1. A nurse is assisting a patient with his bed bath. The patient states, I can
do it m yself. The nurses best response is
a. I reall y have limited time. Let me give you your bath right now.
b. I will set up your bath for you. I will come back and help you with
your back.
c. You will need to sit up for your bath, and then I will change your
bed.
d. You will be able to take your bath by yourself tom orrow when you
can get up.
CORRECT ANSWER: B
Feedback:
The nurse must value and support the patient becoming independent in
care.
2. When an adult patient from Indonesia refuses a complete bath on the day
after abdominal surgery, the nurse should
a. Understand that his culture may influence his hygiene and ask him
his preference
b. Ask another nurse to assist in giving the patient a complete bath
every other day
c. Give the patient a bath pan and tell him she will return when he has
finished
d. Encourage the pa tient to bathe dail y as part of protection from
infection
, CORRECT ANSWER: A
Feedback:
Preferences for hygiene vary widel y among individuals and across
cultures.
3. A 78-year-old patient with diabetes needs to have his toenails trimmed. It
is important for the nurse to
a. Remove ingrown toenails
b. Cut the nail straight across
c. Protect the foot from blisters
d. Soak the foot in witch hazel
CORRECT ANSWER: B
Feedback:
The feet of older adults require special attention, because foot
problems may relate to r educed peripheral blood flow. Poor circulation
makes the feet more vulnerable to infection and skin breakdown,
particularl y after trauma. By cutting the nail straight across, the nurse
can protect the toes from trauma.
4. A grandmother visits the pediatric clinic with her daughter and 18 -month-
old granddaughter. The grandmother states, I told m y daughter she needs
to get that baby potty trained. She is too old to be messing in her pants.
What is the best response the nurse can make?
a. To help with pott y train ing, the child should be placed on the toilet
in the morning.
, b. The child should have fluids limited after 7:00 PM to help decrease
the chance of nighttime accidents.
c. A child her age should have control of the bladder by now, but her
bowels wont be trained until next year.
d. You should start potty training at age 2 to 3 years. At 18 months,
she will not be ready to be pott y trained.
CORRECT ANSWER: D
Feedback:
Many children achieve daytime bowel and bladder control between age
2 and 3 years. They usuall y stay dry through the night by 4 years.
5. A new mother has brought her infant into the pediatric clinic. The infant
has an excoriation on the buttocks. What should the nurse instruct the
mother?
a. Leave the babys buttocks open to air for 2 hours each day
b. Appl y gentian violet to the buttocks with every diaper change
c. Change diaper as soon as it is soiled and appl y cornstarch
d. Keep the diaper and buttocks clean and dry and appl y zinc oxide
CORRECT ANSWER: D
Feedback:
Keeping the skin as dry and clean as possible helps preserve its
integrit y. The diaper area should be inspected with each change.
Topical products, such as those containing zinc oxide, may need to be
applied in cases of rash or excoriation.