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Kozier & Erbs Fundamentals of Nursing, 10/E
Chapter 33
Question 1
Type: MCSA
The nurse is preparing to provide morning care to a client. What should the
nurse explain to the client as the reason for a daily bath?
1. Assess skin integrity
2. Develop a nurseclient relationship
3. Moisturize the skin
4. Stimulate circulation
Correct Answer: 4
Rationale 1: Giving a bath to a client will allow the nurse to assess the skin but
this is not the most important purpose.
Rationale 2: Giving a bath to a client will allow the nurse to develop a

nurseclient relationship but this is not the most important purpose.
Rationale 3: Giving a bath to a client will allow the nurse to moisturize the skin
but this is not the most important purpose.
Rationale 4: The three major reasons for a bath are to remove waste products
such as perspiration, stimulate circulation, and refresh the client.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Basic Care and Comfort
QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and

respect for the diversity of human experience
AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered,

evidence-based care that respects patient and family preferences
NLN Competencies: Context and Environment; Practice; conduct population-

based transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 5. Identify the purposes of bathing.
MNL Learning Outcome: 4.4.1. Describe the hygienic practices implemented in

bathing a client.
Page Number: 674
Question 2
Type: MCSA
The nurse is preparing to bath a client on the first postoperative day. Which
nursing intervention should take priority?
1. Apply lotion to the extremities.
2. Change the water when it becomes cold.
3. Raise side rails when gathering supplies.
4. Remove the soiled dressing during the bath.
Correct Answer: 3
Rationale 1: Applying lotion to the skin would be performed before or after, not
during, the bath.
Rationale 2: Changing the water needs to be done before it becomes cold, but it
is not a priority.
Rationale 3: Raising the side rails would take priority when planning care. This
is a safety issue, and safety is second on Maslows hierarchy of needs. The client
is only 1 day postop and may still be sedated, posing a risk for a potential fall.
Rationale 4: A dressing change would be performed before or after, not during,

the bath and only with a doctors order.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control



Learning Outcome: 7. Compare and contrast the task-centered approach and

the person-centered approach to bathing.

bathing a client.
Page Number: 677
Question 3
Type: MCMA
A client who is ambulatory is able to get out of bed for morning care. What
should the nurse assess before assisting the client out of the bed to change the
linen?
Standard Text: Select all that apply.
1. Pulse
2. Respirations
3. Urine output
4. Blood pressure
5. Mobility status
Correct Answer: 1, 2, 4, 5
Rationale 1: When changing the linen of an unoccupied bed the nurse should
assess the clients pulse.
assess the clients respirations.
Rationale 3: Urine output does not need to be assessed prior to assisting a

client out of the bed to change the linen.
assess the clients blood pressure.
assess the clients mobility status.
Global Rationale:



Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15. Verbalize the steps used in: h. Changing an unoccupied
bed.

bathing a client.
Page Number: 710
Question 4
Type: MCSA
The nurse is shampooing a clients hair. Which assessment finding should the
nurse consider as expected?
1. Dry, dark, thin
2. Smooth, taut, shiny
3. Smooth texture and not oily or dry

4. Tender, warm scalp
Correct Answer: 3
Rationale 1: The hair should not be dry or thin. This could be a sign of alopecia.
Darkness would depend on hair color through the gene pool.
Rationale 2: Skin is assessed as being smooth, taut, or shiny, not hair.
Rationale 3: The hair should be smooth in texture and neither oily nor dry.
Rationale 4: A tender, warm scalp could indicate a problem, so this would not
be normal.
Global Rationale:



Learning Outcome: 3. Identify normal and abnormal assessment findings while

providing hygiene care.
MNL Learning Outcome: 4.4.4. Implement hygienic practices for the care of the
feet, hair, mouth, eyes, and ears.
Page Number: 700
Question 5
Type: MCSA
The nurse identifies the diagnosis Self-Care Deficit related to cognitive

impairment as appropriate for a client. What should the nurse select as an
expected outcome for this client?
1. The client will be able to name the staff that works on the day shift.
2. The client will eliminate safety hazards in her environment.
3. The client, with supervision, will brush her teeth.
4. The nurse will stress the importance of adequate fluid intake.
Correct Answer: 3
Rationale 1: Cognitive impairment limits the clients ability to understand and

comprehend; therefore, naming the staff is not within the clients realm of
understanding.

comprehend; therefore, eliminating safety hazards is not within the clients
realm of understanding.
Rationale 3: A client with cognitive impairment would be able to brush her teeth
but only with supervision. The client would not voluntarily brush her teeth
without prompting from the staff.

comprehend; therefore, stressing adequate fluid intake is not within the clients
realm of understanding.
Global Rationale:



Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 4. Apply the nursing process to common problems related to

hygienic care of the: skin, feet, nails, mouth, hair, eyes, and ears.
MNL Learning Outcome: 4.4.4. Implement hygienic practices for the care of the
Page Number: 672
Question 6
Type: MCSA
The nurse is reviewing assigned clients for morning care needs. Which situation
could pose a threat to one clients personal hygiene?
1. A client has a newly formed ileostomy.
2. A client performs meticulous foot care.
3. A German client refuses to bathe everyday.
4. The room temperature is set at 72F.
Correct Answer: 1
Rationale 1: Some of the factors that influence ones personal hygiene are social
practices, body image, knowledge of physical condition, and cultural variables. A
client who has had an ileostomy has had a body image change, which can
greatly influence whether he will care for it or rely on others. This can pose a
threat if the client chooses not to care for it.
Rationale 2: Performing meticulous foot care does not pose a threat to ones
hygiene.
Rationale 3: Bathing every other day does not pose a threat to ones hygiene.
Rationale 4: Room temperature of 72F does not pose a threat to ones hygiene.
Global Rationale:



Learning Outcome: 2. Identify factors influencing personal hygiene.
MNL Learning Outcome: 4.4.2. Recognize factors that influence hygienic

practices.
Page Number: 699
Question 7
Type: MCSA
The nurse is preparing to provide hygienic care to a client. On what will the
nurse focus this care?
1. Clothes
2. Family
3. Hair
4. Nutritional
Correct Answer: 3
Rationale 1: Hygienic care does not include care of the clients clothes.
Rationale 2: Hygienic care does not include care to the clients family.
Rationale 3: Hygiene care consists of skin, hair, hands, feet, eyes, nose, mouth,
back, and perineum.
Rationale 4: Hygienic care does not include the clients nutritional status.
Global Rationale:



Learning Outcome: 1. Describe hygienic care that nurses provide to clients.
MNL Learning Outcome: 4.4.4 Implement hygienic practices for the care of the
Page Number: 669
Question 8
Type: MCSA
A client needs to have soft contact lenses removed. What should the nurse do
when removing the lenses?
1. Gently pinch the lens and lift it out.
2. Have the client look up.
3. Pull the lower eyelid upward.
4. Use the pad of the ring finger.
Correct Answer: 1
Rationale 1: Gently pinching the lens and lifting it out is one of the correct steps
for removing a clients soft contact lenses.
Rationale 2: The nurse should have the client look straight ahead, not up.
Rationale 3: The upper eyelid is pulled down gently.
Rationale 4: The nurse would use the pad of the index finger, not the ring
finger.
Global Rationale:




Learning Outcome: 10. Identify the steps in removing contact lenses.
Page Number: 703
Question 9
Type: MCSA
The nurse is caring for a client with diabetes. What should the nurse include as
foot care for this client?
1. Cut toenails in a rounded shape and file.
2. Dry toes thoroughly.
3. Wash feet with water at a temperature of 90F to 98.6F.
4. Inspect feet thoroughly once a week.
Correct Answer: 2
Rationale 1: Toenails should be cut straight across, and nurses do not cut
diabetic clients toenails. Only a podiatrist should handle this task.
Rationale 2: Toes should be dried thoroughly after being washed to impede

fungal growth and prevent maceration.
Rationale 3: The water to wash the feet should be 100F to 110F.
Rationale 4: Feet should be inspected each day, not once a week, for early
detection of any problems.
Global Rationale:
Client Need: Health Promotion and Maintenance
Client Need Sub:



Learning Outcome: 15. Verbalize the steps used in: c. Providing foot care.
Page Number: 686
Question 10
Type: MCSA
A client has the nursing diagnosis Risk for Impaired Skin Integrity related to
immobility. Which nursing intervention should be identified for this clients
problem?
1. Encourage the client to eat at least 40% of meals.
2. Keep linens dry and wrinkle-free.
3. Restrict fluid intake.
4. Turn client every 3 hours.
Correct Answer: 2
Rationale 1: For nutritional support to promote healthy tissue, clients should

consume more than 40% of their meals.
Rationale 2: Keeping linens dry and wrinkle-free will prevent pressure areas.
Rationale 3: Fluids should not be restricted unless some other physical condition
dictates. The skin should be kept hydrated.
Rationale 4: To relieve pressure, the client should be turned every 2 hours, not
every 3.
Global Rationale:
Client Need Sub: Reduction of Risk Potential




Page Number: 686
Question 11
Type: MCSA
Unlicensed assistive personnel are caring for a clients ears. What information
should be reported to the nurse?
1. Excessive earwax
2. Loud talking
3. Presence of a hearing aid
4. Presence of any drainage

Correct Answer: 4
Rationale 1: Excess earwax is not an immediate problem.
Rationale 2: Loud talking could be an indication the client is hard of hearing,

which is not an immediate threat.
Rationale 3: The presence of a hearing aid should already be noted on the

clients admission assessment.
Rationale 4: The health care provider should report any drainage from the ears
to the nurse.
Global Rationale:
Client Need Sub: Reduction of Risk Potential

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused

physical, behavioral, psychological, spiritual, socioeconomic, and environmental
assessments of health and illness parameters in patients, using developmentally
and culturally appropriate approaches


providing hygiene care. 16. Recognize when it is appropriate to delegate
hygiene skills for clients to unlicensed assistive personnel.
MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all
aspects of the clients hygienic practices.
Page Number: 704
Question 12
Type: MCSA
A clients hearing aid needs to be removed. What action should the nurse
perform?
1. Assist the client with removal when necessary.
2. Instruct the client to remove the aid in the sunroom.
3. Leave the aid in place when bathing.
4. Send the aid home with the family.
Correct Answer: 1
Rationale 1: The small size of hearing aids may make it difficult for older adults
to manipulate, so they may need assistance in the aids removal.
Rationale 2: Clients are instructed not to remove their aids in common rooms
like a sunroom.
Rationale 3: The removal of the aid is necessary before bathing so that it is not
damaged.
Rationale 4: The aid should always be stored in the clients bedside tablenot sent
home with the familyso it is available for later use.
Global Rationale:



Learning Outcome: 12. Describe the steps for removing, cleaning, and inserting
hearing aids.
Page Number: 704
Question 13
Type: MCSA
A clients hearing aid needs to be cleaned. What action should the nurse take to
complete this task?
1. Clean with a dry, soft cloth.
2. Leave the battery in place when not in use.
3. Store the aid in the bathroom cabinet.
4. Use alcohol to remove any earwax.
Correct Answer: 1
Rationale 1: It is recommended by the manufacturers to clean the aid with a

dry, soft cloth to prevent any damage to the aid.
Rationale 2: The aid should be turned off and the battery removed to preserve
the life of the battery.
Rationale 3: The aid should be stored in a safe place where it will not get
damaged. It should not be stored in the bathroom cabinet.
Rationale 4: Alcohol is not recommended to be used on an aid because it could

damage the aid.
Global Rationale:



Learning Outcome: 12. Describe the steps for removing, cleaning, and inserting
hearing aids.
Page Number: 705
Question 14
Type: MCSA
The nurse is making a clients bed. What safety measure should the nurse
implement at this time?
1. Begin at the head and move toward the foot, loosening bottom linens.
2. Miter corners at the head of the bed.
3. Place the soiled sheet in a laundry bag.
4. Prepare the client.
Correct Answer: 3
Rationale 1: Beginning at the head and moving toward the foot, loosening the
bottom linens, provides maximum work space.
Rationale 2: Mitering the corners at the head of the bed prevents linens from
becoming easily loosened.
Rationale 3: Placing the soiled sheet in the laundry bag reduces the spread of
microorganisms, which is a safety measure for both the nurse and client.
Rationale 4: Preparing the client readies the client for the procedure.
Global Rationale:




Learning Outcome: 14. Identify safety and comfort measures underlying bed-
making procedures.
Page Number: 680
Question 15
Type: MCMA
The nurse is preparing to remove ticks from a clients scalp. Which actions
should the nurse perform to safely remove these pathogens from the client?
1. Grasp the tick with blunt tweezers.
2. Apply heat to the tick with a match.
3. Wash the area with antibacterial soap.
4. Pull the tick away in a perpendicular movement.
5. Apply petroleum jelly to the surface of the tick.
Correct Answer: 1, 3, 4
Rationale 1: To remove a tick, grasp the tick as close to the skin as possible
with blunt tweezers.
Rationale 2: Applying heat to the tick with a match is a dangerous practice and
should not be done.
Rationale 3: After the tick is removed, wash the area with antibacterial soap.
Rationale 4: Gently pull the tick away using a perpendicular motion.
Rationale 5: Applying petroleum jelly to the surface of the tick is an ineffective

approach to remove a tick.
Global Rationale:




Page Number: 698
Question 16
Type: MCSA
The nurse is making an occupied bed. Which step will provide comfort for the
client during this linen change?
1. Allow for a toe pleat.
2. Place a bath blanket over the client.
3. Slide the mattress to the head of the bed.
4. Raise the side rail.
Correct Answer: 1
Rationale 1: Allowing for a toe pleat provides for client comfort.
Rationale 2: Placing the bath blanket over the client prevents unnecessary
exposure.
Rationale 3: Sliding the mattress to the head of the bed makes it easier to tuck
in the linens.
Rationale 4: Raising the side rail maintains client safety.
Global Rationale:



making procedures. 15. Verbalize the steps used in: i. Changing an occupied
bed.
Page Number: 711
Question 17
Type: MCSA
The nurse is preparing to shave a client. Which action step should the nurse
consider when providing this care?
1. Assist the client to a prone position.
2. Pull the skin taut with the dominant hand.

3. Rinse the razor after each stroke.
4. Use long strokes.
Correct Answer: 3
Rationale 1: Assist the client to a sitting positionnot a prone positionbecause

this is a more natural position.
Rationale 2: The skin should be pulled taut with the nondominant handnot the
dominant handbecause this provides uniform shaving.
Rationale 3: Rinsing the razor after each stroke keeps the cutting edge clean.
Rationale 4: Short strokes should be usednot long strokesbecause this provides

for a closer shave without irritation.
Global Rationale:




Page Number: 702
Question 18
Type: MCSA
The nurse is preparing to provide a client with mouth care. What should the
nurse do to ensure safe handling of the clients dentures?
1. Clean biting surfaces.
2. Place a washcloth in the bowl of the sink.
3. Replace the upper dentures first.
4. Rinse dentures thoroughly with hot water.
Correct Answer: 2
Rationale 1: Cleansing biting surfaces prevents bacteria, odor, and stain

formation.
Rationale 2: Placing a washcloth in the bowl of the sink serves as a cushion for
the dentures if accidentally dropped.
Rationale 3: Replacing the upper dentures first promotes comfort.
Rationale 4: Dentures should be rinsed thoroughly with tepid water, not hot
water, because extreme temperatures will harm dentures.
Global Rationale:



Learning Outcome: 15. Verbalize the steps used in: e. Providing special oral
care.
Page Number: 695
Question 19
Type: MCSA
A connection on a clients intravenous solution was dislodged and solution

saturated the clients gown and bed linens. The nurse will provide which type of
hygienic care to the client?
1. Hour-of-sleep care
2. As-needed care
3. Early morning care
4. Morning care
Correct Answer: 2
Rationale 1: Hour-of-sleep care includes providing for elimination needs,

washing the face and hands, oral care, and a back massage.
Rationale 2: As-needed care is provided as required by the client. Because the

intravenous solution has saturated the gown and bed linens, this is the type of
care the client needs at this time.
Rationale 3: Early morning care is provided to clients as they awaken in the

morning and consists of aiding to void, washing the face and hands, and
providing oral care.
Rationale 4: Morning care is usually after breakfast and includes providing for
elimination needs, a bath or shower, perineal care, back massage, and oral,
nail, and hair care.
Global Rationale:



Learning Outcome: 1. Describe hygienic care that nurses provide to clients.
Page Number: 670
Question 20
Type: MCSA
A client tells the nurse that bathing is done at the sink in the bathroom at home
because it is difficult to physically lift the legs to get into the shower. The nurse
identifies which factor as influencing this clients hygienic practice?
1. Religion
2. Personal preference
3. Culture
4. Health and energy
Correct Answer: 4
Rationale 1: The clients inability to lift the legs to get into the shower is not a
religious practice.
personal preference.
cultural preference.
Rationale 4: Ill people or those with neuromuscular disorders may not be able
to perform hygienic care.
Global Rationale:




Learning Outcome: 2. Identify factors influencing personal hygiene.
Page Number: 670
Question 21
Type: MCSA
During the morning bath of a client, the nurse identifies areas of erythema
below the clients breasts. What should the nurse do to enhance comfort and
healing for the client?
1. Wash the skin carefully.
2. Apply alcohol-free lotion.
3. Wash the area without soap.
4. Remove hair in the area.
Correct Answer: 1
Rationale 1: For areas of erythema, the nurse should wash the area carefully to
remove microorganisms.
Rationale 2: Alcohol-free lotion would be applicable for excessively dry skin

areas.
Rationale 3: Washing without soap would be applicable for excessively dry skin
areas.
Rationale 4: Removing the hair would be applicable for hirsutism.
Global Rationale:




Page Number: 671
Question 22
Type: MCSA
While providing a complete bed bath to a client, the nurse discovers abrasions
along the clients back and upper buttock area. What should the nurse do to help
this client?
1. Apply antiseptic spray to the abrasions.
2. Do not wash the client with soap.
3. Find assistance to help with the remainder of the bath.
4. Apply alcohol-free lotion to the abrasions.
Correct Answer: 3
Rationale 1: Applying antiseptic spray would be applicable for areas of erythema

but not for abrasions.
Rationale 2: Avoiding soap would be applicable for excessively dry skin.
Rationale 3: Because the client has abrasions over the back and upper buttock
area, the nurse should lift and not pull or slide the client. The nurse needs to
find assistance to help with the remainder of the bath.
Rationale 4: Applying alcohol-free lotion would be applicable for excessively dry

skin but not for abrasions.
Global Rationale:




Page Number: 671
Question 23
Type: MCMA
The nurse wants to assess a client during the morning bath. What will the nurse
be able to assess during this time?

1. Skin status
2. Financial status
3. Psychosocial needs
4. Learning needs
5. Physical conditions
Rationale 1: Assessment of the skin can be done during the morning bath.
Rationale 2: The clients financial status is an area not usually assessed during
the morning bath.
Rationale 3: The clients psychosocial needs can be assessed during the morning
bath.
Rationale 4: The clients learning needs regarding hygienic care can be assessed
during the morning bath.
Rationale 5: Assessing the clients physical conditions can be done during the
morning bath.
Global Rationale:





providing hygiene care.
Page Number: 672
Question 24
Type: MCMA
A client is prescribed bed rest with bathroom privileges. Which types of bath
would be appropriate for this client?
1. Shower
2. Tub bath
3. Self-help bed bath
4. Therapeutic bath
5. Partial bath
Correct Answer: 3, 5
Rationale 1: Getting into and out of a shower might be too strenuous for a client
prescribed bed rest with bathroom privileges.
Rationale 2: Getting into and out of a bathtub might be too strenuous for a
client prescribed bed rest with bathroom privileges.
Rationale 3: Because the client is prescribed bed rest with bathroom privileges,
the self-help bed bath would be appropriate because the client can
independently wash with some help from the nurse.
Rationale 4: A therapeutic bath is for some physical effect and not used
routinely for morning care.
Rationale 5: Because the client is prescribed bed rest with bathroom privileges,
the partial bath would be appropriate because the client can independently
wash with some help from the nurse to wash the back area.
Global Rationale:


evidence-based care that respects patient and family preferences.

Learning Outcome: 6. Describe various types of baths.
Page Number: 671
Question 25
Type: MCSA
A client with a skin rash is prescribed a bath in which medication is added to the
bath water. The nurse should plan for the client to receive which type of bath?
1. Shower
2. Tub
3. Partial
4. Complete
Correct Answer: 2
Rationale 1: A shower would not permit the medication to be in contact with the
clients skin long enough.
Rationale 2: Therapeutic baths are given for physical effects, such as to soothe
irritated skin or to treat an area. Medications may be placed in the water. A
therapeutic bath is generally taken in a tub one-third or one-half full. The client
remains in the bath for a designated time, often 20 to 30 minutes. If the clients
back, chest, and arms are to be treated, these areas need to be immersed in
the solution.
Rationale 3: A partial bath would not permit the medication to be in contact

with the clients skin long enough.
Rationale 4: A complete bath would not permit the medication to be in contact

with the clients skin long enough.
Global Rationale:
Client Need Sub: Pharmacological and Parenteral Therapies




Page Number: 675
Question 26
Type: MCSA
A client tells the nurse that she does not want to get into the tub for a morning
bath. The client has not been bathed for several days. What should the nurse
do?
1. Assign UAP the task of giving the client a bath.
2. Skip the clients bath and document refused in the medical record.
3. Ask the client the usual way bathing occurs at home.
4. Tell the client that a bath is needed and ignore the clients comment.
Correct Answer: 3
Rationale 1: Assigning a UAP the task of giving the client a bath is following the
task-centered approach.
Rationale 2: Skipping the clients bath and documenting refused is not following
a client-centered approach.
Rationale 3: To provide a person-centered approach to bathing, the nurse

should ask the client to describe the usual way bathing occurs at home.
Rationale 4: Telling the client that a bath is needed and ignoring the clients
comment is not following a client-centered approach.
Global Rationale:
Client Need: Psychosocial Integrity
Client Need Sub:



Learning Outcome: 7. Compare and contrast the task-centered approach and

the person-centered approach to bathing.
MNL Learning Outcome: 4.4.2 Recognize factors that influence hygienic

practices.
Page Number: 674
Question 27
Type: MCSA
An older client tells the nurse that showers are not taken because of a previous
fall. What can the nurse do to support the clients bathing needs?
1. Obtain a shower chair and assist the client in the shower.
2. Document that the client refused a morning bath in the medical record.
3. Tell the client that shower shoes can be worn to prevent falls.
4. Hold the client during the shower.
Correct Answer: 1
Rationale 1: To provide person-centered care with bathing, the nurse should

obtain a shower chair. This should eliminate the clients fear of falling when in
the shower.
Rationale 2: The client did not refuse a morning bath but rather explained why
showers are not used.
Rationale 3: Shower shoes may not be sufficient to eliminate the clients fear of
falling when in the shower.
Rationale 4: The nurse would not be able to hold the client during the shower.
Global Rationale:



Learning Outcome: 13. Discuss factors that support a positive and safe
environment for the client.

practices.
Page Number: 675
Question 28
Type: MCMA
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?
1. Move slowly.
2. Be flexible.
3. Help the client feel in control.
4. Avoid stopping once the bath is started.
5. Be prepared.
Rationale 1: When bathing a client with dementia, the nurse should move
slowly.
Rationale 2: When bathing a client with dementia, the nurse should be flexible
to adapt the approach to meet the needs of the client.
Rationale 3: When bathing a client with dementia, the nurse should offer the
client choices in order for the client to feel in control.
Rationale 4: When bathing a client with dementia, the nurse should stop if the
client begins to feel distressed.
Rationale 5: When bathing a client with dementia, the nurse should be prepared
with all items prior to starting the bath.
Global Rationale:




Learning Outcome: 8. Describe guidelines for bathing persons with dementia.

practices.
Page Number: 681
Question 29
Type: MCSA
A client has hard contact lenses. What should the nurse do to assist the client in
the care of the lenses?
1. Pinch the lenses out of the clients eyes to remove.
2. Remove both of the clients lenses before storing in the appropriate storage
cup.
3. Document when the lenses need to be removed and cleaned every 2 weeks.
4. Ask the client how many hours the lenses are worn each day.
Correct Answer: 4
Rationale 1: Hard contact lenses are not removed by pinching.
Rationale 2: The nurse should remove one lens at a time and store in the
appropriate storage cup.
Rationale 3: Hard contact lenses should be removed and cleaned every day, not
every 2 weeks.
Rationale 4: Hard contact lenses should only be worn for 12 to 14 hours.

Global Rationale:



Learning Outcome: 9. Discuss the different types of contact lenses.

practices.
Page Number: 703
Question 30
Type: MCSA
During an assessment, the nurse learns a client has soft contact lenses that
have not been removed or cleaned for weeks. What should the nurse do?
1. Nothing, because these types of lenses can be worn for months.
2. Remove the clients lenses, wrap in tissue, and place in the bedside table.
3. Assist the client to remove and clean the contacts.
4. Ask the physician for ophthalmology consult because the client will need help
removing the lenses.
Correct Answer: 3
Rationale 1: This type of lens should not be worn for more than 30 days.
Rationale 2: The lenses should not be wrapped in tissue because this will cause
the lenses to dry out and not be able to be worn or used.
Rationale 3: Most eye specialists recommend that soft contact lenses be

removed and cleaned every week. The nurse should assist the client to remove
and clean the contacts.
Rationale 4: The client does not need ophthalmology consult. The nurse can
help the client remove the lenses.
Global Rationale:



Learning Outcome: 9. Discuss the different types of contact lenses. 10. Identify
the steps in removing contact lenses.

practices.
Page Number: 703
Question 31
Type: SEQ
The nurse is assisting a client in removing soft contact lenses. Place in order the
steps the nurse should take to help this client.
Standard Text: Click and drag the options below to move them up or down.
Choice 1. Using the pad of the index finger of the other hand, move the lens
down to the sclera.
Choice 2. Have the client look forward.

Choice 3. Apply gloves.
Choice 4. Gently pinch the lens between the pads of the thumb and index
finger.
Choice 5. Retract the lower lid with one hand.
Correct Answer: 3, 2, 5, 1, 4
Rationale 1: The nurse should use the pad of the index finger of the other hand
to move the lens down to the sclera.
Rationale 2: The nurse should ask the client to look forward.
Rationale 3: The first step is for the nurse to apply gloves.
Rationale 4: The nurse should gently pinch the lens between the pads of the
thumb and index finger to remove the lens.
Rationale 5: The nurse should retract the lower lid with one hand.
Global Rationale:



Learning Outcome: 10. Identify the steps in removing contact lenses.

practices.
Page Number: 703
Question 32
Type: MCSA
The client has a hearing aid with an earpiece that is connected by a cord to a
receiver that the client keeps in a shirt pocket. The nurse would document this
as which type of hearing aid?
1. Body hearing aid
2. In-the-canal aid
3. Completely-in-the-canal aid
4. Eyeglasses aid
Correct Answer: 1
Rationale 1: A body hearing aid is a pocket-sized aid that clips onto a shirt
pocket. The case, containing the microphone and amplifier, is connected by a
cord to the receiver, which snaps into the earpiece.
Rationale 2: An in-the-canal aid is a hearing aid that fits directly into the clients
ear and is barely visible. It is not connected to a receiver worn by the client.
Rationale 3: A completely-in-the-canal aid is a hearing aid that fits inside the

clients ear canal and is not visible. It is not connected to a receiver worn by the
client.
Rationale 4: An eyeglass aid has a hearing aid attached to the eyeglasses and is
not connected to a receiver worn by the client.
Global Rationale:
Client Need: Health Promotion and Maintenance
Client Need Sub:



Learning Outcome: 11. Discuss the different types of hearing aids.

practices.
Page Number: 705
Question 33
Type: MCSA
The nurse has delegated the making of unoccupied beds to unlicensed assistive
personnel. What should the nurse assess regarding client safety once the beds
are completed?
1. Folding of the top sheet
2. Direction of the pillow
3. Call light being readily available
4. Presence of mitered corners
Correct Answer: 3
Rationale 1: The folding of the top sheet is not important for client safety.
Rationale 2: The direction of the pillow is not important for client safety.
Rationale 3: The nurse should assess for the call light being readily available
while the client is out of the bed.
Rationale 4: The presence of mitered corners is not important for client safety.
Global Rationale:



making procedures.
Page Number: 712
Question 34
Type: MCMA
A client recovering from acute illness has just received a tub bath. When
documenting the bath, what should the nurse include?
1. Clients ability to maintain a conversation during the procedure
2. Clients tolerance of the procedure
3. Condition and integrity of the skin
4. Client strength
5. Percentage of bath done without assistance
Rationale 1: It is not necessary for the nurse to document if the client was
maintaining a conversation during the bath.
Rationale 2: When evaluating the clients bath, the nurse should include the
clients tolerance of the procedure.
condition and integrity of the clients skin.
clients strength.
percentage of the bath done without assistance.
Global Rationale:

AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the

effectiveness of psychobiological interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 17. Demonstrate appropriate documentation and reporting

of hygiene skills.
Page Number: 675
Question 35
Type: MCSA
The nurse has completed foot care for a client as part of routine morning care.
What should the nurse document about the procedure?
1. The condition of the skin and nails
2. Nothing unless a problem is noted
3. The amount of time taken on foot care
4. The clients comments about the foot care

Correct Answer: 2
Rationale 1: The nurse does not need to document the condition of the skin and
nails unless a problem is noted.
Rationale 2: Foot care is not generally recorded unless problems are noted.
Rationale 3: The nurse does not need to document the amount of time taken on
foot care.
Rationale 4: The nurse does not need to document the clients comments about
the foot care.
Global Rationale:

AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the

effectiveness of psychobiological interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 17. Demonstrate appropriate documentation and reporting

of hygiene skills.
Page Number: 686

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Kozier & Erbs Fundamentals of Nursing, 10/E

1. Assess skin integrity

2. Develop a nurseclient relationship

3. Moisturize the skin

Rationale 2: Giving a bath to a client will allow the nurse to develop a

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and

AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered,

NLN Competencies: Context and Environment; Practice; conduct population-

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Identify the purposes of bathing.

MNL Learning Outcome: 4.4.1. Describe the hygienic practices implemented in

Page Number: 674

1. Apply lotion to the extremities.

2. Change the water when it becomes cold.

3. Raise side rails when gathering supplies.

4. Remove the soiled dressing during the bath.

Rationale 4: A dressing change would be performed before or after, not during,

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and

AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered,

NLN Competencies: Context and Environment; Practice; conduct population-

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Compare and contrast the task-centered approach and

MNL Learning Outcome: 4.4.1. Describe the hygienic practices implemented in

Page Number: 677

Standard Text: Select all that apply.

Rationale 3: Urine output does not need to be assessed prior to assisting a

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and

AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered,

NLN Competencies: Context and Environment; Practice; conduct population-

Nursing/Integrated Concepts: Nursing Process: Assessment

MNL Learning Outcome: 4.4.1. Describe the hygienic practices implemented in

Page Number: 710

1. Dry, dark, thin

2. Smooth, taut, shiny

3. Smooth texture and not oily or dry

4. Tender, warm scalp

Rationale 2: Skin is assessed as being smooth, taut, or shiny, not hair.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and

AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered,

NLN Competencies: Context and Environment; Practice; conduct population-

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Identify normal and abnormal assessment findings while

Page Number: 700

The nurse identifies the diagnosis Self-Care Deficit related to cognitive

2. The client will eliminate safety hazards in her environment.

3. The client, with supervision, will brush her teeth.

4. The nurse will stress the importance of adequate fluid intake.

Rationale 1: Cognitive impairment limits the clients ability to understand and

Rationale 2: Cognitive impairment limits the clients ability to understand and

Rationale 4: Cognitive impairment limits the clients ability to understand and