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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.
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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.
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.
A nurse assisting a patient with a bed bath observes the older adult has dry skin, which the patient states is 'itchy.' Which intervention is appropriate?
- A. Bathe the patient more frequently.
- B. Use an emollient on the dry skin.
- C. Explain that this is expected as people age.
- D. Limit the patient's fluid intake.
Correct Answer: B
Rationale: An emollient soothes dry skin, whereas frequent bathing increases dryness. Telling the patient this is normal with aging and does not help resolve the issue. Limiting fluid intake can promote dehydration and exacerbate dry skin.
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.
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.