Fundamentals of Nursing NCLEX
A nurse is scheduling hygiene for patients on the unit. What is the priority
consideration when planning a patient's personal hygiene?
A. When the patient had his or her most recent bath
B. The patient's usual hygiene practices and preferences
C. Where the bathing fits in the nurse's schedule
D. The time that is convenient for the patient care assistant - ANSWER
b. Bathing practices and cleansing habits and rituals vary widely. The patient's
preferences should always be taken into consideration, unless there is a clear threat
to health. The patient and nurse should work together to come to a mutually
agreeable time and method to accomplish the patient's personal hygiene. The
availability of staff to assist may be important, but the patient's preferences are a
higher priority.
A nurse caring for patients in a critical care unit knows that providing good oral
hygiene is an essential part of nursing care. What are some of the benefits of
providing this care? Select all that apply.
A. It promotes the patient's sense of well-being.
B. It prevents deterioration of the oral cavity.
C. It contributes to decreased incidence of aspiration pneumonia.
D. It eliminates the need for flossing.
E. It decreases oropharyngeal secretions.
F. It helps to compensate for an inadequate diet. - ANSWER
a, b, c. Adequate oral hygiene is essential for promoting the patient's sense of well-
being and preventing deterioration of the oral cavity. Diligent oral hygiene care can
also improve oral health and limit the growth of pathogens in oropharyngeal
secretions, decreasing the incidence of aspiration pneumonia and other systemic
diseases. Oral care does not eliminate the need for flossing, decrease
oropharyngeal secretions, or compensate for poor nutrition.
,A nurse assisting with a patient bed bath observes that an older female adult has
dry skin. The patient states that her skin is always "itchy." Which nursing action
would be the nurse's best response?
A. Bathe the patient more frequently.
B. Use an emollient on the dry skin.
C. Massage the skin with alcohol.
D. Discourage fluid intake. - ANSWER b. An
emollient soothes dry skin, whereas frequent bathing increases dryness, as does
alcohol. Discouraging fluid intake leads to dehydration and, subsequently, dry
skin.
A nurse caring for patients in a skilled nursing facility performs risk assessment on
the patients for foot and nail problems. Which patients would be at a higher risk?
Select all that apply.
A. A patient who is taking antibiotics for chronic bronchitis
B. A patient diagnosed with type II diabetes
C. A patient who is obese
D. A patient who has a nervous habit of biting his nails
E. A patient diagnosed with prostate cancer
F. A patient whose job involves frequent handwashing - ANSWER
b, c, d, f. Variables known to cause nail and foot problems include deficient self-
care abilities, vascular disease, arthritis, diabetes mellitus, history of biting nails or
trimming them improperly, frequent or prolonged exposure to chemicals or water,
trauma, ill-fitting shoes, and obesity.
, Nurses performing skin assessments on patients must pay careful attention to
cleanliness, color, texture, temperature, tumor, moisture, sensation, vascularity,
and lesions. Which guidelines should nurses follow when performing these
assessments? Select all that apply.
A. Compare bilateral parts for symmetry
B. Proceed in a toe-to-head systematic manner
C. Use standard terminology to report and record findings.
D. Do not allow data from the nursing history to direct the assessment.
E. Document only skin abnormalities on the patient record.
F. Perform the appropriate skin assessment when risk factors are identified. -
ANSWER a, c, f. When performing a skin assessment,
the nurse should compare bilateral parts for symmetry, use standard terminology to
report and record findings, and perform the appropriate skin assessment when risk
factors are identified. The nurse should proceed in a head-to-toe systematic
manner, and allow 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.
A nurse is caring for an adolescent with sever acne. Which recommendations
would be most appropriate to include in the teaching plan for this patient? Select
all that apply.
A. Wash the skin twice a day with a mild cleanser and warm water.
B. Use cosmetics liberally to cover blackheads.
C. Use emollients on the area.
D. Squeeze blackheads as they appear.
E. Keep hair off the face and wash hair daily.
F. Avoid sun-tanning booth exposure an use sunscreen - ANSWER
a, e, f. Washing the skin removes oil and debris, hair should be kept off the face
and washed daily to keep oil from the hair off the face, and sunbathing should be
avoided when using acne treatments. Liberal use of cosmetics and emollients can
clog the pores. Squeezing blackheads is always discouraged because it may lead to
infection.
A nurse is scheduling hygiene for patients on the unit. What is the priority
consideration when planning a patient's personal hygiene?
A. When the patient had his or her most recent bath
B. The patient's usual hygiene practices and preferences
C. Where the bathing fits in the nurse's schedule
D. The time that is convenient for the patient care assistant - ANSWER
b. Bathing practices and cleansing habits and rituals vary widely. The patient's
preferences should always be taken into consideration, unless there is a clear threat
to health. The patient and nurse should work together to come to a mutually
agreeable time and method to accomplish the patient's personal hygiene. The
availability of staff to assist may be important, but the patient's preferences are a
higher priority.
A nurse caring for patients in a critical care unit knows that providing good oral
hygiene is an essential part of nursing care. What are some of the benefits of
providing this care? Select all that apply.
A. It promotes the patient's sense of well-being.
B. It prevents deterioration of the oral cavity.
C. It contributes to decreased incidence of aspiration pneumonia.
D. It eliminates the need for flossing.
E. It decreases oropharyngeal secretions.
F. It helps to compensate for an inadequate diet. - ANSWER
a, b, c. Adequate oral hygiene is essential for promoting the patient's sense of well-
being and preventing deterioration of the oral cavity. Diligent oral hygiene care can
also improve oral health and limit the growth of pathogens in oropharyngeal
secretions, decreasing the incidence of aspiration pneumonia and other systemic
diseases. Oral care does not eliminate the need for flossing, decrease
oropharyngeal secretions, or compensate for poor nutrition.
,A nurse assisting with a patient bed bath observes that an older female adult has
dry skin. The patient states that her skin is always "itchy." Which nursing action
would be the nurse's best response?
A. Bathe the patient more frequently.
B. Use an emollient on the dry skin.
C. Massage the skin with alcohol.
D. Discourage fluid intake. - ANSWER b. An
emollient soothes dry skin, whereas frequent bathing increases dryness, as does
alcohol. Discouraging fluid intake leads to dehydration and, subsequently, dry
skin.
A nurse caring for patients in a skilled nursing facility performs risk assessment on
the patients for foot and nail problems. Which patients would be at a higher risk?
Select all that apply.
A. A patient who is taking antibiotics for chronic bronchitis
B. A patient diagnosed with type II diabetes
C. A patient who is obese
D. A patient who has a nervous habit of biting his nails
E. A patient diagnosed with prostate cancer
F. A patient whose job involves frequent handwashing - ANSWER
b, c, d, f. Variables known to cause nail and foot problems include deficient self-
care abilities, vascular disease, arthritis, diabetes mellitus, history of biting nails or
trimming them improperly, frequent or prolonged exposure to chemicals or water,
trauma, ill-fitting shoes, and obesity.
, Nurses performing skin assessments on patients must pay careful attention to
cleanliness, color, texture, temperature, tumor, moisture, sensation, vascularity,
and lesions. Which guidelines should nurses follow when performing these
assessments? Select all that apply.
A. Compare bilateral parts for symmetry
B. Proceed in a toe-to-head systematic manner
C. Use standard terminology to report and record findings.
D. Do not allow data from the nursing history to direct the assessment.
E. Document only skin abnormalities on the patient record.
F. Perform the appropriate skin assessment when risk factors are identified. -
ANSWER a, c, f. When performing a skin assessment,
the nurse should compare bilateral parts for symmetry, use standard terminology to
report and record findings, and perform the appropriate skin assessment when risk
factors are identified. The nurse should proceed in a head-to-toe systematic
manner, and allow 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.
A nurse is caring for an adolescent with sever acne. Which recommendations
would be most appropriate to include in the teaching plan for this patient? Select
all that apply.
A. Wash the skin twice a day with a mild cleanser and warm water.
B. Use cosmetics liberally to cover blackheads.
C. Use emollients on the area.
D. Squeeze blackheads as they appear.
E. Keep hair off the face and wash hair daily.
F. Avoid sun-tanning booth exposure an use sunscreen - ANSWER
a, e, f. Washing the skin removes oil and debris, hair should be kept off the face
and washed daily to keep oil from the hair off the face, and sunbathing should be
avoided when using acne treatments. Liberal use of cosmetics and emollients can
clog the pores. Squeezing blackheads is always discouraged because it may lead to
infection.
