Nokea
A charge nurse in a skilled nursing facility is working to reduce patients' foot and nail problems. The charge nurse reminds the nurses and APs to closely observe which of these patients at higher risk? Select all that apply.
- A. Patient taking antibiotics for chronic bronchitis
- B. Patient with type 2 diabetes
- C. Patient who has obesity
- D. Patient who frequently bites their nails
- E. Patient with prostate cancer
- F. Patient who frequently washes their hands
Correct Answer: B,C,D,F
Rationale: Variables known to cause nail and foot problems include deficient self-care abilities, vascular disease, arthritis, diabetes mellitus, history of biting nails or trimming them improperly, frequent or prolonged exposure to chemicals or water, trauma, ill-fitting shoes, and obesity. Antibiotic use and prostate cancer do not predispose to foot or nail problems.
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A home care nurse is assisting an older adult with an unsteady gait with a tub bath. Which action is recommended in this procedure?
- A. Adding bath oil to the water to prevent dry skin
- B. Allowing the patient to lock the door to guarantee privacy
- C. Assisting the patient in and out of the tub to prevent falling
- D. Keeping the water temperature very warm because older adults chill easily
Correct Answer: C
Rationale: Safe nursing practice requires that the nurse assists a patient with an unsteady gait in and out of the tub. Adding bath oil to the bath water poses a safety risk because it makes the patient and tub slippery. Although privacy is important, if the patient locks the door, the nurse cannot help if there is an emergency. The water should be comfortably warm at 43?° to 46?°C. Older adults have an increased susceptibility to burns due to diminished sensitivity.
A nurse is caring for an adolescent with severe acne. Which recommendations would be most appropriate to include in the teaching plan for this patient? Select all that apply.
- A. Wash the skin twice a day with a mild cleanser and warm water.
- B. Use cosmetics liberally to cover blackheads.
- C. Apply emollients on the area.
- D. Squeeze blackheads as they appear.
- E. Keep hair off the face and wash hair daily.
- F. Avoid tanning booth exposure and use sunscreen.
Correct Answer: A,E,F
Rationale: Washing the skin removes oil and debris, hair should be kept off the face and washed daily to keep oil from the hair off the face. Exposure to UV light should be avoided, especially when using acne treatments. Liberal use of cosmetics and emollients can clog the pores, worsening acne. Squeezing blackheads is discouraged because it may lead to infection.
A nurse is caring for a patient with an eye infection with a moderate amount of discharge. What is the most appropriate technique for the nurse to use when cleansing this patient's eyes?
- A. Using diluted hydrogen peroxide on a clean washcloth to wipe the eyes
- B. Wiping the eye from the outer canthus toward the inner canthus
- C. Positioning the patient on the opposite side of the eye to be cleansed
- D. Cleansing the eye using a different section of the cloth for each stroke until clean
Correct Answer: D
Rationale: The nurse applies gloves for the cleaning procedure, uses water or normal saline, and a clean washcloth or gauze to cleanse the eyes. After dampening a cleaning cloth with the solution of choice, the nurse wipes once while moving from the inner canthus to the outer canthus of the eye to reduce forcing debris into the area drained by the nasolacrimal duct. The nurse should turn the cleansing cloth and use a different section for each stroke until the eye is clean.
A nurse in a long-term care facility observes the AP providing foot care for patients. Which actions by the AP require the nurse to intervene? Select all that apply.
- A. Bathing the feet thoroughly in a mild soap and tepid water solution
- B. Soaking the resident's feet in warm water and bath oil
- C. Drying the feet and area between the toes thoroughly
- D. Applying an alcohol rub for odor and dryness to the feet
- E. Applying an antifungal foot powder
- F. Cutting the toenails at the lateral corners when trimming the nail
Correct Answer: B,D,F
Rationale: The nurse corrects the AP for soaking the feet or using alcohol and reminds them to use moisturizer if the feet are dry. Digging into or cutting the toenails at the lateral corners when trimming the nails requires correction; toenails should be trimmed straight across. Guidelines for foot care include bathing the feet thoroughly in a mild soap and tepid water solution; drying feet thoroughly, including the area between the toes; and applying an antifungal foot powder when requested.
A nurse is scheduling hygiene for patients on the unit. What is the priority the nurse uses to guide planning for patient's personal hygiene?
- A. When the patient had their most recent bath
- B. The patient's usual hygiene practices and preferences
- C. Where the bathing fits in the nurse's schedule
- D. The time that is convenient for the AP
Correct Answer: B
Rationale: The patient's preferences, practices, and rituals should always be taken into consideration, unless there is a clear threat to health. The patient and nurse should work together to come to a mutually agreeable time and method to accomplish the patient's personal hygiene. The availability of staff to assist may be important, but the patient's preferences are a higher priority.