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 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 2 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 3 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.
Question 4 of 5
A nurse is caring for a 25-year-old patient who is unresponsive following a head injury. The patient has several piercings in the ears and nose that appear crusted and slightly inflamed. What is the most appropriate action to care for this patient's piercings?
Correct Answer: B
Rationale: When providing care for piercings, the nurse performs hand hygiene, applies gloves, then cleanses the site of all crusts and debris by rinsing the site with warm water and removing the crusts with a cotton swab. The nurse should then apply a dab of liquid-medicated cleanser, per policy, to the area, turn the jewelry back and forth to work the cleanser around the opening, rinse well, remove gloves, and perform hand hygiene. The nurse should not use alcohol, peroxide, or ointments at the site and should avoid removing piercings unless it is absolutely necessary (e.g., when an MRI is ordered.)
Question 5 of 5
An RN in a long-term care facility supervises APs as they provide hygiene to older adults. What action by the AP will the nurse correct?
Correct Answer: B
Rationale: Older adults tend to develop dry skin; bathing frequency will change accordingly. Soaking adults' feet is not recommended. It is appropriate to keep a patient warm with bath blankets and provide perineal care washing from front to back.