1. The nurse is delegating to nursing assistive personnel (NAP) the perineal care of a female patient who is totally dependent and confined to bed. Which statement by the NAP requires the nurse's follow-up? Show
INCORRECT. Positioning a totally dependent patient is likely to require more than one person, so this statement requires no follow-up. INCORRECT. It is appropriate to evaluate the patient's ability and willingness to have the care performed at this time, so this statement requires no follow-up. INCORRECT. Observing the patient's perineal area for signs of skin damage or discharge is appropriate, so this statement requires no follow-up. CORRECT. To minimize skin irritation, warm water and mild soap should be used when cleansing the perineal area, so this statement requires the nurse's follow-up.
2. The nurse is preparing to provide perineal care for a female patient who is on bed rest. Which patient position should the nurse use for this care?
INCORRECT. The supine position is not used when performing perineal care. INCORRECT. The prone position is not used when performing perineal care. INCORRECT. The side-lying position is not used when performing perineal care. CORRECT. Dorsal recumbent is the correct patient position to use when performing perineal care.
3. As the nurse is preparing to provide perineal care to a female patient with limited mobility, the patient says, "I can do that myself." Which action would be the priority? INCORRECT. Although it is a nursing responsibility to provide all the items necessary for the patient to perform this task, doing so would not take priority over assessing the patient's ability to perform perineal care. CORRECT. Determining the appropriateness of self-care by assessing the patient's ability to provide her own perineal care is the priority action. INCORRECT. Although it is a nursing responsibility to ensure the patient's privacy during perineal care, doing so would not take priority over assessing the patient's ability to perform this task. INCORRECT. Although documenting patient complaints is a nursing responsibility, doing so would not take priority over assessing the patient's ability to provide her own perineal care.
5. The nurse is delegating a female patient's perineal care to nursing assistive personnel (NAP). What instruction would the nurse give to ensure the NAP's safety while performing this care? INCORRECT. Wearing sterile gloves is not necessary to ensure the NAP's safety while performing perineal care. CORRECT. Wearing clean gloves is the best way to ensure the NAP's safety while performing perineal care. INCORRECT. Wearing an isolation gown is not necessary to ensure the NAP's safety while performing perineal care. INCORRECT. Using hot water would not ensure the NAP's safety while performing perineal care, and doing so could be harmful to the patient.
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A.The nurse should instruct the NAP not to massage any reddened areas on the patient’s skin.
The nurse has washed a patient’s abdomen. Which area should the nurse wash next?FeetFaceChest Legs
Legs should be washed after abdomen
A patient is being given a bed bath. The nurse realizes that another washcloth is needed to complete the bath. What is one way in which the nurse can ensure the patient's safety?A. Use the call light to ask someone else to bring a washcloth.B. Raise all four side rails on the patient's bed.C. Make sure the call light is within the patient's reach.D. Raise the bed to its highest position.
C. Placing the call light within easy reach reduces the likelihood that the patient will fall while trying to get out of bed in the nurse's absence.
Which patient should not have his or her feet soaked during a complete bed bath?A. A patient with arthritisB. A patient who has just complained of shoulder painC. A patient with diabetes mellitusD. A patient who is nauseated
C.Soaking the feet is contraindicated in a patient with diabetes mellitus, because such patients may have reduced sensation in the feet.
The nurse is bathing a patient who is unconscious. What should the nurse do to ensure safe care of the patient’s eyes?A. Remove eye crusts with soapy water.B. Avoid closing the patient's eyes.C. Use eye patches or shields taped in place.D. Tape the patient's eyelids closed.
C. An eye shield or patch should be placed over each eye and taped in place.
Which nursing action reduces the risk of falling as a patient is getting into or out of a bathtub?A. Add 1 oz of bath oil to the tub water before the patient gets into the tub.B. Place an “Occupied” sign on the bathroom door.C. Fill the tub half full of water at 110°F-115°F.D. Place a skidproof disposable bath mat in front of the tub.
A patient with left-sided muscle weakness is prescribed a bath every other day. Which precaution would help the nurse reduce this patient’s risk of falling?A. Maintain the water temperature at 104°F.B. Allow the patient to remain in the bath for 45 minutes.C. Decline the patient's request to add scented oil to the bathwater.D. Discuss the patient's level of fatigue after the bath.
c. Declining the patient's request to add scented oil to the bathwater will reduce her risk of falling. Bath oil increases the patient’s likelihood of slipping and therefore should not be used.
he nurse has just helped a patient into the bathtub. Before leaving the bathroom, what would the nurse do to help ensure the patient's safety?A. Show him how to use the call signal.B. Place an “Occupied” sign on the door.C. Check the cleanliness of the room.D. Remove unneeded supplies from the bathroom.
The nurse is assisting a patient with a tub bath. After the patient has been safely positioned in the tub, he tells the nurse, "I'll call you when I'm done." What is the nurse's best response?A. "All right. Just holler when you're ready, and I'll come help you get out of the tub."B. "Well, I'll check back with you in about 5 minutes to see if you need anything."C. "That's not safe. I'll wait right outside the door for you to finish."D. "I'll be back in 15 minutes. That should be enough time for you to finish up."
The nurse is helping a patient get out of a bathtub, and the patient appears to be unsteady on her feet. What should the nurse do to help ensure the patient’s safety?A. Drape a bath towel over the patient’s shoulders.B. Demonstrate how to use the call light for assistance.C. Drain the bathtub before the patient gets out.D. Apply lotion to the patient's freshly dried skin.
C. When helping an unsteady patient get out of a bathtub, the nurse should first drain the tub. Doing so reduces the patient's risk of falling.
The nurse is delegating to nursing assistive personnel (NAP) the perineal care of a female patient who is totally dependent and confined to bed. Which statement by the NAP requires the nurse's follow-up?A. "I'll ask for assistance if I need help positioning her."B. "I'll see if she's up to the care right now."C. "I'll let you know if I notice any signs of redness or discharge."D. "I'll be sure to use hot, soapy water, since she has been incontinent."
D. To minimize skin irritation, warm water and mild soap should be used when cleansing the perineal area, so this statement requires the nurse's follow-up.
The nurse is preparing to provide perineal care for a female patient who is on bed rest. Which patient position should the nurse use for this care?A. SupineB. ProneC. Side-lyingD. Dorsal recumbent
As the nurse is preparing to provide perineal care to a female patient with limited mobility, the patient says, "I can do that myself." Which action would be the priority?A. Provide all the necessary supplies and linen for this task.B. Assess the patient's ability to perform proper perineal care.C. Ensure that the patient has privacy while performing perineal care.D. Document any complaints of irritation or pain in the perineal area.
How can the nurse promote infection control while providing perineal care for a female patient who has a catheter?A. By avoiding the application of tension on the catheterB. By patting, not rubbing, the skin dry after thoroughly rinsing itC. By cleansing the patient's labia from the pubic area toward the rectumD. By using warm water to cleanse the patient's entire perineal area
The nurse is delegating a female patient's perineal care to nursing assistive personnel (NAP). What instruction would the nurse give to ensure the NAP's safety while performing this care?A. Wear sterile gloves.B. Wear clean gloves.C. Wear an isolation gown.D. Use hot water.
Which of the following interventions directly related to patient safety must the nurse consider when providing perineal care to an elderly male patient with a catheter?A. Wear clean gloves during care.B. Assess the patient's ability to provide self-care.C. Encourage the patient to report any pain originating from the catheter.D. Monitor the amount of urine in the drainage bag to prevent overflow.
The nurse observes the nursing assistive personnel (NAP) providing perineal care to a male patient. Which observation of care requires the nurse's follow-up?A. Assisting the patient into the supine position in bedB. Cleansing the tip of the penis with a circular motion, starting at the meatusC. Reserving the cleansing of the tip of the penis as the final step in perineal careD. Using a gloved hand to grasp the shaft of the penis in order to retract the foreskin
c. Proper cleansing requires that the tip of the penis be cleansed first, to minimize the introduction of pathogens to the meatus. The nurse's observation of improper technique requires follow-up teaching.
A male patient receiving perineal care tells the nurse "It has started to hurt a little down there." What is the nurse's best response?A. "When did you start experiencing the pain?"B. "Rate the pain on a scale of 1 to 10."C. "I'll assess your perineal area for the possible cause of the pain."D. "Would you like some pain medication before I continue with your care?"
A. This is the best response for the nurse. A nurse should ask the patient about his concerns and the perineal pain first.
The nurse has delegated a male patient's perineal care to the nursing assistive personnel (NAP). Which statement made by the NAP requires the nurse's follow-up?A. "I will check to see if he cleans himself well."B. "I will let you know if I see any redness or drainage."C. "I will ask him if he is experiencing any pain in that area"D. "I will be sure to use hot, soapy water to be sure he's clean."
What is the primary reason for performing perineal care on a male patient with incontinence?A. To provide comfort and a relaxed, refreshed feelingB. To promote personal hygiene while minimizing perineal odorC. To remove all microorganisms from the patient's perineal areaD. To reduce the risk of skin breakdown in the patient's genital and perineal area. |
The nurse is delegating to nursing assistive personnel (nap) the perineal care of the female patient who is totally dependent and confined to bed. which statement by the nap requires the nurse's follow-up?
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