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 OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation 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. d. Fanfold the top linen to the bottom of the bed and replace with clean linen.

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?

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 OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation 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.

3. A patient reports itching skin on the back. What should the nurse do initially to relieve the patient’s discomfort?

ANS: B

The nurse addresses the patient’s itchy back by inspecting and assessing the patient’s back for hives, a rash, or redness; the nurse uses the data to formulate a plan of care to relieve the itching. The nurse does not have complete patient data to justify administering an anti-itch cream or recommend shifting positions until the assessment is completed. Being allergic to hospital sheets would cause a reaction on all skin surfaces that made contact with the sheets, not just the back.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Prevent dryness with CHG solution. b. Clean the anus vigorously and dry with a towel. c. Wash the perineal area with warm running water. d. Daily bed baths can cause skin damage.

4. The nurse instructs the spouse of an elderly patient who is on bed rest on how to provide a complete bed bath. What does the nurse include in the patient/family teaching?

ANS: D

The nurse cautions the patient’s spouse that daily bathing can lead to dry skin and irritation for someone on complete bed rest because skin becomes thin, fragile, and prone to bruising and tears. CHG is used in specific hospitalized patients to prevent health care–associated infections. The nurse instructs the patient’s spouse to keep the perineum clean and dry; however, vigorous cleansing can lead to dry skin and irritation, potentially resulting in skin breakdown. Perineal cleansing with warm running water is impractical for home care.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Use long strokes and lotion to massage both legs. b. Perform a complete assessment of the patient’s skin. c. Wash each eye carefully rinsing all traces of soap. d. Soap the entire front of the patient’s body and then rinse.

5. The nurse bathes an unconscious patient. Which action should the nurse implement to maintain infection control during a bed bath?

ANS: B

The nurse assesses the patient’s skin during a bed bath because the skin is a major part of the innate defense of the body against microorganisms. The nurse identifies areas of the patient’s skin with a potential for breakdown and plans preventive or restorative nursing care. Lower extremities are not massaged to prevent dislodging a potential thrombus. Warm water only is used to cleanse the eyes because soap is likely to cause patient discomfort if it seeps into the eyes. The nurse washes and rinses smaller areas of the body to complete a bed bath because wetting a large surface area can cause vasoconstriction and shivering in the patient from the cooling effects of evaporation.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. “The daily baths are great for my dry skin.” b. “The cold water felt good during the bath.” c. “I enjoyed the vigorous massage of my feet.” d. “I feel more relaxed than I have all day.”

6. The nurse is preparing to bathe the patient. Which patient statement would best communicate a desired outcome as a result of the nurse’s bathing and skin care?

ANS: D

Feelings of relaxation and cleanliness are positive in nature and thus are part of a desirable outcome for patient bathing. Daily bathing is discouraged for dry skin because, for patients with rashes, scaling, redness, cracking, or thin, fragile skin, bathing can remove vital skin moisture. Bath water should be warm, not cold. Gentle massage can be done, but not of the feet. Usually the back, shoulders, and sacral area are gently massaged after the bath.

DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation a. Increase bathing to 2 times daily. b. Use super-fatted soap or a prepackaged bath. c. Avoid lotions to help retain skin moisture. d. Massage the skin briskly to increase circulation.

7. The patient’s skin is thin and tight. Which approach should the nurse implement to maintain skin integrity?

ANS: B

The skin needs to be moist and supple for strength and elasticity. A lack of moisture is causing the patient’s tight skin, so the nurse plans care to retain surface oils and moisture. Soap that is super-fatted (such as Dove) or a prepackaged bath product is less likely to remove surface oils vital to retaining skin moisture. Bathing frequency should be reduced, not increased. Hydrating the surface of the skin is less effective than providing adequate hydration to the patient internally for moisture retention, but it is part of a total skin-care program. Brisk massaging is contraindicated for thin, tight skin.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Use suction to remove oral secretions. b. Test the gag reflex with squirts of water. c. Clean the teeth with a firm toothbrush. d. Prevent patient toothbrush biting with an airway.

8. The patient has an endotracheal tube (ET) and is unresponsive to painful stimuli. Which action should the nurse implement while providing oral care?

ANS: A

Oral care is safely provided to patients without a gag reflex by using suction. As secretions build from brushing the teeth and rinsing, the nurse suctions them with a clean, blunt-tipped suction catheter because suctioning helps to prevent fluid buildup in the oropharynx, which can lead to aspiration. The gag reflex is not tested when a patient has an ET and is unresponsive to painful stimuli. A soft toothbrush or toothette is preferred for cleaning teeth. The ET is the patient’s airway. If the patient is biting the ET, the ventilator settings need to be changed, or the patient’s condition is changing. The pressure alarm on the ventilator will sound if the patient bites the tube; however, the nurse leaves the alarm on to prevent patient injury. An airway is used to prevent the patient from biting the tube.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. “Even an unconscious patient can choke on secretions.” b. “Oral care is part of daily hygiene for all patients”. c. “Not doing oral care might cause the patient discomfort.” d. “These patients are prone to infection that good oral care could prevent.”

9. The nurse is caring for an unconscious patient. The student nurse asks why oral care is necessary since the patient does not eat. What response by the nurse is best?

ANS: D

The oral cavity plays a role in defense against infections. Because of changes associated with unconsciousness and the inability to care for their own oral cavities, patients are more prone to infections. Good oral care can help prevent them. The other statements are all accurate, but do not adequately explain the most important reason for performing oral care on this patient.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Store the dentures in a clean, dry container. b. Scrub the dentures with medicated toothpaste. c. Check to see that the dentures are a snug fit. d. Use dental floss to clean between each tooth.

10. A patient wants to put in his dentures after not wearing them for several days. Which intervention by the nurse minimizes the risk of gum irritation that can lead to infection?

ANS: C

The nurse include checks the fit of the dentures to ensure a snug bond between the gums and the dentures to prevent pressure points, soreness, and the formation of oral lesions that can irritate the gums and lead to infection. The nurse stores the dentures in a container with tepid water and a lid. Scrubbing the dentures cleans the surface of buildup, debris, and the microorganism count, but the nurse should use a commercial denture product. Dental floss is not used on dentures.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Trim the beard to a short, manageable length. b. Shampoo the beard at the bedside and comb out debris. c. Determine if there are contraindications to trimming the beard. d. Use baby powder to soak up debris; comb debris out.

11. An unconscious male patient’s beard has become soiled with blood and adhesive tape residue. What should the nurse do initially to maintain the patient’s hygiene?

ANS: C

The nurse ensures that trimming or removing the beard is acceptable to the patient’s family because several cultures forbid removal of facial hair. In addition, patients can spend years growing a beard and want to keep it. Trim the beard only if permission is given and if there are no medical contraindications to the procedure. Shampooing the beard is impractical and likely to soak the bed and patient in the process. Baby powder is an ineffective method of cleaning hair.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Soften the beard with a cool, wet washcloth. b. Hold the razor at a 90-degree angle to the skin. c. Remove the hair in the direction of hair growth. d. Maintain the patient in a prone position for shaving.

12. The nurse is preparing to shave a patient’s beard. Which approach is best for the nurse to use?

ANS: C

To shave the patient, the nurse moves the razor in the direction of hair growth to avoid razor cuts and abrasions. A warm, moist washcloth is used to soften facial hair for removal. The nurse holds the razor at a 45-degree angle to the skin. The patient is placed in the semi-Fowler’s or supine position for shaving for easy access to the facial hair.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Use short, light strokes when washing the legs. b. Use long, firm strokes when washing the legs. c. Use circular strokes up and down the legs. d. Pat the legs gently with a warm, wet washcloth.

13. The nurse is providing a bath for a patient at risk of deep vein thrombosis. Which technique should the nurse use?

ANS: A

The nurse uses short, light strokes when washing the legs to prevent dislodging any clots if present. Long, firm strokes are contraindicated because the pressure exerted against the walls of the veins could dislodge clots if present. Circular strokes up and down the legs are not used to clean the legs. The strokes move toward the heart to promote venous return. Patting the legs with a warm, wet washcloth would be ineffective in cleaning.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Explain how important it is for the patient to care for him- or herself. b. Assess the patient’s psychological status. c. Encourage the family to take over the personal hygiene. d. Encourage the patient to help in any way possible.

14. The nurse determines that the patient is physically incapable of maintaining his personal hygiene. What is the most appropriate nursing approach for this patient?

ANS: D

The patient’s participation in any way possible can help his or her self -esteem, improve function, and increase endurance. Because of the patient’s diminished ability, assistance is needed and should be provided. The family should be encouraged to help with hygiene only if the patient wants them to help and in ways that are appropriate.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Soak the feet in warm water. b. Allow the feet to stay moist. c. Use warm water to cleanse the feet. d. Cut the nails in a curved shape.

15. The patient with type 1 diabetes mellitus and peripheral arterial disease receives a bed bath. Which foot care technique would the nurse use for this patient?

ANS: C

The nurse uses warm water to cleanse the feet of a patient with diabetes and impaired perfusion to a lower extremity gently to avoid injury to the foot from hot water, scrubbing, or harsh cleansing agents. Foot soaks are contraindicated for patients with diabetes. The feet are dried carefully after cleansing to prevent fungal overgrowth and irritation. Toenails are cut straight across to prevent ingrown toenails. A podiatrist cuts the nails to prevent patient injury.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. “Are you able to reach your feet when you bathe?” b. “Would you like me to give you a back massage?” c. “Do you get chilled easily when you bathe?” d. “How often do you usually bathe?”

16. An older adult is admitted for a respiratory infection and is found to have very dry skin with several areas exhibiting some cracking. What question is most important for the nurse to ask the patient?

ANS: D

Older adults have skin that is dry and can easily become cracked. Bathing too often can cause this problem. This is the most important question to ask based on the assessment data. The other options do not relate to assessing the patient’s skin.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Apply antibiotic ointment. b. Apply calamine lotion. c. Shave the immediate area. d. Wash the area with soap and water.

17. The nurse identifies several abrasions on the patient’s skin. Which intervention does the nurse use for the patient?

ANS: D

Washing an abrasion with soap and water is a suitable nursing intervention. Soap helps to emulsify dirt, debris, and microorganisms; water helps to remove these potential contaminants. An antibiotic ointment is not indicated because the wound is not infected. Calamine lotion can be used for contact dermatitis. Shaving is inappropriate.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Uses the patient’s personal care products. b. Explains hospital policy and procedure. c. Provides care at scheduled times as promised. d. Determines cultural and personal preferences.

18. The nurse offers personal hygiene to a very modest patient. Which does the nurse implement to maintain patient dignity and respect?

ANS: D

The nurse questions a modest patient about cultural and personal hygienic customs and preferences beforehand to display respect and caring. This helps to ensure that nursing actions facilitate patient hygienic preferences and avoids creating patient psychosocial or physical discomfort while providing hygiene. The patient may use personal care products as long as there is no contraindication. Explanations of policies and procedures are patient expectations and an aspect of patients’ rights, a legal and ethical matter, more than a display of respect. The objective is to provide culturally sensitive hygienic care for a modest patient; providing care at a given time is less important than the nature of the care.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Integrated Process: Caring a. Prone b. Supine c. Dorsal recumbent d. Fowler’s

19. A female patient is on bed rest. In which position should the nurse place her to provide perineal care?

ANS: C

The nurse uses the dorsal recumbent position to provide perineal care for a female patient because this position provides the most access to the perineum while maintaining patient privacy. The prone position is not recommended because bath water will flow in retrograde fashion and contaminate the vagina and urinary meatus with microorganisms from the anus. The supine and Fowler’s positions are not recommended because they do not allow the best access to the perineal area.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. The patient with hypertension b. The patient with high cholesterol c. The patient with a closed head injury d. The patient with a pulmonary embolus

20. The nurse is caring for four patients with different diagnoses. Which patient should the nurse shave with an electric razor?

ANS: D

A patient with a pulmonary embolus is treated with anticoagulant therapy. The nurse avoids shaving patients receiving anticoagulants with a razor to prevent prolonged bleeding of potential facial cuts from the razor. Hypertension, high cholesterol, and a closed head injury are unlikely to require precautions for prolonged bleeding caused by anticoagulation.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Minimize exposure of the perineum to soap and water. b. Apply an antiinflammatory agent to the affected area. c. Provide frequent perineal care, especially after incontinence episodes. d. Remove the incontinence brief and expose the skin to air for an hour.

21. The nurse assesses the incontinent patient’s perineal skin and notes redness. What does the nurse include in the patient’s plan of care to individualize nursing care?

ANS: C

To maintain skin integrity, reduce inflammation, and prevent deterioration of the affected area, the nurse provides more frequent perineal care paying special attention to ensuring urine does not remain in contact with the skin. Removing the incontinence brief is usually impractical; it can remain in place to contain urine and fecal matter, with prompt perineal care after exposure to urine or fecal matter. The risk of skin breakdown from incontinence does not improve with exposure to air because the basic problem is frequent skin exposure to irritating waste products and not an anaerobic environment. The nurse allows every patient adequate time to use the commode, bedpan, or bathroom, but, since this patient is incontinent, toileting time is not an issue. An antiinflammatory agent may or may not be needed but the first step would be to ensure the perineal area stays clean and dry.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Postoperative after a hip fracture b. Diabetic patient c. Patient with a head injury d. Pneumonia patient

22. The nurse is planning to delegate foot care to the NAP for three patients. Which patient should the nurse do the foot care for?

ANS: B

The skill of foot and nail care may be delegated to nursing assistive personnel (NAP) except for patients with diabetes or patients with peripheral vascular disease or circulatory compromise.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Shampoo the hair as planned. b. Do not shampoo the hair. c. Put the person in isolation. d. Use a medication shampoo.

23. The nurse is getting ready to shampoo a patient’s hair and notices bites behind the ears and on the hairline. After notifying the health care provider, what is the next step?

ANS: D

The CDC recommends treatment for persons diagnosed with an active infection (CDC, 2013). Over-the-counter or prescription treatment may be needed. Isolation precautions are specified by agency policy.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation

Multiple Response

1. The nurse is orientating a NAP about bathing patients. Which statement by the NAP indicates a good understanding of the process? (Select all that apply.)

a. “I should let the nurse know if I see any redness on the patient’s skin.” b. “I should make sure I do not leave the patient unattended with side-rails down.” c. “I should provide females perineal care with the patients on their sides.” d. “I should report any unusual perineal drainage.” e. “I can disconnect the IV tubing to put on the gown.”

ANS: A, B, D

The skill of bathing can be delegated. The nurse instructs the NAP about reporting early signs of impaired skin integrity, including redness or pallor; reporting perineal drainage, discomfort, or tenderness; proper ways to position male and female patients with musculoskeletal limitations and indwelling catheters; and reporting fatigue or report of pain. The IV should be threaded through the gown. The female patient should be placed in the dorsal recumbent position for perineal care.

DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation