Nursing Process Approach, 11th Edition by Linda E.
McCuistion
when should you perform skin assessment? - ANSWER:While bathing
When caring for the skin of patients of different age groups, which of the following
should the nurse consider?
A) An infant's skin and mucous membranes are protected from infection by a natural
immunity.
B) Secretions from skin glands are at their maximum from age 3 on.
C) The skin becomes thicker and more leathery with aging and is prone to wrinkles
and dryness.
D) An adolescent's skin ordinarily has enlarged sebaceous glands and increased
glandular secretions. - ANSWER:d
HS care - ANSWER:bedtime care
bed bath: was extremities _____ to ______ - ANSWER:distal
proximal
PRN care - ANSWER:as needed care
commercially prepared
make your own - ANSWER:bag bath
decolonization of antibiotic resistant organisms - ANSWER:CHG bath
During a bed bath, the correct procedure used when washing a limb is to
A) wash the extremity using short, circular motions
B) wash the extremity using long strokes in the direction of proximal to distal
C) wash the extremity using a back and forth scrubbing motion
D) wash the extremity in the direction of distal to proximal - ANSWER:d
Used for patients at risk for DVT, PE, phlebiis
Promote venous return
Perform skin and neurovascular checks regularly - ANSWER:TEDS (antiembolism)
stockings
Used for patients with chronic venous disease, post-op, at risk for DVT
Promote venous return
Perform skin and neurovascular checks regularly - ANSWER:Intermittent Pneumatic
Compression Stockings (SCDs)
, why wash distal to proximal? - ANSWER:increased venous return
prevent clots
When making an occupied bed, which of the following is most important for the
nurse to do?
A) Keep the bed in the low position
B) Use a bath blanket or top sheet for warmth and privacy
C) Constantly keep the side rails raised on both sides
D) Move back and forth from one side to the other when adjusting the linens -
ANSWER:b
types of bedmaking - ANSWER:Occupied
Unoccupied
Closed
Open
While making a bed, the nurse chooses to reuse the bedspread because it is not
soiled. The nurse should
A) fan-fold it and place it on the floor
B) drape it on the linen hamper while changing the sheets
C) fold it neatly and place it on the roommate's bed
D) remove and fold the spread, and place it on a clean work area - ANSWER:d
When handling linen, what technique would minimize the spread of
microorganisms?
A) rolling soiled linens to the middle of the bed
B) placement of seamed side toward mattress
C) fanning the linens before placing them on the mattress
D) carrying the clean linens against one's uniform - ANSWER:a
When providing oral care for the comatose patient, the nurse should
A) turn the patient's head to the side, with a basin placed under the mouth
B) position the patient upright with the head centered
C) only administer mouth care if a gag reflex is present
D) vigorously brush the teeth while wiping secretions away from the mouth -
ANSWER:a
denture care - ANSWER:Place washcloth in sink
Use cool or warm water
Brush dentures with toothpaste
oral hygiene decreases _____ - ANSWER:the risk of respiratory diseases
hair care - ANSWER:brush daily
shampoo prn