Nokea
Which of the following are generally performed as part of morning care (a.m. care)?
- A. Hair care
- B. Bath
- C. Shaving
- D. Oral care
- E. Back massage
- F. Washing hands and face only
- G. Dressing or changing the gown
Correct Answer: A,B,C,D,F,G
Rationale: Morning care typically includes routine hygiene tasks performed at the start of the day to prepare the patient for daily activities. These tasks include hair care, bathing, shaving, oral care, washing hands and face, and dressing or changing the gown to promote cleanliness and comfort. Back massage is not typically part of routine morning care unless specified for therapeutic reasons.
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Label the following bed positions:
- A. Fowler's position
- B. Trendelenburg position
- C. Supine position
- D. Prone position
- E. Lateral position
- F. Sims' position
- G. Reverse Trendelenburg position
Correct Answer: A,B,C
Rationale: Common bed positions include Fowler's (head elevated), Trendelenburg (head lower than feet), and Supine (lying flat on back). These are standard positions used in patient care for comfort, breathing, or procedural needs.
You are caring for a patient with a nasogastric tube who is unable to take food or fluids by mouth. How often will you perform oral care for this patient?
- A. Unnecessary because the patient is not eating or drinking anything
- B. Every 2 hours
- C. Every 4 hours
- D. Every 8 hours
Correct Answer: B
Rationale: Patients with nasogastric tubes are at risk for dry mouth and oral infections due to lack of oral intake and tube irritation. Oral care every 2 hours helps maintain oral hygiene, prevent infections, and ensure patient comfort.
Your patient is slightly confused. He has activity orders to be up in the chair three times per day. He is unstable on his feet when he walks or stands for more than a few minutes. What type of bath will you plan to give this patient?
- A. Bed bath
- B. Assisted or help bath
- C. Tub bath
- D. Shower
Correct Answer: B
Rationale: Given the patient's confusion and instability when standing for extended periods, an assisted or help bath is appropriate. This allows the nurse to provide support while the patient participates in bathing, accommodating their activity orders while ensuring safety. A bed bath is too restrictive, and a tub bath or shower poses a fall risk.
You are preparing to assist a conscious patient with oral care. The patient has had a stroke, causing partial paralysis of his throat. Once the toothpaste, toothbrush, water, and emesis basin are set up on the overbed table, what will you do?
- A. Instruct the patient to brush her teeth and spit into the emesis basin, then leave the room.
- B. Ask a family member to assist the patient if she needs help while you are out of the room.
- C. Brush the patient's teeth for her, then instruct her to rinse her mouth with water and mouthwash while you prepare for the partial bath.
- D. Stay with the patient in case she chokes while performing oral care, and assist her as needed.
Correct Answer: D
Rationale: Due to partial throat paralysis from the stroke, the patient is at risk of choking or aspiration during oral care. Staying with the patient ensures safety and allows assistance as needed, preventing complications.
When you provide oral care to an unconscious patient, you will
- A. Position the patient on the left or right side with the bed flat.
- B. Use lemon glycerin swabs to clean the patient's lips and gums.
- C. Assess the mouth for lesions and sores.
- D. Use plenty of water to rinse the toothpaste from the teeth and gums.
- E. Keep a suction device on and ready for use.
Correct Answer: A,C,E
Rationale: For an unconscious patient, positioning on the side with the bed flat prevents aspiration during oral care. Assessing the mouth for lesions ensures proper care and identifies issues. A suction device is essential to remove fluids and prevent choking. Lemon glycerin swabs can dry the mucosa, and rinsing with water is avoided to prevent aspiration.