Foundations of Nursing, 8th Edition Hygiene and Care of the Patient’s Environment COOPER TEST BANK,100% CORRECT

MULTIPLE CHOICE 1. The nurse is preparing to bathe a patient. What should the room temperature be set at? a. No warmer than 67°F (19.4°C) b. No cooler than 68°F (20°C) c. No cooler than 70°F (21.1°C) d. 75°F or warmer (23.8°C) ANS: B The recommended room temperature is 68° to 74°F (20° to 23.3°C). DIF: Cognitive Level: Application REF: 188 OBJ: 1 | 2 | 4 TOP: Patient's environment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse explains that the purpose of a sitz bath is to reduce inflammation in the perineal and anal area. What is the least amount of time the nurse will instruct for a sitz bath? a. 10 to 15 minutes b. 20 to 30 minutes c. 30 to 40 minutes d. 1 hour ANS: B The sitz bath should last 20 to 30 minutes. DIF: Cognitive Level: Application REF: 192 OBJ: 2 | 3 TOP: Therapeutic baths KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. A patient is recovering from a hemorrhoidectomy and experiences dizziness within 5 minutes when taking a sitz bath. What action should the nurse implement? a. Cover the patient to prevent chilling. b. Stay with the patient until the full time for the bath has elapsed. c. Remove the patient from the sitz bath and return to bed. d. Assess vital signs every 5 minutes during the remainder of the sitz bath. ANS: C The patient may become dizzy during a sitz bath due to dilation of the large vessels in the abdomen. If this occurs, the patient should be removed from the sitz bath and returned to bed. Vital signs should be assessed until they return to normal. DIF: Cognitive Level: Application REF: 193 OBJ: 3 TOP: Sitz bath KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. What should the water temperature be when preparing a tepid bath for a patient? a. 98.6°F (37°C) b. 100.2°F (37.8°C) NURSINGTB.COM Foundations of Nursing 8th Edition Cooper Test Bank . NU RS IN GT B.CO M c. 104.8°F (40.4°C) d. 110.4°F (43.5°C) ANS: A The tepid bath is taken in water that is 98.6°F (37°C). DIF: Cognitive Level: Knowledge REF: 193 OBJ: 4 TOP: Tepid bath KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse is assessing a patient’s skin for signs of impaired skin integrity. Which finding by the nurse is considered a major manifestation? a. Burn b. Laceration c. Pressure injury d. Infection ANS: C A major manifestation of impaired skin integrity is a pressure injury. DIF: Cognitive Level: Comprehension REF: 202 OBJ: 5 TOP: Pressure injuries KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. A nurse assesses an area of sustained redness on the coccyx area of a resident in long-term care. What is the most likely cause of this pressure area? a. Heat from pressure b. Collapse of blood vessels c. Friction from pressure d. Collapse of skin tissue ANS: B A pressure injury occurs when there is sufficient pressure to collapse the blood vessels. DIF: Cognitive Level: Comprehension REF: 202 OBJ: 5 TOP: Pressure injuries KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 7. The nurse is caring for an unconscious patient with a risk for skin impairment. How often will the nurse plan to change the position of this patient? a. Every 30 minutes b. Every 60 minutes c. Every 120 minutes d. Every 180 minutes ANS: C The bedfast patient should have a position change every 2 hours (120 minutes) because skin compromise can occur if there is unrelieved pressure during that amount of time. DIF: Cognitive Level: Application REF: 231 OBJ: 5 TOP: Pressure injuries KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity NURSINGTB.COM Foundations of Nursing 8th Edition Cooper Test Bank NU RS IN GT B.CO M 8. The nurse assesses a red blister over the right superior iliac area of a patient. What stage is this decubitus injury? a. 1 b. 2 c. 3 d. 4 ANS: B A pressure injury demonstrating blisters is a stage 2 decubitus injury. DIF: Cognitive Level: Application REF: 203 OBJ: 5 TOP: Pressure injuries KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. The nursing assessment of a pressure injury includes size, depth, pain, odor, and color of tissue. What does this evaluate? a. Treatment needed b. Effectiveness of implementation c. Whether improvement is occurring d. Need for additional interventions ANS: C Ongoing assessment of a pressure injury will evaluate whether improvement is occurring. DIF: Cognitive Level: Comprehension REF: 202 | 203 OBJ: 5 TOP: Pressure injuries KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 10. The nurse attempts to avoid a pressure injury for a bedridden patient by turning the patient frequently. What is the most favorable position for the nurse to move this patient into? a. Back-lying b. Full lateral c. 30-degree lateral d. Full prone ANS: C It is preferable to use the 30-degree lateral incline position. DIF: Cognitive Level: Application REF: 205 OBJ: 5 TOP: Pressure injuries KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. One reason the nurse focuses on oral hygiene is to maintain a healthy state of the oral cavity.