Nokea
While you are assisting a patient with a bed bath, you notice a purplish blotching on the skin of the lower legs and feet. This is an indication of
- A. A reaction to medications.
- B. Increased heat in the legs and feet.
- C. Infection.
- D. Decreased circulation to the legs and feet.
Correct Answer: D
Rationale: Purplish blotching on the lower legs and feet is often a sign of poor blood flow, indicating decreased circulation. This can be associated with conditions like peripheral vascular disease. It is not typically a reaction to medications, increased heat, or infection unless accompanied by other specific symptoms.
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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.
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.
Your patient has multiple body piercings with jewelry in place. He has been in a motor vehicle accident and is scheduled for an MRI of his left arm and left leg. Which question will you ask this patient?
- A. Do I have your permission to remove the jewelry from your piercings before your MRI?
- B. Are the metals in your jewelry nonmagnetic stainless steel or titanium?
- C. You understand that you will need to remove all of the jewelry from your piercings before you go for an MRI, don't you?
- D. How long has the jewelry in your piercings been in place?
Correct Answer: B
Rationale: MRI machines use strong magnetic fields, and nonmagnetic metals like certain stainless steels or titanium are safe. Asking about the metal type ensures safety during the MRI, as magnetic metals can cause injury or imaging artifacts.
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.
When cleaning dentures, you will do which of the following?
- A. Line the sink with a towel or washcloth for a soft surface in case the dentures slip.
- B. Use hot water to rinse the dentures before cleaning them to remove food particles.
- C. Use cool water when washing the dentures to prevent damage to them.
- D. Store them in a denture cup with cool water and a cleaning tablet if the patient wishes.
- E. Clean a partial denture with metal parts by soaking it in water containing a dissolved cleaning tablet.
Correct Answer: A,C,D
Rationale: Lining the sink prevents denture damage if dropped. Cool water is used to avoid warping or damaging dentures. Storing in a denture cup with cool water and a cleaning tablet is standard practice if desired. Hot water can damage dentures, and soaking partial dentures with metal parts in cleaning solutions may cause corrosion.