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The nurse is educating a patient regarding a tub bath. What is the maximum length of time the nurse should instruct the patient to remain in the water?
- A. 5 to 10 minutes
- B. 10 to 20 minutes
- C. 20 to 30 minutes
- D. 30 to 40 minutes
Correct Answer: B
Rationale: A patient should not stay in the water for more than 20 minutes.
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The nurse is bathing a patient with a deep vein thrombosis in the left leg. What modification will the nurse make when attending to the left leg?
- A. Washing the leg with long firm strokes and drying with a towel
- B. Omitting washing the leg at all
- C. Gently washing the leg and patting dry with a towel
- D. Applying lotion in long smooth strokes
Correct Answer: C
Rationale: The lower extremities of people with circulatory disorders are gently washed and patted dry, omitting any stroking or massaging.
To prevent skin breakdown in a wheelchair-bound patient the nurse teaches the patient to shift the patient's weight every ____ minutes.
Correct Answer: 15
Rationale: People who are wheelchair-bound should shift their weight by pushing on the arms of their chair every 15 minutes to prevent skin breakdown.
Which guideline should be followed when giving a backrub?
- A. Observing the skin for abnormalities
- B. Massaging for at least 10 minutes
- C. Following massage with a brisk alcohol rub
- D. Conversing with patient continually throughout the backrub
- E. Using alcohol-based lotion for disinfection
Correct Answer: A
Rationale: The backrub should last for about 3 to 5 minutes, giving the nurse an opportunity to observe for skin abnormalities. Conversation should be kept to a minimum to enhance relaxation. Alcohol either as a rub or used as disinfectant is drying to the skin.
The nurse is assisting a patient to perform personal hygiene. What is the most important focus of the nurse when assisting this patient?
- A. Nursing care
- B. Independence
- C. Repetition
- D. Performance
Correct Answer: B
Rationale: The nurse should encourage the patient's independence as much as possible.
The nurse is preparing to bathe a patient. What should the room temperature be set at?
- A. No warmer than 67°F (19.4°C)
- B. No cooler than 68°F (20°C)
- C. No cooler than 70°F (21.1°C)
- D. 75°F or warmer (23.8°C)
Correct Answer: B
Rationale: The recommended room temperature is 68° to 74°F (20° to 23.3°C).