Potter: Fundamentals of Nursing, 9th Edition

Chapter 40: Hygiene

Answer Key - Review Questions and Rationales

1. Answer: 2, 3.
Place the unconscious patient in semi-Fowler’s position with head to the side or use the Sims’
position to help avoid aspiration while performing oral care. The supine and Trendelenburg
positions would make it easier for a patient to aspirate. The prone position would not be suitable
for accessing the oral cavity.

2. Answer: 2, 4, 5.
Because of a patient’s risk for infection, it is important to assess skin for redness, abrasions, and
open areas daily. Apply lotion to feet daily to keep the skin hydrated, but do not leave excess
lotion on the skin. Clean between toes carefully after bathing to avoid maceration. Do not cut
nails or soak the feet of a patient with diabetes because this may create skin breakdown and open
sores, leading to skin breakdown or infection.

3. Answer 1.
Bathing a patient with long, firm strokes distal to proximal promotes circulation and increases
venous return.

4. Answer: 3, 4.
Radiation therapy reduces salivary flow. Dehydration impairs salivary secretion in the mouth.
Cough drops increase sugar or acid content in the mouth, causing caries. Immunosuppression
causes inflammation and bleeding of the gums. An oral airway irritates oral mucosa.

5. Answer: 4.
All of the patients require careful bathing. The 44-yearold female needs good perineal hygiene.
The 56-year-old patient is at risk for drying and fragility of the skin. The 60-year-old patient has
reduced sensation and mobility and thus is unaware of skin problems or pressure areas. However,
the 70-year-old patient has reduced circulation, which increases risk for infection, and is likely
unaware of skin problems because of dementia. The presence of stool will also irritate the skin.

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Answer Key - Review Questions and Rationales 2

6. Answer: 3, 4.
Check a patient’s respirations and whether there is a gag reflex present to determine risk for
aspiration and to establish a baseline for the patient’s condition.

7. Answer: 1.
The patient should not use water to clean soft contact lenses.

8. Answer: 1, 3, 4.
The American Dental Association guidelines (2014) for effective oral hygiene include brushing
the teeth at least twice a day with an American Dental Association–approved fluoride toothpaste.
Use antimicrobial toothpastes and 0.12% CHG oral rinses for patients at increased risk for poor
oral hygiene (e.g., older adults and patients with cognitive impairments and who are
immunocompromised). Rounded soft bristles stimulate the gums without causing abrasion and
bleeding. Patients should clean gum and the surface of the tongue.

9. Answer: 3.
A patient with urinary and bowel incontinence needs perineal cleaning with each episode of
soiling, whereas patients who are normally inactive during the day and have skin that tends to be
dry may need to bathe only twice a week.

10. Answer: 1, 4.
Dentures or partial plates do not always fit properly, causing pain and discomfort. Many older
adults are edentulous (without teeth), and the teeth that are present are often diseased or decayed.
An age-related decline in saliva secretion is common. The periodontal membrane weakens with
aging, making the area prone to infection. Normally aging does not affect temperature sensitivity.

11. Answer: 2, 5, 1, 3, 6, 4.

12. Answer: 2.
ROM may be delegated to nursing assistive personnel. The other activities should be performed
by the nurse.

13. Answer: 3.
Cultural beliefs often influence patients’ hygiene practices. Middle Eastern practices encourage
one hand to be kept clean at all times.

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Answer Key - Review Questions and Rationales 3

14. Answer: 4.
Patients prone to bleeding (e.g., those receiving anticoagulants or high doses of aspirin or those
with low platelet counts) need to use an electric razor.

15. Answer: 3.
Normal saline is the safest solution to use in caring for a patient with stomatitis. Alcohol and
community mouthwashes can be irritating and burning. A soft toothbrush should be used.

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