H32/142480/2021 Gituku Sandra Waithera

QUESTIONS

1. The client is unresponsive & requires total care by nursing staff. Which assessment does nurse
check first before providing special oral care to client?
A. Presence of pain
B. Condition of the skin
C. Gag reflex
D. Range of motion

2. A nurse is scheduling hygiene for patients on her unit. What is the most important consideration
when planning a patient's personal hygiene?
A) When the patient had his or her most recent bath
B) The patient's usual hygiene practices and preferences
C) Where the bathing fits in the nurse's schedule
D) The time that is convenient for the patient care assistant

3. A nurse assisting with a patient bed bath observes that an older female patient has dry skin. The
patient states that her skin is always "itchy." Which nursing action would be the nurse's best
response?
A) Bathe the patient more frequently.
B) Use an emollient on the dry skin.
C) Massage the skin with alcohol.
D) Discourage fluid intake.

4. A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an
essential part of nursing care. What are some of the benefits of providing this care? Select all that
apply.
A) It promotes the patient's sense of well-being.
B It prevents deterioration of the oral cavity.
C) It contributes to decreased incidence of aspiration pneumonia.
D) It eliminates the need for flossing.
E) It decreases oropharyngeal secretions.
F) It compensates for an inadequate diet.

5. Nurses performing skin assessments on patients must pay careful attention to cleanliness, color,
texture, temperature, turgor, moisture, sensation, vascularity, and lesions. Which guidelines
should nurses follow when performing these assessments? Select all that apply.
A) Compare bilateral parts for symmetry.
B) Proceed in a toe-to-head systematic manner.
C) Use standard terminology to report and record findings.
D) Do not allow data from the nursing history to direct the assessment.
E) Document only skin abnormalities on the patient record.
F) Perform the appropriate skin assessment when risk factors are identified.
6. Mr. James has an eye infection with a moderate amount of discharge. Which action would be
most appropriate for the nurse to use when cleaning his eyes?
A) Using hydrogen peroxide
B) Wiping from the outer canthus to the inner canthus
C) Positioning him on the same side as the eye to be cleansed
D) Using only one cotton ball per eye

7. A nurse is teaching a student nurse how to cleanse the perineal area of both male and female
patients. What are accurate guidelines when performing this procedure? Select all that apply.
A) For male and female patients, wash the groin area with a small amount of soap and
water and rinse.
B) For a female patient, spread the labia and move the washcloth from the anal area toward the
pubic area.
C) For male and female patients, always proceed from the most contaminated area to the least
contaminated area.
D) For male and female patients, use a clean portion of the washcloth for each stroke.
E) For a male patient, clean the tip of the penis first, moving the washcloth in a circular
motion from the meatus outward.
F) In an uncircumcised male patient do not retract the foreskin (prepuce) while washing the penis.

8. Partial bath means cleanse only the areas that may cause odor or discomfort
A. True
B. False
9. Wash patients extremities from ____
A. Front to Back
B. Proximal to Distal
C. Distal to Proximal
10. Which is not a type of bath ?
A. Towel Bath
B. Bag Bath
C. Shower Bath
D. Tub Bath
E. Chair Bath

11. Describe how pressure ulcers can be graded 10 marks

Grade 1 pressure ulcers are usually noted when there is skin discolouration. The skin is
usually red, blue, purple or black depending on the patient’s skin tone. The affected area is
non-blanchable, may be painful and may feel warmer or cooler than the adjacent tissue.
Grade 2 pressure ulcers are noted when the upper layers of the skin like the epidermis and
dermis break open and form what may appear to be an abrasion, a blister or a shallow
crater like open ulcer on the skin. They are usually painful and tender and have a red or
pink wound bed.
Grade 3 pressure ulcers are noted when the subcutaneous fat tissue is exposed due to full
thickness skin loss and worsening of the sore that was present in grade 2.
Grade 4 pressure ulcers are noted when muscle and bone are exposed due to severe and
extensive damage of the overlying tissues. Tendons and joints may also be involved.
Infection is a great risk at this stage.
Unstageable is when there is full tissue loss in a pressure ulcer but the base of the ulcer is
covered in slough hence the true depth and stage of the ulcer cannot be immediately
determined.