ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 32 : Hygiene Questions
Question 1 of 5
A nurse in a long-term care facility observes the AP providing foot care for patients. Which actions by the AP require the nurse to intervene? Select all that apply.
Correct Answer: B,D,F
Rationale: The nurse corrects the AP for soaking the feet or using alcohol and reminds them to use moisturizer if the feet are dry. Digging into or cutting the toenails at the lateral corners when trimming the nails requires correction; toenails should be trimmed straight across. Guidelines for foot care include bathing the feet thoroughly in a mild soap and tepid water solution; drying feet thoroughly, including the area between the toes; and applying an antifungal foot powder when requested.
Question 2 of 5
A nurse in a memory care unit is assisting a patient with dementia with bathing. Which nursing action will enhance patient comfort and prevent anxiety?
Correct Answer: C
Rationale: The nurse use music to soothe anxiety and agitation. The nurse should also shift the focus of the interaction from the 'task of bathing' to the needs and abilities of the patient, and focus on comfort, safety, autonomy, and self-esteem, in addition to cleanliness. Wash the face and hair at the end of the bath or at a separate time. Water dripping in the face and having a wet head are often the most upsetting parts of the bathing process for people with dementia. The nurse should also consider methods for bathing aside from showers and tub baths.
Towel baths, washing under clothes, and bathing 'body sections' one day at a time, as well as dry shampoo or 'shower cap' shampoos, are additional options.
Question 3 of 5
A nurse is teaching a nursing student how to perform perineal care for patients. What actions are appropriate when performing this procedure? Select all that apply.
Correct Answer: A,D,E
Rationale: Wash and rinse the groin area (both male and female patients) with a small amount of soap and water, and rinse. For male and female patients, always proceed from the least contaminated area to the most contaminated area and use a clean portion of the washcloth for each stroke. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. For a female patient, spread the labia and move the washcloth from the pubic area toward the anal area. In an uncircumcised male patient (teenage or older), retract the foreskin (prepuce) while washing the penis and return it to its original position when finished.
Question 4 of 5
A home care nurse is assisting an older adult with an unsteady gait with a tub bath. Which action is recommended in this procedure?
Correct Answer: C
Rationale: Safe nursing practice requires that the nurse assists a patient with an unsteady gait in and out of the tub. Adding bath oil to the bath water poses a safety risk because it makes the patient and tub slippery. Although privacy is important, if the patient locks the door, the nurse cannot help if there is an emergency. The water should be comfortably warm at 43?° to 46?°C. Older adults have an increased susceptibility to burns due to diminished sensitivity.
Question 5 of 5
A nurse is about to bathe a female patient who has an IV in the forearm. The patient's gown, which does not have snaps on the sleeves, needs to be removed prior to bathing. How will the nurse proceed?
Correct Answer: C
Rationale: Threading the bag and tubing through the gown sleeve maintains a closed system and prevents contamination. No matter how quickly performed, any disconnection of IV tubing results in a breach of the sterile system, creating risk for infection. Cutting a gown is not an alternative except in an emergency.