1. The nurse is providing perineal care to an uncircumcised male patient. Which
action will the nurse take?
a. Leave the foreskin alone because there is... [Show More] little chance of infection.
b. Retract the foreskin for cleansing and allow it to return on its own.
c. Retract the foreskin and return it to its natural position when done.
d. Leave the foreskin retracted.
ANS: C
Return the foreskin to its natural position. Keeping the foreskin retracted leads to
tightening of the foreskin around the shaft of the penis, causing local edema and
discomfort. The foreskin may not return to its natural position on its own. Patients
at greatest risk for infection are uncircumcised males.
2. Which instruction will the nurse provide to the nursing assistive personnel
when providing foot care for a patient with diabetes?
a. Do not place slippers on the patient’s feet.
b. Trim the patient’s toenails daily.
c. Report sores on the patient’s toes.
d. Check the brachial artery.
ANS: C
Report any changes that may indicate inflammation or injury to tissue. Do not
allow the diabetic patient to go barefoot; injury can lead to amputations. Clipping
toenails is not allowed. Patients with peripheral vascular disease or diabetes
mellitus often require nail care from a specialist to reduce the risk of infection.
When assessing the patient’s feet, the nurse palpates the dorsalis pedis of the foot,
not the brachial artery.
3. The debilitated patient is resisting attempts by the nurse to provide oral
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hygiene. Which action will the nurse take next?
a. Insert an oral airway.
b. Place the patient in a flat, supine position.
c. Use undiluted hydrogen peroxide as a cleaner.
d. Quickly proceed while not talking to the patient.
ANS: A
If the patient is uncooperative, or is having difficulty keeping the mouth open,
insert an oral airway. Insert it upside down, and then turn the airway sideways and
over the tongue to keep the teeth apart. Do not use force. Position the patient on
his or her side or turn the head to allow for drainage. Placing the patient in a flat,
supine position could lead to aspiration. Hydrogen peroxide is irritating to mucosa.
Even though the patient is debilitated, explain the steps of mouth care and the
sensations that he or she will feel. Also tell the patient when the procedure is
completed.
4. A nurse is providing oral care to a patient with stomatitis. Which technique will
the nurse use?
a. Avoid commercial mouthwashes.
b. Avoid normal saline rinses.
c. Brush with a hard toothbrush.
d. Brush with an alcohol-based toothpaste.
ANS: A
Stomatitis causes burning, pain, and change in food and fluid tolerance. Advise
patients to avoid alcohol and commercial mouthwash and stop smoking. When
caring for patients with stomatitis, brush with a soft toothbrush and floss gently to
prevent bleeding of the gums. In some cases, flossing needs to be temporarily
omitted from oral care. Normal saline rinses (approximately 30 mL) on awaking in
the morning, after each meal, and at bedtime help clean the oral cavity.
5. The nurse is teaching a patient about contact lens care. Which instructions
will the nurse include in the teaching session?
a. Use tap water to clean soft lenses.
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b. Wash and rinse lens storage case daily.
c. Reuse storage solution for up to a week.
d. Keep the lenses is a cool dry place when not being used.
ANS: B
Thoroughly wash and rinse lens storage case on a daily basis. Clean periodically
with soap or liquid detergent, rinse thoroughly with warm water, and air-dry. Do
not use tap water to clean soft lenses. Lenses should be kept moist or wet when not
worn. Use fresh solution daily when storing and disinfecting lenses.
6. The patient reports to the nurse about a perceived decrease in hearing. When
the nurse examines the patient’s ear, a large amount of cerumen buildup at the
entrance to the ear canal is observed. Which action will the nurse take next?
a. Teach the patient how to use cotton-tipped applicators.
b. Tell the patient to use a bobby pin to extract earwax.
c. Apply gentle, downward retraction of the ear canal.
d. Instill hot water into the ear canal to melt the wax.
ANS: C
When cerumen is visible, gentle, downward retraction at the entrance to the ear
canal causes the wax to loosen and slip out. Instruct the patient never to use sharp
objects such as bobby pins or paper clips to remove earwax. Use of such objects
can traumatize the ear canal and ruptures the tympanic membrane. Avoid the use of
cotton- tipped applicators as well because they cause earwax to become impacted
within the canal. Instilling cold or hot water causes nausea or vomiting. [Show Less]
