Foundations of Nursing, 8th Edition Hygiene and Care of the Patient’s Environment COOPER TEST BANK,100% CORRECT

MULTIPLE CHOICE 1. 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) ANS: B The recommended room temperature is 68° to 74°F (20° to 23.3°C). DIF: Cognitive Level: Application REF: 188 OBJ: 1 | 2 | 4 TOP: Patient's environment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse explains that the purpose of a sitz bath is to reduce inflammation in the perineal and anal area. What is the least amount of time the nurse will instruct for a sitz bath? a. 10 to 15 minutes b. 20 to 30 minutes c. 30 to 40 minutes d. 1 hour ANS: B The sitz bath should last 20 to 30 minutes. DIF: Cognitive Level: Application REF: 192 OBJ: 2 | 3 TOP: Therapeutic baths KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. A patient is recovering from a hemorrhoidectomy and experiences dizziness within 5 minutes when taking a sitz bath. What action should the nurse implement? a. Cover the patient to prevent chilling. b. Stay with the patient until the full time for the bath has elapsed. c. Remove the patient from the sitz bath and return to bed. d. Assess vital signs every 5 minutes during the remainder of the sitz bath. ANS: C The patient may become dizzy during a sitz bath due to dilation of the large vessels in the abdomen. If this occurs, the patient should be removed from the sitz bath and returned to bed. Vital signs should be assessed until they return to normal. DIF: Cognitive Level: Application REF: 193 OBJ: 3 TOP: Sitz bath KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. What should the water temperature be when preparing a tepid bath for a patient? a. 98.6°F (37°C) b. 100.2°F (37.8°C) NURSINGTB.COM Foundations of Nursing 8th Edition Cooper Test Bank . NU RS IN GT B.CO M c. 104.8°F (40.4°C) d. 110.4°F (43.5°C) ANS: A The tepid bath is taken in water that is 98.6°F (37°C). DIF: Cognitive Level: Knowledge REF: 193 OBJ: 4 TOP: Tepid bath KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse is assessing a patient’s skin for signs of impaired skin integrity. Which finding by the nurse is considered a major manifestation? a. Burn b. Laceration c. Pressure injury d. Infection ANS: C A major manifestation of impaired skin integrity is a pressure injury. DIF: Cognitive Level: Comprehension REF: 202 OBJ: 5 TOP: Pressure injuries KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. A nurse assesses an area of sustained redness on the coccyx area of a resident in long-term care. What is the most likely cause of this pressure area? a. Heat from pressure b. Collapse of blood vessels c. Friction from pressure d. Collapse of skin tissue ANS: B A pressure injury occurs when there is sufficient pressure to collapse the blood vessels. DIF: Cognitive Level: Comprehension REF: 202 OBJ: 5 TOP: Pressure injuries KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 7. The nurse is caring for an unconscious patient with a risk for skin impairment. How often will the nurse plan to change the position of this patient? a. Every 30 minutes b. Every 60 minutes c. Every 120 minutes d. Every 180 minutes ANS: C The bedfast patient should have a position change every 2 hours (120 minutes) because skin compromise can occur if there is unrelieved pressure during that amount of time. DIF: Cognitive Level: Application REF: 231 OBJ: 5 TOP: Pressure injuries KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity NURSINGTB.COM Foundations of Nursing 8th Edition Cooper Test Bank NU RS IN GT B.CO M 8. The nurse assesses a red blister over the right superior iliac area of a patient. What stage is this decubitus injury? a. 1 b. 2 c. 3 d. 4 ANS: B A pressure injury demonstrating blisters is a stage 2 decubitus injury. DIF: Cognitive Level: Application REF: 203 OBJ: 5 TOP: Pressure injuries KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. The nursing assessment of a pressure injury includes size, depth, pain, odor, and color of tissue. What does this evaluate? a. Treatment needed b. Effectiveness of implementation c. Whether improvement is occurring d. Need for additional interventions ANS: C Ongoing assessment of a pressure injury will evaluate whether improvement is occurring. DIF: Cognitive Level: Comprehension REF: 202 | 203 OBJ: 5 TOP: Pressure injuries KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 10. The nurse attempts to avoid a pressure injury for a bedridden patient by turning the patient frequently. What is the most favorable position for the nurse to move this patient into? a. Back-lying b. Full lateral c. 30-degree lateral d. Full prone ANS: C It is preferable to use the 30-degree lateral incline position. DIF: Cognitive Level: Application REF: 205 OBJ: 5 TOP: Pressure injuries KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. One reason the nurse focuses on oral hygiene is to maintain a healthy state of the oral cavity. What is another reason to promote oral hygiene? a. To improve self-esteem b. To stimulate appetite c. To restore tooth destruction d. To assist with periodontitis ANS: B A sense of well-being can stimulate appetite. NURSINGTB.COM Foundations of Nursing 8th Edition Cooper Test Bank NU RS IN GT B.CO M DIF: Cognitive Level: Comprehension REF: 211 OBJ: 6 TOP: Oral hygiene KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. How will the nurse correctly replace a patient’s dentures after cleaning? a. Inserting the lower denture first b. Asking the patient to insert them c. Inserting both dentures together d. Inserting the upper denture first ANS: D When reinserting dentures, replace the upper dentures first. DIF: Cognitive Level: Application REF: 213 OBJ: 6 TOP: Oral hygiene KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. Proper hair care is important for the patient’s self-image. What is the proper water temperature when shampooing a patient’s hair? a. 101°F (38.3°C) b. 105°F (40.5°C) c. 110°F (43.3°C) d. 120°F (48.8°C) ANS: C Water at 110°F (38.3°C) should be used to shampoo a patient’s hair. DIF: Cognitive Level: Knowledge REF: 193 OBJ: 6 TOP: Hair care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. When must the nurse remember to use an electric razor when shaving a patient? a. When a bleeding tendency is present b. When there is a risk for suicide c. When the facial hair is fine d. When speed is essential ANS: A A patient with a bleeding disorder should use an electric razor. DIF: Cognitive Level: Application REF: 214 OBJ: 6 TOP: Shaving KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. 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 ANS: C NURSINGTB.COM Foundations of Nursing 8th Edition Cooper Test Bank NU RS IN GT B.CO M The lower extremities of people with circulatory disorders are gently washed and patted dry, omitting any stroking or massaging. DIF: Cognitive Level: Application REF: 196 OBJ: 3 TOP: Bathing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. The nurse is providing hand and foot care to a patient and notices the patient has extremely hard nails. Who is the person best prepared to provide nail care for patients with extremely hard nails? a. Health care provider b. RN c. CNA d. Podiatrist ANS: D If the patient’s nails are extremely hard, a podiatrist should provide care. DIF: Cognitive Level: Comprehension REF: 216 OBJ: 6 TOP: Foot care KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 17. How often should the nurse cleanse the meatal-catheter junction of a patient with an indwelling catheter? a. At least once a day b. At least twice a day c. At bedtime d. Each shift ANS: B Catheter care should be performed at least two times daily. DIF: Cognitive Level: Comprehension REF: 214 OBJ: 8 TOP: Catheter care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. The nurse is preparing to perform perineal care for the female patient. What is the best method