hygiene and personal care

The objective and subjective signs placing client at risk for skin problems

Age, impaired circulation, impaired sensation, impaired mobility, cognitive impairment, nutritional status and bowel and urinary incontinence

Before providing oral care to unconscious client, the nurse should perform this action first to reduce the risk of aspiration.

place in left recumbent position with suction present

Never put fingers in the patients mouth to hold mouth open (use tongue depressant)

The nurse is teaching a client about proper denture care. Which instructions should the nurse include. Select all that apply.

A. Apply PPE prior to denture and oral care

B. clean dentures with soft bristled tooth brush

C. place dentures in hot water to disinfect them

D. inspect, clean, lubricate

E. Handle Dentures over a towel or basin to prevent breakage. Store in labeled container =

F. Use a sharp object to remove food particles stuck between the dentures

A. Apply PPE

B. Clean dentures w/ soft bristles

D. inspect, clean, lubricate

E. Handle dentures over a towel or basin of water to prevent breakage

C IS NOT ACCURATE BC OF BOILING WATER

Use cool water and never use sharp objects that break the denture

Nurse is providing care to an older adult who is at risk for impaired skin integrity. Why is proper skin care important?

A. it promotes circulation and helps prevent pressure injuries

b. it prevents all skin infections

C. it maintains skin integrity and reduces the risk of breakdown

D. eliminates the need to reposition immobile clients

E. it help keeps the skin clean, dry, and protected from moisture

A. it promotes circulation and helps prevent pressure injuries

C. it maintains skin integrity and reduces the risk of breakdown

E. it help keeps the skin clean, dry, and protected from moisture

B IS NOT ACCURATE BC PROPER SKIN CARE CAN REDUCE INFECTION RISK BUT CANNOT PREVENT ALL INFECTIONS

D IS WRONG BC REPOSITIONING REMAINS ESSENTIAL FOR ALL CLIENTS AT RISK FOR PRESSURE INJURIES

The nurse will take these into consideration with performing skin/beard care.

Culture, preference, ethnicity, ancestry, cultural identity, faith and spiritual practices

Always consider if a patient is on anticoagulants - they should not use a straight edge razor, but an electric razor

The RN is caring for 4 clients and needs to delegate a hygiene task to the UAP. Which task is the most appropriate for the RN to delegate?

A. assess a clients skin for signs of pressure injury

B. assist a stable client with a routine bed bath

C. determine whether a client needs specialized wound care

D. teach a client how to perform pernieal care

B. Assist a stable client with routine bed bath.

Never delegate to a non-licensed professional person what a licensed person can do. Only the nurse can assess, plan, teach, or evaluate, or accountability for care. The nurse can delegate a task to an aide if the nurse validated the aide is confidently capable to achieve the task

Before assigning a task to UAP, the RN uses the Five Rights of Delegation to ensure safe client care. which of five rights should the nurse consider?

A. Right task

B. Right circumstance

C. Right person

D. Right direction/communication

E. Right supervision/evaluation

F. Right diagnosis

G. Right medication

A. Right task

B. Right circumstance

C. Right person

D. Right direction/communication

E. Right supervision/evaulation

A nurse is caring for a clients with different levels of mobility and independence. Which descriptions correctly match the type of bed bath?

A. Complete bed bath: The nurse/UAP provides care for the client's entire body when the client cannot bathe independently.

B. Partial bed bath: Only areas that require attention, such as the face, hands, underarms, and perineal area, are washed.

C. Assisted bed bath: The client performs as much of the bath as possible, while the nurse/UAP assists with areas the client cannot reach.

D. Complete bed bath: The client must independently wash the entire body.

E. Partial bed bath: The entire body is washed from head to toe.

F. Assisted bed bath: Used when the client has some ability to participate but needs assistance.

A, complete bed bath: the nurse/UAP provides care for the client’s entire body when the client cannot bathe independently

B. Partial Bed Bath: only areas that require attention, such as the face, hands, underarms, and perineal area, are washed

C. assisted bed bath: the client performs as much if the bath as possible, while the nurse/UAP assists with the areas the client cannot reach

F. Assisted bed bath: used when the client has some ability to participate but needs assistance

The nurse is assessing a client for impaired self-care, particularly personal hygiene. Which findings would suggest limited capacity, unmet hygiene needs, or an intact hygiene routine? SATA

A. Client has limited range of motion and cannot reach the back or lower legs.

B. Client has strong body odor and has not bathed for several days.

C. Client independently showers every morning and brushes their teeth twice daily.

D. Client has difficulty standing long enough to complete a shower.

E. Client's hair is matted and clothing is visibly soiled.

F. Client gathers bathing supplies independently and completes personal hygiene without assistance.

G. Client reports fatigue that makes completing daily hygiene difficult.

A. Client has limited range of motion and cannot reach the back or lower legs.

B. Client has strong body odor and has not bathed for several days.

D. Client has difficulty standing long enough to complete a shower.

E. Client's hair is matted and clothing is visibly soiled.

Limited capacity — "Can't do it independently" 2. Evidence hygiene is unmet — "It's not getting done" 3. Evidence of an intact routine - "The client can and does do it" Impaired self-care = CAN'T + ISN'T | CAN'T → limited ability to perform hygiene | ISN'T → hygiene needs are not being met

Don't count a chronic assist device as a impairment.

The nurse is performing a bed bath and changing a client's linens.

Which actions demonstrate proper linen management? SATA

A. Keep clean linens away from the floor.

B. Place soiled linens directly into the designated linen hamper or bag.

C. Shake linens before placing them on the bed to remove wrinkles.

D. Avoid placing soiled linens on the floor.

E. Hold soiled linens away from the uniform while transporting them.

F. Reuse a clean sheet that has fallen onto the floor.

G. Keep the client covered with a bath blanket while changing linens.

A. Keep clean linens away from the floor.

B. Place soiled linens directly into the designated linen hamper or bag.

D. Avoid placing soiled linens on the floor.

E. Hold soiled linens away from the uniform while transporting them.

G. Keep the client covered with a bath blanket while changing linens.

C - Incorrect: Never shake linens because this can

spread microorganisms into the environment.

F - Incorrect: A linen that touches the floor is considered contaminated and should not be reused. "Clean stays clean; dirty stays contained."

The nurse is providing perineal care to a client. Which actions demonstrate correct technique? SATA

A. Perform hand hygiene before and after providing care.

B. Provide privacy and explain the procedure.

C. Clean the perineal area from front to back.

D. Use a clean portion of the washcloth for each stroke.

E. Clean the rectal area first and then move toward the urethra.

F. Wear gloves when contact with body fluids is anticipated.

G. Use the same area of the washcloth repeatedly to avoid wasting supplies.

A. Perform hand hygiene before and after providing care.

B. Provide privacy and explain the procedure.

C. Clean the perineal area from front to back.

D. Use a clean portion of the washcloth for each stroke.

F. Wear gloves when contact with body fluids is anticipated.

E - Incorrect: Clean the least contaminated area first,

then move toward the more contaminated area.

G- Incorrect: Reusing the same area can spread microorganisms. "Clean → Dirty, Front → Back."

The nurse is planning morning hygiene for 4 clients. Which client should the nurse assist first?

A. A stable client who requests a shower before breakfast

B. A client who is incontinent of urine and has soiled linens.

C. A client who wants assistance brushing their teeth.

D. A stable client who requests a bed bath later in the morning.

B. A client who is incontinent of urine and has soiled linens.

Physiological risk comes before preferences. Pain would be treated before care and recovery from a procedure may mean delay, not omit.

During a return demonstration, the student nurse is teaching a client with diabetes how to perform daily foot care. Select the actions that demonstrate correct technique.

A. Inspect the feet and between the toes every day.

B. Test bath water with the foot before stepping in.

C. Wash feet with warm water and dry thoroughly, especially between the toes.

D. Apply moisturizer to dry skin, avoiding between the toes.

E Walk barefoot indoors when the floor is clean.

F. Wear properly fitting shoes and clean socks.

G. Use a heating pad when the feet feel cold.

H. Report cuts, blisters, redness, swelling, drainage, or nonhealing sores.

A. Inspect the feet and between the toes every day.

C. Wash feet with warm water and dry thoroughly, especially between the toes.

D. Apply moisturizer to dry skin, avoiding between the toes.

F. Wear properly fitting shoes and clean socks.

H. Report cuts, blisters, redness, swelling, drainage, or nonhealing sores.

A nurse is assisting a client with dementia during a bath, which actions should the nurse take to promote, safety, and cooperation?

A. Explain each step using a simple, short sentences

B. Maintain a calm, quiet, environment

Position of bed for self oral care

Fowlers

The nurse is positioning clients for different procedures and nursing interventions. Which positions is correctly matched with its common purpose:

A. Fowler

B. Supine

C. Prone

D. sims (aka lateral recumbent)

E. Litothomy

F. Trendelenburg

G. Dorsal recumbent

The nurse is reviewing common

The patient became tearful during morning care so the nurse will do this.

Pause the care

A client is unable to brush their own teeth. Before providing oral care, the nurse should assess for this important

A nurse is preparing to bathe the client who is weak at risk for falling. The nurse should take this action before beginning.

A client says “I don’t need help, I can do this myself,”