1. The nurse is preparing to bathe a patient. What should the room temperature be set at?

A. No warmer than 67° F

B. No cooler than 68° F
C. No cooler than 70° F
D. 75° F or warmer

The recommended room temperature is 68° to 74° F.

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

The sitz bath should last 20 to 30 minutes.

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

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.

4. What should the water temperature be when preparing a tepid bath for a patient?

a. 98.6° F
b. 100.2° F
c. 104.8° F
d. 110.4° F

The tepid bath is taken in water that is 98.6° F.

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 ulcer
d. Infection

A major manifestation of impaired skin integrity is a pressure ulcer.

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

A pressure ulcer occurs when there is sufficient pressure to collapse the blood vessels.

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

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.

8. The nurse assesses a red blister over the right superior iliac area of a patient. What stage is this
decubitus ulcer?

a. I
b. II
c. III
d. IV

A pressure ulcer demonstrating blisters is a stage II decubitus ulcer.

9. The nursing assessment of a pressure ulcer 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

Ongoing assessment of a pressure ulcer will evaluate whether improvement is occurring.

10. The nurse attempts to avoid a pressure ulcer 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

It is preferable to use the 30-degree lateral incline position.

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

A sense of well-being can stimulate appetite.

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

When reinserting dentures, replace the upper dentures first.

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
b. 105° F
c. 110° F
d. 120° F

Water at 110° F should be used to shampoo a patient's hair.

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

A patient with a bleeding disorder should use an electric razor.

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

The lower extremities of people with circulatory disorders are gently washed and patted dry, omitting
any stroking or massaging.
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. Physician
b. RN
c. CNA
d. Podiatrist

If the patient's nails are extremely hard, a podiatrist should provide care.

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

Catheter care should be performed at least two times daily.

18. The nurse is preparing to perform perineal care for the female patient. What is the best method for
using a bath blanket to drape the patient?

A. Square position
B. Long position
C. Diamond position
D. Rectangular position

Drape the patient with a bath blanket in the diamond position.

19. Clear water is used to cleanse the eyes. It is important to use proper technique when cleansing the
eyes to prevent infection. What direction will the water flow when cleansing a patient's eyes?

a. Upward toward the forehead

b. Downward toward the chin
c. From the outer toward the inner canthus
d. From the inner toward the outer canthus

The eye is cleansed from the inner to outer canthus.

20. How frequently should the nurse clean the nares of patients who have a nasogastric tube or are
receiving oxygen by nasal cannula?

a. At least every 2 hours

b. At least every 6 hours
c. At least every 8 hours
d. At least every 10 hours

When receiving oxygen by a nasal cannula or when a nasogastric tube is in place, the nurse should
cleanse the nares every 8 hours.
21. The nurse must follow the principles of medical asepsis while making a patient's bed, including
procedures for handling linens. How should the nurse handle soiled linens?

a. Place on the floor

b. Fan in the air
c. Hold away from the uniform
d. Place at the end of the bed

Soiled linen should not come into contact with a uniform.

22. How should the nurse cleanse the meatal opening when performing male perineal care?

a. From the meatus outward

b. With an alcohol swab
c. In a circular motion
d. With a cotton-tipped applicator

The nurse should cleanse the meatal opening from the meatus outward.

23. The nurse lowers the bed to place the patient on the bedpan. The angle of the head of the bed
should be raised to:

a. 20 degrees.
b. 45 degrees.
c. 90 degrees.
d. 30 degrees.

Elimination is facilitated with the head of the bed elevated 30 degrees.

24. What does the nurse recognize is important to consider when using the nursing process to plan
hygiene care of the patient?

a. Nurse's orders
b. Physician's orders
c. Patient's preferences
d. Outcome goals

Individual patients will have individual desires and choices.

25. The nurse is providing personal hygiene for a Hindu patient from India. What intervention should the
nurse implement?

a. Not serve meat

b. Shampoo the patient's hair weekly
c. Give a daily bath
d. Cut nails monthly

A daily bath is part of the religious duty of Indian Hindus.

26. The nurse is assisting a patient to perform personal hygiene. What is the most important focus of the
nurse when assisting this patient?

a. Nursing care
b. Independence
c. Repetition
d. Performance

The nurse should encourage the patient's independence as much as possible.

27. The nurse discovers a reddened area over a patient's hip. What should be the nurse's first
intervention?

a. Cover the area with an occlusive dressing

b. Apply mild ointment with a cotton-tipped applicator
c. Press the area gently to assess for blanching
d. Rub gently to increase circulation

If the area is a stage I decubitus ulcer, the area will not blanch.

28. The nurse is educating a patient regarding a tub bath. What is the maximum length of time the nurse
should instruct the patient to remain in the water?

a. 5 to 10 minutes
b. 10 to 20 minutes
c. 20 to 30 minutes
d. 30 to 40 minutes

A patient should not stay in the water for more than 20 minutes.

29. Where should a nurse performing a backrub begin?

a. Shoulder
b. Base of the neck
c. Sacral area
d. Lumbar area

The nurse should begin a massage in the sacral area.

30. The nurse is caring for a patient experiencing presbycusis. What intervention should the nursing
personnel be instructed to implement?

a. Speak quickly to the patient

b. Speak in loud tones to the patient
c. Speak slowly and clearly to the patient
d. Tell the patient they must purchase a hearing aid

Age-related hearing loss, presbycusis, is a common finding in older adults. It is important to speak slowly
and clearly to the patient with presbycusis. Not all patients with this type of hearing loss require a
hearing aid.
31. A physician orders a patient to be placed in the Trendelenburg position. How will the nurse position
the bed?

a. On the floor
b. Parallel with the floor
c. Tilted with the head of the bed down
d. Tilted with the foot of the bed down

The entire bed is tilted downward with the head of the bed down when placing a patient in the
Trendelenburg position.

32. The physician orders a patient to be placed in the reverse Trendelenburg position. How should the
nurse place the bed?

a. On the floor
b. Parallel with the floor
c. Tilted with the head of the bed down
d. Tilted with the foot of the bed down

The entire bed is tilted downward with the foot of the bed down when placing a patient in the reverse
Trendelenburg position.

33. Which guideline should be followed when giving a backrub?

a. Observing the skin for abnormalities

b. Massaging for at least 10 minutes
c. Following massage with a brisk alcohol rub
d. Conversing with patient continually throughout the backrub
e. Using alcohol-based lotion for disinfection

The backrub should last for about 3 to 5 minutes, giving the nurse an opportunity to observe for skin
abnormalities. Conversation should be kept to a minimum to enhance relaxation.

Alcohol either as a rub or used as disinfectant is drying to the skin.

34. The nurse is preparing to make an occupied bed. What procedure will the nurse follow to correctly
complete this task? (Select all that apply.)

a. Remove spread and blanket separately

b. Place soiled sheet at end of bed
c. Place bath blanket over patient on top sheet
d. Slide mattress to bottom of bed
e. Position patient to far side of bed

When making an occupied bed the nurse will remove the spread and blanket separately. The bath
blanket is placed over the patient on the top sheet and the patient is positioned to the far side of the
bed. Soiled linen is placed in the laundry bin, not at the end of the bed. The mattress is slid to the top of
the bed.
35. The nurse avoids dragging the patient across the bed linen to decrease the potential risk of skin
injury by _.

ANS:

friction

Dragging the patient across bed linen rather than lifting can cause skin damage from friction.

36. Because of its effect on epithelization, the LPN/LVN should confirm the order to use

or on a stage III pressure ulcer.

ANS:

peroxide, alcohol

Peroxide and alcohol have a negative effect on epithelization of a pressure ulcer.

37. To prevent skin breakdown in a wheelchair-bound patient, the nurse teaches the patient to shift the
patient's weight every minutes.

ANS:

15

People who are wheelchair-bound should shift their weight by pushing on the arms of their chair every
15 minutes to prevent skin breakdown.

38. As a safety precaution against breakage of dentures, the nurse should place in the emesis basin
before cleaning the dentures.

ANS:

water

Water in the basin will break the fall of the dentures if they are dropped.