ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 32 Questions
Question 1 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 2 of 5
A nursing student asks an experienced nurse why they provide massage for their patients. Which of these would be reflected in the nurse's response?
Correct Answer: A,B,C,F
Rationale: The benefits of massage include general relaxation and increased circulation, pain relief, sleep promotion, and increased patient comfort and well-being. Massage also provides an opportunity for the nurse to communicate and connect with the patient through touch. Back massage is contraindicated if the patient has had back surgery or has fractured ribs.
Question 3 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.
Question 4 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 5 of 5
When assessing the skin, nurses use techniques to provide complete data and correct documentation. Which actions are appropriate during the skin assessment? Select all that apply.
Correct Answer: A,C,F
Rationale: During skin assessment, the nurse should compare bilateral parts for symmetry, use standard terminology to communicate and document findings, and perform the appropriate skin assessment when risk factors are identified. The nurse should proceed in a head-to-toe systematic manner, using cues/data from the nursing history to direct the assessment. When documenting a physical assessment of the skin, the nurse should describe exactly what is observed or palpated, including appearance, texture, size, location or distribution, and characteristics of any findings.