CORRECT ANSWERS
What should the nurse do to prepare the unconscious patient for oral care?
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1 Use small amounts of water and suction device
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2 Place the patient in high Fowler's position
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3 Place the patient in the supine position with the head lowered
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4 Place the patient in the Fowler's position with the head turned to the side - correct answer 1
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A male client is experiencing weakness and is unable to shave himself. When assisting this client with shaving,
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which of the following would be most important?
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1 Ensuring that the face is dry
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2 Keeping the skin loose
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3 Shaving in the direction of hair growth
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4 Angling the razor at 45 degrees - correct answer 3 To avoid cuts, soften the beard with warm towels before
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shaving. Use soap lather or shaving cream, pull the skin taut, and shave in the direction in which the hair grows
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to decrease irritation.
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A nurse is caring for a patient who is unable to perform oral hygiene. The patient has dentures, including both
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upper and lower plates. Which technique should the nurse use to correctly perform oral hygiene?
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1 Don sterile gloves before removing the dentures.
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2 Use a foam swab to pry the upper dentures loose.
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,3 Loosen the upper plate by grasping it at the front teeth with a piece of gauze and moving the plate up and
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down to loosen it prior to removing it.
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4 Leave the dentures in the patient's mouth and use a toothbrush to brush the teeth. - correct answer 3
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Removing the denture plate is a clean procedure. Dentures must be removed to properly clean the patient's
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mouth and the dentures. e e e
A nurse is caring for a patient in restraints. The nurse knows that skin integrity should be assessed how often?
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2 hours
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3 hours
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4 hours
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30 minutes - correct answer 4 CMS checks should be done every 30 minutes
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A hospitalized patient has anti-embolic hose ordered. A nurse discusses the correct use of the stockings with
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the patient and spouse. Which direction should the nurse include in teaching?
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1 If ambulating 10 times for 5 minutes at a time, wearing stockings is unnecessary.
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2 The most appropriate time to apply the stockings is before standing to get out of bed in the morning.
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3 If the stockings become painful to wear, increase use of pain medication.
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4 You can cross your legs while sitting if you are wearing the stockings. - correct answer 2 This will maximize the
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compression effects and thus lessening the venous distension and development of edema. e e e e e e e e e e e
Frequent ambulation is a positive intervention to prevent DVT formation but should be done in conjunction
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with anti-embolic stockings.
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Stockings should be removed twice a day to inspect the skin. e e e e e e e e e e
Crossing legs impede blood flow and should be avoided with or without the use of stockings.
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A nurse is teaching a client with diabetes how to care for his feet. The nurse determines that additional
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teaching is needed when the client states which of the following?
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1 "I need to soak them frequently in water."
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, 2 "I should use warm water and a mild soap to clean them."
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3 "I can apply lotion to the tops, but not between the toes."
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4 "I need to inspect my feet every day." - correct answer 1 Patients with diabetes require special attention to
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foot care. They have decreased sensation in the feet, placing them at great risk for injury from burns or foreign
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objects. The feet should be inspected daily, cleaned thoroughly with warm water and a mild soap, and
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carefully dried, especially between the toes. The feet should not be soaked in water because soaking will dry
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skin, which may lead to cracking. Lotion or cream can be applied to the tops and bottoms of the feet, but not
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between the toes. e e
An acute medicine unit of a hospital currently has a number of patients who have tested positive for
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clostridium difficile (c-diff). Which of the following measure should the nursing staff prioritize in preventing
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the spread of c-diff to patients who are currently c-diff negative?
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1 Reduce the length of stay for c-diff positive patients
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2 Constant use of gloves when on the unit
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3 Prophylactic antibiotic therapy for c-diff negative patients
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4 Diligent hand washing practices - correct answer 4 Rationale: As with all other forms of infection, thorough
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hand washing is the most important infection control measure. Gloves at all times would not be necessary and
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prophylactic antibiotics are not typically used.
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A patient is admitted with a positive culture for methicillin resistant Staphylococcus aureus (MRSA). Which
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are components of contact precautions?
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1 Wearing a mask when working within 3 feet of the patient.
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2 Placing the client in a private room.
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3 Wearing an N-95 respirator.
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4 Placing the client in a negative pressure room. - correct answer 2 Client should be placed in a private room or
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in a room with a client with the same organism.
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A nurse is caring for a patient admitted with Hepatitis A. The patient is incontinent of stool. A patient care tech
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(PCT) is assisting the RN with patient care. The RN determines that the PCT understands correct infection
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prevention when the PCT is observed: e e e e e