Nokea
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 may also like to solve these questions
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.
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.
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.
You are providing personal care to a patient with diabetes. Her toenails are a bit long. What will you do?
- A. Do nothing to her toenails because you could cause her to have an infection if you damage her toes.
- B. Clip her toenails carefully straight across but do not file them.
- C. Clip her toenails carefully in a rounded shape to help prevent ingrown toenails.
- D. File her toenails straight across but do not clip them.
Correct Answer: A
Rationale: Patients with diabetes are at high risk for infections due to poor wound healing. Cutting or filing toenails can cause microtrauma, leading to infections. It is safer to refer toenail care to a podiatrist to avoid complications.
It is important to stay with a patient during the first bath or shower after surgery because the patient may
- A. Be unsteady while standing and sitting.
- B. Have an increase in pain when moving about.
- C. Cause the incision to open up when getting in the water.
- D. Experience vasodilation and become dizzy or faint.
Correct Answer: A,D
Rationale: Post-surgical patients may be weak or unsteady due to anesthesia effects or reduced mobility, increasing the risk of falls. Vasodilation from warm water can also cause dizziness or fainting, especially in a weakened state. While pain may increase with movement, it is not the primary concern for supervision, and incisions are unlikely to open from bathing alone.