Review Practice Exercise 3

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Practice Exercise 3

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Total Questions : 6

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Question 1:

Why is adequate oral hygiene an essential part of nursing care? Select all that apply

A. It promotes the patient’s sense of well-being. B. It prevents deterioration of the oral cavity C. It contributes to decreased incidence of aspiration pneumonia. D. It eliminates the need for flossing. E. It decreases oropharyngeal secretions.

Answer and Explanation

Choice A:

It promotes the patient’s sense of well-being: Oral hygiene enhances comfort, self-image, and confidence. Patients often feel refreshed and more willing to interact socially after oral care, supporting psychological and emotional well-being.

Choice B:

It prevents deterioration of the oral cavity: Regular oral care reduces plaque buildup, tooth decay, gingivitis, halitosis, and ulcer formation. This preserves oral integrity, reduces pain, and prevents long-term complications.

Choice C:

It contributes to decreased incidence of aspiration pneumonia: In debilitated or ventilated patients, poor oral hygiene increases bacterial colonization, which can be aspirated into the lungs, causing pneumonia. Oral care reduces microbial load, lowering infection risk.

Choice D:

It eliminates the need for flossing: Oral hygiene does not eliminate the need for flossing. Flossing helps remove debris and plaque between teeth, which brushing or swabbing may not reach. Nurses may adapt methods, but flossing is not made unnecessary.

Choice E:

It decreases oropharyngeal secretions: Oral hygiene improves comfort and reduces bacterial growth but does not physiologically decrease secretions. Instead, it helps manage them more effectively.

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Question 2:

During a bath, the nurse observes that a patient has dry skin. Which action would be best?

A. Bathe the patient more frequently. B. Use an emollient on the dry skin. C. Massage the skin with alcohol. D. Discourage fluid intake.

Answer and Explanation

Choice A:

Bathe the patient more frequently: More frequent bathing actually worsens dryness by stripping natural oils, further irritating the skin. This is counterproductive in managing dry skin.

Choice B:

Use an emollient on the dry skin: Emollients restore moisture, improve skin barrier function, and prevent cracking and infection. This is the best intervention to address dryness directly.

Choice C:

Massage the skin with alcohol: Alcohol is drying and irritating, removing essential oils and worsening the condition. It should never be used for dry skin care.

Choice D:

Discourage fluid intake: Hydration is essential for healthy skin. Discouraging fluids could worsen dehydration and dryness, increasing the risk of skin breakdown.

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Question 3:

Which action would be the priority when administering oral care to a dependent patient?

A. Assisting the patient to the dorsal recumbent position B. Wearing disposable gloves C. Using a firm toothbrush to cleanse teeth and gums D. Irrigating forcefully with hydrogen peroxide

Answer and Explanation

Choice A:

Assisting the patient to the dorsal recumbent position: This position places the patient flat on the back, increasing aspiration risk. A side-lying or semi-Fowler’s position is safer.

Choice B:

Wearing disposable gloves: Gloves protect both the nurse and the patient from cross-infection. This is the priority because it ensures safe practice before any oral care is performed.

Choice C:

Using a firm toothbrush to cleanse teeth and gums: Firm brushes may cause gum trauma. A soft-bristled toothbrush is safer and equally effective.

Choice D:

Irrigating forcefully with hydrogen peroxide: Forceful irrigation risks aspiration and mucosal irritation. Gentle rinsing with approved solutions is safer.

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Question 4:

Mr. James has an eye infection with a moderate amount of discharge. Which action would be most appropriate for the nurse to use when cleaning his eyes?

A. Using hydrogen peroxide B. Wiping from the outer canthus to the inner canthus C. Positioning him on the same side as the eye to be cleansed D. Using only one cotton ball per eye

Answer and Explanation

Choice A:

Using hydrogen peroxide: Hydrogen peroxide is too harsh for the delicate eye structures and can cause chemical irritation.

Choice B:

Wiping from the outer canthus to the inner canthus: Correct technique is inner canthus to outer canthus to avoid dragging debris into the nasolacrimal duct.

Choice C:

Positioning him on the same side as the eye to be cleansed: Proper technique is to position the patient on the opposite side so discharge drains away from the unaffected eye.

Choice D:

Using only one cotton ball per eye: This prevents cross-contamination between the eyes and is essential in infection control.

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Question 5:

Providing perineal care to a patient requires which of the following?

A. Using a clean portion of the washcloth for each stroke B. Moving from most contaminated to least contaminated area C. Using sterile gloves D. Leaving the foreskin undisturbed in an uncircumcised adult male

Answer and Explanation

Choice A:

Using a clean portion of the washcloth for each stroke: This prevents reintroducing microorganisms and helps maintain infection control by keeping each stroke clean.

Choice B:

Moving from most contaminated to least contaminated area: Correct technique is least to most contaminated (e.g., front to back in females) to prevent carrying bacteria from contaminated areas to cleaner ones.

Choice C:

Using sterile gloves: Sterile gloves are not required. Clean gloves are adequate for perineal care unless a sterile procedure (e.g., catheter insertion) is being performed.

Choice D:

Leaving the foreskin undisturbed in an uncircumcised adult male: The foreskin should be gently retracted for cleaning and then returned to its normal position to prevent infection and paraphimosis.

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Question 6:

The student nurse is teaching a family member the importance of foot care for their mother, who has diabetes mellitus. Which safety precautions are important for the family member to know to prevent infection? Select all that apply

A. Cut nails frequently. B. Assess skin for redness, abrasions, and open areas daily. C. Soak feet in water at least 10 minutes before nail care. D. Apply lotion to feet daily. E. Clean between toes after bathing.

Answer and Explanation

Choice A:

Cut nails frequently: Frequent cutting can cause trauma; nails should be trimmed carefully and not overly short, and diabetic patients often need podiatry referral for nail care.

Choice B:

Assess skin for redness, abrasions, and open areas daily: Daily inspection detects early problems (breaks in skin, infection) so treatment can begin promptly.

Choice C:

Soak feet in water at least 10 minutes before nail care: Prolonged soaking can macerate skin and increase infection risk; caution is advised.

Choice D:

Apply lotion to feet daily: But avoid applying lotion between toes (to prevent fungal growth). Moisturizing prevents cracking and preserves skin integrity.

Choice E:

Clean between toes after bathing: Cleaning and then thoroughly drying between toes reduces fungal and bacterial growth.

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Total Questions : 6

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Practice Exercise 3

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