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A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential to good patient outcomes, especially for those receiving mechanical ventilation. What are positive outcomes expected from this care? Select all that apply.
- A. Promoting the patient's sense of well-being
- B. Preventing deterioration of the oral cavity
- C. Contributing to decreased incidence of aspiration pneumonia
- D. Eliminating the need for flossing
- E. Decreasing oropharyngeal secretions
- F. Compensating for an inadequate diet
Correct Answer: A,B,C
Rationale: Adequate oral hygiene is essential for promoting the patient's sense of well-being and preventing deterioration of the oral cavity. Diligent oral hygiene and use of chlorhexidine gluconate (CHG) in critical care areas, can limit the growth of pathogens in oropharyngeal secretions, decreasing the incidence of ventilator-associated pneumonia, aspiration pneumonia, and other systemic diseases. Oral care does not eliminate the need for flossing, decrease oropharyngeal secretions, or compensate for poor nutrition.
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A nurse in a memory care unit is assisting a patient with dementia with bathing. Which nursing action will enhance patient comfort and prevent anxiety?
- A. Shifting the focus of the interaction to the 'process of bathing'
- B. Washing the face and hair at the beginning of the bath
- C. Using music to soothe anxiety and agitation
- D. Avoiding towel baths or forms of bathing with which the patient is unfamiliar
Correct Answer: C
Rationale: The nurse use music to soothe anxiety and agitation. The nurse should also shift the focus of the interaction from the 'task of bathing' to the needs and abilities of the patient, and focus on comfort, safety, autonomy, and self-esteem, in addition to cleanliness. Wash the face and hair at the end of the bath or at a separate time. Water dripping in the face and having a wet head are often the most upsetting parts of the bathing process for people with dementia. The nurse should also consider methods for bathing aside from showers and tub baths. Towel baths, washing under clothes, and bathing 'body sections' one day at a time, as well as dry shampoo or 'shower cap' shampoos, are additional options.
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.
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 performing oral care on a patient who has advanced dementia. The nurse notes that the mouth is extremely dry with crusts remaining after the oral care. What action will the nurse take next?
- A. Recommend a consultation with an oral surgeon.
- B. Communicate the condition to the health care team.
- C. Gently scrape the oral cavity with a tongue depressor.
- D. Increase the frequency of the oral hygiene and apply mouth moisturizer to oral mucosa.
Correct Answer: D
Rationale: If initial oral care results in continued dryness of the oral cavity with crusting, the nurse should increase frequency of oral hygiene, apply mouth moisturizer to oral mucosa, and monitor fluid intake and output to ensure adequate intake of fluid. It is not necessary to report this condition prior to providing the interventions mentioned above; however, mouth care and re-evaluation of the oral cavity is documented. The crusts should not be scraped with a tongue depressor.
A nurse is about to bathe a female patient who has an IV in the forearm. The patient's gown, which does not have snaps on the sleeves, needs to be removed prior to bathing. How will the nurse proceed?
- A. Quickly disconnecting the IV tubing closest to the patient and thread it through the gown sleeve
- B. Cutting the gown with scissors to allow arm movement
- C. Threading the bag and tubing through the gown sleeve, keeping the line intact
- D. Temporarily disconnecting the tubing from the IV container, threading it through the gown
Correct Answer: C
Rationale: Threading the bag and tubing through the gown sleeve maintains a closed system and prevents contamination. No matter how quickly performed, any disconnection of IV tubing results in a breach of the sterile system, creating risk for infection. Cutting a gown is not an alternative except in an emergency.