TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER
Chapter 11: Bathing and Personal Hygiene Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The patient is able to sit in the chair while the bed is being made. What nursing process step
should the nurse implement for bed making? a. Keep the bed in the low position. b. Pull the blanket up to the head of the bed. c. Instruct the patient to hold the side rail. d. Delegate the task to nursing assistive personnel (NAP). ANS: D
The nurse delegates making an unoccupied bed to the NAP because the assistants are specifically trained in bed making and because the patient is stable enough to sit in a chair while the bed is made. This frees the nurse to perform tasks requiring skills specific to registered nurses. DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation
OBJ: NCLEX: Safe and Effective Care Environment
2. The patient is bedridden, in pain, and doesn’t want the head of the bed raised. Which method
should the nurse use to change the patient’s bed linens? a. Ask the patient to raise the lower body to remove the soiled linen. b. Keep the top sheets over the patient and slowly roll him or her to each side. c. Keep the patient on the left side and get extra help to remove soiled linens quickly. N d. Fanfold the top linen to the bottom of the bed and replace with clean linen. ANS: B
Because the patient is in pain and can’t get out of the bed, the nurse makes the bed using the occupied bed technique. To maintain patient comfort and privacy, the nurse keeps the patient covered while rolling from side to side slowly to prevent dizziness while exchanging the soiled and clean linens. The soiled linens are folded toward the center of the bed and tucked under the patient; then the fresh linens are applied. When the first side is completed, the patient is gently rolled over the ridge of linens in the center so the other side may be accessed. The soiled linens are then removed, and the fresh linens are smoothed over and tucked in. DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation
OBJ: NCLEX: Physiological Integrity
3. A patient reports itching skin on the back. What should the nurse do initially to relieve the
patient’s discomfort? a. Administer an anti-itch cream. b. Assess the patient’s skin condition. c. Remind the patient to shift positions. d. Assess for skin allergies to laundry soap. ANS: B
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