FON Ch 15 Personal Care

The nurse is providing oral care to an unconscious patient. Which technique would the nurse use?

A) Use a lemon-glycerin swab

B) Use 15 mL of water

C) Use water-soluble lip balm

D) Use intermittent suction

Answer:

C) Use water-soluble lip balm

Rationale:

The nurse is making an occupied bed. Which order would the nurse follow when performing the steps? Put in correct order.

1) Fanfold clean fitted sheet and draw sheet toward patient

2) Change pillowcase

3) Roll soiled linens, place in hamper, pull clean linens tightly

4) Fold dirty linens toward the patient and tuck next to patient

5) Turn patient over lump

6) Put on top sheet and blanket/spread

Answer: 4, 1, 5, 3, 6, 2

4) Fold dirty linens toward the patient and tuck next to patient

1) Fanfold clean fitted sheet and draw sheet toward patient

5) Turn patient over lump

3) Roll soiled linens, place in hamper, pull clean linens tightly

6) Put on top sheet and blanket/spread

2) Change pillowcase

Rationale:

The nurse is helping a patient turn over the "lump" when making the bed. Which action should the nurse take to safely assist the patient with turning?

A) Turn the patient toward the nurse

B) Remove the pillow

C) Lower the side rail

D) Go to the other side of the bed

Answer:

A) Turn the patient toward the nurse

Rationale:

The nurse is changing the bed linens of an incontinent patient. Which action should the nurse take?

A) Hold soiled linens close to uniform

B) Place soiled linens neatly on the floor

C) Spray mattress with disinfectant spray

D) Use uncovered hand to change linens

Answer:

C) Spray mattress with disinfectant spray

Rationale:

The nurse is giving a partial bath to a patient. Which areas would the nurse clean? Select all that apply.

A) Buttocks

B) Chest

C) Hands

D) Face

E) Axilla

Answer: A, C, D, & E

Rationale:

The nurse is assisting a conscious patient with oral care. Which action should be included?

A) Brush the teeth at a 90-degree angle

B) Brush in small circles over chewing surfaces

C) Floss below the gum line

D) Floss in a backward and forward motion

Answer:

D) Floss in a backward and forward motion

Rationale:

The nurse would instruct the unlicensed assistive personnel to use an electric razor on which patient?

A) A male patient on anticoagulant medication

B) A male patient with a three-day beard growth

C) A female patient with underarm stubble

D) A female patient on asthma medication

Answer:

A) A male patient on anticoagulant medication

Rationale:

The nurse working in a long-term care facility is bathing residents. Which action should the nurse take?

A) Bathe residents every day

B) Provide extra blankets when bathing

C) Avoid using lotion on skin

D) Rub the skin briskly to towel dry

Answer:

B) Provide extra blankets when bathing

Rationale:

A patient receives continuous tube feedings via a nasogastric tube. Which bed position is appropriate for this feeding route?

A) Supine

B) Fowler's

C) Semi-Fowler's

D) Trendelenburg

Answer:

C) Semi-Fowler's

Rationale:

How would the nurse best describe the difference between a blanket bath and bag bath?

A) "One is heated and one is not."

B) "One has a no-rinse skin cleanser and the other uses soap and water."

C) "One has blanket, washcloths, and towels and the other has just washcloths."

D) "One is in a bag and one is in a metal basin."

Answer:

C) "One has blanket, washcloths, and towels and the other has just washcloths."

Rationale:

A patient is sitting in the bedside chair while the nurse makes the bed. The nurse has just finished tucking in the clean fitted sheet and draw sheet. What should the nurse do next?

A) Pull the side rail up.

B) Lower the bed

C) Unfold the top sheet to cover half of the bed.

D) Prepare the pillow.

Answer:

C) Unfold the top sheet to cover half of the bed.

Rationale:

The nurse is providing care to a patient with multiple body piercings. Which technique is used to remove a curved barbell piercing?

A) Unscrew the knob and slide the shaft out

B) Use small needle-nose type pliers

C) Gently separate the handles to widen the ring

D) Apply Vaseline to remove the piercing

Answer:

A) Unscrew the knob and slide the shaft out

Rationale:

The nurse is observing an unlicensed assistive personnel (UAP) provide denture care. Which action by the UAP is correct?

A) Washes dentures in hot water

B) Places metal, partial dentures in water only

C) Gently removes dental implants

D) Cleans denture over a metal sink

Answer:

B) Places metal, partial dentures in water only

Rationale:

The nurse is helping a patient with the bath by getting supplies and washing the back and buttocks. Which type of care is the nurse providing?

A) Self-care

B) Assisted care

C) Total care

D) Holistic care

Answer:

B) Assisted care

Rationale:

The nurse assigns the unlicensed assistive personnel (UAP) to give a patient a bed bath. Which statement by the UAP indicates a correct understanding of performing a bed bath?

A) "I put the washcloth in the palm of my hand."

B) "I wash from dirty areas to clean areas."

C) "I will wash the arm closest to me first."

D) "I change the water after bathing the feet."

Answer:

D) "I change the water after bathing the feet."

Rationale:

The nurse is providing oral care to a conscious patient receiving oxygen at 2 L/min per nasal cannula. The patient begins to cough. Which action should the nurse take?

A) Use Vaseline on lips.

B) Brush tongue inside mouth.

C) Apply gloves, face shield, and gown.

D) Place in supine position.

Answer:

C) Apply gloves, face shield, and gown.

Rationale:

The nurse is giving a female patient a bed bath. Which actions would be included? Select all that apply.

A) Wash from the inner to outer canthus of the eye.

B) Test the temperature of the water using the inner wrist.

C) Disconnect the intravenous tubing to change the patient's gown.

D) Per patient's preference, apply deodorant after drying arms.

E) Wash the perineal area from front to back.

Answer: A, B, D, & E

Rationale:

Which strategies would the nurse use to safely maintain a patient's environment? Select all that apply.

A) Place the lunch tray on the bedside stand.

B) Keep the patient's door open.

C) Place water, glass, and straw within the patient's reach.

D) Use neutralizing odor sprays.

E) Encourage unlicensed assistive personnel to wear cologne.

Answer: C & D

Rationale:

The nurse inhales a foul odor when entering a patient's room. What best describes the result when personal hygiene is poor?

A) Sweat from the apocrine sweat glands is being broken down by bacteria.

B) The sebaceous glands are overproducing sebum.

C) There is excessive moisture from the eccrine glands interacting with the keratin.

D) The follicles have become infected, producing a malodorous byproduct of dead cells.

Answer:

A) Sweat from the apocrine sweat glands is being broken down by bacteria.

Rationale:

The nurse is bathing a patient who has a urinary catheter. What technique is used when cleaning the catheter?

A) Use betadine to clean the catheter and perineum.

B) Hold the catheter taut while washing.

C) Begin cleaning at the insertion site and clean down the tube.

D) Gently pull the catheter out 0.5 inches to clean thoroughly

Answer:

C) Begin cleaning at the insertion site and clean down the tube.

Rationale:

The nurse is giving a patient a back massage. In which area should the nurse massage using their thumbs?

A) Lower back

B) Neck to shoulders

C) Around the scapula

D) Over the vertebrae

Answer:

C) Around the scapula

Rationale:

The nurse is caring for a patient with body piercings. Which situations would cause the nurse to remove the body piercings? Select all that apply.

A) Patient is being intubated for abdominal surgery and has a tongue piercing.

B) Patient is scheduled for a magnetic resonance imaging and has an abdominal captive ring piercing.

C) Patient needs a Foley catheter inserted and has a Prince Albert piercing.

D) Patient is going to receive a complete bed bath and has a nipple piercing.

E) Patient is receiving oral care and has a lip piercing.

Answer: A, B, & C

Rationale:

The unlicensed assistive personnel (UAP) provided perineal care to a male patient. What comment by the UAP is most concerning to the nurse?

A) "I pulled back the foreskin and left it there."

B) "I used a circular motion around the top of the penis."

C) "I rinsed and patted dry."

D) "I washed the patient's scrotum, too."

Answer:

A) "I pulled back the foreskin and left it there."

Rationale:

The nurse working in a long-term care facility is providing ear care to an older adult patient. The patient has an in-the-canal-style hearing aid with a filter. Which strategy should the nurse use for hearing aid care?

A) Remove the hearing aid by turning the earmold slightly toward the back of the ear

B) Replace the battery if whistling is heard

C) Clean hearing aid with a pipe cleaner

D) Gently tap the hearing aid against the cloth placed on a hard surface to remove wax

Answer:

D) Gently tap the hearing aid against the cloth placed on a hard surface to remove wax

Rationale:

During the bath, the nurse notices excoriation on a patient's arms. What best describes this appearance?

A) Softened skin from excessive moisture

B) Scrapes on the skin

C) Purplish blotching of the skin

D) A large bruise on the skin

Answer:

B) Scrapes on the skin

Rationale:

Which technique should the nurse use when providing a back massage to a patient?

A) Use fingertips to massage the neck

B) Use the side of the thumbs to massage muscles

C) Use alcohol gel to massage the skin

D) Use light pressure on patients with broken ribs

Answer:

B) Use the side of the thumbs to massage muscles

Rationale:

A patient is incontinent of urine and soils the bed. Which is the best response by the nurse?

A) "Can't you call us when you need to go to the bathroom?"

B) "Let's get you cleaned up."

C) "Should I put you in a diaper like a baby?"

D) "This is the third time you've done this."

Answer:

B) "Let's get you cleaned up."

Rationale:

The nurse is washing the patient's leg during a complete bed bath. Which cleansing motion is best?

A) From anterior to posterior

B) From the thigh to the foot

C) From top to bottom

D) From distal to proximal

Answer:

D) From distal to proximal

Rationale:

The nurse administers a bath to a patient who is recovering from upper body burns. The patient states, "I look like a monster." Which is the best response by the nurse?

A) "You'll be fine. I had a burn like that on my knee."

B) "Oh, you don't look that bad."

C) "It gets better with time."

D) "Tell me more about this."

Answer:

D) "Tell me more about this."

Rationale:

The nurse is checking the bed made by an unlicensed assistive personnel (UAP). Which is not part of an appropriately made bed?

A) Cuffed spread over the top sheet

B) Wrinkles in the bottom fitted sheet

C) Draw sheet placed horizontally at the patient's shoulders and the patient's knees

D) Formation of a mitered corner for the top sheet and or the blanket

Answer:

B) Wrinkles in the bottom fitted sheet

Rationale:

The nurse is providing personal care to several different patients. Which actions would be included? Select all that apply.

A) The nurse assigns a total bed bath to a comatose patient.

B) The nurse assigns a shower for a patient who is dizzy and weak.

C) The nurse stays with the patient during the initial shower after surgery.

D) The nurse shaves the neck of a male patient using downward strokes.

E) The nurse uses gauze and gloved hands to remove dentures.

Answer: A, C, & E

Rationale:

The nurse is helping a new, long-term care resident adjust to their surroundings. The nurse discovers the resident prefers to take a bath at night. Which action by the nurse is best?

A) Allow the resident to bathe at night

B) Suggest the resident take a bath in the mornings

C) Tell the resident facility policy is to take the bath in the mornings

D) Compromise and have the resident bathe in the afternoon

Answer:

A) Allow the resident to bathe at night

Rationale:

The nurse is reviewing perineal care for a female patient with the unlicensed assistive personnel (UAP). Which order would the steps be taken if the UAP is standing on the right side of the bed? Put in correct order.

1) Continue to wash the outer labia and perineum until clean

2) Clean the middle of the vulva

3) Spread the patient's labia with nondominant hand

4) Clean the inner right labia

5) Clean the inner left labia

Answer:

3) Spread the patient's labia with nondominant hand

5) Clean the inner left labia

4) Clean the inner right labia

2) Clean the middle of the vulva

1) Continue to wash the outer labia and perineum until clean

Rationale:

The nurse is helping a patient take a tub bath. The nurse notices the patient having dyspnea. Which action would the nurse take?

A) Ask the patient to take deep breaths while finishing the bath.

B) Assist the patient to finish the bath.

C) This is an expected response.

D) Leave the patient to obtain a clean gown.

Answer:

B) Assist the patient to finish the bath.

Rationale:

The nurse is caring for a patient who is hesitant to take a bath. What is the best response by the nurse?

A) "Are you sure you want to take a bath now?"

B) "Would you like to take your bath now or after breakfast?"

C) "Do you want to take a bath?"

D) "You can wait a little longer for your bath, can't you?"

Answer:

B) "Would you like to take your bath now or after breakfast?"

Rationale:

The nurse grasps the top linen and spread at the patient's foot and pulls up two inches. What is the purpose of this action?

A) To prevent footdrop

B) To enhance plantar flexion

C) To promote dorsiflexion

D) To reduce sordes

Answer:

A) To prevent footdrop

Rationale:

The nurse is revising the plan of care for a diabetic patient. Which intervention should be included regarding nail care?

A) Trim toenails deeply at the corners

B) Cut toenails straight across

C) File toenails only

D) Encourage walking barefoot

Answer:

C) File toenails only

Rationale:

The nurse is educating staff about the benefits of bathing a patient. Which information should be included in this new hygiene program? Select all that apply.

A) Removes debris and dead cells

B) Allows for skin inspection

C) Restricts blood flow to extremities

D) Increases sensory input

E) Improves communication

Answer: A, B, D, & E

Rationale:

The nurse is having a patient perform activities of daily living (ADLs). Which activities are included? Select all that apply.

A) Taking a shower in the morning

B) Flossing teeth after breakfast

C) Preparing for a diagnostic test

D) Returning from a physical therapy session

E) Brushing hair before breakfast

Answer: A, B, & E

Rationale: