Chapter 9: Hygiene and Care of the Patients Environment My Nursing Test Banks

Chapter 9: Hygiene and Care of the Patients Environment

Cooper and Gosnell: Foundations and Adult Health Nursing, 7th Edition

MULTIPLE CHOICE

1.The nurse is preparing to bathe a patient. What should the room temperature be set at?

a. No warmer than 67 F
b. No cooler than 68 F
c. No cooler than 70 F
d. 75 F or warmer

ANS: B

The recommended room temperature is 68 to 74 F.

PTS: 1 DIF: Cognitive Level: Application REF: Page 186

OBJ:1 | 2 | 4TOPatients environment

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

2.The nurse explains that the purpose of a sitz bath is to reduce inflammation in the perineal and anal area. What is the least amount of time the nurse will instruct for a sitz bath?

a. 10 to 15 minutes
b. 20 to 30 minutes
c. 30 to 40 minutes
d. 1 hour

ANS: B

The sitz bath should last 20 to 30 minutes.

PTS: 1 DIF: Cognitive Level: Application REF: Page 191

OBJ:2 | 3TOP:Therapeutic baths

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

3.A patient is recovering from a hemorrhoidectomy and experiences dizziness within 5 minutes when taking a sitz bath. What action should the nurse implement?

a. Cover the patient to prevent chilling
b. Stay with the patient until the full time for the bath has elapsed
c. Remove the patient from the sitz bath and return to bed
d. Assess vital signs every 5 minutes during the remainder of the sitz bath

ANS: C

The patient may become dizzy during a sitz bath due to dilation of the large vessels in the abdomen. If this occurs, the patient should be removed from the sitz bath and returned to bed. Vital signs should be assessed until they return to normal.

PTS: 1 DIF: Cognitive Level: Application REF: Page 191

OBJ: 3 TOP: Sitz bath KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

4.What should the water temperature be when preparing a tepid bath for a patient?

a. 98.6 F
b. 100.2 F
c. 104.8 F
d. 110.4 F

ANS: A

The tepid bath is taken in water that is 98.6 F.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 191

OBJ: 4 TOP: Tepid bath KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

5.The nurse is assessing a patients skin for signs of impaired skin integrity. Which finding by the nurse is considered a major manifestation?

a. Burn
b. Laceration
c. Pressure ulcer
d. Infection

ANS: C

A major manifestation of impaired skin integrity is a pressure ulcer.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 200

OBJ:5TOPressure ulcers

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

6.A nurse assesses an area of sustained redness on the coccyx area of a resident in long-term care. What is the most likely cause of this pressure area?

a. Heat from pressure
b. Collapse of blood vessels
c. Friction from pressure
d. Collapse of skin tissue

ANS: B

A pressure ulcer occurs when there is sufficient pressure to collapse the blood vessels.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 200

OBJ:5TOPressure ulcers

KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

7.The nurse is caring for an unconscious patient with a risk for skin impairment. How often will the nurse plan to change the position of this patient?

a. Every 30 minutes
b. Every 60 minutes
c. Every 120 minutes
d. Every 180 minutes

ANS: C

The bedfast patient should have a position change every 2 hours (120 minutes) because skin compromise can occur if there is unrelieved pressure during that amount of time.

PTS: 1 DIF: Cognitive Level: Application REF: Page 202 Box 9-5

OBJ:5TOPressure ulcers

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

8.The nurse assesses a red blister over the right superior iliac area of a patient. What stage is this decubitus ulcer?

a. I
b. II
c. III
d. IV

ANS: B

A pressure ulcer demonstrating blisters is a stage II decubitus ulcer.

PTS: 1 DIF: Cognitive Level: Application REF: Page 202

OBJ:5TOPressure ulcers

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

9.The nursing assessment of a pressure ulcer includes size, depth, pain, odor, and color of tissue. What does this evaluate?

a. Treatment needed
b. Effectiveness of implementation
c. Whether improvement is occurring
d. Need for additional interventions

ANS: C

Ongoing assessment of a pressure ulcer will evaluate whether improvement is occurring.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 201

OBJ:5TOPressure ulcers

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

10.The nurse attempts to avoid a pressure ulcer for a bedridden patient by turning the patient frequently. What is the most favorable position for the nurse to move this patient into?

a. Back-lying
b. Full lateral
c. 30-degree lateral
d. Full prone

ANS: C

It is preferable to use the 30-degree lateral incline position.

PTS: 1 DIF: Cognitive Level: Application REF: Page 202 Box 9-5

OBJ:5TOPressure ulcers

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

11.One reason the nurse focuses on oral hygiene is to maintain a healthy state of the oral cavity. What is another reason to promote oral hygiene?

a. To improve self-esteem
b. To stimulate appetite
c. To restore tooth destruction
d. To assist with periodontitis

ANS: B

A sense of well-being can stimulate appetite.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 204

OBJ:6TOP:Oral hygiene

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

12.How will the nurse correctly replace a patients dentures after cleaning?

a. Inserting the lower denture first
b. Asking the patient to insert them
c. Inserting both dentures together
d. Inserting the upper denture first

ANS: D

When reinserting dentures, replace the upper dentures first.

PTS: 1 DIF: Cognitive Level: Application REF: Page 206 Skill 9-2

OBJ:6TOP:Oral hygiene

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

13.Proper hair care is important for the patients self-image. What is the proper water temperature when shampooing a patients hair?

a. 101 F
b. 105 F
c. 110 F
d. 120 F

ANS: C

Water at 110 F should be used to shampoo a patients hair.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 208 Skill 9-3

OBJ: 6 TOP: Hair care KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

14.When must the nurse remember to use an electric razor when shaving a patient?

a. When a bleeding tendency is present
b. When there is a risk for suicide
c. When the facial hair is fine
d. When speed is essential

ANS: A

A patient with a bleeding disorder should use an electric razor.

PTS: 1 DIF: Cognitive Level: Application REF: Page 207

OBJ: 6 TOP: Shaving KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

15.The nurse is bathing a patient with a deep vein thrombosis in the left leg. What modification will the nurse make when attending to the left leg?

a. Washing the leg with long, firm strokes and drying with a towel
b. Omitting washing the leg at all
c. Gently washing the leg and patting dry with a towel
d. Applying lotion in long, smooth strokes

ANS: C

The lower extremities of people with circulatory disorders are gently washed and patted dry, omitting any stroking or massaging.

PTS: 1 DIF: Cognitive Level: Application REF: Page 194 Skill 9-1

OBJ: 3 TOP: Bathing KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

16.The nurse is providing hand and foot care to a patient and notices the patient has extremely hard nails. Who is the person best prepared to provide nail care for patients with extremely hard nails?

a. Physician
b. RN
c. CNA
d. Podiatrist

ANS: D

If the patients nails are extremely hard, a podiatrist should provide care.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 207, 210 Skill 9-3

OBJ: 6 TOP: Foot care KEY: Nursing Process Step: N/A

MSC: NCLEX: Physiological Integrity

17.How often should the nurse cleanse the meatal-catheter junction of a patient with an indwelling catheter?

a. At least once a day
b. At least twice a day
c. At bedtime
d. Each shift

ANS: B

Catheter care should be performed at least two times daily.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 207

OBJ:8TOP:Catheter care

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

18.The nurse is preparing to perform perineal care for the female patient. What is the best method for using a bath blanket to drape the patient?

a. Square position
b. Long position
c. Diamond position
d. Rectangular position

ANS: C

Drape the patient with a bath blanket in the diamond position.

PTS: 1 DIF: Cognitive Level: Application REF: Page 211 Skill 9-4

OBJ:8TOPerineal care

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

19.Clear water is used to cleanse the eyes. It is important to use proper technique when cleansing the eyes to prevent infection. What direction will the water flow when cleansing a patients eyes?

a. Upward toward the forehead
b. Downward toward the chin
c. From the outer toward the inner canthus
d. From the inner toward the outer canthus

ANS: D

The eye is cleansed from the inner to outer canthus.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 213

OBJ: 6 TOP: Eye care KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

20.How frequently should the nurse clean the nares of patients who have a nasogastric tube or are receiving oxygen by nasal cannula?

a. At least every 2 hours
b. At least every 6 hours
c. At least every 8 hours
d. At least every 10 hours

ANS: C

When receiving oxygen by a nasal cannula or when a nasogastric tube is in place, the nurse should cleanse the nares every 8 hours.

PTS: 1 DIF: Cognitive Level: Application REF: Page 214

OBJ: 6 TOP: Nasal care KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

21.The nurse must follow the principles of medical asepsis while making a patients bed, including procedures for handling linens. How should the nurse handle soiled linens?

a. Place on the floor
b. Fan in the air
c. Hold away from the uniform
d. Place at the end of the bed

ANS: C

Soiled linen should not come into contact with a uniform.

PTS: 1 DIF: Cognitive Level: Application REF: Page 215 Skill 9-5

OBJ: 10 TOP: Bed making KEY: Nursing Process Step: Implementation

MSC:NCLEX: Safe, Effective Care Environment

22.How should the nurse cleanse the meatal opening when performing male perineal care?

a. From the meatus outward
b. With an alcohol swab
c. In a circular motion
d. With a cotton-tipped applicator

ANS: A

The nurse should cleanse the meatal opening from the meatus outward.

PTS: 1 DIF: Cognitive Level: Application REF: Page 212 Skill 9-4

OBJ:8TOPerineal care

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

23.The nurse lowers the bed to place the patient on the bedpan. The angle of the head of the bed should be raised to:

a. 20 degrees.
b. 45 degrees.
c. 90 degrees.
d. 30 degrees.

ANS: D

Elimination is facilitated with the head of the bed elevated 30 degrees.

PTS: 1 DIF: Cognitive Level: Application REF: Page 221 Skill 9-6

OBJ: 12 TOP: Elimination KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

24.What does the nurse recognize is important to consider when using the nursing process to plan hygiene care of the patient?

a. Nurses orders
b. Physicians orders
c. Patients preferences
d. Outcome goals

ANS: C

Individual patients will have individual desires and choices.

PTS: 1 DIF: Cognitive Level: Application REF: Page 222

OBJ: 2 TOP: Hygiene KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity

25.The nurse is providing personal hygiene for a Hindu patient from India. What intervention should the nurse implement?

a. Not serve meat
b. Shampoo the patients hair weekly
c. Give a daily bath
d. Cut nails monthly

ANS: C

A daily bath is part of the religious duty of Indian Hindus.

PTS:1DIF:Cognitive Level: Application

REF: Page 186, Cultural Considerations OBJ: 2 TOP: Hygiene

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

26.The nurse is assisting a patient to perform personal hygiene. What is the most important focus of the nurse when assisting this patient?

a. Nursing care
b. Independence
c. Repetition
d. Performance

ANS: B

The nurse should encourage the patients independence as much as possible.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 185

OBJ: 2 TOP: Hygiene KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

27.The nurse discovers a reddened area over a patients hip. What should be the nurses first intervention?

a. Cover the area with an occlusive dressing
b. Apply mild ointment with a cotton-tipped applicator
c. Press the area gently to assess for blanching
d. Rub gently to increase circulation

ANS: C

If the area is a stage I decubitus ulcer, the area will not blanch.

PTS: 1 DIF: Cognitive Level: Application REF: Page 201

OBJ:5TOPressure ulcers

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

28.The nurse is educating a patient regarding a tub bath. What is the maximum length of time the nurse should instruct the patient to remain in the water?

a. 5 to 10 minutes
b. 10 to 20 minutes
c. 20 to 30 minutes
d. 30 to 40 minutes

ANS: B

A patient should not stay in the water for more than 20 minutes.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 195 Skill 9-1

OBJ: 3 TOP: Hygiene KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

29.Where should a nurse performing a backrub begin?

a. Shoulder
b. Base of the neck
c. Sacral area
d. Lumbar area

ANS: C

The nurse should begin a massage in the sacral area.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 199 Skill 9-1

OBJ: 7 TOP: Hygiene KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

30.The nurse is caring for a patient experiencing presbycusis. What intervention should the nursing personnel be instructed to implement?

a. Speak quickly to the patient
b. Speak in loud tones to the patient
c. Speak slowly and clearly to the patient
d. Tell the patient they must purchase a hearing aid

ANS: C

Age-related hearing loss, presbycusis, is a common finding in older adults. It is important to speak slowly and clearly to the patient with presbycusis. Not all patients with this type of hearing loss require a hearing aid.

PTS: 1 DIF: Cognitive Level: Application REF: Page 214

OBJ: 6 TOP: Hearing loss KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

31.A physician orders a patient to be placed in the Trendelenburg position. How will the nurse position the bed?

a. On the floor
b. Parallel with the floor
c. Tilted with the head of the bed down
d. Tilted with the foot of the bed down

ANS: C

The entire bed is tilted downward with the head of the bed down when placing a patient in the Trendelenburg position.

PTS: 1 DIF: Cognitive Level: Application REF: Page 189 Table 9-1

OBJ: 1 TOP: Positioning KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

32.The physician orders a patient to be placed in the reverse Trendelenburg position. How should the nurse place the bed?

a. On the floor
b. Parallel with the floor
c. Tilted with the head of the bed down
d. Tilted with the foot of the bed down

ANS: D

The entire bed is tilted downward with the foot of the bed down when placing a patient in the reverse Trendelenburg position.

PTS: 1 DIF: Cognitive Level: Application REF: Page 189 Table 9-1

OBJ: 1 TOP: Positioning KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

33.Which guideline should be followed when giving a backrub?

a. Observing the skin for abnormalities
b. Massaging for at least 10 minutes
c. Following massage with a brisk alcohol rub
d. Conversing with patient continually throughout the backrub
e. Using alcohol-based lotion for disinfection

ANS: A

The backrub should last for about 3 to 5 minutes, giving the nurse an opportunity to observe for skin abnormalities. Conversation should be kept to a minimum to enhance relaxation. Alcohol either as a rub or used as disinfectant is drying to the skin.

PTS: 1 DIF: Cognitive Level: Application REF: Page 199 Skill 9-1

OBJ: 7 TOP: Backrub KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

34.The nurse is preparing to make an occupied bed. What procedure will the nurse follow to correctly complete this task? (Select all that apply.)

a. Remove spread and blanket separately
b. Place soiled sheet at end of bed
c. Place bath blanket over patient on top sheet
d. Slide mattress to bottom of bed
e. Position patient to far side of bed

ANS: A, C, E

When making an occupied bed the nurse will remove the spread and blanket separately. The bath blanket is placed over the patient on the top sheet and the patient is positioned to the far side of the bed. Soiled linen is placed in the laundry bin, not at the end of the bed.  The mattress is slid to the top of the bed.

PTS: 1 DIF: Cognitive Level: Application REF: Pages 215-216 Skill 9-5

OBJ:11TOP:Making occupied bed

KEY:Nursing Process Step: Implementation

MSC:NCLEX: Safe, Effective Care Environment

COMPLETION

35.The nurse avoids dragging the patient across the bed linen to decrease the potential risk of skin injury by _________.

ANS:

friction

Dragging the patient across bed linen rather than lifting can cause skin damage from friction.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 201-202

OBJ: 5 | 9 TOP: Friction KEY: Nursing Process Step: Implementation

MSC:NCLEX: Safe, Effective Care Environment

36.Because of its effect on epithelization, the LPN/LVN should confirm the order to use ____________ or _____________ on a stage III pressure ulcer.

ANS:

peroxide, alcohol

alcohol, peroxide

Peroxide and alcohol have a negative effect on epithelization of a pressure ulcer.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 202 Box 9-5

OBJ:5TOPressure ulcers

KEY:Nursing Process Step: Implementation

MSC:NCLEX: Safe, Effective Care Environment

37.To prevent skin breakdown in a wheelchair-bound patient, the nurse teaches the patient to shift the patients weight every _______ minutes.

ANS:

15

fifteen

People who are wheelchair-bound should shift their weight by pushing on the arms of their chair every 15 minutes to prevent skin breakdown.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 202 Box 9-5

OBJ:5TOP:Skin breakdown

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

38.As a safety precaution against breakage of dentures, the nurse should place __________ in the emesis basin before cleaning the dentures.

ANS:

water

Water in the basin will break the fall of the dentures if they are dropped.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 206 Skill 9-2

OBJ:6TOP:Oral hygiene

KEY:Nursing Process Step: Implementation

MSC:NCLEX: Safe, Effective Care Environment

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