Chapter 25. Facilitating Hygiene

Chapter 25. Facilitating Hygiene

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. During morning care, the patient asks the nurse to shave him with a disposable razor. Before shaving him, the nurse should:

ANS:  B

If the patient is taking anticoagulant medication or has a bleeding disorder, he is at risk for bleeding. You should use an electric razor, not a disposable razor that may nick the patient’s skin.

Difficulty: Easy

Nursing Process: Interventions

Client Need: PHSI

Cognitive Level: Application

PTS:   1

2. The nurse is caring for a patient admitted with a closed head injury. Which action by the nurse is appropriate when providing hygiene for this patient?

ANS:  C

The nurse should provide care in short intervals to avoid overstimulating the patient, thereby causing a rise in his intracranial pressure. It is not necessary to avoid bathing the patient. Using cool water to bathe the patient may cause shivering, which may elevate intracranial pressure and increase metabolic demands. Rubbing briskly when drying might also overstimulate, leading to an elevation in intracranial pressure.

Difficulty: Difficult

Nursing Process: Interventions

Client Need: PHSI

Cognitive Level: Application

PTS:   1

3. During the bath, the nurse observed that the patient has dry skin. The best action by the nurse is to:

ANS:  B

Use an emollient on the dry skin

Using an emollient will aid in soothing dry skin. Frequent bathing will increase dryness, as will discouraging fluids. Massaging skin with water will not play a role in improving dry skin.

Difficulty: Easy

Nursing Process: Interventions

Client Need: Safe and Effective Care

Cognitive Level: Analysis

PTS:   1

4. The nurse is about to bathe a female patient who has an intravenous line, and needs to remove her gown. The nurse should:

ANS:  C

Thread the bag and tubing through the gown sleeve, keeping the line intact.

If the patient has an IV line and is wearing a gown that does not have snap-open sleeves, the nurse should remove the gown first from the arm without the IV, then lower the IV container, and pass the gown over the tubing and the container, taking care to keep the container above the level of the patient’s arm. Using this technique will keep blood from backing up into the IV line. Manipulating the IV equipment may change the flow rate; flow rate must be maintained as prescribed. The nurse should not disconnect the IV tubing; this breaks the sterile system and provides a portal of entry for pathogens.

Difficulty: Moderate

Nursing Process: Interventions

Client Need: PHSI

Cognitive Level: Application

PTS:   1