nursing fundamentals chapter 15 – Flashcards
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The nurse delegates morning care to a certified nursing assistant (CNA). The nurse intervenes when observing the CNA
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Morning (AM) care is done after breakfast. For many patients, this will include assisting with a bath. For all patients, this includes toileting, oral care, back massage, shaving, hair care, and dressing or changing the gown. CNAs do not administer medications to any patients
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When delegating morning care to a certified nursing assistant (CNA), the nurse intervenes when observing the CNA
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Bedtime (HS) care includes removing glasses and hearing aids.
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When delegating early morning care to a certified nursing assistant (CNA), the nurse intervenes when observing the CNA
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Bedtime (HS) care includes removing glasses and hearing aids.
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When delegating bedtime care to a certified nursing assistant (CNA), the nurse intervenes when observing the CNA
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Bedtime (HS) care includes assisting the patient with sleep preparation by placing needed items within reach, such as the call light, fresh water, and urinal.
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When providing a bed bath, the nurse assesses the patient's skin. The nurse observes an area of skin on the buttocks that is softened from continuous exposure to urine. The nurse documents this finding as
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Maceration is softened skin due to continuous exposure to fluid. This often occurs in skin crevices such as under the breasts and scrotum, in the axilla and groin areas, between the toes, and between the buttocks
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When performing a morning assessment on a terminally ill patient, the nurse observes a generalized purplish blotching of the patient's skin. The nurse documents this finding as
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Mottling is a purplish blotching of the skin when circulation slows greatly.
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A nurse applies hand mitts to a patient who has been repeatedly scratching himself. When assessing the patient's skin, the nurse notes scrapes on the skin where the patient had scratched. The nurse documents this finding as
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Excoriation, or scrapes on the skin, may be due to scratching or may occur during care
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The glands that secrete sebum onto the skin surface or into hair follicles to keep the skin and hair lubricated are called
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The sebaceous glands secrete sebum (oil) onto the skin surface or into hair follicles to keep the skin and hair lubricated.
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A patient complains of perspiration in the axillae and genital regions when encountering stressful events. The nurse recognizes that the glands that are responsible for producing sweat in the axillae and genital areas during stressful circumstances are called the
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The sweat glands, especially the apocrine glands located in the axillae and genital areas, produce sweat during stressful and emotional circumstances.
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When ambulating with physical therapy, a patient complains of sweating on his forehead, upper lip, and the palms of his hands. The nurse recognizes the glands responsible for this are called the
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The exocrine glands are found over the rest of the body, but are concentrated in the palms of the hands, upper lip, and forehead. They produce sweat in response to heat and exercise
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When supervising a student nurse who is providing patient care, the nursing instructor intervenes when hearing a student nurse tell a patient,
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Most patients are ready for a fresh gown and straightened sheets in the mornings at the very least, as well as personal care such as oral hygiene and grooming. If you are hesitant as a student, the patient may decide that you do not really want to help them with bathing and dressing. If you say, "You don't want me to help you with your bath now, do you?" it is clear that you would rather not perform this task.
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When supervising a certified nursing assistant (CNA) who is assisting a patient with bathing, the charge nurse intervenes when the CNA
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One problem encountered often in the care of hospitalized patients is that the nursing staff may think the patient can do more than is really possible. As a result, the staff member places a pan of water with soap in front of the patient and disappears. When the staff person returns, they assume that the bath has been done and put it all away. The patient may not have really had a bath.
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A nurse is caring for a patient who is lethargic, unable to tolerate standing for long periods of time, and short of breath with exertion. When deciding how to bathe the patient, the nurse chooses the method that will require the least effort on the part of the patient, which is a
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After determining which type of bath to perform, it is important to consider the patient's energy level, ability to tolerate standing or sitting for the duration of the activity, and his or her respiratory status to tolerate steam and exertion. A complete bed bath or towel bath requires the least effort on the part of the patient. Tub baths, showers, or therapeutic baths require the most effort because the patient must be able to sit or stand for the duration of the bath, usually 5 to 15 minutes, as well as be able to get in and out of the tub or shower.
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When supervising an unlicensed assistive personnel (UAP), the nurse intervenes when the UAP performs a bed bath and
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When performing a bed bath, the nurse should cover the patient with a bath blanket, a large lightweight flannel blanket, to prevent exposure. The nurse should uncover only the area of the body that he or she is washing, leaving the rest of the body covered. This also prevents the patient from becoming chilled during the bath.
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When observing a student nurse performing a bed bath, the nursing instructor recognizes that additional instruction is needed when observing the student nurse
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When performing a bed bath, the nurse should wash extremities from distal to proximal, which helps return blood to the heart. While a patient lies in bed, blood tends to pool in his or her extremities. Using the distal to proximal motion helps move the blood in the veins back to the heart (venous return).
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A student nurse correctly performs a bed bath when
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When performing a bed bath, the nurse should change the water when it becomes dirty, soapy, or too cool; additionally, the nurse should always change the water after bathing feet and again after bathing the buttocks and rectal area.
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While showering a patient, the nurse recognizes that the heat of the shower can cause the patient to experience
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The heat of a shower or bath can cause vasodilation, or widening of blood vessels. This, in turn, causes a lowering of the blood pressure. As a result, it is not unusual for patients to become light-headed or dizzy, or even to faint during a bath or shower.
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While taking a shower, a patient becomes light-headed and dizzy. The nurse recognizes that these symptoms are most likely the result of
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The heat of a shower or bath can cause vasodilation, or widening of blood vessels. This, in turn, causes a lowering of the blood pressure. As a result, it is not unusual for patients to become light-headed or dizzy, or even to faint during a bath or shower.
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The nurse is caring for a patient who insists on using antibacterial soap during bathing. The patient states, "It kills more germs than that soap you have." The nurse recognizes that a Food and Drug Administration advisory panel has shown that, when compared to regular soap for the prevention of infections, antibacterial soaps have
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Antibacterial hand soaps are extremely prevalent in homes and public places. However, these antibacterial soaps have not been proven to be any more effective than regular soap for the prevention of infections by a Food and Drug Administration advisory panel.
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The nurse is providing oral care to an unconscious patient. The nurse attempts to minimize any chance of aspiration of fluids by placing the patient in a
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When caring for a patient who is unconscious, it is still necessary to give oral care. The nurse must be careful to minimize any chance of aspiration of fluids. To do this, the patient should be positioned on either side (lateral) with the bed flat. In this way, fluids can run out of the mouth instead of down the throat.
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When instructing a certified nursing assistant (CNA) about how to correctly clean a patient's eyeglasses, the CNA demonstrates understanding by
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Some patients wear glasses or contact lenses and may require assistance with them. Clean patients' glasses with warm water and a soft cloth. Avoid using paper towels or tissues because they can scratch the lenses.
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1. When assisting a patient with bedtime care, a nurse demonstrates caring by (select all that apply):
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Bedtime (HS) care includes assisting the patient with sleep preparation by dimming the lights or turning them off and providing a night-light, according to the patient's preference; placing needed items within reach, such as the call light, fresh water, and urinal; and removing glasses and hearing aids.
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2. The nurse delegates activities of daily living (ADLs) to a certified nursing assistant (CNA). ADLs that can be delegated to a CNA include (select all that apply):
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When each of us prepares for the day, the activities involved, such as bathing, washing and styling hair, brushing and flossing teeth, dressing, and shaving, are referred to as activities of daily living (ADLs). Performing an assessment is the first step in the nursing process and is not within the scope of practice for a CNA.
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3.A nursing instructor educates a class of student nurses about the benefits of bathing patients. The nursing instructor teaches that bathing (select all that apply):
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Bathing cleanses the skin because dirt, bacteria, dead skin cells, sweat, and odors are removed as the nurse washes the patient. Bathing increases sensation because if the patient is comatose or neurologically impaired, the bath provides sensory input for the brain to process, including friction from the wash cloth, moisture and warmth from the water, olfactory stimulation from the clean, soapy smell, and the silky, slippery feeling of soap and suds. Even patients without neurosensory deficits tend to have decreased sensation when lying in a hospital bed. Bathing increases circulation because during a bed bath, the patient is washed from distal to proximal to improve blood return from the extremities back to the heart, which is referred to as venous return. Bathing provides improved self-esteem because individuals feel better when looking and smelling fresh. Bathing increases circulation because during a bed bath, the patient is washed from distal to proximal to improve blood return from the extremities back to the heart. This is referred to as venous return. Bathing provides an opportunity for skin assessment because it gives the nurse an opportunity to observe nonobvious skin problems, such as redness, cracking, maceration, and excoriation.
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4. When providing personal care to a child, the nurse should (select all that apply):
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When providing personal care to children, be sure to consider the modesty in school-age children and adolescents. Be respectful of their need for privacy by placing a sign on the door stating that a bath is in progress so that patients won't be embarrassed by interruptions. Always knock before entering the room.
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5.When providing personal care to older adults, the nurse should (select all that apply):
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The skin of older adults requires frequent application of lotion to prevent dryness. Older adults chill easily due to decreased circulation, so the environment should be kept warm when they are bathed. In older adults, the sebaceous and sweat glands produce less oil and sweat. It is not necessary or desirable to bathe daily; however, if patients are incontinent, it is important to provide frequent and thorough perineal care to prevent skin breakdown and odor
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6. When the nurse determines which type of bath to perform on a patient, it is important to consider the (select all that apply):
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After determining which type of bath to perform, it is important to consider the patient's energy level, ability to tolerate standing or sitting for the duration of the activity, and his or her respiratory status to tolerate steam and exertion.
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7. When performing a bed bath, the nurse should (select all that apply):
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When performing a bed bath, the nurse should cover the patient with a bath blanket, a large lightweight flannel blanket, during the bath to prevent exposure. The nurse should uncover only the area of the body that he or she is washing, leaving the rest of the body covered. The nurse should also fold the washcloth into a mitt around his or her hand to prevent trailing cold edges of the washcloth over the patient as he or she is bathed. These measures prevent the patient from becoming chilled during the bath. The nurse should wash extremities from distal to proximal, which helps return blood to the heart. While a patient lies in bed, blood tends to pool in his or her extremities. Using the distal-to-proximal motion helps move the blood in the veins back to the heart (venous return). The nurse should also wash from the cleanest areas to the dirtiest areas to prevent transferring bacteria from a dirty area to a clean area
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8.While assisting a patient with bathing, the nurse is responsible for (select all that apply):
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Nursing responsibilities during bathing include assessing the skin for rashes, breaks in integrity, bruising, and lesions. The nurse should avoid leaving the patient without a gown and be alert to signs of patient fatigue so that assistance can be provided to the patient as needed. If the patient becomes short of breath or begins to experience pain, the nurse should be prepared to assume the responsibility for the bath. If the patient is unable to stand for the duration of the shower, the nurse should use a bench in the shower so that the patient can sit and save the energy required to bend over to wash the legs and feet. The bathing process should be completed in a timely manner.
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9. When educating a class of nursing students about providing back massages, the nursing instructor teaches that back massages (select all that apply):
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Back massages help relax the patient, stimulate and increase circulation, and prevent pressure ulcers. They may not be indicated if the patient has certain heart conditions, as it can stimulate the vagus nerve and slow the heart rate.
