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Hygiene

1. A client can bathe most of her body except for the back, hands, and feet. She also can walk to and from the bathroom and dress herself when given clothing. Which functional level describes this client?

Totally dependent (+4)

Moderately dependent (+3)

Semidependent (+2)

Independent (0)

2. The client is unresponsive and requires total care by nursing staff. Which assessment does the nurse check first before providing special oral care to the client?

Presence of pain

Condition of the skin

Gag reflex

Range of motion

3. Which assessment finding would be normal with a client’s hair when giving shampoo?

Dry, dark, thin

Smooth, taut, shiny

Smooth texture and not oily or dry

Tender, warm scalp

4. The client wears an in-the-ear (ITE) hearing aid and because of arthritis needs someone to insert the hearing aid. Which action does the nurse teach the unlicensed assistive personnel (UAP) to do before inserting the client’s hearing aid?

Turn the hearing aid off.

Soak the hearing aid in soapy solution to clean it.

Turn the volume all the way up.

Remove the batteries.

5. When making a client’s bed, the nurse will implement which safety measure?

Begin at the head and move toward the foot, loosening the bottom linens

Miter concerns at the head of the bed

Place the soiled sheet in a laundry bag

Prepare the client

6. The nurse is preparing to provide a morning bath to a client diagnosed with dementia. What can the nurse do to ensure a positive bathing experience for the client? Select all that apply

Move slowly

Be flexible

Help the client feel in control

Avoid stopping once the bath has started

Be prepared

7. The nurse is observing the unlicensed assistive personnel (UAP) perform perineal care for a client. Which action indicates that the nurse needs to discuss additional teaching with the UAP?

Uses a clean portion of the washcloth for each stroke

Wipes from the pubis to the rectum

Uses clean gloves

Does not retract the foreskin

8. The nurse is planning a presentation on oral health at an intergenerational community center. Which statements will be important to include? Select all that apply.

Using a bottle during naps and bedtime can cause dental caries in a toddler.

Schedule a visit to the dentist when your child is ready to go to school.

It is important for parents to supervise a child’s brushing of their teeth.

Most older adults have dentures and don’t need to worry about oral care.

Older adults are at risk for periodontal disease.

9. The nurse is discussing foot care with a client who was recently diagnosed with diabetes. Which statement by the client indicates a need for further teaching?

“I am going to use a mirror to check my feet.”

“I enjoy walking barefoot around the house.”

“I will file my nails.”

“I will increase the time that I wear new shoes each day.”

10. The client is complaining of shortness of breath. His respirations are 28 and labored. The bed is currently in the flat position. The nurse puts the bed in which position?

Fowler’s

Semi-Fowler’s

Trendelenburg

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