Nokea
A nurse is caring for a 25-year-old patient who is unresponsive following a head injury. The patient has several piercings in the ears and nose that appear crusted and slightly inflamed. What is the most appropriate action to care for this patient's piercings?
- A. Avoiding removing or washing the piercings until the patient is responsive
- B. Rinsing the sites with warm water and remove crusts with a cotton swab
- C. Washing the sites with alcohol and apply an antibiotic ointment
- D. Removing the jewelry and allow the sites to heal over
Correct Answer: B
Rationale: When providing care for piercings, the nurse performs hand hygiene, applies gloves, then cleanses the site of all crusts and debris by rinsing the site with warm water and removing the crusts with a cotton swab. The nurse should then apply a dab of liquid-medicated cleanser, per policy, to the area, turn the jewelry back and forth to work the cleanser around the opening, rinse well, remove gloves, and perform hand hygiene. The nurse should not use alcohol, peroxide, or ointments at the site and should avoid removing piercings unless it is absolutely necessary (e.g., when an MRI is ordered.)
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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.
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 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 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.