PRACTICE QUESTIONS & ANSWERS
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1. The nurse is providing a complete bed bath to a patient using a commercial
bath cleansing pack (bag bath). What should the nurse do?
a. Rinse thoroughly.
b. Allow the skin to air-dry.
c. Do not use a bath towel.
d. Dry the skin with a towel.
ANS: B
The nurse should allow the skin to air-dry for 30 seconds. Drying the skin
with a towel removes the emollient that is left behind after the
water/cleanser solution evaporates. It is permissible to lightly cover the
patient with a bath blanket or towel to prevent chilling. Do not rinse when
using a bag bath.
2. A nurse is providing perineal care to a female patient. Which washing
technique will the nurse use?
a. Back to front
b. In a circular motion
c. From pubic area to rectum
d. Upward from rectum to pubic area
ANS: C
Cleansing from pubic area to rectum (front to back) reduces the transfer of
microorganisms to the urinary meatus and decreases the risk of urinary tract
infection. Cleansing from rectum to pubic area or back to front increases the
risk of urinary tract infection. Circular motions are used in male perineal
,care.
3. The nurse is providing perineal care to an uncircumcised male patient.
Which action will the nurse take?
a. Leave the foreskin alone because there is little chance of infection. 1
b. Retract the foreskin for cleansing and allow it to return on its own.
c. Retract the foreskin and return it to its natural position when done.
d. Leave the foreskin
retracted. ANS: C
Return the foreskin to its natural position. Keeping the foreskin retracted
leads to tightening of the foreskin around the shaft of the penis, causing local
edema and discomfort. The foreskin may not return to its natural position on
its own. Patients at greatest risk for infection are uncircumcised males.
4. Which instruction will the nurse provide to the nursing assistive
personnel when providing foot care for a patient with diabetes?
a. Do not place slippers on the patient’s feet.
b. Trim the patient’s toenails daily.
c. Report sores on the patient’s toes.
d. Check the brachial artery.
ANS: C
Report any changes that may indicate inflammation or injury to tissue. Do
not allow the diabetic patient to go barefoot; injury can lead to amputations.
Clipping toenails is not allowed. Patients with peripheral vascular disease or
diabetes mellitus often require nail care from a specialist to reduce the risk
of infection. When assessing the patient’s feet, the nurse palpates the
dorsalis pedis of the foot, not the brachial artery.
5. The debilitated patient is resisting attempts by the nurse to provide oral
hygiene. Which action will the nurse take next?
a. Insert an oral airway.
b. Place the patient in a flat, supine position.
c. Use undiluted hydrogen peroxide as a cleaner.
, d. Quickly proceed while not talking to the patient.
ANS: A 2
If the patient is uncooperative, or is having difficulty keeping the mouth open,
insert an oral airway. Insert it upside down, and then turn the airway
sideways and over the tongue to keep the teeth apart. Do not use force.
Position the patient on his or her side or turn the head to allow for drainage.
Placing the patient in a flat, supine position could lead to aspiration. Hydrogen
peroxide is irritating to mucosa. Even though the patient is debilitated,
explain the steps of mouth care and the sensations that he or she will feel.
Also tell the patient when the procedure is completed.
6. A nurse is providing oral care to a patient with stomatitis. Which technique
will the nurse use?
a. Avoid commercial mouthwashes.
b. Avoid normal saline rinses.
c. Brush with a hard toothbrush.
d. Brush with an alcohol-based toothpaste.
ANS: A
Stomatitis causes burning, pain, and change in food and fluid tolerance.
Advise patients to avoid alcohol and commercial mouthwash and stop
smoking. When caring for patients with stomatitis, brush with a soft
toothbrush and floss gently to prevent bleeding of the gums. In some cases,
flossing needs to be temporarily omitted from oral care. Normal saline rinses
(approximately 30 mL) on awaking in the morning, after each meal, and at
bedtime help clean the oral cavity.