Nokea
The nurse explains that the purpose of a sitz bath is to reduce inflammation in the perineal and anal area. What is the least amount of time the nurse will instruct for a sitz bath?
- A. 10 to 15 minutes
- B. 20 to 30 minutes
- C. 30 to 40 minutes
- D. 1 hour
Correct Answer: B
Rationale: The sitz bath should last 20 to 30 minutes.
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The nurse is assessing a patient's skin for signs of impaired skin integrity. Which finding by the nurse is considered a major manifestation?
- A. Burn
- B. Laceration
- C. Pressure injury
- D. Infection
Correct Answer: C
Rationale: A major manifestation of impaired skin integrity is a pressure injury.
A patient is recovering from a hemorrhoidectomy and experiences dizziness within 5 minutes, when taking a sitz bath. What action should the nurse implement?
- A. Cover the patient to prevent chilling.
- B. Stay with the patient until the full time for the bath has elapsed.
- C. Remove the patient from the sitz bath and return to bed.
- D. Assess vital signs every 5 minutes during the remainder of the sitz bath.
Correct Answer: C
Rationale: The patient may become dizzy during a sitz bath due to dilation of the large vessels in the abdomen. If this occurs, the patient should be removed from the sitz bath and returned to bed. Vital signs should be assessed until they return to normal.
How frequently should the nurse clean the nares of patients who have a nasogastric tube or are receiving oxygen by nasal cannula?
- A. At least every 2 hours
- B. At least every 6 hours
- C. At least every 8 hours
- D. At least every 10 hours
Correct Answer: C
Rationale: When receiving oxygen by a nasal cannula or when a nasogastric tube is in place, the nurse should cleanse the nares every 8 hours.
The nurse is caring for an unconscious patient with a risk for skin impairment. How often will the nurse plan to change the position of this patient?
- A. Every 30 minutes
- B. Every 60 minutes
- C. Every 120 minutes
- D. Every 180 minutes
Correct Answer: C
Rationale: The bedfast patient should have a position change every 2 hours (120 minutes) because skin compromise can occur if there is unrelieved pressure during that amount of time.
Clear water is used to cleanse the eyes. It is important to use proper technique when cleansing the eyes to prevent infection. What direction will the water flow when cleansing a patient's eyes?
- A. Upward toward the forehead
- B. Downward toward the chin
- C. From the outer toward the inner canthus
- D. From the inner toward the outer canthus
Correct Answer: D
Rationale: The eye is cleansed from the inner to outer canthus.