Introduction to Nursing Skills Final Review

A female nurse is assisting an older man who has dementia with a bath in his hospital room. Which approach should the nurse take?

The client should be allowed to complete as much of the bath as he can.

A nurse is assisting an older, continent client with dry skin who is hospitalized. Which approach to hygiene should the nurse take with this client?

Alternate between a full bed bath on one day and use of skin lotion or bath oil on the next.

A nurse is assisting a 72-year-old client with a tub bath. The nurse fills the tub halfway with water and checks the temperature of the bath water. Which temperature would the nurse identify as appropriate for this client?

100 f

Which modification to bathing should be implemented for a client who is incontinent?

Use special perineal skin cleansers and moisture barriers.

The acute care nurse is talking with an older adult client who had a complete bed bath earlier in the day. The client states, "I like to be scrubbed clean during my bath, and the person who bathed me today didn't even use soap and water and barely rubbed my skin to dry it." Which response by the nurse is most appropriate?

"Use of special bathing products and avoidance of scrubbing help keep your skin intact."

After assisting a bed-bound client with oral care, what action does the nurse take?

Assist the client to a comfortable position in the bed.

The acute care nurse is talking with a client who just finished performing oral care. The client states, "I have some whitish-yellow patches on my tongue. Should I be concerned?" Which response by the nurse is most appropriate?

"Let me assess the patches. They may indicate the development of a fungal infection."

The nurse is providing oral care to a hospitalized client. Which outcome of this intervention is the priority?

Decreasing the incidence of hospital-acquired pneumonia

Diligent oral care inhibits the growth of pathogens in the oropharyngeal secretions, decreasing the incidence of aspiration pneumonia, hospital-acquired non-ventilator pneumonia and ventilator associated pneumonia. While the other choices are expected outcomes of oral care, preventing respiratory complications is the priority.

A client has requested assistance with tooth brushing. What necessary supplies will the nurse gather? Select all that apply.

Disposable gloves, Towel, Emesis basin, Toothbrush, Toothpaste

5The nurse is assisting a hospitalized client with oral care. How will the nurse position the client?

Sitting at the edge of the bed

When making an occupied bed, the nurse positions and tucks in the bottom linens on one side of the bed. What would be the nurse's next action?

Raise the side rail.

The nurse cleans the client after a bowel movement and notes stool on the gloves. The nurse has not finished cleaning the client. What action should the nurse take?

Change into a new pair of gloves.

The nurse uses perineal cleansing wipes for the client who has had a bowel movement. Which action does the nurse take?

Change to a clean wipe after each stroke.

The nurse is changing the linens for a client who could not be turned on the side due to a surgical incision on the right hip and pain from a fall in the left hip. What nursing intervention would be appropriate for this client?

Change the bed linens from the top to the bottom.

When a client cannot be turned on the side, what recommended nursing action would the nurse perform, with assistance from another nurse, to replace the soiled linens once they have been removed?

Ease the clean linens under the client, from the top to the bottom of the bed.

The nurse provides care to a sedated client with soiled sheets. Which action does the nurse take to move the client?

Ask for help from a staff member.

The nurse is making a bed occupied by a client. How would the nurse position the client when loosening bottom bed linens?

Lying on one side

How would the nurse remove the top linens when making an occupied bed?

Have the client hold onto the bath blanket and reach under it to remove the linens.

The nurse is preparing to change the linens from the top to the bottom for a client who cannot be turned on the side. Which accurately describes a recommended step in this procedure when removing the soiled linens?

Keep the blanket in place over the client to provide privacy and remove the top sheet.

A nurse must change the linens on a bed while it is occupied. Which actions should the nurse take? Select all that apply.

Put on gloves before removing soiled linens., Place a bath blanket over the client., Help the client turn toward the opposite side of the bed and fan-fold soiled lines as close to the client as possible.

The nurse making an occupied bed. Under which body part of the client would the nurse place the drawsheet?

Midsection

The nurse is preparing to make a bed occupied by a client who is on bedrest. What is the first action the nurse would take in this procedure?

Check the client's chart.

The nurse has placed the rolled, soiled linens in the laundry hamper. What should be the nurse's next action?

Remove gloves, unless indicated for transmission precautions.

Where should the nurse roll soiled linens when removing them from an unoccupied bed?

Inside the bottom sheet

How should the nurse open the bottom sheet when making an unoccupied bed?

Fanfold to the center

The nurse is changing the linens on a client's bed. What is the nurse's primary objective for this nursing action?

Provide client comfort

The nurse is changing a client's bedding while the client is out of the room getting an X-ray. What would the nurse do with the reusable linens?

Fold the linens in fourths on the bed and then hang them over a clean chair.

The nurse is preparing to perform oral care for a client who has full dentures. Which actions should the nurse take? Select all that apply.

Place paper towels or a washcloth in the sink to prevent damage if the dentures are dropped during cleaning., Use a toothbrush and paste to gently brush all surfaces., Provide privacy while the client removes dentures from the mouth.

The nurse is teaching a client about denture care. Which statement from the client indicates a need for further teaching?

"When I eat, I will remove my dentures and place them in a napkin."

Which aspect of denture care is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

Brushing the dentures

The nurse is providing denture care for a client who is too sedated to assist. Which is a recommended guideline for this procedure?

Apply gentle pressure with a piece of gauze to remove the upper dentures.

A nurse is assisting a client with denture care. What is the best way to remove the client's dentures?

Apply gentle pressure with a 4 × 4 gauze to grasp the denture plate.

When performing perineal care for the male client, the nurse should be particularly gentle and avoid pressure when cleansing which area?

Scrotum

An unlicensed assistive personal (UAP) is performing perineal care for a female client. Which action by the UAP requires intervention by the nurse?

The UAP begins cleansing from the anus toward the pubic bone.

The nurse is planning to bathe a client who has thigh-high antiembolism stockings in place. Which action is correct?

Remove the antiembolism stockings before the bath.

The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. Which technique for cleaning the penis is correct?

Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place.

In an uncircumcised male client (teenage or older), retract the foreskin (prepuce) while washing the penis but pull it back into place over the glans penis immediately afterwards to prevent constriction of the penis, which may result in edema and tissue injury. However, it is not recommended to retract the foreskin for cleaning during infancy and childhood, because injury and scarring could occur. The nurse should clean the tip of the penis first, not soak it in water, by moving the washcloth in a circular motion from the meatus outward.

The nurse is providing a bed bath for a female client who is unconscious. The nurse should pay special attention to cleaning which areas of the body?

Underneath the breasts and in between skin folds

The nurse is preparing to give a bad bath to a client. Which supplies would the nurse need to gather before entering the client's room? Select all that apply.

Bath blanket, Protective pads, Towels, Linen, Gown

The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. What is the correct technique for cleaning the penis?

Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place.

The nurse is performing perineal care on an adult male client who was incontinent of stool. After cleansing the perineal area, what is the most appropriate intervention by the nurse?

Apply a thin barrier of skin protectant to the perineal area

The nurse is performing perineal care for a male client. What part of the perineum would the nurse clean first?

tip of the penis

A nurse is preparing to give a bed bath to a client. What approach should the nurse take?

Start with cleanest areas and end with most soiled areas.

The acute care nurse is preparing to bathe a client and notices that the client is wearing a regular hospital gown and has continuous intravenous (IV) fluids infusing. Which action by the nurse is appropriate?

carefully thread the IV bag and tubing through the arm of the regular gown, and then replace it with a snap-arm gown at the end of the bath.

The client requests powder to be applied to the genitalia after perineal care. Which explanation from the nurse to the client is best?

"Powder in the genital area can create a medium for bacterial growth."

The nurse observes a staff member performing perineal care on a female client. The staff member washes the client's rectal area and then washes the client's urinary meatus. What is the most useful instruction for the nurse to give the staff member?

"Microbial contamination can occur when cleaning the anal area first."

The nurse is performing perineal care for a female client when the client asks the nurse to use baby powder to help keep her perineum dry. What is the best response by the nurse?

"It is recommended to avoid the use of baby powder in the perineal area because it creates a place for bacteria to grow."

The nurse is preparing to bathe a client using a self-contained bathing system that has premoistened, disposable washcloths. Which method for warming the premoistened cloths is correct?

Heat the entire package in the microwave, following the manufacturer's recommendation.

The nurse is providing perineal care for an uncircumcised adult male client. What is a recommended guideline for this action?

Retract the foreskin when washing the prepuce of adolescents and older.

A nurse is performing perineal care for a female client. Which action would most be important to maintain the client's privacy?

Uncover only the area being cleaned.

basic principles of medical asepsis in patient care

hand hygiene, ppe, change linens often, don't touch linens to clothing

when is hand hygiene necessary

before and after entering patient room, hands are visibly soiled, after touching surfaces in patient room, before and after touching patient, etc

when is standard precaution necessary

all patient care

differences between contact/droplet/airborne precautions

-contact: glove, gown, mask, googles

-droplet: glove, gown, mask, googles, educate family (distancing, masks)

-airborne: negative pressure in room, ppe, patient wears mask

nurse's responsibilities when getting bp

watching range/accuracy of bp, interpret bp

factors that affect body temperature

eating, bath/shower, infection in area

normal pulse for adults

60-100

if a patient had shallow respirations how should the nurse observe

place hand on back of patient, have patient place hand across chest, observe sternal notch, stethoscope

factors that affect bp

healthy people that exercise a lot, position of patient, stress, meds, smoking, pain

what areas would you include in situational assessment

identify patient, placement of things in relation to patient, brakes, call light

what nursing interventions to prevent falls

check on patient every 2 hours, patient teaching, clear clutter, bed alarm, walker/cane, bedside commode, non slip socks

alternatives to restraints

dim lights, lower bed, family member to watch (last resort)

assessments after applying restraints

skin breakdown, avoid bony prominences, every 24 hours renew order with doctor

interventions to prevent pressure ulcer

turn patient every 2 hours, check wounds, use pillows/wedges to elevate

why limit warm compress? how long to leave on?

used 48 hours after injury, 20-30 minutes, assess area

considerations before moving patient

cognition level, patient's weight, physical limitations, pain level, activity level, iv lines

what assessments before rom exercise

pain level, if patient can do it on their own, contraindications

when to apply/remove compression stockings

put on in the morning because the body is at equilibrium in the morning

contraindications of pneumatic compression devices

vascular issues, circulation problems, injuries on leg, ongoing blood clot on leg (clot can move around)

when are pneumatic compression devices used

after surgery

what assessments to do before patient uses bedpan

cognition, fracture bedpan?, how patient takes instructions, injuries, physical limitations

responsibilities of nurse when offering urinal

patient should stand unless contraindicated (to fully empty bladder, prevent uti)

considerations when applying condom catheter

assess for correct size

how to approach oral/bath care

patient teaching, physical limitations

some nutrition considerations for patients with different culture

ask for preferences, family can bring in food (unless contraindicated)

considerations when feeding patient with dysphagia

not to have a conversation while they're eating, give them time to swallow, small amounts of food/liquid at a time, sitting upright, make sure they swallow everything before giving more to swallow, alternate between solids/liquids

how to promote comfort

pain meds, pillows/wedges to elevate, environment, distractions

difference between physiological responses/behavioral response

physio: heart r8, bp, respiration, sweat

behav: guarding injury, fetal position