A nurse is bathing a client who has a fever.

Why should the nurse use tepid bath water

for this procedure?
1. Increases heat loss
2. Removes surface debris
3. Reduces surface tension of skin
4. Stimulates peripheral circulation
1. Increases heat loss - heat is transferred from the warm surface of the skin to the
water that is in direct contact with the body, and evaporation of the water promotes
cooling. Tepid water is slightly below body temperature, and a person with a fever has
an elevated body temperature (febrile).
A nurse must make the decision to give a patient a full or partial bed bath. Which
criterion is most important for the basis of the decision?
1. Primary health-care provider's prescription for the client's activity
2. Immediate need of the client
3. Time of client's last bath
4. Client preference
2. Immediate need of the client - a total client assessment with an analysis of the data
identifies the needs of the client and the appropriate intervention to meet those needs.
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A client has had a nasogastric tube to decompress the stomach for 3 days and is
scheduled for intestinal surgery in the morning. For which of the following is the client at
highest risk?
1. Physical injury
2. Ineffective social interaction
3. Decreased nutritional intake
4. Altered oral mucous membranes
4. Altered oral mucous membranes - not drinking anything by mouth and having a tube
through the nose and posterior pharynx can result in drying of the oral mucous
membranes and a coated, furrowed tongue
A client is incontinent of urine and stool. For which client response should the nurse be
most concerned?
1. Impaired skin integrity
2. Altered sexuality
3. Dehydration
4. Confusion
1. Impaired skin integrity - fecal material contains enzymes that erode the skin, and
urine is an acidic fluid that macerates the skin. As a result, altered skin integrity is a
serious concern
A nurse is giving a client a bed bath. Which nursing action is most important?
1. Lower the 2 side rails on the working side of the bed
2. Ensure that the bath water is at least 110°F
3. Fold the washcloth like a mitt on the hand
4. Raise the bed to the highest position
2. Ensure that the bath water is at least 110°F - the temperature of bath water should be
between 110°F and 115°F to promote comfort, dilate blood vessels, and prevent
chilling. A lower temperature can cause chilling, and a higher temperature can cause
skin trauma.
A nurse plans to give a client a back rub. Which product should the nurse use for this
intervention?
1. Baby powder
2. Running alcohol
3. Moisturizing lotion
4. Antimicrobial cream
3. Moisturizing lotion - it lubricates the skin and reduces friction between the nurse's
hands and the client's back. Lotion facilitates smooth movement of the hands across the
client's skin, which is relaxing and prevents trauma to the skin. The use of a moisturizing
lotion for a back rub does not require a primary health-care providers prescription
A nurse changes the sheets and pillowcase of a bed while the client sits in a chair. Of
the options presented, which is the most important nursing action when changed before
linens?
1. Ensuring the hem of the bottom of the sheet is facing the mattress
2. Arranging the linen in the order in which it is to be used
3. Shifting the mattress up to the headboard of the bed
4. Checking the soiled bed linens for personal items
4. Checking the soiled bed linens for personal items - a nurse must take reasonable
precautions to ensure that a client's personal belongings, especially eyeglasses,
dentures, and prosthetic devices, are kept safe. Checking for personal belongings
before placing soiled linen into a linen hamper is a reasonable, prudent nursing action.
A nurse is responsible for providing hair care for a client. Which should the nurse do to
distribute oil evenly along the hair shafts?
1. Brush the hair from the scalp towards the hair ends
2. Lift opened fingers through the length of the hair
3. Apply a hydrating conditioner to wet hair
4. Comb hair with a fine-toothed comb
1. Brush the hair from the scalp towards the hair ends - brushing the hair from the scalp
to the ends of the hair massages the scalp and distributes oils secreted by the scalp
down along the length of the hair shaft
Which condition identified by the nurse places a client at the highest risk for impaired
self-care when toileting?
1. Amputation of a foot
2. Early dementia
3. Fractured hip
4. Pregnancy
3. Fractured hip - discomfort resulting from the proximity of the fracture to the pelvic
area and the limitations placed on the positioning of, or weight-bearing on, the affected
leg influence a client's ability to use a bedpan or transfer to a commode
A client asks the nurse, "why do I have to use mouthwash if I brush my teeth?" Which
rationale about the use of all mouthwashes should the nurse include when responding
to this question?
1. Reduces offensive mouth odors
2. Minimizes the formation of cavities
3. Softens debris that accumulates in the mouth
4. Destroys pathogens that are found in the oral cavity
1. Reduces offensive mouth odors - an offensive odor to the breath (halitosis) can be
caused by inadequate oral hygiene, periodontal disease, or systemic disease. Rinsing
the mouth with mouthwash will flush the oral cavity of debris and microorganisms, which
will reduce halitosis if it is caused by a localized problem.
A nurse is planning to shampoo the hair of a client who has a prescription for bed rest.
Which should the nurse do first?
1. Wet hair thoroughly before applying shampoo
2. Encourage the use of dry shampoo
3. Brush the hair to remove tangled
4. Tape eye shields over both eyes
3. Brush the hair to remove tangles - it is easier and causes less trauma to the hair to
brush out tangles when the hair is dry rather than wet.
A client just had perineal surgery. Which type of bath should the nurse expect to be
prescribed for this client?
1. Sponge bath
2. Sitz bath
3. Tub bath
4. Bed bath
2. Sitz bath - a sitz bath immerses a client from the mid-thighs to the iliac crests, or
umbilicus, in a special tub, or the client sits in a basin that fits onto the toilet seat, so the
legs and feet remain out of water. The moist heat to the genital area increases local
circulation, cleans the skin, reduces soreness, and promotes relaxation, voiding,
drainage, and healing. A sitz bath requires a primary health-care provider's prescription
because it is a method of applying local heat to the perineal area.
A nurse plans to assist a client who has impaired vision with a bed bath. Which is the
most appropriate nursing intervention to facilitate bathing for this client?
1. Providing the client with a liquid bath gel rather than a bar of soap
2. Giving the client an adapted toothbrush to use when brushing teeth
3. Checking the client's ability to give self-care through a crack in the curtain
4. Ensuring the client can locate bathing supplies placed on the over-bed table
4. Ensuring the client can locate bathing supplies placed on the over-bed table -
identifying the placement of supplies on the over-bed table facilitates the use of
equipment by a person with impaired vision and encourages self-care
A nurse plans to meet the hygiene needs of a hospitalized client who is experiencing
hemiparesis because of a brain attack (cerebrovascular accident). Which is an
appropriate nursing intervention?
1. Assisting the client to bathe as needed
2. Giving total assistance with a complete bath
3. Providing minimal supervision during the bath
4. Encouraging a family member to bathe the client
1. Assisting the client to bathe as needed - hemiparesis is a weakness on one side of
the body that can interfere with the performance of activities of daily living. Encouraging
the client to do as much as possible will support self-esteem, and assisting when
necessary will ensure that hygiene needs are met
A nurse is making an occupied bed. Which nursing action is most important?
1. Securing top linens under the foot of the mattress and mitering the corners
2. Ensuring that the client's head is supported and is in functional alignment
3. Fan-folding soiled linens as close to the client's body as possible
4. Placing the bed in the horizontal position
2. Ensuring that the client's head is supported and is in functional alignment -
maintaining functional alignment of a client's head when making an occupied bed
promotes comfort and minimizes stress to the respiratory passages and vital anatomy in
the neck
A nurse must bathe the feet of a client with diabetes. Which should the nurse do before
bathing this client's feet?
1. File the nails straight across with an emery board
2. Teach that daily foot care is essential for adequate hygiene
3. Ensure a provider's prescription for hygienic foot care is obtained
4. Assess for additional risk factors that may contribute to localized problems
Assess for additional risk factors that may contribute to localized problems - a thorough
assessment of the client is the first step of the nursing process. People with diabetes
frequently have thick, hardened toenails, peripheral neuropathy, impaired arterial and
venous circulation in the feet, and foot or leg ulcers
Which should be the nurse's first intervention after removing a bedpan from under a
debilitated client who has just had a bowel movement?
1. Document results
2. Provide perineal care
3. Reposition the client
4. Cover the client with the top linens
2. Provide perineal care - when rolling a debilitated client off a bedpan, the perianal area
is exposed, which permits the nurse to provide immediate perineal hygiene. A bed-
bound, debilitated client is incapable of providing self-hygiene after having a bowel
movement
Which common problem with the hair should the nurse anticipate when clients are on
complete bed rest?
1. Dry hair
2. Oily hair
3. Split hair
4. Matted hair
4. Matted hair - bed rest causes matted, tangled hair because of friction and pressure
related to the movement of the head on a pillow
A nurse is helping a client who has right hemiparesis to get dressed. Which action
should the nurse implement?
1. Put the gown's right sleeve on first
2. Keep the client in an open-backed gown
3. Encourage the client to dress independently
4. Leave the right sleeve off while adjusting the tie at the neck
1. Put the gown's right sleeve on first - putting the right sleeve of the gown on the weak
extremity first puts less stress on affected muscles; the stronger side can stretch more
easily to dress
A cognitively impaired client is incontinent of loose stools. Which action should the
nurse insolent to help the client prevent skin breakdown?
1. Wash the buttocks with strong soap and water
2. Bathe immediately after a bowel movement
3. Apply Talcum powder after the bath
4. Put a pad under the buttocks
2. Bathe immediately after a bowel movement - loose stool contains digestive enzymes
that are irritating to the skin and should be cleaned from the skin as soon as possible
after soiling
A nurse covers the client with a cotton blanket during a bath. Which of the following
mechanisms of heat loss is prevented by the nurse's action?
1. Vasodilation
2. Conduction
3. Convection
4. Diffusion
3. Convection - convection is the transfer of heat by movement of air along a surface.
Using a bath blanket limits the amount of air flowing across the client, which prevents
heat loss
A client who has a fever experienced significant diaphoresis during the night. The client
states, "I am tired, and I just want to sleep this morning." Which should the nurse do
regarding bathing the client?
1. Wait until the client feels better
2. Postpone bathing until the afternoon
3. Give a bed bath with complete assistance
4. Consult with the primary health-care provider before providing care
3. Give a bed bath with complete assistance- after explaining the need for the bath, the
nurse should administer a bath with complete assistance. This while meet the client's
immediate hygiene needs while conserving the clients energy
A nurse gives a bed-bound client a bed bath. Which is the primary reason why the
nurse provides hygiene care to this client?
1. Support a sense of well-being by increasing self-esteem
2. Promote circulation by stimulating peripheral nerve endings
3. Remove excess oil, perspiration, and bacteria by mechanical cleansing
4. Exercise muscles by contraction and relaxation of muscles when bathing
3. Remove excess oil, perspiration, and bacteria by mechanical cleansing - the removal
of accumulated oil, perspiration, dead cells, and bacteria from the skin limits the
environment conductive to the growth of the bacteria and skin breakdown. Intact,
healthy skin is one of the body's first lines of defense
Which human response, identified by the nurse, best supports the concern that a client
has a reduced capacity to provide for activities of daily living?
1. Presence of joint contractures
2. Inability to wash body parts
3. Postoperative lethargy
4. Visual disorders
2. Inability to wash body parts - being unable to wash body parts is a human response
indicating that a client is unable to provide for one's own activities of daily living, such as
meeting hygiene and grooming needs.
When giving a client a bed bath, a nurse washes the client's extremities from distal to
proximal. Which is the rationale for this nursing action?
1. Decreases the chance of infection
2. Facilitated removal of dry skin
3. Stimulates venous return
4. Minimizes skin tears
3. Stimulates venous return - the pressure exerted on the skin surface by long, smooth
strokes moving from distal to proximal areas also presses on the veins, which promotes
venous return
During oral care, the nurse identifies a patch of dried food and debris adhered to the
hard palate of the client's mouth. Which word should the nurse use when documenting
this condition?
1. Sordes
2. Plaque
3. Glossitis
4. Stomatitis
1. Sordes - the accumulation of matter, such as food, epithelial elements, dried
secretions, and microorganisms (sordes) eventually can lead to dental caries and
periodontal disease and therefore must be removed during oral hygiene
A nurse is teaching a client about how many times a day it is necessary to brush the
teeth or achieve effective dental hygiene. According to the American Dental
Association, how many times a day should the nurse teach the client to brush the teeth?
1. 6
2. 4
3. 3
4. 2
4. 2 - the American Dental Association recommends brushing the teeth for 2 minutes
two times a day, and it should be done at least 30 minutes after consuming acidic food
or drinks
A nurse is providing hygiene to a client with peripheral neuropathy. Which action should
the nurse implement?
1. Seem a prescription for foot care
2. File the toenails straight across the nail
3. Wash the feet with lukewarm water and dry well
4. Apply moisturizing lotion to the feet, especially between the toes
3. Wash the feet with lukewarm water and dry well - lukewarm water is comfortable and
limits the potential for burns. Drying the feet limits moisture that promotes bacterial
growth.
Which nursing intervention most requires the nurse to consider the concept of intimate
space?
1. Providing a bed bath
2. Obtaining the vital signs
3. Performing a health history
4. Ambulating the client down the hall
1. Providing a bed bath - touching a client during a bed bath invades the person's
intimate space (physical contact to 1 1/2 feet) because the need to expose and touch
personal body parts
Which nursing action is common to both a bed bad and a tub bath? Select all that apply
1. Obtaining a prescription from the primary health-care provider
2. Helping the client wash body parts that cannot be reached
3. Exposing just the part of the body being washed
4. Providing for privacy throughout the bath
5. Ensuring that the call bell is in reach
2. Helping the client wash body parts that cannot be reached
4. Providing for privacy throughout the bath
A nurse plans to provide a client with a partial bath. Place the following steps in the
order in which the nurse should proceed.
1. Back
2. Face
3. Axilla
4. Both hands
5. Genital area
6. Change water
2-face, 3-axilla, 4-both hands, 6-change water, 1-back, 5-genital area
Which should the nurse implement when caring for a client who wears eyeglasses?
Select all that apply
1. Encourage use of artificial tears while hospitalized
2. Store eyeglasses in a safe place when not being worn
3. Dry the lenses with a paper towel after they are washed
4. Limit the time that eyeglasses are worn in an effort to rest the eyes
5. Use warm water to clean the lenses of eyeglasses at least once a day
2. Store eyeglasses in a safe place when not being worn
5. Use warm water to clean the lenses of eyeglasses at least once a day
When providing morning care for a client, the nurse identifies crusty debris around the
client's eyes. Which of the following should the nurse implement when cleaning the
client's eyes? Select all that apply
1. Wear sterile gloves
2. Use a tear-free baby soap
3. Position the client on the same side as the eye to be cleaned
4. Wash the eyes with cotton balls from the inner to outer canthus
5. Use a separate cotton ball for each stroke when washing the eyes
3. Position the client on the same side as the eye to be cleaned
4. Wash the eyes with cotton balls from the inner to outer canthus
5. Use a separate cotton ball for each stroke when washing the eyes
A nurse must make an unoccupied bed. Which nursing action is essential? Select all
that apply
1. Position the call bell in reach
2. Place a pull sheet on top of the draw sheet
3. Ensure that the bottom sheet is free of wrinkles
4. Ensure that there is a toe pleat at the foot of the bed
5. Complete one side of the bed before completing the other side
3. Ensure that the bottom sheet is free of wrinkles
4. Ensure that there is a toe pleat at the foot of the bed
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A nurse plans to administer a foot bath to a client who is sitting in a chair and has no
contraindications for this intervention. Place the following steps in the order in which
they should be implemented.
1. Soak each foot individually for 5 to 20 minutes, subject to the client's tolerance,
condition of the skin, and absence of a history of diabetes or peripheral vascular
disease
2. Don clean gloves and assist the client to position one foot in the water, verifying with
the client that the water temperature is comfortable
3. Position a waterproof pad on the floor on which to place a basin half-filled with warm
water (approximately 105°F to 110°F)
4. Wash each foot with rinse-free soap and clean under the nails with an orange stick
5. Apply lotion to each foot, avoiding between the toes
6. Dry each foot gently, especially between the toes
3, 2, 1, 4, 6, 5
A nurse teaches a client effective oral hygiene practices. Which of the following
indicates that the teaching about preventing and removing dental plaque was
understood by the client? Select all that apply
1. Uses a nonabrasive toothpaste
2. Brushes the teeth with a toothbrush
3. Gargles with anti plaque mouthwash
4. Flosses the teeth with unwaxed floss
5. Has teeth cleaned regularly by a dental hygienist
All of the above
A nurse is providing for the hygiene and grooming needs of an obese client who easily
becomes short of breath when moving about. Which nursing intervention is important?
1. Administering oxygen during provision of care
2. Maintaining the bed in a high-Fowler position
3. Assessing the client's response to the activity
4. Bathing areas that the client cannot reach
5. Providing rest periods every ten minutes
3. Assessing the client's response to the activity
4. Bathing areas that the client cannot reach
A nurse plans to shave a male client's facial hair with a safety razor. Which of the
following should the nurse implement? Select all that apply
1. Hold the razor perpendicular to the skin
2. Use long, downward strokes with the razor
3. Shave in the opposite direction of hair growth
4. Ensure that the client is not receiving an anticoagulant
5. Use a hot, wet wash cloth to wrap the face before shaving
4. Ensure that the client is not receiving an anticoagulant
A nurse is caring for a client who was newly admitted to a rehabilitation facility. After
reviewing the client's clinical record, the nurse chooses which of the following bathing
plans to meet the client's hygiene needs?
1. Complete bath with partial assistance
2. Towel bath with total assistance
3. Shower with partial assistance
4. Tub bath with total assistance

History: a 74 yr old woman admitted for rehabilitation after a total hip replacement 6
days ago due to chronic pain from osteoarthritis. Postoperative status was uneventful;
suture line intact and free of signs of symptoms of complications. Ingesting a regular
diet; fluid and electrolytes in balance. Vital signs stable, although the respiratory rate is
slightly elevated and labored due to a history of emphysema

Nursing admission assessment: resting in the semi-Fowler position with an abduction

pillow in place. Oriented to person but not time and place. Client keeps saying, "this
does not look like my home. I want to go home." Surgical site is dry and intact, wound
edges approximated, and is free of any signs or symptoms of complications. Client is
pulling on the linen, appears agitated, and is attempting to turn from side to side.
Incontinent of urine

Vitals: temp: 99.4°F, temporal

Pulse: 98 bpm, regular
Respirations: 28 breaths per minute, pursed-lip breathing
Blood pressure: 150/90 mmHg
2. Towel bath with total assistance - a towel bath is the most appropriate bathing plan
for this client. It is quick and easy to administer and is the intervention that is least
taxing physically, considering the client's recent surgery, confusion, and respiratory
status
A nurse is caring for a client with an excessively dry mouth. Which nursing action is
important when providing care for this client? Select all that apply
1. Wearing clean gloves
2. Providing oral care every 2 years
3. Rinsing frequently with mouthwash
4. Cleansing 4 times a day with a water pick
5. Swabbing with a sponge-tipped applicator is lemon and glycerin
1. Wearing clean gloves
2. Providing oral care every 2 years
A nurse is providing perineal care to a male client. What should the nurse do? Select all
that apply
1. Wash the genital area with hot, sudsy water
2. Wash the scrotum before washing the glans penis
3. Wash the shaft of the penis while moving toward the urinary meatus
4. Wash the penis with one hand while holding it firmly with the other hand
5. Wash the glans with a circular motion, starting at the tip and then proceeding down
the shaft
4. Wash the penis with one hand while holding it firmly with the other hand
5. Wash the glans with a circular motion, starting at the tip and then proceeding down
the shaft
A school nurse teaches an adolescent who has dry skin and acne about skin care.
Which statement by the adolescent indicates that the information is understood? Select
all that apply
1. "I will scrub my face every day with a strong soap"
2. "I will break pustules carefully after washing my face"
3. "I will apply and oil-based emollient after washing my face"
4. "I will bathe my face with cool water when I shower in the morning
5. "I will use mild soap to gently cleanse my face thoroughly twice a day"
5. "I will use mild soap to gently cleanse my face thoroughly twice a day"
A nurse is observing a nursing assistant in a home-care setting administering a bed
bath. Which issue is apparent in the photograph indicates that the nursing assistant has
violated the standards of care for a bed bath? Select all that apply
1. The pillows behind the client's body should be removed before the bath
2. The nursing assistant's uniform is in contact with the client's linens
3. The nursing assistant should be making eye contact with the client
4. The client's left leg should be covered with the bath blanket
5. The nursing assistant is not wearing clean gloves
2. The nursing assistant's uniform is in contact with the client's linens
4. The client's left leg should be covered with the bath blanket
5. The nursing assistant is not wearing clean gloves
Which statement made by an older adult indicates to the nurse that additional teaching
about skin care is necessary? Select all that apply
1. "I limit my baths to twice a week"
2. "I humidify my home in the winter"
3. "I apply moisturizing lotion to my body daily"
4. "I use a bubble bath product when I take a bath"
5. "I love to relax in a hot bath before going to bed"
1. "I limit my baths to twice a week"
4. "I use a bubble bath product when I take a bath"
5. "I love to relax in a hot bath before going to bed"
Which of the following should the nurse implement when providing fingernail care during
a client's bath? Select all that apply
1. Push cuticles back with a section of a soft washcloth
2. File nails straight across, rounding corners slightly
3. Apply a moisturizing lotion around cuticles
4. Clean under nails with an orange stick
5. Soak hands in warm water first
All of the above