Session 11

1. A young, handsome man with a diagnosis of antisocial personality disorder is being discharged from the hospital next week.
He asks the nurse for her phone number so that he can call her for a date. The nurse’s best response would be:
A. “We are not permitted to date clients.”
B. “No, you are a client and I am a nurse.”
C. “I like you, but our relationship is professional.”
D. “It’s against my professional ethics to date clients.”

Answer: C
Rationale: This accepts the client as a person of worth rather than being cold or implying rejection. However, the nurse
maintains a professional rather than a social role.

2. A client with avoidant personality disorder says occupational therapy is boring and doesn’t want to go. Which action would
be best?
A. State firmly that you’ll escort him to OT.
B. Arrange with OT for the client to do a project on the unit.
C. Ask the client to talk about why OT is boring
D. Arrange for the client not to attend OT until he is feeling better

Answer: A
Rationale: If given the chance, a client with avoidant personality disorder typically elects to remain immobilized. The nurse
should insist that the client participates in OT.

3. A nurse notices other clients on the unit avoiding a client diagnosed with antisocial personality disorder. When discussing
appropriate behavior in group therapy, which of the following comments is expected about this client by his peers?
A. Lack of honesty
B. Belief in superstitions
C. Show of temper tantrums
D. Constant need for attention

Answer: A
Rationale: Clients with antisocial personality disorder tend to engage in acts of dishonesty as shown by lying.

4. Which of the following information must be included for the family of a client diagnosed with dependent personality disorder?
A. Address coping skills
B. Explore panic attacks
C. Promote exercise programs
D. Decrease aggressive outbursts

Answer: A
Rationale: The family needs information about coping skills to help the client learn to handle stress.

5. Which of the following characteristics is expected for a client with paranoid personality disorder who receives bad news?
A. The client is overly dramatic after hearing the facts
B. The client focuses on self to not become over-anxious
C. The client responds from a rational, objective point of view
D. The client doesn’t spend time thinking about the information.

Answer: C
Rationale: Clients with paranoid personality disorder are affectively restricted, appear unemotional, and appear rational and
objective.

6. A hospitalized client, diagnosed with a borderline personality disorder, consistently breaks the unit’s rules. This behavior
should be confronted because it will help the client:
A. Control anger
B. Reduce anxiety
C. Set realistic goals
D. Become more self-aware

Answer: D
Rationale: Client’s must first become aware of their behavior before they can change it. Occurs after the client is aware of the
behavior and has a desire to change the behavior.

7. Which of the following types of behavior is expected from a client diagnosed with a paranoid personality disorder?
A. Eccentric
B. Exploitative
C. Hypersensitive
D. Seductive

Answer: C
Rationale: People with paranoid personality disorders are hypersensitive to perceived threats.

8. An adult client with a borderline personality disorder become nauseated and vomits immediately after drinking after drinking
2 ounces of shampoo as a suicide gesture. The most appropriate initial response by the nurse would be to:
A. Promptly notify the attending physician
B. Immediately initiate suicide precautions
C. Sit quietly with the client until nausea and vomiting subsides
D. Assess the client’s vital signs and administer syrup of ipecac

Answer: C
Rationale: This intervention demonstrates the nurse’s caring presence which is vital for this client.

9. A client with schizotypal personality disorder is sitting in a puddle of urine. She’s playing in it, smiling, and softly singing a
child’s song. Which action would be best?
A. Admonish the client for not using the bathroom
B. Firmly tell the client that her behavior is unacceptable
C. Ask the client if she’s ready to get cleaned up now
D. Help the client to the shower, and change the bedclothes.

Answer: D
Rationale: A client with schizotypal personality disorder can experience high levels of anxiety and regress to childlike
behaviors. This client may require help needing self-care needs. The client may not respond to the other options or those
options may generate more anxiety.

10. Which of the following behaviors by a client with dependent personality disorder shows the client has made progress
toward the goal of increasing problem solving skills?
A. The client is courteous
B. The client asks questions
C. The client stops acting out
D. The client controls emotions

Answer: B
Rationale: The client with a dependent personality disorder is passive and tries to please others. By asking questions, the client
is beginning to gather information, the first step of decision making.

Session 12
Session 13

1. These are quick and efficient way of monitoring a patient's condition or identifying problems and evaluating
his or her response to intervention.
A. Vital signs C. Respiratory rate
B. Body temperature D. All of the above

Answer: A – Vital signs are are quick and efficient way of monitoring a patient's condition or identifying problems and
evaluating his or her response to intervention.

2. This occurs because heat-loss mechanisms are unable to keep pace with excessive heat production.
A. Heat exhaustion C. Hyperthermia
B. Heat stroke D. Fever or pyrexia

Answer: D – Fever occurs because heat-loss mechanisms are unable to keep pace with excessive heat production.

3. A patient complains in the ER that her axillary temperature rises and falls for the last two days but has never
returned within the normal range. What is this pattern called?
A. Sustained C. Remittent
B. Intermittent D. Relapsing

Answer: C – Remittent fever is where the temperature spikes and falls without a return to acceptable temperature levels.

4. As it was endorsed, the newly admitted patient has lesions on her left axilla. How will you measure her
temperature?
A. Do not measure her temperature, document the reason, inform the health care provider
B. Measure her temperature, inform her that it will be quick
C. Assess the right axillar for lesions, if none, use that site to measure the temperature.
D. Proceed with measuring the temperature orally.
Answer: C – Check the right axilla; Presence of skin lesions may alter local temperature or area may be painful to touch.

5. The thermometer measured a patient’s axillary temperature at 38.9 oC. What will you do?
A. Document at the appropriate log
B. Document, inform patient & give paracetamol
C. Document, inform patient & cover the patient with thick blankets
D. Document, inform patient & offer tepid sponge bath
Answer: D – Body temperature regulation; is bathing a patient with a cool cloth increases conductive heat loss.

6. Using this site for measuring the temperature is prescribed as it is reliable for stable term and preterm infants,
however, not recommended for detecting fever:
A. Oral C. Temporal artery
B. Axillary D. Skin

Answer: B – Prescribed as it is reliable for stable term and preterm infants, however, not recommended for detecting
fever.

7. This site for measuring temperature is sensitive to core temperature changes but inaccuracies are reported
due to incorrect positioning of the device:
A. Temporal Artery C. Rectal
B. Skin D. Tympanic membrane

Answer: D – Sensitive to core temperature changes but inaccuracies are reported due to incorrect positioning of the
device.

8. Refers to a temperature alteration where an elevated body temperature is related to the inability of the body to
promote heat loss or reduce heat production:
A. Heat exhaustion C. Hyperthermia
B. Heat stroke D. Fever or pyrexia

Answer: A - Respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation.
 9. This is described as the involuntary body response to temperature differences in the body:
A. Basal metabolic regulation C. Shivering
B. Radiation D. Diaphoresis

Answer: C - Shivering is an involuntary body response to temperature differences in the body.

10. It is a fever pattern that is regarded for fever spikes interspersed with usual temperature levels; returns to
acceptable value at least once in 24 hours.
A. Sustained
B. Intermittent
C. Remittent
D. Relapsing

Answer: B – Fever spikes interspersed with usual temperature levels; returns to acceptable value at least once in 24 hours.

Session 14

1. It is described as the movement of gases in and out of the lungs:

A. Respiration C. Diffusion
B. Ventilation D. Perfusion

Answer: B – is described as the movement of gases in and out of the lungs

2. A nurse knows not to let the patient know that her respirations are being assessed for what rationale?
A. Patients should be informed of all procedures C. Alter rate and depth of breathing
done D. A and B
B. Provide inaccurate results

Answer: D – An inaccurate result can be obtained as patients who are aware of of the assessment can alter the rate and
depth of breathing.

3. Which of the following factors result to increased respiratory rate and depth? Select all that apply.
A. Exercise D. Smoking
B. Acute pain E. Opioid analgesics
C. Anxiety F. Increased altitude

Answer: A, C, D, E, F – These factors result to increased respiratory rate and depth.

4. The process of diffusion and perfusion by measuring which among the choices:
A. Respiratory rate C. Oxygen saturation
B. Respiratory depth D. A and B

Answer: C – valuate the respiratory processes of diffusion and perfusion by measuring the oxygen saturation of the
blood.

5. Which among the following statement is regarded as incorrect:

A. Diaphragmatic breathing results from the contraction and relaxation of the diaphragm
B. Observed it best by watching abdominal movements
C. Healthy men and children usually demonstrate diaphragmatic breathing
D. Women tend to use thoracic muscles to breathe, assessed by observing movements in the upper chest.
E. All of the above
F. None of the above
Answer: E – All of the statements are correct regarding ventilator rhythm.

6. By observing the degree of excursion or movement in the chest wall, which of the following are you
assessing?
A. Respiratory Rate
B. Ventilatory Depth
 Answer: B – Assessing the ventilatory depth of respirations is done by observing the degree of excursion or movement in
the chest wall.

7. Which breathing pattern is characterized by increase in rate & depth of respirations, where hypocarbia
sometime occur?
A. Tachypnea C. Hyperventilation
B. Hyperpnea D. None of the above

Answer: C – In hyperventilation, rate and depth of respirations increase and hypocarbia sometimes occur.

8. What is the expected breathing pattern for Cheyne-Stokes respiration?

A. Respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth. The pattern
reverses; breathing slows and becomes shallow, concluding as apnea before respiration resumes.
B. Respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth. The pattern
reverses; breathing catches pace and becomes deep, concluding as apnea before respiration resumes.
C. Respirations are abnormally deep, regular, and increased in rate.
D. Respirations are abnormally shallow for two to three breaths, followed by irregular period of apnea.
Answer: A - Respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation.

9. A nurse notices irregularities as he measured the patient’s respiratory rate. For how long should he measure?
A. 15 seconds the multiply by 4 C. Full one minute
B. 30 seconds then multiply by 2 D. 2 minutes to be sure

Answer: C - Respiratory rate is equivalent to the number of respirations/minute. Suspected irregularities require 1 minute.

10. You are caring for a patient who is 3 months old, you have measured his RR at 48 bpm, at rest. What should
you do?
A. Document the measured RR at the appropriate log
B. Document the measured RR & inform the guardian
C. Document the measured RR & inform the guardian & the nurse-in-charge
D. Document the measured RR; inform the guardian & the health care provider
Answer: A – The RR measured is with the normal range

Session 15

1. Typically used in assessing pulse is the radial artery, for what reason?
A. It’s the proper site.
B. It’s convenient.
C. It’s the most accurate.
D. All of the above
Answer: B – You can assess any artery for pulse rate, but you typically use the radial artery because it is easy to palpate.

2. You are to measure the pulse of patient with casts over her upper extremities. What should you do?
A. Do not take the pulse since she has casts over her arms.
B. Do not take the pulse since she has casts over her arms & document the reason.
C. Use the apical pulse in measuring her pulse rate.
D. Base the pulse rate from the previous shifts since it’s the same.
Answer: C – If the radial pulse is abnormal or intermittent resulting from dysrhythmias or if it is inaccessible because of a
dressing or cast, assess the apical pulse.

3. In auscultating for bowel, lung & heart sounds, which particular of the stethoscope should be used?
A. Stethoscope
B. Chest piece
C. Bell
D. Diaphragm
Answer: D – It transmits high-pitched sounds created by the high-velocity movement of air and blood.

4. In assessing the patient’s pulse, you noticed that it is irregular. For long should you assess his pulse?
A. 15 seconds the multiply by 4
B. 30 seconds then multiply by 2

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 C. Full one minute
D. 2 minutes to be sure
Answer: C – Inefficient contraction of heart fails to transmit pulse wave, interfering with cardiac output, resulting in
irregular pulse. Assessing for a full minute ensures accurate count.

5. Which among the following data would you refer to a physician?

A. Infant, HR 155bpm
B. Toddler, 140bpm
C. Preschooler, 130bpm
D. Adult, 100bpm
Answer: C – The other choices present a heart rate acceptable within their age group.

6. Among the given pulse sites, which is used during cardiac arrest?
A. Radial
B. Brachial
C. Carotid
D. Apical
Answer: C – Easily accessible site used during physiological shock or cardiac arrest when other sites are not palpable.

7. Which of the following pulse sites is best used in assessing the status of blood circulation to the foot? Select
all that apply.
A. Femoral
B. Popliteal
C. Posterior tibial
D. Dorsalis pedis

Answer: C, D – Are the pulse sites used to assess status of circulation to foot.

8. In auscultating the apical pulse, which of the following should be assessed? Select all that apply.
A. Rate
B. Rhythm
C. Strength
D. Equality
Answer: A, B - Assessment of the radial pulse includes measuring the rate, rhythm, strength, and equality. When
auscultating an apical pulse, assess rate and rhythm only.

9. When the regular interval is interrupted by an early or late beat or a missed beat this indicates an alteration or
abnormality in which of the following parameters:
A. Rate
B. Rhythm
C. Strength
D. Equality
Answer: B – An interval interrupted by an early or late beat or a missed beat indicates an abnormal rhythm or
dysrhythmia.

10. You are documenting the pulse strength of a patient who is having a panic attack. You have given a score of
4, how is this score described?
A. Absent
B. Barely palpable
C. Normal
D. Strong
E. Bounding
Answer: E – Document the pulse strength as bounding (4); full or strong (3); normal and expected (2); diminished or
barely palpable (1); or absent (0).

Session 16

1. It is the difference between the systolic and diastolic pressure:

A. Blood pressure C. Diastolic pressure
B. Systolic pressure D. Pulse pressure

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Answer: D – is the difference between the systolic and diastolic pressure.

2. Which among the following statements is not true about Cardiac Output:
A. The BP depends on the cardiac output.
B. Cardiac output increases as a result of an increase in HR, greater heart muscle contractility, or an increase in blood
volume.
C. When volume decreases in an enclosed space such as a blood vessel, the pressure in that space rises.
D. As cardiac output increases, more blood is pumped against arterial walls, causing the BP to rise.
Answer: C – When volume INCREASES in an enclosed space such as a blood vessel, the pressure in that space rises.

3. According to James et al. (2014), which of the following is defined as hypertension

A. 120/80 mmHg C. 145/95 mmHg
B. 135/85 mmHg D. 130/75 mmHg

Answer: C – Diastolic readings greater than 90 mm Hg and systolic readings greater than 140 mm Hg define
hypertension (James et al., 2014).

4. It occurs when a normotensive person develops symptoms and a drop in systolic pressure by at least 20
mmHg:
A. Hypertension
B. Hypotension
C. Orthostatic hypertension
D. Postural hypotension
Answer: C – occurs when a normotensive person develops symptoms and a drop in systolic pressure by at least 20 mm
Hg or a drop in diastolic pressure by at least 20 mm Hg within 3 minutes of rising to an upright position (Shibao et al.,
2013).

5. When can a patient be diagnosed as hypertensive?

A. A first time reading of 130/80 mmHg
B. A patient who has familial history of hypertension
C. A mother who is angry and shouts
D. A client with 3 or more consecutive readings of 140/90 mmHg
Answer: D – A client with 3 or more consecutive readings of 140/90 mmHg.

6. It is the minimal pressure exerted against the arterial walls at all times.
A. Blood pressure C. Diastolic pressure
B. Systolic pressure D. Pulse pressure

Answer: C – When the ventricles relax, the blood remaining in the arteries exerts a minimum pressure.

7. A patient suddenly claimed to experience dizziness as he immediately got up from the bed. What could be a
reason?
A. Hypertension C. Orthostatic hypotension
B. Hypotension D. Anemia

Answer: C – occurs when a normotensive person develops symptoms and a drop in systolic pressure by at least
20 mm Hg or a drop in diastolic pressure by at least 20 mm Hg within 3 minutes of rising to an upright position.
8. You have noticed a student nurse is to measure a patient’s BP with loose-fitting cuff. What will you do?
A. Check if the student documented the reading.
B. Let the student check his blood pressure.
C. Call the attention of the student and instruct to tighten the cuff on the patient’s arm.
D. Call the attention of the student and instruct to place the cuff snugly on the patient’s arm.
Answer: D - Loose-fitting cuff causes false-high readings.

9. A client claims to have hypertension as he had his BP taken once at 150/100. How will you deal with the
patient?
A. Confirm that the patient is hypertensive.
B. Instruct the patient to observe natural ways such as taking in garlic.

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 C. Instruct the patient to have his BP checked regularly & return within 2 months.
D. Instruct the patient to come back tomorrow to have his BP checked.
Answer: C – One elevated BP measurement does not qualify as a diagnosis of hypertension; if a high reading during the
first BP measurement is obtained, the patient is encouraged to return for another check-up within 2 months.

10. You are instructed to measure the BP of a 6 y/o patient and you only have an adult cuff. What will you do?
A. Use the adult cuff as it is needed in patient care.
B. Inform the physician & document the reason.
C. Let the patient’s guardian buy a pediatric cuff as it is for their patient.
D. None of the above.
Answer: B –Properly inform the physician of the situation then document; using the adult cuff may give you inaccurate
reading.

Session 17

1. Measuring the oxygen saturation of the blood evaluates which respiratory processes? Select all that apply.
A. Respiratory rate C. Respiratory diffusion
B. Respiratory depth D. Respiratory perfusion

Answer: C, D – Evaluate the respiratory processes of diffusion and perfusion by measuring the oxygen saturation of the
blood. Blood flow through the pulmonary capillaries delivers red blood cells for oxygen attachment.

2. After oxygen diffuses from the alveoli into the pulmonary blood, where do most oxygen attach?
A. Red blood cells C. Hemoglobin
B. White blood cells D. Hematocrit

Answer: C – After oxygen diffuses from the alveoli into the pulmonary blood, most of the oxygen attaches to hemoglobin
molecules in red blood cells.

3. What carries the oxygenated hemoglobin molecules to the left side of the heart and out to the peripheral
capillaries?
A. Red blood cells C. Hemoglobin
B. White blood cells D. Hematocrit

Answer: B – Red blood cells carry the oxygenated hemoglobin molecules through the left side of the heart and out to the
peripheral capillaries, where the oxygen detaches, depending on the needs of the tissues.

4. All, but one, affect the percent of saturation of oxygen (SaO2):

A. Respiration C. Perfusion
B. Ventilation D. Diffusion

Answer: B – Percent of saturation of oxygen (SaO2) is affected by factors that interfere with ventilation, perfusion, or
diffusion.

5. Which of the following devices permit the indirect measuremen of oxygen saturation:
A. Arterial blood gas analysis C. Oxygen rebreather face mask
B. Complete blood count D. Pulse oximeter

Answer: D – A pulse oximeter permits the indirect measurement of oxygen saturation.

6. All, but one, of the following statements about arterial oxygen saturation measurement is correct:
A. A saturation of less than 90% is a clinical emergency (WHO, 2011).
B. SpO2 is a reliable estimate of SaO2 when the SaO2 is over 80%.
C. Values obtained with pulse oximetry are less accurate at saturations less than 70%.
D. All are correct.
Answer: B – SpO2 is a reliable estimate of SaO2 when the SaO2 is over 70%.

7. All, but one, of the following statements about pulse oximeter t is correct:

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 A. Digit probes are spring loaded and conform to various sizes.
B. Earlobe probes have greater accuracy at lower saturations and are least affected by peripheral vasoconstriction.
C. Oxygen saturation measurement using a forehead probe is quicker than finger probes (Yont et al., 2011) and more
accurate in conditions that decrease blood flow (Nesseler et al., 2012).
D. All are correct.
Answer: D – All statements are true.

8. All, but one, of the following statements about interference with arterial pulsations is correct:
A. Peripheral vascular disease (atherosclerosis) reduces pulse volume.
B. Hyperthermia at assessment site decreases peripheral blood flow.
C. Pharmacological vasoconstrictors (e.g., epinephrine) decrease peripheral pulse volume.
D. All are correct.
Answer: B – Hypothermia at assessment site decreases peripheral blood flow.

9. All, but one, of the following statements about interference with light transmission is correct:
A. Outside light sources interfere with ability of oximeter to process reflected light.
B. Patient motion does not interferes with ability of oximeter to process reflected light.
C. Jaundice interferes with ability of oximeter to process reflected light.
D. All are incorrect.
Answer: B – Patient motion does not interferes with ability of oximeter to process reflected light.

10. A patient comes in with a dark blue nail polish on her nails. Prior assessing the patient’s oxygen saturation,
what should a nurse perform first?
A. Monitor vital signs C. Remove nail polish
B. Ask permission to connect finger probe D. Do not assess the oxygen saturation

Answer: C – Black or brown nail polish or metal studs in nails and thickened nails can interfere with light absorption and
the ability of the oximeter to process reflected light (Chan et al., 2013).

Session 18
1. This layer of the skin is regarded as a relatively impermeable membrane that prevents entrance of
microorganism:
A. Epidermis C. Hyperdermis
B. Dermis D. Hypodermis

Answer: A – Epidermis is a relatively impermeable layer that prevents entrance of microorganisms.

2. All of the following skin protection implications are true except for one:
A. Weakening of the epidermis occurs by scraping or stripping its surface.
B. Excessive dryness causes cracks and breaks in skin and mucosa that allow bacteria to enter.
C. Constant exposure of skin to moisture prevents maceration or softening and interrupting dermal integrity.
D. Misuse of soap, detergents, cosmetics, deodorant, and depilatories cause chemical irritation.
Answer: C – Constant exposure of skin to moisture CAUSES maceration or softening, interrupting dermal integrity.

3. Among the following interventions which should be observed:

A. Minimize friction to avoid loss of stratum corneum, which results in development of pressure ulcers.
B. Smooth linen out to remove sources of mechanical irritation.
C. Remove rings from fingers to prevent accidentally injuring patient's skin.
D. Make sure that bath water is excessively hot or cold.
Answer: D – Make sure that bath water is NOT excessively hot or cold.

4. One among the following statements is true regarding temperature regulation:

A. Excess blankets or bed coverings interfere with heat loss through radiation and conduction.
B. Wet bed linen or gowns promote with convection and conduction.
C. Coverings interfere with heat conservation.
D. All of the above
Answer: A – Excess blankets or bed coverings interfere with heat loss through radiation and conduction.

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 5. Which among the following is true about sebum: Select all that apply.
A. Sebaceous glands secrete sebum, an oily, odorous fluid, into the hair follicles.
B. Sebum softens and lubricates the skin and slows water loss from the skin when the humidity is low.
C. Sebum has bactericidal action.
D. None of the above
Answer: A, B C – All statements provided are correct regarding sebum.

6. Which among the following is true about subcutaneous tissue: Select all that apply.
A. The fatty tissue functions as a heat insulator for the body.
B. Subcutaneous tissue also supports upper skin layers to withstand stresses and pressure.
C. Very little subcutaneous tissue underlies the oral mucosa.
D. None of the above.
Answer: A, B C – All statements provided are correct regarding subcutaneous tissue.

7. The following statements are considered as correct regarding the skin: Select all that apply.
A. The neonate's skin is relatively immature at birth.
B. A toddler's skin layers become more tightly bound together.
C. During adolescence the growth and maturation of the integument deceases.
D. The condition of the adult's skin depends on bathing practices and exposure to environmental irritants.
Answer: A, B, D – All statements provided are correct.

8. All but one of the following statements are considered as correct regarding the skin:
A. When an adult bathes frequently or is exposed to an environment with low humidity, it becomes dry and flaky.
B. With aging the rate of epidermal cell replacement slows, and the skin thins and loses resiliency.
C. Moisture leaves the skin, increasing the risk for bruising and other types of injury.
D. As the production of lubricating substances from skin glands increase, the skin becomes dry and itchy.
Answer: D – As the production of lubricating substances from skin glands decreases, the skin becomes dry and itchy
9. Which of the following is NOT observed in integumentary maturation during the adolescent stage:
A. In girls estrogen secretion causes the skin to become soft, smooth, and thicker with increased vascularity.
B. In boys male hormones produce an decreased thickness of the skin with some darkening in color.
C. Sebaceous glands become more active, predisposing adolescents to acne (i.e., active inflammation of the
sebaceous glands accompanied by pimples).
D. Sweat glands become fully functional during puberty.
Answer: B – In boys male hormones produce a DECREASED thickness of the skin with some darkening in color.

10. Among the statements regarding Hair which is NOT true:

A. Males reach adolescence; shaving becomes a part of routine grooming.
B. Young girls who reach puberty often begin to shave their legs and axillae.
C. With aging, as scalp hair becomes thinner and drier, shampooing is usually performed less frequently.
D. None of the above
Answer: D – All statements provided are correct.

Session 19

1. Which among the following nursing care does not apply to Early Morning Care: Select all that apply.
A. Change a patient's gown or pajamas.
B. Offering a bedpan or urinal if the patient is not ambulatory.
C. Provide a full or partial bath or a shower.
D. Washing the patient's hands and face.
Answer: A, C – These nursing care are done in the routine morning care.

2. Among the following nursing care, which will you render before bedtime? Select all that apply.
A. Changing soiled bed linens, gowns, or pajamas;
B. Helping patients wash the face and hands
C. Offering the bedpan or urinal to nonambulatory patients
D. Providing oral hygiene

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Answer: A, B, C, D – All the given nursing care are observed during Evening/Hour-before-sleep Care.

3. Which of the following statement best defines a partial bed bath:

A. Bath administered to totally dependent patient in bed.
B. Patient sits or stands under a continuous stream of water.
C. Bed bath that consists of bathing only body parts that would cause discomfort if left unbathed
D. Involves bathing from a bath basin or sink with patient sitting in a chair.
Answer: C – This statement best defines a partial bed bath.

4. This is a type of bath where an antimicrobial wipe is used to decrease the frequency of hospital-acquired
infections on skin, invasive lines, and catheters:
A. Antimicrobial tub bath
B. Antimicrobial shower
C. Chlorhexidine gluconate (CHG) bath
D. Chlorhexidine gluconate (CHG) wipes
Answer: C – Chlorhexidine gluconate (CHG) bath: This antimicrobial bath wipe is used to decrease the frequency of hospital-
acquired infections on skin, invasive lines, and catheters.

5. A complete bed bath, tub bath, or shower often exhausts a patient. What should be assessed to measure her
physical tolerance?
A. Range of motion
B. Blood pressure
C. Heart rate
D. Activity tolerance test
Answer: C – Assessing heart rate before, during, and after a bath provides a measure of his her physical tolerance.

6. Who among the following patients are candidates for a partial bed bath? Select all that apply.
A. An 84 year old hypertensive patient.
B. A post-operative patient on her 2nd day.
C. A bedridden patient.
D. None of the above
Answer: A, B, C – All patients are candidates for a partial bed bath. Provide a partial bed bath to patients who are aging,
dependent, in need of only partial hygiene, or bedridden and unable to reach all body parts.

7. The question of whether to use bath basins with soap and water is an issue because bath basins provide a
reservoir for bacteria and are a possible source of transmission of hospital-acquired infections. To prevent
this from occurring, what actions should be observed? Select all that apply.
A. Do not bathe patients.
B. Use CHG 4% solution and soap together with water.
C. Use CHG 4% solution instead of soap then water.
D. Air-dry bath basins and avoid using as storage for bath supplies.
Answer: C, D – In contrast, the use of CHG 4% solution in place of standard soap and water in wash basins has been shown to
decrease bacterial growth in basins (Powers et al., 2012) and reduce critical care unit–acquired methicillin- resistant
Staphylococcus aureus (MRSA) (Petlin et al., 2014). It is important to air-dry bath basins completely and not to use a basin for
storing supplies.

8. In providing bed bath, what should be used if there’s a potential contact with body fluids?
A. Waterproof apron
B. Mask
C. Face shield
D. Gloves
Answer: D – Gloves are necessary if there is potential contact with blood or body fluids.

9. In assuring the safety of the client while performing bed bath, what should you do?
A. Ask the significant other to stay at the bedside if something happens.
B. Secure consent to restrain the patient.
C. Raise the side rails.
D. All of the above.
Answer: C – Side rails maintain patient safety.

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 10. To promote venous return, what should be observed in providing a bed bath?
A. Use warm water
B. Use cotton bath towels
C. Avoid CHG
D. Use firm stroke from ankle to groin
Answer: D – Washing from ankle to groin with firm strokes promotes venous return.

Session 20

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