Online Practice Test 33

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Site Title: Kozier & Erb's Fundamentals of Nursing Book Title: Kozier & Erb's Fundamentals of Nursing Location on Site: Chapter 33 > NCLEX® Review Date/Time Submitted: July 20, 2012 at 2:23 PM (UTC/GMT)

Summary of Results 70% Correct of 10 Scored items: 7 Correct:  70% 3 Incorrect:  30% More information about scoring

1.		A home health nurse develops a plan for personal hygiene with the client and immediate family prior to discharge. Which home health hygienic plan best reflects the client's personal preferences? Your Answer: Prepare the shower before taking the client into the bathroom. The client's spouse will set supplies on the counter that are to be used for bathing. Client prefers a daily shower. Explain that this is not possible. Walk the client into the shower with the walker and spouse providing assistance. Allow the client to sit on a chair in the shower while washing self. Rewash those areas that require additional cleansing. Correct Answer: Shower on Tuesday and Friday at 9 a.m. using shower chair in lower-level bathroom. Transfers using walker, with assist of spouse holding the right arm and the nurse partially supporting and balancing the client with a gait belt on the left side. Prefers the water to be warm but not hot, to use baby shampoo with conditioner on the hair and unscented gentle soap on the body.
		Objective: Describe hygienic care that nurses provide to clients. Rationale: A client's personal preferences should be followed as long as they are compatible with the client's health status and equipment available. None of the other answers contain the amount of detail present in Answer 3. The more personal detail that is included in a plan, the more prepared will be the nurse who actually makes the home visit. Nursing Process: Planning Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
2.		Which client is most likely to have hearing loss related to cerumen impaction? Your Answer: A 4-year-old with bilateral otitis media Correct Answer: An older adult in a long-term care facility
		Objective: Identify normal and abnormal assessment findings while providing hygiene care. Rationale: Older adults have the highest incidence of cerumen impaction. The incidence of cerumen impaction in older adults in the community, such as the client in Answer 2, is 35%. Older adults in institutions have an incidence greater than 35%. Nursing Process: Assessment Client Need: Physiologic Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection
3.		Bathing a client provides an excellent opportunity to assess the client's integument. Which finding indicates the need for referral to another health care professional?  Your Answer: Pitting edema of the ankles and feet
		Objective: Identify normal and abnormal assessment findings while providing hygiene care. Rationale: Nursing care usually will treat the conditions mentioned in Answers 1, 2, and 4, while the condition noted in Answer 3 can be caused by serious medical problems. Nursing Process: Assessment Client Need: Physiologic Integrity Cognitive Level: Application Strategy: Decide what is the best action for client and situation.
4.		A client has significant body odor. The best solution is: Your Answer: Cleanliness
		Objective: Identify factors influencing personal hygiene. Rationale: Deodorant and talcum powder disguise odors rather than rid the body of the odors. Antiperspirants reduce perspiration; they are applied only after the skin is cleaned. Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Decide what is the best action for client and situation
5.		While supervising certified nursing assistants using a hydraulic lift to bathe a client in the bathtub, the nurse instructs them regarding a safety precaution after the nurse observes:  Your Answer: The hydraulic lift being lowered to tub level when the client is removed from the bathtub
		Objective: Explain specific ways in which nurses help hospitalized clients with hygiene. Rationale: All of the answers represent proper techniques except for Answer 4. When transferring clients to and from a hydraulic lift, it must be positioned at its lowest position, to prevent injury to the client or nurse. Nursing Process: Evaluation Client Need: Safe, Effective Care Environment Cognitive Level: Application Strategy: Physiologic needs come first then safety. Psychosocial needs are addressed after physiologic and safety.
6.		When cleaning the male genitalia, interventions are used to prevent infection. One such intervention is: Your Answer: Retracting the foreskin to remove smegma
		Objective: Describe steps for identified hygienic-care procedures. Rationale: The scrotum is closer to the rectum, so it is washed after the penis. The glans is the cleanest area and is washed before other areas of the genitalia. Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
7.		An elderly, bedridden relative is returning home to die. Family members will take turns caring for the client. A nurse reviews care of the client, including hygiene and skin care. Which statement by a relative indicates that additional instruction is required? Your Answer: "Bathe less frequently when the skin or humidity is dry." Correct Answer: "Cornstarch used in the axilla and groin absorbs excess moisture and odors."
		Objective: Describe steps for identified hygienic-care procedures. Rationale: Answers 1, 3, and 4 are statements by relatives that indicate understanding of instructions. Cornstarch can break down into simpler compounds and promote bacterial growth. Nursing Process: Evaluation Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Read question and prioritize nursing actions
8.		A client has reddened areas under the breasts. What should the nurse do after cleaning and drying the skin? Your Answer: Apply nonirritating powder lightly to the area
		Objective: Describe steps for identified hygienic-care procedures. Rationale: The nurse should apply nonirritating powder lightly to the area. There is no evidence that the treatment in Answers 1, 3, and 4 benefit the skin irritation. Nursing Process: Planning Client Need: Physiologic Integrity Cognitive Level: Application Strategy: Read question and prioritize nursing actions.
9.		A client who is NPO, comatose, and receiving oxygen has cracked lips, dry mucus membranes, swollen gums, and caked mucus on the tongue and teeth. The best intervention is to: Your Answer: Swab the oral cavity with a water-soaked sponge as needed.
		Objective: Identify normal and abnormal assessment findings while providing hygiene care. Rationale: The best intervention is to swab the oral cavity with a water-soaked sponge swab as needed. Answer 2 leads to further dryness of mucosa and changes in tooth enamel. Aspiration can initiate lipid pneumonia. Swabbing the oral cavity with hydrogen peroxide, followed with water, irritates healthy oral mucosa and may alter the microflora of the mouth. Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Read question and prioritize nursing actions
10.		Before inserting a client's hearing aid, the nurse should: Your Answer: Turn the volume all the way down
		Objective: Describe steps for removing, cleaning, and inserting hearing aids. Rationale: Cleaning the aid and removing batteries are done when the aid is removed and stored. Turning the volume all the way up could hurt the client. Hearing aids should not be submersed in water. Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.