place a bath blanket over the client.

3. Slide the mattress to the head of the bed.

4. Raise the side rail.

Correct Answer: 1

Rationale 1: Allowing for a toe pleat provides for client comfort.

Rationale 2: Placing the bath blanket over the client prevents unnecessary exposure.

Rationale 3: Sliding the mattress to the head of the bed makes it easier to tuck in the linens.

Rationale 4: Raising the side rail maintains client safety.

Global Rationale: Page Reference: 802

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14 Identify safety and comfort measures underlying bed-making procedures.
15 Verbalize the steps used in:
j. Changing an occupied bed.

Question 17

Type: MCSA

Which step should be included when shaving a client?

1. Assist the client to a prone position.

2. Pull the skin taut with the dominant hand.

3. Rinse the razor after each stroke.

4. Use long strokes.

Correct Answer: 3

Rationale 1: Assist the client to a sitting position-not a prone position-because this is a more natural position.

Rationale 2: The skin should be pulled taut with the nondominant hand-not the dominant-because this provides uniform shaving.

Rationale 3: Rinsing the razor after each stroke keeps the cutting edge clean.

Rationale 4: Short strokes should be used-not long strokes-because this provides for a closer shave without irritation.

Global Rationale: Page Reference: 789

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts:

Learning Outcome: 04 Apply the nursing process to common problems related to hygienic care of the:
Skin.
Feet.
Nails.
Mouth.
Hair.
Eyes.
Ears.

Question 18

Type: MCSA

To ensure safe handling of a clients dentures, the nurse will:

1. Clean biting surfaces.

2. Place a washcloth in the bowl of the sink.

3. Replace the upper dentures first.

4. Rinse dentures thoroughly with hot water.

Correct Answer: 2

Rationale 1: Cleansing biting surfaces prevents bacteria, odor, and stain formation.

Rationale 2: Placing a washcloth in the bowl of the sink serves as a cushion for the dentures if accidentally dropped.

Rationale 3: Replacing the upper dentures first promotes comfort.

Rationale 4: Dentures should be rinsed thoroughly with tepid water, not hot water, because extreme temperatures will harm dentures.

Global Rationale: Page Reference: 789

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 15 Verbalize the steps used in:
e. Providing special oral care.

Question 19

Type: MCSA

Which of the following activities would be included in taking care of a clients artificial eye?

1. Apply lubricant.

2. Clean regularly.

3. Drape the client.

4. Firmly pat dry.

Correct Answer: 2

Rationale 1: The eye and orbit should be cleaned regularly to remove any exudates that may be present. A lubricant is not necessary as it could cause damage to the prosthesis. Draping the client is not necessary, but providing privacy by pulling the curtain or shutting the door to the room may make the client more comfortable. The area should be gently dried once cleaned, but firmly patting dry may cause damage.

Rationale 2: The eye and orbit should be cleaned regularly to remove any exudates that may be present. A lubricant is not necessary as it could cause damage to the prosthesis. Draping the client is not necessary, but providing privacy by pulling the curtain or shutting the door to the room may make the client more comfortable. The area should be gently dried once cleaned, but firmly patting dry may cause damage.

Rationale 3: The eye and orbit should be cleaned regularly to remove any exudates that may be present. A lubricant is not necessary as it could cause damage to the prosthesis. Draping the client is not necessary, but providing privacy by pulling the curtain or shutting the door to the room may make the client more comfortable. The area should be gently dried once cleaned, but firmly patting dry may cause damage.

Rationale 4: The eye and orbit should be cleaned regularly to remove any exudates that may be present. A lubricant is not necessary as it could cause damage to the prosthesis. Draping the client is not necessary, but providing privacy by pulling the curtain or shutting the door to the room may make the client more comfortable. The area should be gently dried once cleaned, but firmly patting dry may cause damage.

Global Rationale: Page Reference: 789-792

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 04 Apply the nursing process to common problems related to hygienic care of the:
Skin.
Feet.
Nails.
Mouth.
Hair.
Eyes.
Ears.

Question 20

Type: MCSA

Which of the following techniques is used to remove a clients artificial eye?

1. Compress the upper eyelid in, and pop out the eye from the supraorbital bone.

2. Grasp the upper eyelid, and turn it inside out.

3. Retract the lower eyelid down over the infraorbital bone while exerting slight pressure below the eyelid.

4. Use the thumb and index finger to grasp hold of the eye.

Correct Answer: 3

Rationale 1: Retracting the lower eyelid down over the infraorbital bone while exerting slight pressure below the eyelid is the correct technique for removing an artificial eye. Compressing the upper eyelid will not allow the eye to come out. The nurses fingers cannot get a grasp of the eye with the thumb and the index finger; the suction needs to be released first. Turning the upper eyelid inside out will not release the suction.

Rationale 2: Retracting the lower eyelid down over the infraorbital bone while exerting slight pressure below the eyelid is the correct technique for removing an artificial eye. Compressing the upper eyelid will not allow the eye to come out. The nurses fingers cannot get a grasp of the eye with the thumb and the index finger; the suction needs to be released first. Turning the upper eyelid inside out will not release the suction.

Rationale 3: Retracting the lower eyelid down over the infraorbital bone while exerting slight pressure below the eyelid is the correct technique for removing an artificial eye. Compressing the upper eyelid will not allow the eye to come out. The nurses fingers cannot get a grasp of the eye with the thumb and the index finger; the suction needs to be released first. Turning the upper eyelid inside out will not release the suction.

Rationale 4: Retracting the lower eyelid down over the infraorbital bone while exerting slight pressure below the eyelid is the correct technique for removing an artificial eye. Compressing the upper eyelid will not allow the eye to come out. The nurses fingers cannot get a grasp of the eye with the thumb and the index finger; the suction needs to be released first. Turning the upper eyelid inside out will not release the suction.

Global Rationale: Page Reference: 749-797

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Apply the nursing process to common problems related to hygienic care of the:
Skin.
Feet.
Nails.
Mouth.
Hair.
Eyes.
Ears.

Question 21

Type: MCSA

A connection on a clients intravenous solution was dislodged and solution saturated the clients gown and bed linen. The nurse will provide which type of hygienic care to the client?

1. Hour of sleep care

2. As needed care

3. Early morning care

4. Morning care

Correct Answer: 2

Rationale 1: Hour of sleep care includes providing for elimination needs, washing the face and hands, oral care, and a back massage.

Rationale 2: As needed care is provided as required by the client. Since the intravenous solution has saturated the own and bed linen, this is the type of care the client needs at this time.

Rationale 3: Early morning care is provided to clients as they awaken in the morning and consists of aiding to void, washing the face and hands, and providing oral care.

Rationale 4: Morning care is usually after breakfast and includes providing for elimination needs, a bath or shower, perineal care, back massage, oral, nail, and hair care.

Global Rationale: Page Reference: 750

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 Describe hygienic care that nurses provide to clients.

Question 22

Type: MCSA

A client tells the nurse that bathing is done at the sink in the bathroom at home because it is difficult to physically lift the legs to get into the shower. The nurse identifies the factor influencing this clients hygienic practice as being:

1. Religion

2. Personal preference

3. Culture

4. Health and energy

Correct Answer: 4

Rationale 1: The clients inability to lift the legs to get into the shower is not a religious practice.

Rationale 2: The clients inability to lift the legs to get into the shower is not a personal preference.

Rationale 3: The clients inability to lift the legs to get into the shower is not a cultural preference.

Rationale 4: Ill people or those with neuromuscular disorders may not be able to perform hygienic care.

Global Rationale: Page Reference: 750

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 02 Identify factors influencing personal hygiene.

Question 23

Type: MCSA

During the morning bath of a client, the nurse identifies areas of erythema below the clients breasts. What should the nurse do to enhance comfort and healing for the client?

1. Wash the skin carefully

2. Apply alcohol free lotion

3. Wash the area without soap

4. Remove hair in the area

Correct Answer: 1

Rationale 1: For areas of erythema, the nurse should wash the area carefully to remove microorganisms.

Rationale 2: Alcohol free lotion would be applicable for excessively dry skin areas.

Rationale 3: Washing without soap would be applicable for excessively dry skin areas.

Rationale 4: Removing the hair would be applicable for hirsutism.

Global Rationale: Page Reference: 752

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Apply the nursing process to common problems related to hygienic care of the:
Skin.
Feet.
Nails.
Mouth.
Hair.
Eyes.
Ears.

Question 24

Type: MCSA

While providing a complete bed bath to a client, the nurse discovers abrasions along the clients back and upper buttock area. What should the nurse do to help this client?

1. Apply antiseptic spray to the abrasions

2. Do not wash the client with soap

3. Find assistance to help with the remainder of the bath

4. Apply alcohol free lotion to the abrasions

Correct Answer: 3

Rationale 1: Applying antiseptic spray would be applicable for areas of erythema but not for abrasions.

Rationale 2: Avoiding soap would be applicable for excessively dry skin.

Rationale 3: Since the client has abrasions over the back and upper buttock area, the nurse should lift and not pull or slide the client. The nurse needs to find assistance to help with the remainder of the bath.

Rationale 4: Applying alcohol free lotion would be applicable for excessively dry skin but not for abrasions.

Global Rationale: Page Reference: 752

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Apply the nursing process to common problems related to hygienic care of the:
Skin.
Feet.
Nails.
Mouth.
Hair.
Eyes.
Ears.

Question 25

Type: MCMA

The nurse wants to assess a client during the morning bath. What will the nurse be able to assess during this time?

Standard Text: Select all that apply.

1. Skin status

2. Financial status

3. Psychosocial needs

4. Learning needs

5. Physical conditions

Correct Answer: 1,3,4,5

Rationale 1: Assessment of the skin can be done during the morning bath.

Rationale 2: The clients financial status is an area not usually assessed during the morning bath.

Rationale 3: The clients psychosocial needs can be assessed during the morning bath.

Rationale 4: The clients learning needs regarding hygienic care can be assessed during the morning bath.

Rationale 5: Assessing the clients physical conditions can be done during the morning bath.

Global Rationale: Page Reference: 751

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 04 Apply the nursing process to common problems related to hygienic care of the:
Skin.
Feet.
Nails.
Mouth.
Hair.
Eyes.
Ears.

Question 26

Type: MCMA

A client is prescribed bed rest with bathroom privileges. Which types of bath would be appropriate for this client?

Standard Text: Select all that apply.

1. Shower

2. Tub bath

3. Self-help bed bath

4. Therapeutic bath

5. Partial bath

Correct Answer: 3,5

Rationale 1: Getting into and out of a shower might be too strenuous for a client prescribed bed rest with bathroom privileges.

Rationale 2: Getting into and out of a bathtub might be too strenuous for a client prescribed bed rest with bathroom privileges.

Rationale 3: Since the client is prescribed bed rest with bathroom privileges, the self-help bed bath would be appropriate since the client can independently wash with some help from the nurse.

Rationale 4: A therapeutic bath is for some physical effect and not used routinely for morning care.

Rationale 5: Since the client is prescribed bed rest with bathroom privileges, the partial bath would be appropriate since the client can independently was with some help from the nurse to wash the back area.

Global Rationale: Page Reference: 756

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 06 Describe various types of baths.

Question 27

Type: MCSA

A client with a skin rash is prescribed a bath in which medication is added to the bath water. The nurse would plan for the client to receive which type of bath?

1. Shower

2. Therapeutic

3. Partial

4. Complete

Correct Answer: 2

Rationale 1: A shower would not permit the medication to be in contact with the clients skin long enough.

Rationale 2: Therapeutic baths are given for physical effects, such as to soothe irritated skin or to treat an area. Medications may be placed in the water. A therapeutic bath is generally taken in a tub one-third or one-half full. The client remains in the bath for a designated time, often 20 to 30 minutes. If the clients back, chest, and arms are to be treated, these areas need to be immersed in the solution.

Rationale 3: A partial bath would not permit the medication to be in contact with the clients skin long enough.

Rationale 4: A complete bath would not permit the medication to be in contact with the clients skin long enough.

Global Rationale: Page Reference: 757

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 04 Apply the nursing process to common problems related to hygienic care of the:
Skin.
Feet.
Nails.
Mouth.
Hair.
Eyes.
Ears.

Question 28

Type: MCSA

A client tells the nurse that she does not want to get into the tub for a morning bath. The client has not been bathed for several days. What should the nurse do?

1. Assign UAP the task of giving the client a bath

2. Skip the clients bath and document refused in the medical record

3. Ask the client the usual way bathing occurs at home

4. Tell the client that a bath is needed and ignore the clients comment

Correct Answer: 3

Rationale 1: Assigning a UAP the task of giving the client a bath is following the task-centered approach.

Rationale 2: Skipping the clients bath and documenting refused is not following a client-centered approach.

Rationale 3: To provide a person-centered approach to bathing, the nurse should ask the client to describe the usual way bathing occurs at home.

Rationale 4: Telling the client that a bath is needed an ignoring the clients comment is not following a client-centered approach.

Global Rationale: Page Reference: 750

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 07 Compare and contrast the task-centered approach and the person-centered approach to bathing.

Question 29

Type: MCSA

An older client tells the nurse that showers are not taken because of a previous fall. What can the nurse do to support the clients bathing needs?

1. Obtain a shower chair and assist the client in the shower

2. Document the client refused a morning bath in the medical record

3. Tell the client that shower shoes can be worn to prevent falls

4. Hold the client during the shower

Correct Answer: 1

Rationale 1: To provide person-centered care with bathing, the nurse should obtain a shower chair. This should eliminate the clients fear of falling when in the shower.

Rationale 2: The client did not refuse a morning bath but rather explained why showers are not used.

Rationale 3: Shower shoes may not be sufficient to eliminate the clients fear of falling when in the shower.

Rationale 4: The nurse would not be able to hold the client during the shower.

Global Rationale: Page Reference: 756

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13 Discuss factors that support a positive and safe environment for the client.

Question 30

Type: MCMA

The nurse is preparing to provide a morning bath to a client diagnosed with dementia. What can the nurse do to ensure a positive bathing experience for the client?

Standard Text: Select all that apply.

1. Move slowly

2. Be flexible

3. Help the client feel in control

4. Avoid stopping once the bath is started

5. Be prepared

Correct Answer: 1,2,3,5

Rationale 1: When bathing a client with dementia, the nurse should move slowly.

Rationale 2: When bathing a client with dementia, the nurse should be flexible to adapt the approach to meet the needs of the client.

Rationale 3: When bathing a client with dementia, the nurse should offer the client choices in order for the client to feel in control.

Rationale 4: When bathing a client with dementia, the nurse should stop if the client begins to feel distressed

Rationale 5: When bathing a client with dementia, the nurse should be prepared with all items prior to starting the bath.

Global Rationale: Page Reference: 763

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 08 Describe guidelines for bathing persons with dementia.

Question 31

Type: MCSA

A client has hard contact lenses. What should the nurse do to assist the client in the care of the lenses?

1. Pinch the lenses out of the clients eyes to remove

2. Remove both of the clients lenses before storing in the appropriate storage cup

3. Document when the lenses need to be removed and cleaned every 2 weeks

4. Ask the client how many hours the lenses are worn each day

Correct Answer: 4

Rationale 1: Hard contact lenses are not removed by pinching.

Rationale 2: The nurse should remove one lens at a time and store in the appropriate storage cup.

Rationale 3: Hard contact lenses should be removed and cleaned every day and not every 2 weeks.

Rationale 4: Hard contact lenses should only be worn for 12 to 14 hours.

Global Rationale: Page Reference: 790-791

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 09 Discuss the different types of contact lenses.

Question 32

Type: MCSA

During an assessment, the nurse learns a client has soft contact lenses that have not been removed or cleaned for weeks. What should the nurse do?

1. Nothing since these types of lenses can be worn for months

2. Remove the clients lenses, wrap in tissue, and place in the bedside table

3. Assist the client to remove and clean the contacts

4. Ask the physician for an ophthalmology consult since the client will need help removing the lenses

Correct Answer: 3

Rationale 1: This type of lens should not be worn for more than 30 days.

Rationale 2: The lenses should not be wrapped in tissue because this will cause the lenses to dry out and not be able to be worn or used.

Rationale 3: Most eye specialists recommend soft contact lenses be removed and cleaned every week. The nurse should assist the client to remove and clean the contacts.

Rationale 4: The client does not need an ophthalmology consult. The nurse can help the client remove the lenses.

Global Rationale: Page Reference: 790

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 09 Discuss the different types of contact lenses.
10 Identify the steps in removing contact lenses.

Question 33

Type: SEQ

The nurse is assisting a client in removing soft contact lenses. Place in order the steps the nurse should take to help this client.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Using the pad of the index finger of the other hand, move the lens down to the sclera

Choice 2. Have the client look forward

Choice 3. Apply gloves

Choice 4. Gently pinch the lens between the pads of the thumb and index finger

Choice 5. Retract the lower lid with one hand

Correct Answer: 3,2,5,1,4

Rationale 1: The nurse should use the pad of the index finger of the other hand to move the lens down to the sclera.

Rationale 2: The nurse should ask the client to look forward.

Rationale 3: The first step is for the nurse to apply gloves.

Rationale 4: The nurse should gently pinch the lens between the pads of the thumb and index finger to remove the lens.

Rationale 5: The nurse should retract the lower lid with one hand.

Global Rationale: Page Reference: 790-791

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10 Identify the steps in removing contact lenses.

Question 34

Type: MCSA

The client has a hearing aid with an earpiece that is connected by a cord to a receiver that the client keeps in a shirt pocket. The nurse would document this type of hearing aid as:

1. Body hearing aid

2. In the canal aid

3. Completely in the canal aid

4. Eyeglasses aid

Correct Answer: 1

Rationale 1: A body hearing aid is a pocket-sized aid that clips onto a shirt pocket. The case, containing the microphone and amplifier, is connected by a cord to the receiver, which snaps into the earpiece.

Rationale 2: An in the canal aid is a hearing aid that sits directly into the clients ear and is barely visible. It is not connected to a receiver worn by the client.

Rationale 3: A completely in the canal aid is a hearing aid that sits inside the clients ear canal and is not visible. It is not connected to a receiver worn by the client.

Rationale 4: An eyeglass aid has a hearing aid attached to the eyeglasses and is not connected to a receiver worn by the client.

Global Rationale: Page Reference: 793

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11 Discuss the different types of hearing aids.

Question 35

Type: MCSA

The nurse has delegated the making of unoccupied beds to unlicensed assistive personnel. What should the nurse assess regarding client safety once the beds are completed?

1. Folding of the top sheet

2. Direction of the pillow

3. Call light being readily available

4. Presence of mitered corners

Correct Answer: 3

Rationale 1: The folding of the top sheet is not important for client safety.

Rationale 2: The direction of the pillow is not important for client safety.

Rationale 3: The nurse should assess for the call light being readily available while the client is out of the bed.

Rationale 4: The presence of mitered corners is not important for client safety.

Global Rationale: Page Reference: 798

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14 Identify safety and comfort measures underlying bed-making procedures.

Question 36

Type: MCMA

A client recovering from acute illness has just received a tub bath. When documenting the bath, the nurse should include:

Standard Text: Select all that apply.

1. Clients ability to maintain a conversation during the procedure

2. The clients tolerance of the procedure

3. Condition and integrity of the skin

4. Client strength

5. Percentage of bath done without assistance

Correct Answer: 2,3,4,5

Rationale 1: It is not necessary for the nurse to document if the client was maintaining a conversation during the bath.

Rationale 2: When evaluating the clients bath, the nurse should include the clients tolerance of the procedure.

Rationale 3: When evaluating the clients bath, the nurse should include the condition and integrity of the clients skin.

Rationale 4: When evaluating the clients bath, the nurse should include the clients strength.

Rationale 5: When evaluating the clients bath, the nurse should include the percentage of the bath done without assistance.

Global Rationale: Page Reference: 762

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 06 Describe various types of baths.
17 Demonstrate appropriate documentation and reporting of hygiene skills.

Question 37

Type: MCSA

The nurse has completed foot care for a client as part of routine morning care. What should the nurse document about the procedure?

1. The condition of the skin and nails

2. Nothing unless a problem is noted

3. The amount of time taken on foot care

4. The clients comments about the foot care

Correct Answer: 2

Rationale 1: The nurse does not need to document the condition of the skin and nails unless a problem is noted.

Rationale 2: Foot care is not generally recorded unless problems are noted.

Rationale 3: The nurse does not need to document the amount of time taken on foot care.

Rationale 4: The nurse does not need to document the clients comments about the foot care.

Global Rationale: Page Reference: 771

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 15 Verbalize the steps used in:
c. Providing foot care.
17 Demonstrate appropriate documentation and reporting of hygiene skills.

Kozier & Erbs Fundamentals of Nursing, 9/E Test Bank

Copyright 2012 by Pearson Education, Inc.

Leave a Reply