Nokea
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.
You may also like to solve these questions
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.
An RN in a long-term care facility supervises APs as they provide hygiene to older adults. What action by the AP will the nurse correct?
- A. When providing perineal care, washing the area from front to back
- B. Insisting the older adult must take a bath or shower each day
- C. Telling the patient to avoid soaking feet, helps the patient dry between the toes
- D. Covering areas not being bathed with a bath blanket
Correct Answer: B
Rationale: Older adults tend to develop dry skin; bathing frequency will change accordingly. Soaking adults' feet is not recommended. It is appropriate to keep a patient warm with bath blankets and provide perineal care washing from front to back.
A nurse is teaching a nursing student how to perform perineal care for patients. What actions are appropriate when performing this procedure? Select all that apply.
- A. For male and female patients, wash the groin area with a small amount of soap and water and rinse.
- B. For a female patient, spread the labia and move the washcloth from the anal area toward the pubic area.
- C. For male and female patients, always proceed from the most contaminated area to the least contaminated area.
- D. For male and female patients, use a clean portion of the washcloth for each stroke.
- E. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward.
- F. In an uncircumcised male patient, avoid retracting the foreskin (prepuce) while washing the penis.
Correct Answer: A,D,E
Rationale: Wash and rinse the groin area (both male and female patients) with a small amount of soap and water, and rinse. For male and female patients, always proceed from the least contaminated area to the most contaminated area and use a clean portion of the washcloth for each stroke. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. For a female patient, spread the labia and move the washcloth from the pubic area toward the anal area. In an uncircumcised male patient (teenage or older), retract the foreskin (prepuce) while washing the penis and return it to its original position when finished.
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.
When assessing the skin, nurses use techniques to provide complete data and correct documentation. Which actions are appropriate during the skin assessment? Select all that apply.
- A. Comparing bilateral parts for symmetry
- B. Proceeding in a toe-to-head, systematic manner
- C. Using standard terminology to communicate and document findings
- D. Avoiding using data from the nursing history to direct the assessment
- E. Documenting only skin abnormalities on the health record
- F. When risk factors are identified, following up with a related skin assessment
Correct Answer: A,C,F
Rationale: During skin assessment, the nurse should compare bilateral parts for symmetry, use standard terminology to communicate and document findings, and perform the appropriate skin assessment when risk factors are identified. The nurse should proceed in a head-to-toe systematic manner, using cues/data from the nursing history to direct the assessment. When documenting a physical assessment of the skin, the nurse should describe exactly what is observed or palpated, including appearance, texture, size, location or distribution, and characteristics of any findings.