The Nurse’s Role in Hygiene

Every question here, with the answer

1. A nurse is planning hygiene care for a patient who prefers to bathe in the evening but becomes unsteady when tired. What should guide the nurse’s scheduling decision?

   1. Prioritize the patient’s safety while also considering preferences.
   2. Schedule the bath only at the patient’s preferred time, regardless of condition.
   3. Skip hygiene care until the patient can bathe independently.
   4. Delegate the bath to UAP so the nurse can complete other care.

   Answer: Prioritize the patient’s safety while also considering preferences.

   The nurse should incorporate the patient’s preferences, but safety is the priority when scheduling hygiene. Ignoring unsteadiness creates a safety risk, while skipping care or delegating without considering condition does not meet the patient’s hygiene needs safely.

2. An RN is deciding whether to delegate hygiene care to a UAP. Which task is appropriate to delegate?

   1. Providing a bed bath for a patient in severe physical distress.
   2. Asking the unit secretary to bathe a patient because supplies are available.
   3. Providing a bed bath for a stable patient when the purpose is cleanliness.
   4. Evaluating a confused, unstable patient’s response to hygiene care.

   Answer: Providing a bed bath for a stable patient when the purpose is cleanliness.

   A stable patient’s bath may be delegated to UAP when the bath is for cleanliness rather than assessment. Severe distress, unstable or confused status, and evaluation of response require nursing judgment and are not appropriate delegation in this section.

3. An unconscious patient who breathes through the mouth is unable to perform oral care. Which nursing actions are appropriate? Select all that apply.

   1. Routinely moisten the mouth.
   2. Raise the head of the bed to 30–45 degrees.
   3. Use mouthwash instead of suction to manage excess secretions.
   4. Apply lip balm to prevent the lips from cracking.
   5. Ensure suction equipment is available.

   Answer: Routinely moisten the mouth., Raise the head of the bed to 30–45 degrees., Apply lip balm to prevent the lips from cracking., Ensure suction equipment is available.

   The section identifies suction availability, head-of-bed elevation, removing excess fluid or secretions, moistening the mouth, and lip balm as important oral care measures for patients who cannot perform their own care. Mouthwash does not replace suction for preventing aspiration or removing secretions.

4. During eye care, the nurse notices dried exudate on a patient’s eyelid that is not easily loosened. What is the best action?

   1. Use the same section of the washcloth for both eyes to avoid chilling the patient.
   2. Clean the eye area with soap to remove the exudate.
   3. Apply direct pressure over the eyeball to loosen the crusting.
   4. Place damp gauze or a cotton ball on the lid margins to loosen secretions.

   Answer: Place damp gauze or a cotton ball on the lid margins to loosen secretions.

   A damp gauze or cotton ball can be placed on the lid margins to loosen dried secretions. Soap may irritate the eye, direct pressure can injure the eyeball, and reusing the same washcloth section can spread infection.

5. A patient wears reusable contact lenses but is too weak today to independently insert and remove them. Which nursing actions or teaching points are appropriate? Select all that apply.

   1. Soak reusable lenses in the owner’s chosen solution when not in use.
   2. Encourage the patient to keep the contacts in because most patients prefer to care for their own lenses.
   3. Keep the contacts clean and sterile.
   4. Assess the type of contacts and the patient’s preferred special care measures.
   5. Place a towel in the sink to prevent a dropped contact from going down the drain.
   6. Perform hand hygiene before inserting or removing contacts.

   Answer: Soak reusable lenses in the owner’s chosen solution when not in use., Keep the contacts clean and sterile., Assess the type of contacts and the patient’s preferred special care measures., Place a towel in the sink to prevent a dropped contact from going down the drain., Perform hand hygiene before inserting or removing contacts.

   The nurse should assess the type of contacts and preferred care, maintain cleanliness and sterility, use hand hygiene, soak reusable lenses appropriately, and prevent loss down the drain. The patient should not wear contacts if unable to independently insert and remove them.

6. A patient with diabetes asks how to care for the feet at home. Which teaching points should the nurse include? Select all that apply.

   1. Use cotton socks for warmth and perspiration absorption.
   2. Wear properly fitting footwear.
   3. See a podiatrist for treatment of corns, calluses, or bunions if needed.
   4. Examine and care for the feet daily.
   5. Soak the feet regularly to prevent odor and infection.
   6. Leave the feet damp after washing so the skin stays soft.

   Answer: Use cotton socks for warmth and perspiration absorption., Wear properly fitting footwear., See a podiatrist for treatment of corns, calluses, or bunions if needed., Examine and care for the feet daily.

   Patients with diabetes may have reduced sensation and need daily foot examination and care, cotton socks, proper footwear, and podiatry care for certain foot problems. The section states feet should not be soaked and should be dried immediately after being washed.