The nurse is caring for a patient admitted with weakness and has a history of osteoporosis and obesity. What nursing intervention should the nurse implement while providing hygiene care?

Inspect the patient's feet for a diabetic ulcer.

Expose the full body to ensure efficiency.

Encourage the patient to provide self-care.

Apply baby powder to the perineal area and skin folds.

Answer and Explanation

The Correct Answer is C

A. Inspect the patient's feet for a diabetic ulcer: Patients with obesity are at increased risk for skin breakdown, and foot ulcers may go unnoticed. Early detection prevents complications.

B. Expose the full body to ensure efficiency: Patients should be kept covered as much as possible to maintain dignity, privacy, and body temperature.

C. Encourage the patient to provide self-care: If the patient is able, self-care promotes independence and helps maintain mobility.

D. Apply baby powder to the perineal area and skin folds: Powder can clump and retain moisture, leading to skin irritation and fungal infections, especially in skin folds.

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Correct Answer is D

Explanation

A. Applying sterile gloves to assist with a procedure: This is part of surgical asepsis (sterile technique) rather than medical asepsis.
B. Inserting an indwelling urinary catheter: This requires sterile technique, not just medical asepsis.
C. Preparing injectable medications: Medication preparation requires aseptic (sterile) technique to prevent contamination.
D. Picking up soiled tissues off of the bedside table: Medical asepsis includes hand hygiene and proper handling of contaminated items to prevent the spread of infection.

A. Educate the patient about hand hygiene with alcohol based hand sanitizer. B. Notify the patient's spouse about the result and arrange for HIV testing C. Provide information on antibiotic therapy to help control the infection. D. Initiate contact precautions with gown and gloves.

Correct Answer is A

Explanation

A. Educate the patient about hand hygiene with alcohol-based hand sanitizer: Standard precautions apply to all patients, including hand hygiene education. HIV is not transmitted through casual contact.

B. Notify the patient's spouse about the result and arrange for HIV testing: Patient confidentiality must be maintained. The patient should be encouraged to inform their partner, but the nurse cannot disclose the results.

C. Provide information on antibiotic therapy to help control the infection: HIV is a viral infection, not bacterial. Antibiotics do not treat HIV.

D. Initiate contact precautions with gown and gloves: HIV is bloodborne and not spread via casual contact, so contact precautions are not required unless the patient has an open wound or secondary infection.

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Laboratory Test	Reference Range	Patient Results
White Blood Cells	5,000- 10,000/mm3	9,500/mm3
Neutrophil Count	2.500-8,000/mm3	5,200/mm3
HIV	Negative	Positive

The nurse is caring for a patient admitted with weakness and has a history of osteoporosis and obesity. What nursing intervention should the nurse implement while providing hygiene care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing care for patients on the medical-surgical unit. Which of the following situations requires the nurse to implement medical asepsis?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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