Nursing Role Q&A | Nursing
1. Select all factors that may influence a person's hygiene practices.
A) Personal preferences
B) Health status
C) Culture
D) Religion
E) Energy level
F) All of the above
Correct Answer: All of the above
Rationale: Hygiene practices are influenced by multiple factors including
personal preferences, health status, culture, religion, and energy level.
Nurses must assess these factors to provide individualized, culturally
competent care. This holistic approach ensures that hygiene interventions
respect patient values while meeting clinical needs.
2. Which scheduled hygiene care is usually thought of as including a back
massage to help the patient relax?
A) Early morning care
B) Hour of sleep care (HS care)
C) As needed (PRN) care
D) Morning care
Correct Answer: Hour of sleep care (HS care)
Rationale: Hour of sleep (HS) care is the routine provided to patients at
bedtime to promote relaxation and rest. It typically includes a back massage,
,which helps reduce tension, improve circulation, and facilitate sleep onset.
This intervention is a key component of holistic nursing care.
3. The nurse is teaching nursing assistive personnel how to give a complete
bed bath. Which instruction should the nurse include?
A) "Cleanse only those areas likely to cause odor."
B) "Wash the patient's back, buttocks, and perineum first."
C) "Provide the patient with warm water for washing his perineum."
D) "Bathe the patient from head-to-toe, cleanest areas first."
Correct Answer: "Bathe the patient from head-to-toe, cleanest areas first."
Rationale: A complete bed bath should be performed from head to toe,
starting with the cleanest areas (face, eyes, neck) and progressing to the
perineum, which is the least clean. This technique prevents the spread of
microorganisms from the perineum to cleaner areas of the body.
4. A nurse has been teaching a student how to perform mouth care for an
unconscious patient. The student will show evidence of learning if the patient
is placed in which position?
A) Side-lying
B) Semi-Fowler's
C) Prone
D) Supine
Correct Answer: Side-lying
Rationale: Mouth care for an unconscious patient should be performed with
the patient in a side-lying position. This position facilitates drainage of fluids,
,prevents aspiration, and allows the care provider better access to the oral
cavity while maintaining airway safety.
5. A nurse prepares to change a client's bed. Which actions will the nurse
take to minimize the effects of the environment during this task? (Select all
that apply)
A) Hold contaminated linen away from the body
B) Place pillows on the sink
C) Place used linen on the floor
D) Fold and place bedspread on the roommate's chair
E) Avoid shaking the linen
Correct Answer: Avoid shaking the linen, Hold contaminated linen away from
the body
Rationale: To minimize the spread of microorganisms during bed-making, the
nurse should avoid shaking linen, as this disperses dust and pathogens into
the air. Contaminated linen should be held away from the body to prevent
cross-contamination. Used linen should not be placed on the floor or on other
surfaces.
6. When using the SBAR method of communicating a client's condition, the
nurse would include which information in the background section?
A) Patient states that he feels dizzy and light-headed
B) Request fingerstick glucose monitoring
C) Admission diagnosis is new-onset type 2 diabetes
D) Blood pressure is 130/90 mm Hg; heart rate is 89 beats per minute
Correct Answer: Admission diagnosis is new-onset type 2 diabetes
, Rationale: SBAR stands for Situation, Background, Assessment,
Recommendation. The background section includes relevant patient history,
current diagnoses, and contextual information. The admission diagnosis
belongs in the background section. Patient symptoms and vital signs belong
in the assessment section, and requests belong in the recommendation
section.
7. Which question would the nurse ask to identify an immediate physiologic
consequence when an older adult's teeth are in poor condition and the client
says that he or she only eats soft foods?
A) "Would you like me to help you make an appointment with the dentist?"
B) "Have you lost any weight recently?"
C) "Do you have any problems with your bowel movements?"
D) "Do you take any over-the-counter vitamin supplements?"
Correct Answer: "Have you lost any weight recently?"
Rationale: Poor dentition and a soft-food diet can lead to inadequate nutrition
and unintended weight loss. Asking about recent weight loss identifies the
most immediate physiological consequence of this condition, allowing the
nurse to address nutritional status and plan appropriate interventions.
8. Which older adult has the greatest risk for falls?
A) A 73-year-old who takes frequent walking excursions
B) A 90-year-old who frequently calls for help to change position
C) An 80-year-old who uses a cane when ambulating
D) A 68-year-old who has decreased sensation in the lower extremities
Correct Answer: A 68-year-old who has decreased sensation in the lower
extremities