Chapter 25 Facilitating Hygiene

Chapter 25  Facilitating Hygiene

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. During morning care, the patient asks the nurse to shave him with a disposable razor. Before shaving him, the nurse should:
a)
Have him sign a permission form
b)
Check to see whether the patient is taking anticoagulants
c)
Tell him that only a family member may shave a patient
d)
Position him flat in bed

ANS: B
If the patient is taking anticoagulant medication or has a bleeding disorder, he is at risk for bleeding. You should use an electric razor, not a disposable razor that may nick the patient’s skin.

Difficulty: Easy
Nursing Process: Interventions
Client Need: PHSI
Cognitive Level: Application

PTS: 1

2. The nurse is caring for a patient admitted with a closed head injury. Which action by the nurse is appropriate when providing hygiene for this patient?
a)
Avoid bathing the patient.
b)
Use cool water for bathing.
c)
Provide care in short intervals.
d)
Rub briskly when towel drying.

ANS: C
The nurse should provide care in short intervals to avoid overstimulating the patient, thereby causing a rise in his intracranial pressure. It is not necessary to avoid bathing the patient. Using cool water to bathe the patient may cause shivering, which may elevate intracranial pressure and increase metabolic demands. Rubbing briskly when drying might also overstimulate, leading to an elevation in intracranial pressure.

Difficulty: Difficult
Nursing Process: Interventions
Client Need: PHSI
Cognitive Level: Application

PTS: 1

3. During the bath, the nurse observed that the patient has dry skin. The best action by the nurse is to:
a)
Bathe the patient more frequently.
b)
Use an emollient on the dry skin.
c)
Massage the skin with warm water.
d)
Discourage fluid intake.

ANS: B
Use an emollient on the dry skin
Using an emollient will aid in soothing dry skin. Frequent bathing will increase dryness, as will discouraging fluids. Massaging skin with water will not play a role in improving dry skin.

Difficulty: Easy
Nursing Process: Interventions
Client Need: Safe and Effective Care
Cognitive Level: Analysis

PTS: 1

4. The nurse is about to bathe a female patient who has an intravenous line, and needs to remove her gown. The nurse should:
a)
Temporarily disconnect the IV tubing at a point close to the patient and thread it through the gown.
b)
Cut the gown with scissors to allow the arm to be easily removed from gown.
c)
Thread the bag and tubing through the gown sleeve, keeping the line intact.
d)
Disconnect the tubing, thread it through the gown, and reconnect the tubing.

ANS: C
Thread the bag and tubing through the gown sleeve, keeping the line intact.
If the patient has an IV line and is wearing a gown that does not have snap-open sleeves, the nurse should remove the gown first from the arm without the IV, then lower the IV container, and pass the gown over the tubing and the container, taking care to keep the container above the level of the patient’s arm. Using this technique will keep blood from backing up into the IV line. Manipulating the IV equipment may change the flow rate; flow rate must be maintained as prescribed. The nurse should not disconnect the IV tubing; this breaks the sterile system and provides a portal of entry for pathogens.

Difficulty: Moderate
Nursing Process: Interventions
Client Need: PHSI
Cognitive Level: Application

PTS: 1

5. For which patient can the nurse safely delegate morning care to the nursing assistive personnel (NAP)? Assume an experienced NAP, and base your decision on patient condition. Assume there are no complications other than the conditions stated.
a)
32-year-old admitted with a closed head injury
b)
76-year-old admitted with septic shock
c)
62-year-old who underwent surgical repair of a bowel obstruction 2 days ago
d)
23-year-old admitted with an exacerbation of asthma with dyspnea on exertion

ANS: C
Morning care for the patient who underwent surgical repair of a bowel 2 days ago can be safely delegated to the nursing assistive personnel because the patient should be stable. The patient who sustained a closed head injury may develop increased intracranial pressure during care. Therefore, he requires the critical-thinking skills of a registered nurse to perform his morning care safely. The patient admitted with septic shock may easily become unstable with care; therefore, a registered nurse is required to provide his morning care safely. The patient admitted with an exacerbation of asthma who becomes short of breath with activity also requires the critical-thinking skills of a registered nurse to detect respiratory compromise quickly.

Difficulty: Difficult
Nursing Process: Interventions
Client Need: Safe and Effective Care
Cognitive Level: Analysis

PTS: 1