Centering care on the patient’s preferences preserves dignity and autonomy, improves cooperation and comfort, and helps prevent complications such as skin breakdown or infection.

Rationale for correct answer:

2. The patient’s usual hygiene practices and preferences: This is primary because safe, effective hygiene care should be individualized: respect cultural practices, daily routines, independence level, and comfort.

Rationale for incorrect answers:

1. When the patient had his or her most recent bath: Knowing when the last bath occurred is useful - it helps assess current hygiene needs, skin condition, odor, and infection risk. It informs what to do, not how or when to plan care in a person-centered way.

3. Where the bathing fits in the nurse’s schedule: Nurse workflow considerations matter for practicality and staffing, but they are nurse-centered. Scheduling should be flexible to meet the patient’s needs.

4. The time that is convenient for the patient care assistant: Coordinating with assistants is necessary for safe delivery, but the assistant’s convenience should not drive the plan. The goal is to balance staff availability with the patient’s preferences and clinical needs.

Take home points

• Prioritize the patient’s usual hygiene habits and preferences - it promotes dignity, trust, and better clinical and psychosocial outcomes.
• Logistics (nurse/assistant schedules, last bath) inform safe, timely care but should be adjusted to fit the patient-centered plan, not replace it.

The semi dependent level indicates partial independence -the client performs most tasks but needs assistance with specific portions. Correctly identifying the level guides the amount of assistance, care planning, and how much to encourage independence.

Rationale for correct answer:

3. Semi dependent (+2): Semi dependent fits a client who can perform many ADLs independently (ambulates, dresses when given clothing) but needs help with parts of bathing (areas she cannot reach).

Rationale for incorrect answers:

1. Totally dependent (+4): Totally dependent means the client needs complete assistance with bathing, ambulation, and dressing; this client can walk and dress (with clothing provided), so not totally dependent.

2. Moderately dependent (+3): Moderately dependent implies more extensive help with most ADLs; here the client only needs help with specific areas (back, hands, feet).

4. Independent (0): The client is not fully independent because she requires help for some body areas.

Take home points

• Match the dependence level to what the client can actually do, not assumptions.
• Promote independence by assisting only where needed (help with back/hands/feet, encourage remaining self-care).

When delegating hygiene tasks, the nurse must communicate culturally relevant information (preferred products, timing, gender preferences, religious practices) so APs can provide respectful, acceptable care that maintains dignity and promotes cooperation.

Rationale for correct answer:

1. Specific hygiene products: Important to communicate (e.g., preference for particular soap, culturally specific products) so AP can deliver culturally sensitive care.

2. Timing of hygiene care: Many cultures have preferred times for bathing or prayer-related washing -timing matters for respect and cooperation.

4. The need for gender congruent caregiver: Critical for many cultures/religions -patients may refuse care from opposite sex providers; AP must be informed to honor this.

5. Religious practices: Religious rules (e.g., modesty, ritual washing, fasting) can affect hygiene routines and must be communicated to ensure respectful care.

Rationale for incorrect answer:

3. Socioeconomic status: Not necessary for the AP to know when performing hygiene care; irrelevant to the immediate cultural care plan and risks stereotyping.

Take home points

• Share specific cultural/hygiene preferences (products, timing, gender preference, religious needs) when delegating to ensure respectful care.
• Avoid irrelevant personal data (like socioeconomic status) unless it directly affects care; focus on actionable cultural information.

Accurate documentation is essential for communication and treatment planning. Differentiating between common oral conditions ensures proper referrals and interventions to prevent progression and complications.

Rationale for correct answer:

4. Periodontitis is a serious gum infection causing inflammation, bleeding, and gum recession, which can lead to tooth loss if untreated.

Rationale for incorrect answers:

1. Glossitis refers to inflammation of the tongue, often appearing red, swollen, and painful. It does not describe gum changes.

2. Caries are cavities caused by tooth enamel breakdown from bacterial action. Caries do not involve gum inflammation or bleeding.

3. Cheilosis is cracking or inflammation at the corners of the mouth, often linked to riboflavin deficiency. This is unrelated to gum recession or bleeding.

Take home points:

• Use correct terminology (e.g., periodontitis for gum inflammation and recession) when documenting oral findings.
• Oral health assessment is a key part of nursing care and can reveal both local and systemic health problems.

Accurate diagnosis requires linking observed data (weakness, inability to wash, need for help) to an appropriate label. Using NANDA-I terminology, “Self-Care Deficit” captures the patient’s limitation, guiding nursing interventions like assistance, energy conservation, and independence support.

Rationale for correct answer: 2

2. Bathing/Hygiene Self-Care Deficit related to decreased strength and endurance: This diagnosis directly matches the observed problem: inability to bathe and perform oral hygiene due to fatigue and weakness.

Rationale for incorrect answers:

1. Risk for Impaired Skin Integrity related to immobility: While immobility can cause skin issues, the scenario highlights difficulty performing hygiene tasks, not skin breakdown.

3. Social Isolation related to lack of visitors: There’s no evidence of social isolation; the patient’s problem is physical limitation, not social withdrawal.

4. Impaired Oral Mucous Membrane related to inability to brush his teeth: Oral mucosa impairment is not documented. The issue is inability to perform self-care, not tissue damage.

Take home points:

• Nursing diagnoses must match observed patient problems, not just possible risks.
• “Self-Care Deficit” diagnoses are key for older or weak patients needing help with ADLs.

Major direct causes include gland damage from radiation and reduced fluid volume from dehydration. Xerostomia increases risk of dental decay, difficulty swallowing, and oral discomfort, so identifying and managing etiologies is important.

Rationale for correct answer:

3. Radiation therapy: Head-and-neck radiation commonly damages salivary glands, causing marked reduction in saliva (xerostomia).

4. Dehydration: Low body fluid volume reduces salivary production and causes dry mouth.

Rationale for incorrect answers:

1. Use of cough drops: Cough drops may stimulate saliva in some people; they do not directly impair gland secretion.

2. Immunosuppression: Immunosuppression per se doesn’t directly reduce salivary gland secretion (though some underlying causes/meds might).

5. Presence of oral airway: An oral airway may interfere with comfort or cause local trauma, but it does not directly reduce salivary gland secretion.

Take home points

• Radiation to the head/neck and dehydration are common direct causes of reduced saliva.
• Address xerostomia by treating underlying causes, encouraging hydration, and using saliva substitutes or frequent oral lubrication as needed.

Continuous exposure to urine/feces plus diabetes (impaired healing) and dementia (reduced ability to report discomfort or participate in care) places a patient at very high risk for incontinence-associated dermatitis, fungal infection, and pressure injuries; these patients require frequent cleansing, moisture management, and protective skin barriers.

Rationale for correct answer:

4. 70-year-old with diabetes, dementia, and urinary/fecal incontinence: Incontinence plus diabetes and cognitive impairment creates the highest immediate risk of moisture-associated skin damage, infection, and delayed healing-so intensive perineal care and frequent skin assessment are needed.

Rationale for incorrect answers:

1.44-year-old post breast lesion, in pain and unwilling to ambulate: While immobility raises risk, this patient is less likely to have ongoing skin contamination or the chronic risks linked to incontinence and cognitive impairment.

2. 56-year-old homeless with malnutrition and dehydration: High risk for skin problems overall (poor nutrition, hygiene), but the scenario does not describe active incontinence that mechanically increases local skin breakdown risk.

3. 60-year-old stroke patient with right-sided paralysis and an orthopedic brace: This patient is at risk for pressure areas under the brace and from immobility, but the question asks which patient is most at risk for skin problems requiring thorough bathing/skin care.

Take home points

• Incontinence, diabetes and cognitive impairment lead to a very high risk for skin breakdown.
• Provide frequent cleansing, moisture control, and barrier creams.

Before providing mouth care to a patient who cannot protect their airway, the nurse should evaluate oxygenation (SpO₂), respiratory effort, and airway protective reflexes (gag/cough). These findings guide whether to proceed, take extra precautions (positioning, suction at bedside), or defer and request additional support.

Rationale for correct answer:

1. Oxygen saturation: Low SpO₂ suggests compromised respiratory function; you should assess oxygenation before mouth care because hypoxia and poor airway protection increase risk if aspiration occurs.

3. Respirations: Assessing respiratory rate and quality helps determine breathing adequacy and aspiration risk during mouth care.

4. Gag reflex: Presence or absence of gag/cough reflex indicates whether the patient can protect their airway; an absent gag reflex significantly increases aspiration risk during oral interventions.

Rationale for incorrect answers:

2. Heart rate: Heart rate is important for overall status but does not directly determine safety of oral care in a reduced-LOC patient.

5. Response to painful stimulus: This is a general neurologic assessment of responsiveness but not as directly relevant to airway protection prior to mouth care as gag reflex and respiratory/oxygen assessments.

Take home points

• Check gag reflex and respirations (and SpO₂) before oral care in patients with decreased consciousness
• These are direct indicators of airway protection and aspiration risk.
• If airway protection is compromised, position for drainage and have suction ready; modify or delay care and get help if needed.

Before shaving, the nurse must assess bleeding risk (medications like warfarin, heparin, antiplatelet agents, or coagulopathies) because shaving with a blade can cause bleeding. If the patient is anticoagulated or at high bleeding risk, use an electric razor or consult policy/MD. Routine hygiene tasks require assessment and adaptation to the patient’s safety needs.

Rationale for correct answer:

2. Check to see if the patient is taking anticoagulants: Anticoagulants (and bleeding disorders) increase the risk of significant bleeding from nicks - so you must assess medications/bleeding risk and choose an electric razor or other safe method if indicated.

Rationale for incorrect answers:

1. Have him sign a permission form: Routine shaving is part of basic hygiene and does not require formal written consent.

3. Tell him that only a family member may shave a patient: Nurses routinely perform shaving; family is not required.

4. Position him flat in bed: Lying flat increases aspiration risk and may be uncomfortable; a seated or semi-upright position is preferred for shaving.

Take home points

• Always assess for anticoagulants or bleeding disorders before shaving with a blade.
• Choose safer alternatives (electric razor) when bleeding risk is present.

Oral care is not only about comfort; it plays a vital role in infection prevention, oral tissue health, and reducing systemic complications such as aspiration pneumonia. Nurses must prioritize oral hygiene, especially in dependent or critically ill patients, as neglect can lead to preventable, serious outcomes.

Rationale for correct answer:

1. 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.

2. 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.

3. 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.

Rationale for incorrect answers:

4. 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.

5. 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.

Take home points:

• Oral hygiene improves both comfort and clinical outcomes, particularly in preventing aspiration pneumonia.
• Nurses should integrate oral care as an essential intervention, not just as a comfort measure.

Skin is the body’s first defense against infection, and maintaining its health is vital. Observing changes during hygiene care allows nurses to intervene promptly with evidence-based strategies, such as using emollients, while avoiding harmful practices like excessive bathing or alcohol use.

Rationale for correct answer:

2. 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.

Rationale for incorrect answers:

1. 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.

2. 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.

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

Take home points:

• Dry skin should be treated with moisturizing interventions, not drying agents.
• Nursing care should focus on preserving skin integrity as part of overall patient safety and comfort.

Dependent patients often have higher risks for infection and aspiration, so the nurse must first prioritize self-protection and patient safety. Using gloves is a fundamental standard of practice and should always precede the technical steps of oral care.

Rationale for correct answer:

2. 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.

Rationale for incorrect answers:

1. 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.

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

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

Take home points:

• Gloves are priority to protect against infection during oral care.
• Positioning and technique matter, but safety always starts with standard precautions.

The eyes are vulnerable to cross-contamination and irritation, so meticulous cleaning with separate materials for each eye and using correct wiping direction are critical for safe and effective care.

Rationale for correct answer:

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

Rationale for incorrect answers:

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

2. 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.

3. 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.

Take home points:

• Always use separate cleaning materials for each eye to prevent cross-infection.
• Clean the eye from inner to outer canthus, never the reverse.

Correct technique during perineal care emphasizes using clean strokes, moving from cleaner to dirtier areas, and ensuring all areas are thoroughly cleansed. Proper hygiene in this sensitive area prevents urinary tract infections, skin irritation, and discomfort.

Rationale for correct answer:

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

Rationale for incorrect answers:

2. 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.

3. 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.

4. 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.

Take home points:

• Always use a clean washcloth section for each stroke during perineal care.
• Clean from least to most contaminated areas to reduce infection risk.

Diabetes increases risk of neuropathy, poor circulation, and impaired healing-so prevention focuses on daily inspection, careful moisturizing (not between toes), gentle cleansing and drying, and avoiding activities that increase infection risk (like soaking or aggressive nail cutting).

Rationale for correct answer:

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

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

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

Rationale for incorrect answers:

1. 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.

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

Take home points

• Inspect feet daily and report any redness, blisters, or breaks immediately.
• Moisturize daily (but not between toes) and avoid risky practices-refer nail problems to a podiatrist.

Acne management requires teaching safe and effective hygiene and discouraging harmful practices. Nurses should emphasize consistent cleansing, avoidance of pore-clogging products, and not manipulating lesions. Proper guidance empowers adolescents to manage their condition while reducing risk of infection and scarring.

Rationale for correct answer:

1. Wash the skin twice a day: Gentle cleansing twice daily removes excess oil and bacteria without over-drying or irritating the skin. This is the best evidence-based recommendation for acne care.

Rationale for incorrect answer:

2. Use cosmetics liberally to cover blackheads: Heavy cosmetic use clogs pores and worsens acne. Non-comedogenic products may be used sparingly, but liberal cosmetic use is not advisable.

3. Use emollients on the area: Emollients are meant to hydrate dry skin, but in acne-prone skin, they can worsen oiliness and clog pores, aggravating lesions.

4. Squeeze blackheads as they appear: Squeezing introduces bacteria, increases inflammation, and can lead to scarring. Patients should be advised against this practice.

Take home points:

• Encourage gentle cleansing twice daily for acne management.
• Discourage harmful practices like squeezing lesions or overusing cosmetics.

Older adults are at high risk for foot complications due to poor circulation, diabetes, or fragile skin. Nurses must emphasize gentle cleansing, moisturizing, and safe nail care while avoiding practices that increase risk of infection or injury.

Rationale for correct answer:

4. Bathing the feet at least daily: Daily washing removes bacteria, reduces odor, and promotes comfort. Proper drying (especially between toes) helps prevent fungal infections.

Rationale for incorrect answers:

1. Using scissors to correct an ingrown toenail: Nurses should not attempt to cut or correct ingrown toenails; this is a podiatrist’s responsibility due to the risk of infection and poor healing in older adults.

2. Trimming toenails as short as possible: Nails should be trimmed straight across, not too short, to prevent ingrown nails and injury.

3. Using an alcohol rub if the feet are dry: Alcohol dries the skin further, increasing the risk of cracks and infection. Emollients or mild moisturizers are preferred.

Take home points:

• Daily cleansing and moisturizing are safe, essential practices in foot care for older adults.
• Nail trimming and ingrown nail correction should be referred to qualified professionals to prevent complications.

Falls are a leading cause of injury in the elderly, especially in slippery environments like bathrooms. Nurses must prioritize fall prevention strategies, while also supporting comfort and dignity in bathing.

Rationale for correct answer:

3. Assist the patient in and out of the tub to prevent falling: This addresses the main risk- falls- while still respecting the patient’s wish for a tub bath. It balances safety with patient preference.

Rationale for incorrect answers:

1. Add Alpha-Keri oil to the water to prevent dry skin: Oils make the tub slippery, increasing fall risk. Safer skin-hydrating methods (like moisturizers after bathing) should be used.

2. Allow the patient to lock the door to guarantee privacy: Safety outweighs privacy in this case. The door should not be locked so staff can respond quickly if the patient falls.

4. Keep the water temperature very warm because the patient chills easily: Very warm water can cause burns, dizziness, or hypotension in older adults. Lukewarm water is safer.

Take home points:

• Safety comes first when providing hygiene care to older adults with mobility issues.
• Assistive care (help in/out of tub, no locking door) prevents falls while maintaining dignity.

Gas-permeable (rigid) lenses are removed differently from soft lenses -often by a gentle pinching or using a small suction device. The nurse should use clean gloves, moisten the eye if needed with saline, stabilize the lids, and remove the lens gently to avoid corneal abrasion. If removal is difficult or ocular damage is suspected, stop and get specialized help.

Rationale for correct answer:

4. Ensure that the lens is centered on the cornea before gently manipulating the lids to release it: The lens must be situated on the cornea, not the sclera, before removal. To remove hard contact lenses, the upper and lower eyelids are gently maneuvered to help loosen the lens and slide it out of the eye.

Rationale for incorrect answers:

1. Gently irrigate the eye with an irrigating solution from the inner canthus outward: Irrigation can help remove debris but typically will not remove a rigid gas-permeable lens; also direction of irrigation should avoid pushing material toward nasolacrimal duct.

2. Grasp the lens with a gentle pinching motion: An attempt to grasp a hard lens might result in a scratch on the cornea.

3. Don sterile gloves before attempting the removal procedure: Sterile gloves are not required; clean gloves are appropriate. Sterile technique is reserved for invasive procedures.

Take home points

• For rigid lenses, a gentle pinch technique (with clean gloves and lubrication if needed) is commonly used- be very gentle to avoid corneal injury.
• Use clean technique (not sterile) and consult eye care specialists if removal is difficult or if there is redness, pain, or corneal abrasion.

Maintaining a closed IV system when changing clothing or gowns minimizes the risk of contamination, interruption of therapy, and air embolism. The nurse should plan the gown change so the tubing/infusion bag remains intact and secure, and never disconnect tubing unnecessarily.

Rationale for correct answer:

3. Thread the bag and tubing through the gown sleeve, keeping the line intact: Keep the IV system closed and intact; carefully thread the tubing/bag through the sleeve so the gown can be removed without disconnecting or contaminating the line.

Rationale for incorrect answers:

1. Temporarily disconnect the IV tubing at a point close to the patient and thread it through the gown sleeve. Unnecessary disconnection increases infection risk and interrupts infusion.

2. Cut the gown with scissors to allow arm movement. Cutting the gown damages clothing and is unsafe/inappropriate around an IV site.

4. Temporarily disconnect the tubing from the IV container, threading it through the gown. Avoid disconnecting the system unless absolutely necessary and under appropriate aseptic conditions.

Take home points

• Never disconnect IV tubing unnecessarily- keep the infusion system intact to prevent infection and infusion interruption.
• When removing clothing, thread the tubing/bag through the sleeve or remove the gown from the uninvolved side first to protect the IV site.

When making an occupied bed, the nurse must prioritize actions that minimize risk to the patient. Other considerations like privacy, warmth, and proper technique are important but secondary to safety.

Rationale for correct answer:

1. Keep the bed in the low position: The priority while making an occupied bed is patient safety- a low bed reduces fall risk if the patient moves or tries to get up.

Rationale for incorrect answers:

2. Use a bath blanket or top sheet for warmth and privacy: Important for comfort and privacy, but not the single most important safety action.

3. Constantly keep the side rails raised on both sides: Side rails are not a substitute for assessment and may be considered a restraint if used improperly; they should be used judiciously per policy.

4. Move back and forth from one side to the other when adjusting the linens: Frequent, unnecessary movement around the bed can confuse or stress the patient; use safe, coordinated turns and good body mechanics but prioritize patient safety (bed height, call light within reach).

Take home points

• Safety first: keep the bed low to reduce fall risk when a patient is in bed.
• Maintain privacy and comfort (use bath blanket/sheet), but don’t let comfort measures override safety precautions

Positioning to prevent aspiration during oral care for patients with reduced consciousness. Proper positioning (side-lying or semi-Fowler’s with the head turned) allows saliva and oral secretions to drain away from the airway so they can be suctioned or cleared, decreasing the chance of aspiration pneumonia.

Rationale for correct answer:

2. Modified left lateral recumbent position: Side-lying (modified lateral) helps secretions drain out of the mouth instead of being aspirated into the airway; it is commonly used for unresponsive patients during mouth care.

3. Semi-Fowler’s position with head to side: Semi-Fowler’s (head elevated) with the head turned to the side permits gravity-assisted drainage and reduces aspiration risk while allowing access to the mouth.

Rationale for incorrect answers:

1. Prone position: Prone makes access to the mouth difficult and may allow secretions to pool in ways that are hard to suction; it’s not recommended for oral care in an unresponsive patient.

4. Trendelenburg position: Head-down increases risk of aspiration and is inappropriate for oral care.

5. Supine position: Lying flat on the back allows secretions to pool and raises aspiration risk.

Take home points

• Position unresponsive patients so secretions can drain (side-lying or semi-Fowler’s with head to side) before oral care.
• Always have suction available and monitor the patient’s respiratory status during mouth care.

Evidence-based oral care interventions for patients at increased risk of oral disease or systemic infection- Preventive measures (fluoride toothpaste, soft toothbrush) preserve dental health, while antiseptic rinses like CHG are added tools for high-risk patients to reduce pathogenic oral flora. Oral mucosa, gums, and tongue should be included in care.

Rationale for correct answer:

1. Use fluoride toothpaste: Fluoride helps prevent dental caries and strengthens enamel -a standard preventive measure for patients at risk of poor oral health.

3. Use 0.12% chlorhexidine gluconate (CHG) oral rinses for high-risk patients: CHG is often recommended for high-risk or critically ill patients to reduce oral microbial load and decrease risk of nosocomial infections (used per policy).

4. Use a soft toothbrush for oral care: Soft bristles clean effectively while minimizing gum trauma -important in fragile or inflamed oral tissues.

Rationale for incorrect answers:

2. Brush teeth 4 times a day: Excessively frequent vigorous brushing isn’t generally recommended; routine care is usually twice daily with additional cleaning after certain events (e.g., after vomiting). Overbrushing can injure gums.

5. Avoid cleaning the gums and tongue: Cleaning gums and tongue is important to reduce bacterial colonization, maintain comfort, and prevent halitosis and infection.

Take home points

• Use gentle, effective daily oral care (soft brush and fluoride) as the foundation.
• For high-risk patients, add antiseptic measures (e.g., CHG) per facility policy- never omit cleaning gums/tongue.

When scheduling limited resources (morning care), prioritize patients whose hygiene needs directly affect safety and tissue integrity -e.g., those with incontinence, draining wounds, or heavy soiling. Prompt perineal/skin care prevents moisture-associated skin damage and infection.

Rationale for correct answer:

3. Patient with frequent incontinent diarrheal stools and urine: Ongoing fecal and urinary contamination rapidly damages skin, promotes infection, and requires prompt cleansing and skin protection.

Rationale for incorrect answers:

1. Patient just returned from a diagnostic test: May need assessment or rest after the test; not the highest hygiene priority unless contaminated.

2. Patient with a fever who just finished IV antibiotics: Fever may require comfort measures, but immediate skin/mucosal contamination from incontinence presents greater risk of skin breakdown and infection.

4. Patient who has been awake all night with pain 8/10: Pain management and rest are priorities, but active contamination leading to skin breakdown takes precedence for immediate bathing/cleansing.

Take home points

• Give highest priority to patients with active contamination (incontinence, diarrhea) to prevent skin breakdown and infection.
• Other needs (pain, post-procedure rest) are important but can often be deferred until immediate infection/skin-risk issues are addressed.

Correct order emphasizes safe positioning first, removal of prostheses, airway management if needed, and systematic cleaning (teeth then tongue), using appropriate devices (brush vs. toothette) and antiseptic agents (chlorhexidine) to lower infection risk while avoiding gag stimulation or aspiration.

Rationale for correct answers:

2. Begin by raising the bed, lowering the side rail, and positioning the patient close to the side of the bed with the head of the bed elevated to about 30 degrees: This positioning is essential for safety and accessibility. Elevating the head helps prevent aspiration and allows gravity to assist in draining fluids away from the airway.

5. Next, remove any partial plates or dentures if the patient has them: Dentures can obstruct access to the oral cavity and may pose a choking hazard if left in during care. Removing them ensures a thorough and safe cleaning process.

1. If the patient is uncooperative or has difficulty keeping their mouth open, insert an oral airway: This device helps maintain mouth opening without requiring active cooperation from the patient, which is especially important when consciousness is impaired.

3. Using a toothbrush moistened with chlorhexidine paste, clean the chewing surfaces and the inner surfaces of the teeth first: Chlorhexidine is an effective antimicrobial agent that reduces oral bacteria. Starting with the teeth targets the areas most prone to plaque and debris buildup.

6. Gently brush the tongue, being careful not to stimulate the gag reflex: Cleaning the tongue helps reduce bacterial load and improve oral hygiene, but care must be taken to avoid triggering vomiting or choking, especially in neurologically compromised patients.

4. If the patient does not have teeth, use a toothette moistened with chlorhexidine rinse to clean the oral cavity: Toothettes are soft and gentle, making them ideal for cleaning gums and other soft tissues in edentulous patients. The chlorhexidine rinse helps disinfect and maintain oral health.

Take home points

• Positioning and removing dentures come before mechanical cleaning; airway protection (oral airway, suction) is essential if needed.
• Use the appropriate cleaning tool (toothbrush vs. toothette) and be cautious with tongue manipulation to avoid triggering gag/aspiration.

The nurse must evaluate airway-protective functions (gag/cough reflex) before performing oral interventions. If protective reflexes are absent or impaired, position the patient for drainage, have suction available, or delay/modify care.

Rationale for correct answer:

3. Gag reflex: Checking gag reflex tells you whether the patient can protect the airway; absence increases aspiration risk during mouth care.

Rationale for incorrect answers:

1. Presence of pain: Important for comfort, but an unresponsive client’s gag reflex is more immediately relevant to airway protection before oral care.

2. Condition of the skin: Important for overall care, but not the first check before oral care.

4. Range of motion: Not relevant to performing oral care for an unresponsive client.

Take home points

• Always assess gag reflex (and breathing) before oral care in unresponsive or low-LOC patients.
• If airway protection is questionable, position for drainage and have suction ready -patient safety first.

Diabetes predisposes to dry, cracked skin that can become a portal for infection. Safe care emphasizes gentle cleansing, daily inspection, moisturizing with an appropriate lotion (not between toes), and avoiding practices that increase maceration or trauma.

Rationale for correct answer:

2. Use a nonperfumed lotion: Moisturizing with a nonperfumed lotion helps prevent cracking while avoiding irritants; avoid putting lotion between the toes.

Rationale for incorrect answers:

1. Soak her feet frequently: Frequent soaking can macerate skin and increase infection risk in diabetic patients.

3. Apply foot powder: Powders may dry but can also irritate or mask skin breakdown; not first-line for very dry diabetic skin.

4. Avoid knee-high elastic stockings: Not the best direct intervention for dry skin; stockings relate more to circulation/pressure, not moisturizing.

Take home points

• Use nonperfumed lotion to hydrate dry diabetic skin-but do not apply between toes.
• Avoid soaking and risky self-care (aggressive nail cutting); inspect feet daily and refer to podiatry as needed.

Safe handling and basic pre-insertion checks for in-the-ear (ITE) hearing aids- For clients who need assistance with insertion (e.g., due to arthritis), caregivers/UAP should turn the device off and ensure it’s clean/dry and the correct orientation before placing it in the ear.

Rationale for correct answer:

1. Turn the hearing aid off: Turning the device off before insertion prevents sudden loud feedback, reduces noise that may frighten the patient, and conserves battery life while handling.

Rationale for incorrect answers:

2. Soak the hearing aid in soapy solution to clean it: Electronic hearing aids should not be soaked; they should be cleaned per manufacturer instructions (dry methods, wipes) and batteries removed if immersion is needed.

3. Turn the volume all the way up: That can produce painful feedback and should never be done before insertion.

4. Remove the batteries: Removing batteries makes the device nonfunctional. Batteries are removed for certain cleaning procedures, but not as a routine pre-insert step.

Take home points

• Turn the hearing aid off before inserting to avoid feedback and ensure comfort.
• Follow manufacturer cleaning instructions (no soaking) and handle batteries per policy; teach helpers safe, gentle technique.

Preparing a surgical bed in a high position makes transferring a patient from a stretcher safer and quicker, reduces staff strain, and helps preserve patient dignity and comfort during transfer.

Rationale for correct answer:

4. Surgical bed in high position: A surgical bed (fan-folded linens to the foot in a high bed position) facilitates a safe, efficient transfer from stretcher to bed and protects linens and patient during the move.

Rationale for incorrect answers:

1. Open bed in low position: An open bed (top linens folded) is for daytime rest; low position is safe for occupied patients but not ideal for receiving a stretcher transfer.

2. Occupied bed in low position: The patient is not in the bed yet; an occupied bed is for a patient already in it.

3. Closed bed in high position: A closed bed indicates no immediate return; a high position alone is not the specific preparation for stretcher transfer.

Take home points

• Plan the bed type and height ahead of the patient’s return.
• A little prep improves safety, decreases transfer time, and reduces fall/injury risk.