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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.
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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.
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 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.
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 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.