Chapter 22 Hygiene

Chapter 22 Hygiene

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.1)A nurse asks a student nurse to make a surgical bed for a client who has gone to surgery. Whichaction by the student nurse indicates an understanding of the purpose and procedure for this typeof bed? (Select all that apply.)1)A)All of the bed linens are left untucked.B)The pillow is placed at the head of the bed.C)The side rails are up on one side of the bed.D)The bed is left in the highest position.E)The top bed linen is folded to the side or the bottom of the bed.F)The bed is left in the lowest position.Answer:D, EExplanation:A)The purpose of a surgical bed is to facilitate transfer of the postoperative clientfrom a gurney to a bed with ease for all involved and to provide warmth quicklyfor the client. Because no one is in the bed, it can be left in the highest positionwith the side rails down. Only the top linen is adapted to facilitate transfer, thebottom linen should be made as usual. A pillow may impede the smooth transferof the client; it can be placed after the transfer.ImplementationPhysiological Integrity-Basic Care and ComfortApplicationB)The purpose of a surgical bed is to facilitate transfer of the postoperative clientfrom a gurney to a bed with ease for all involved and to provide warmth quicklyfor the client. Because no one is in the bed, it can be left in the highest positionwith the side rails down. Only the top linen is adapted to facilitate transfer, thebottom linen should be made as usual. A pillow may impede the smooth transferof the client; it can be placed after the transfer.ImplementationPhysiological Integrity-Basic Care and ComfortApplicationC)The purpose of a surgical bed is to facilitate transfer of the postoperative clientfrom a gurney to a bed with ease for all involved and to provide warmth quicklyfor the client. Because no one is in the bed, it can be left in the highest positionwith the side rails down. Only the top linen is adapted to facilitate transfer, thebottom linen should be made as usual. A pillow may impede the smooth transferof the client; it can be placed after the transfer.ImplementationPhysiological Integrity-Basic Care and ComfortApplicationD)The purpose of a surgical bed is to facilitate transfer of the postoperative clientfrom a gurney to a bed with ease for all involved and to provide warmth quicklyfor the client. Because no one is in the bed, it can be left in the highest positionwith the side rails down. Only the top linen is adapted to facilitate transfer, thebottom linen should be made as usual. A pillow may impede the smooth transferof the client; it can be placed after the transfer.ImplementationPhysiological Integrity-Basic Care and ComfortApplication1
E)The purpose of a surgical bed is to facilitate transfer of the postoperative clientfrom a gurney to a bed with ease for all involved and to provide warmth quicklyfor the client. Because no one is in the bed, it can be left in the highest positionwith the side rails down. Only the top linen is adapted to facilitate transfer, thebottom linen should be made as usual. A pillow may impede the smooth transferof the client; it can be placed after the transfer.ImplementationPhysiological Integrity-Basic Care and ComfortApplicationF)The purpose of a surgical bed is to facilitate transfer of the postoperative clientfrom a gurney to a bed with ease for all involved and to provide warmth quicklyfor the client. Because no one is in the bed, it can be left in the highest positionwith the side rails down. Only the top linen is adapted to facilitate transfer, thebottom linen should be made as usual. A pillow may impede the smooth transferof the client; it can be placed after the transfer.ImplementationPhysiological Integrity-Basic Care and ComfortApplication2)A client with a diagnosis of leukemia complains of halitosis and a bad taste in the mouth frombleeding gums and two small open sores in the buccal cavity. Which of the following possiblenursing measures is the most appropriate to include in the client’s nursing care plan?2)A)Assist the client to use dental floss and rinse with an antibacterial mouthwash before andafter meals and at bedtime.B)Have the client use a very soft bristle toothbrush or a moistened sponge to clean the mouthand rinse with normal saline frequently throughout the day.C)Encourage the client to suck on hard candy or chew gum throughout the day.D)Provide the client with lemon and glycerin oral swabs and a selection of iced beverages todrink.Answer:BExplanation:A)Modifications may need to be made in the usual method of oral hygiene when aclient has bleeding gums. The client with leukemia often has thrombocytopeniaand is at increased risk for bleeding. Crusts and debris need to be removed withoutcausing the gums to bleed. Having the client suck on a hard candy or chew gumaddresses the bad taste, not the bleeding gums. Dental floss and astringentmouthwash should not be used with a client who has any risk for increasedbleeding. Lemon and glycerin swabs may temporarily refresh the client’s mouth;cold beverages may slow any bleeding but they also cause vasoconstriction, whichinterferes with tissue healing.ImplementationSafe, Effective Care Environment-Safety and Infection ControlApplication2
B)Modifications may need to be made in the usual method of oral hygiene when aclient has bleeding gums. The client with leukemia often has thrombocytopeniaand is at increased risk for bleeding. Crusts and debris need to be removed withoutcausing the gums to bleed. Having the client suck on a hard candy or chew gumaddresses the bad taste, not the bleeding gums. Dental floss and astringentmouthwash should not be used with a client who has any risk for increasedbleeding. Lemon and glycerin swabs may temporarily refresh the client’s mouth;cold beverages may slow any bleeding but they also cause vasoconstriction, whichinterferes with tissue healing.ImplementationSafe, Effective Care Environment-Safety and Infection ControlApplicationC)Modifications may need to be made in the usual method of oral hygiene when aclient has bleeding gums. The client with leukemia often has thrombocytopeniaand is at increased risk for bleeding. Crusts and debris need to be removed withoutcausing the gums to bleed. Having the client suck on a hard candy or chew gumaddresses the bad taste, not the bleeding gums. Dental floss and astringentmouthwash should not be used with a client who has any risk for increasedbleeding. Lemon and glycerin swabs may temporarily refresh the client’s mouth;cold beverages may slow any bleeding but they also cause vasoconstriction, whichinterferes with tissue healing.ImplementationSafe, Effective Care Environment-Safety and Infection ControlApplicationD)Modifications may need to be made in the usual method of oral hygiene when aclient has bleeding gums. The client with leukemia often has thrombocytopeniaand is at increased risk for bleeding. Crusts and debris need to be removed withoutcausing the gums to bleed. Having the client suck on a hard candy or chew gumaddresses the bad taste, not the bleeding gums. Dental floss and astringentmouthwash should not be used with a client who has any risk for increasedbleeding. Lemon and glycerin swabs may temporarily refresh the client’s mouth;cold beverages may slow any bleeding but they also cause vasoconstriction, whichinterferes with tissue healing.ImplementationSafe, Effective Care Environment-Safety and Infection ControlApplication3)A student nurse is being taught to read a tuberculin test done on a client receiving care at aneighborhood health clinic. The student nurse observes the injection site for erythema and palpatesthe site for induration. To be initially evaluated as negative, the site of the test:3)A)Must have no redness or induration.B)May or may not be reddened, with induration less than 5 mm.C)Is pale, cool to the touch, and flat.D)May have induration of up to 10 mm.Answer:B3
Explanation:A)The determining factor for evaluating results of a tuberculin test is the degree ofinduration (firmness and elevation of the reaction). The presence of erythemawithout induration is not considered significant. If induration is greater than 5mm., the nurse should gather additional information about anyimmune-compromising conditions, previous exposure to or active disease, andprior immunization with bacille Calmette-Guerin (BCG) vaccine. Older adults arefrequently tested twice at a one or two week interval, as they may have delayedreactivity to the purified protein derivative (PPD) solution. Immune-compromisedindividuals may not react secondary to inadequate stimulation of the immuneresponse (anergy).EvaluationHealth Promotion and MaintenanceApplicationB)The determining factor for evaluating results of a tuberculin test is the degree ofinduration (firmness and elevation of the reaction). The presence of erythemawithout induration is not considered significant. If induration is greater than 5mm., the nurse should gather additional information about anyimmune-compromising conditions, previous exposure to or active disease, andprior immunization with bacille Calmette-Guerin (BCG) vaccine. Older adults arefrequently tested twice at a one or two week interval, as they may have delayedreactivity to the purified protein derivative (PPD) solution. Immune-compromisedindividuals may not react secondary to inadequate stimulation of the immuneresponse (anergy).EvaluationHealth Promotion and MaintenanceApplicationC)The determining factor for evaluating results of a tuberculin test is the degree ofinduration (firmness and elevation of the reaction). The presence of erythemawithout induration is not considered significant. If induration is greater than 5mm., the nurse should gather additional information about anyimmune-compromising conditions, previous exposure to or active disease, andprior immunization with bacille Calmette-Guerin (BCG) vaccine. Older adults arefrequently tested twice at a one or two week interval, as they may have delayedreactivity to the purified protein derivative (PPD) solution. Immune-compromisedindividuals may not react secondary to inadequate stimulation of the immuneresponse (anergy).EvaluationHealth Promotion and MaintenanceApplicationD)The determining factor for evaluating results of a tuberculin test is the degree ofinduration (firmness and elevation of the reaction). The presence of erythemawithout induration is not considered significant. If induration is greater than 5mm., the nurse should gather additional information about anyimmune-compromising conditions, previous exposure to or active disease, andprior immunization with bacille Calmette-Guerin (BCG) vaccine. Older adults arefrequently tested twice at a one or two week interval, as they may have delayedreactivity to the purified protein derivative (PPD) solution. Immune-compromisedindividuals may not react secondary to inadequate stimulation of the immuneresponse (anergy).EvaluationHealth Promotion and MaintenanceApplication