Week 7 - Skin Integrity + Hygiene

2, 4, 5

The student nurse is teaching a family member the importance of foot care for their mother, who has diabetes. Which safety precautions are important for the family member to know to prevent infection? Select all that apply

1. Cut nails frequently

2. Assess skin for redness, abrasions, and open areas daily

3. Soak feet in water at least 10 minutes before nail care

4. Apply lotion to feet daily

5. Clean between toes after bathing

3

While planning morning care, which of the following patients would have the highest priority to receive a bath first?

1. A patient who just returned to the nursing unit from a diagnostic test

2. A patient with a fever who just finished a dose of IV antibiotics

3. A patient who is experiencing frequent incontinent diarrheal stools and urine

4. A patient who has been awake all night because of 8/10 pain

2, 3

What is the proper position to use for an unresponsive patient during oral care to prevent aspiration? Select all that apply

1. Prone position

2. Modified left lateral recumbent position

3. Semi-Fowler’s position with head to side

4. Trendelenburg position

5. Supine position

1

A nurse is beginning a complete bed bath for a client. After removing the client’s gown and placing a bath blanket over the body, which of the following areas should the nurse wash first?

1. Face

2. Feet

3. Chest

4. Arms

5. Perineal Area

4

A nurse is planning care for a client who develops dyspnea and feels tired after completing morning care. Which of the following actions should the nurse include in the client’s plan of care?

1. Discontinue morning care for 2 days

2. Perform all care as quickly as possible

3. Ask a family member to come in to bathe the client

4. Schedule rest periods during morning care

1

The nurse is caring for a patient who has a large laceration from a motor vehicle accident. It is day 10 and the patient is showing signs of wound repair. Which type of tissue will the nurse expect to observe when the wound is healing?

1. Granulation tissue

2. Purulent drainage

3. Eschar 

4. Slough

4

The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation related to the incision will indicate the patient is experiencing a complication of wound healing?

1. Patient reports minimal to moderate incisional pain controlled with pain medication

2. Incision is approximated

3. Patient complains of itching at incision site

4. The incision site is hot and edematous

3

The nurse is collaborating with the dietitian about a patient with a Stage III pressure ulcer. Which nutrient will the nurse expect to be increased after collaboration with the dietitian?

1. Carbohydrates

2. Vitamin K

3. Protein 

4. Potassium

A

A postoperative patient arrives at an ambulatory care center and states, “I am not feeling good.” Upon assessment, you note an elevated temperature. An indication that the wound is infected would be:

A. It shows purulent drainage coming from the incision site

B. It has no odor

C. A culture of the wound is negative

D. The edges are pink in color

B, D

A nurse is caring for a 50-year-old client who is 2 days postoperative following an appendectomy and has type II diabetes mellitus. Their hemoglobin is 15.5 g/dL (reference range 13.5-17.5 g/dL), and BMI is 17.1 (reference range 18.5-24.9). The incision is approximated and free of redness, with minimal serous drainage on the dressing. Based on this information, the nurse should recognize that the client has which of the following risk factors for impaired wound healing? (Select all that apply). 

A. Extremes in age

B. Chronic disease

C. Hemoglobin level

D. Malnutrition

E. Poor wound care

B

The nurse is caring for a client who is at high risk for pressure injury. Which intervention should the nurse implement?

A. Turn and reposition every 3 hours

B. Float the patient's heels

C. Keep the head of the bed elevated at 45 degrees

D. Encourage the patient to eat only fruits and vegetables

A

Which of the following nursing actions help to prevent skin fold yeast infection (cutaneous Candidiasis) in a patient with large abdominal skin folds?

A. Minimize moisture in skin folds by patting the area dry following bathing

B. Instruct the patient to limit showering to once per week

C. Advise the patient to avoid physical exercise as it increases skin friction

D. Apply fragranced lotion to skin folds

B

Which of the following actions by the nurse demonstrates patient-centered care during bathing?

A. Addresses pain concerns after the bathing is completed

B. Empowers the patient to do as much as possible independently

C. Determines the best time for the bed bath based on the nurse's schedule

D. Avoids conversation and eye contact with the patient during bathing

C, D

The student nurse is teaching a family member the importance of foot care for their mother, who has diabetes mellitus. Which safety precautions are important for the family member to know to prevent infection? (Select all that apply.)

A. Cut nails short, following the curve of the nailbed

B. Soak feet in water at least 10 minutes before nail care

C. Apply lotion to feet daily, avoiding between the toes

D. Clean and dry between toes after bathing

E. Wash the feet with very hot water to help remove bacteria

D

A nurse is providing oral care to a client who is at risk for aspiration. Which action is most important to prevent aspiration during oral care?

A. Use a soft-bristled toothbrush and gentle toothpaste

B. Offer the client water to rinse after brushing

C. Brush teeth for at least 2 minutes twice daily

D. Place the client in an upright position

D

A nurse is providing a client with a stage 3 pressure injury education on foods that promote wound healing. Which of the following client statements indicates a need for further teaching?

A. “I will eat more eggs, chicken, and beans to increase my protein intake.”

B. “I will include citrus fruits and berries to get vitamin C for healing.”

C. “I will add leafy greens like spinach to my meals for vitamins and minerals.”

D. "I will focus on eating more carbohydrates such as white pasta."

B

A nurse is providing teaching to the parents of a 4-month-old infant diagnosed with diaper dermatitis. Which statement by the parents indicates a need for further teaching?

A. “We will change the diaper every 2 to 3 hours and after each bowel movement.”

B. “We’ll gently clean the area with scented soap and water at each diaper change.”

C. “We’ll apply a zinc oxide barrier cream after cleaning and drying the skin.”

D. “We’ll allow the baby to go without a diaper for short periods to let the skin air out.”