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50 Cards in this Set
- Front
- Back
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The client has a red, raised skin rash. Which of the following is most important when cleansing the skin? |
Assess for further inflammatory reactions |
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The nurse is caring for a client who is paralyzed on the right side. Which of the following factors is most likely to result in decubitus ulcer formation? |
Immobility |
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When giving a bath to a newborn, the nurse should: |
Wash with water only |
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The nurse delegates morning care to a new certified nursing assistant. Which of the following actions by the assistant would appropriate? |
Washing the client's legs with long strokes from the ankle to the knee |
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A 61-year-old client with diabetes mellitus has physician’s orders for meticulous foot care. Which of the following is the best rationale for this order? |
There is increased neuropathy with diabetes mellitus that places the client at risk. |
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The client is unable to rest even after medication. The nurse decides to give the client a backrub. Which of the following strokes should the nurse use when finishing the backrub? |
Long firm strokes down the back |
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The nurse should avoid using lemon-glycerin swabs on a client’s tongue and mucous membranes because regular use of this product: |
Erodes tooth enamel |
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To administer oral care to a semi-comatose client, the nurse should place the client in which of the following positions? |
Side-lying with the head turned toward the nurse |
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The client is unable to perform self-care for the hair. Which of the following is accurate when performing hair care? |
Brushing the hair distributes the natural oils evenly. |
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A client has recently experienced difficulty hearing out of both ears. Which of the following is the best nursing response to the client? |
"Try to avoid putting a Q-Tip (cotton-tipped applicator) into your ears. " |
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The nurse is assisting a patient with rheumatoid arthritis to bathe at the sink. During the bath the patient states that she is tired. The nurse notices the patient is breathing rapidly and the pulse is rapid. What is the nurse’s best response? |
Help the patient return to bed |
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A patient who is cognitively impaired and has dementia requires hygiene care. The patient often displays aggressive behavior such as screaming and hitting during the bath. Which techniques make the bathing experience less stressful for both the nurse and the patient? (Select all that apply.) |
-Allow the patient to perform as much of the care as possible. -Try an alternative to traditional bathing such as the “bag bath.” |
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What is the priority concern when providing oral hygiene for a patient who is unconscious? |
Preventing aspiration |
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A male nurse is caring for a 32-year-old female Muslim patient who has an indwelling Foley catheter. After introducing himself to the patient, the nurse learns that the patient does not want him to help her with personal hygiene care. Which of the following is(are) appropriate actions? (Select all that apply.) |
-Finding a female nurse to help the patient -Asking the patient if she prefers a family member assist with the care |
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You are helping a female patient bathe. As you are about to perform perineal care, the patient says, “I can finish my bath.” The patient has discomfort and burning in the perineal area. What action do you need to take initially? |
Explain to the patient that, because of her symptoms, you need to observe the perineal area. |
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Your patient wears full dentures. His usual denture care includes taking the teeth out once a day to brush. He wears the dentures overnight. You are concerned that he might be at risk for developing denture-induced stomatitis. Which points do you include in a teaching plan for denture care? (Select all that apply.) |
-Do not wear damaged or poorly fitting dentures. -Observe mouth for reddened areas under the dentures and small red sores on the roof of the mouth. -See dentist regularly. -Rinse dentures after meals. |
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A patient who is receiving chemotherapy has inflamed gums and oral mucosa and painful sores in the mouth. Which of the following oral care actions are appropriate? (Select all that apply.) |
-Applying water-soluble moisturizing gel on the oral mucosa -Encouraging intake of soft foods |
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While planning morning care, which of the following patients would receive the highest priority to receive his or her bath first? |
A patient who is experiencing frequent incontinent diarrheal stools |
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During bathing your patient experiences shortness of breath and labored breathing with a respiratory rate of 30. The bed is in a flat position. You change the bed position to: |
-Fowler’s. -Fowler’s upright sitting position facilitates breathing by allowing for full expansion of the chest and lungs. Although reverse Trendelenburg’s position raises the head of the bed, it is a straight tilt position and is not likely as comfortable as the more supported Fowler’s position. |
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A nurse caring for a male patient observes the nursing assistive personnel (NAP) performing perineal care. Which of the following observed actions indicates a need for further teaching for the NAP? The NAP: |
-Did not retract the foreskin before cleansing. |
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A nurse teaching a family member caregiver how to bathe the patient explains the importance of using long strokes on the patient’s extremities, moving from distal to proximal. Which explanation does the nurse include? Long strokes moving from distal to proximal are used to: |
Stimulate venous return. |
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Which of the following actions would best help prevent skin breakdown in a patient who is incontinent of stools and very weak and drowsy? |
Checking frequently for soiling |
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The nurse is caring for a patient who has reduced sensation in both feet. Which of the following should the nurse do? (Select all that apply.) |
-Wash the feet with lukewarm water and then dry well. -File the toenails straight across. |
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The nurse recognizes that her older-adult patient needs additional teaching about skin care when the older adult says, “I should: |
Use hot water for bathing. |
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You ask the nursing assistive personnel (NAP) to clean a patient who has been incontinent of urine. Several minutes later you pass the open door of the room and see the NAP changing the patient’s gown and linen. Which of the following requires your immediate attention? |
Room door is open to the hallway. |
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Function of the skin |
-protection -secretion -excretion -temperature -regulation -sensation |
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layers of the skin |
-epidermis -dermis |
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subcutaneous |
tissue that lies beneath the skin |
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epidermis |
shields underlying tissue |
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dermis |
contains bundles of collagen, nerve fibers, blood vessels, sweat glands, sebaceous glands, and hair follicles |
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oral cavity |
lines with mucous membrane |
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xerostomia |
dry mouth |
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gingivitis |
inflammation of the gums |
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dental caries |
tooth decay |
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hygiene is never |
routine, it is unique to each person |
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hygiene asses: |
-emotional status -health promotion practices -health care education needs |
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factors inlfuencing hygeine |
-social patterns -personal preferences -body image -socioeconomic status -health beliefs and motivation -cultural variables -developmental stage -physical condition |
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you are caring for a non-English speaking male patient. when preparing to assist him with personal hygiene, you should |
remember that culture and ethnicity influence hygiene practices |
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bath guidelines |
-provide privacy -maintain safety -maintain warmth -promote independence -anticipate needs |
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types of baths |
-complete -partial -sponge tub -shower -bag bath |
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shaving |
- Shave in the direction of hair growth. -Use longer strokeson the larger areas of the face. -Use short strokes around the chinand lips. |
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a young girl with long hair is experiencing a problem with matting. the most appropriate action to take would be |
braiding the hair to reduce tangles |
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Fowler’s bed |
-Head of bed raised to angle of 45 degrees or more; semi-sittingposition; foot of bed may also be raised at knee - While patient is eating -During nasogastric tube insertion and nasotracheal suction -Promotes lung expansion -Eases dif cult breathing |
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Semi-Fowler’s bed |
- Head of bed raised approximately 30 degrees; inclination lessthan Fowler’s position; foot of bed may also be raised atknee - Promotes lung expansion, especially with ventilator-assistedpatients - Used when patients receive gastric feedings to reduceregurgitation and risk of aspiration |
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Trendelenburg’s bed |
- Entire bed frame tilted with head of bed down - Used for postural drainage -Facilitates venous return in patients with poor peripheral perfusion |
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Reverse Trendelenburg’s bed |
- Entire bed frame tilted with foot of bed down - Used infrequently -Promotes gastric emptying -Prevents esophageal reflux |
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Flat bed |
- Entire bed frame horizontally parallel with floor - Used for patients with vertebral injuries and in cervical traction -Used for patients who are hypotensive -Patients usually prefer for sleeping |
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Which response or action by Jamie is the appropriate initialresponse to the daughter’s statement? |
Explains why not to soak the feet. |
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Which assessment does Jamie need to complete before helping Mrs. Winkler and Carol continue with foot care? |
Observing condition of the feet and nails |
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Jamie helps wash Mrs. Winkler’s feet and applies a lanolin cream. Which approach should Jamie take regarding trimming Mrs. Winkler’s toenails? |
Collaborate with Mrs. Winkler’s nurse to obtain a podiatrist consult order |
