Question 1

In what position should mouth care be given to an unconscious patient?

Accepted Answer

Answer reason: Side-lying (lateral) positioning reduces aspiration risk during oral care in an unconscious patient.

Question 2

Which type of hygiene includes cleanliness, physical exercise, rest, and sleep?

Accepted Answer

Answer reason: Cleanliness, exercise, rest, and sleep are components of individual self-care habits that define personal hygiene.

Question 3

Which change in hygiene practices may be necessary as the patient ages?

Accepted Answer

Answer reason: Older adults have drier, more fragile skin; reducing bathing frequency helps prevent excessive drying. They typically need gentler soap and more moisturizer, not less.

Question 4

To prevent keratitis in an unconscious client, the nurse should apply moisturizing ointment?

Accepted Answer

Answer reason: Unconscious clients may have incomplete eyelid closure and a decreased blink reflex, leading to corneal exposure and risk of keratitis. Applying a moisturizing ointment to the eyes protects the cornea.

Question 5

How long can you use a toothbrush at most?

Accepted Answer

Answer reason: Toothbrushes should be replaced about every three months (or sooner if the bristles are frayed). Thus, the maximum recommended duration of use is three months.

Question 6

For a morbidly obese patient, which intervention should the nurse choose to counteract the pressure created by skin folds?

Accepted Answer

Answer reason: Separating skin folds with towels reduces pressure, friction, and moisture accumulation in intertriginous areas, directly addressing skin-fold pressure risk. The other options do not relieve the localized pressure caused by the folds.

Question 7

What is intact skin with non-blanchable redness of a localized area, usually over a bony prominence (darkly pigmented skin may not have visible blanching), called?

Accepted Answer

Answer reason: Non-blanchable erythema of intact skin over a bony prominence is the hallmark of a Stage 1 pressure injury.

Question 8

A 6-year-old female is diagnosed with recurrent urinary tract infections (UTIs). Which one of the following instructions would be best for the nurse to tell the caregiver?

Accepted Answer

Answer reason: Plain water and shampooing hair last avoids soap and bubble bath residue over the genital area, reducing vulvar irritation and UTI risk. Delaying voiding promotes stasis and infection; extra clothing rinses are unnecessary; antibacterial soaps can irritate.

Question 9

What should be used to clean a thermometer?

Accepted Answer

Answer reason: Thermometers should be cleaned and disinfected in warm or boiled water to remove pathogens and prevent cross-contamination between patients.

Question 10

During the oedematous phase of nephrotic syndrome an important nursing intervention is to?

Accepted Answer

Answer reason: Edematous skin is fragile and at high risk for breakdown and infection in nephrotic syndrome; meticulous skin care is a key priority. Fluids are typically restricted, activity is not the priority in the edematous phase, and weights should be daily, not every other day.

Question 11

Which of the following instructions is most important when teaching home management of a child with haemophilia?

Accepted Answer

Answer reason: Softening toothbrush bristles with warm water reduces gum trauma and bleeding in children with hemophilia. Other options are unsafe or incorrect: aspirin is contraindicated, bleeding limbs should be elevated rather than dependent, and carpeting can help cushion falls rather than be avoided.

Question 12

What should you use to clean a tracheostomy tube?

Accepted Answer

Answer reason: Routine tracheostomy tube cleaning is done with sterile normal saline; alcohol and hydrogen peroxide can irritate or damage mucosa, and soap and water are not appropriate for airway devices.

Question 13

Which actions should the nurse take when caring for a client with incontinence-associated dermatitis?

Accepted Answer

Answer reason: Incontinence-associated dermatitis is treated by protecting the skin with a moisture barrier such as zinc oxide. Alcohol-based cleansing, additional briefs, or dressings can worsen irritation or trap moisture.

Question 14

Which statements made by the parent about caring for a child with atopic dermatitis indicate a need for further teaching?

Accepted Answer

Answer reason: Hot water strips natural oils and worsens dryness and itching in atopic dermatitis. Care should include lukewarm baths, gentle cleansers, and immediate moisturization; the other listed practices are appropriate.

Question 15

Which nursing action best maintains skin integrity for a toddler with a hip spica cast after surgery?

Accepted Answer

Answer reason: Frequent diaper changes keep the perineal area clean and dry, preventing moisture-related maceration and skin breakdown around a hip spica cast. Leaving the area open to air is impractical, a 3-hour turning schedule is too infrequent, and merely assessing for redness does not maintain skin integrity.

Question 16

Which nursing measure is inappropriate when providing oral hygiene for a client who has had a stroke?

Accepted Answer

Answer reason: Stroke patients are at high risk for aspiration during oral care. A supine position increases aspiration risk; the client should be positioned side-lying or with the head of bed elevated and head turned to the side. The other measures are appropriate.

Question 17

Which action by a 65-year-old female experiencing pruritus would aggravate flare-ups?

Accepted Answer

Answer reason: Frequent bathing with fragranced soaps dries and irritates the skin, worsening itching and triggering pruritus flare-ups. The other actions promote skin comfort and hydration.

Question 18

The nurse is teaching the mother of an infant with eczema. Which of the following instructions should be included in the nurse's teaching?

Accepted Answer

Answer reason: Keeping nails short minimizes scratching and skin injury, which helps prevent eczema exacerbations and secondary infection. Bubble baths and fabric softeners are irritating, and overdressing can worsen sweating and itching.

Question 19

The nurse is caring for a client with acquired immunodeficiency syndrome who has oral candidiasis. The nurse should clean the client's mouth using?

Accepted Answer

Answer reason: Oral candidiasis makes the mucosa tender and easily traumatized; use gentle cleaning with a soft gauze pad. Avoid antiseptic mouthwashes and lemon–glycerin swabs because they are irritating and drying; a toothbrush may abrade lesions.

Question 20

The nurse is preparing to discharge a client following a laparoscopic cholecystectomy. The nurse should?

Accepted Answer

Answer reason: After laparoscopic cholecystectomy, clients may shower after about a day but should avoid soaking incisions; avoiding tub baths for the first 48 hours is appropriate. Clay-colored stools are abnormal (suggest biliary obstruction), lower abdominal pain for a week is not typical, and shoulder pain is expected from CO2 insufflation and not usually reportable.

Question 21

A 3-year-old is immobilized in a hip spica cast. Which discharge instruction should be given to the parents?

Accepted Answer

Answer reason: In a hip spica cast, protecting the cast from urine/stool is essential to prevent skin breakdown and cast damage. Double-diapering with a small diaper tucked inside the perineal opening is standard teaching. The other options are nonessential or potentially harmful (e.g., bed flat with pillow under cast may cause pressure problems).

Question 22

Nurse Farrah is providing care for Kristoff who has jaundice. Which statement indicates that the nurse understands the rationale for instituting skin care measures for the client?

Accepted Answer

Answer reason: Cholestasis in jaundice causes retention of bile salts in the skin, leading to intense pruritus; skin care is instituted to protect skin and reduce itching.

Question 23

The client is admitted to the unit after a cholecystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because?

Accepted Answer

Answer reason: Montgomery straps secure large dressings while allowing frequent changes without repeatedly removing adhesive tape, thereby protecting the skin. They are not used to prevent evisceration, support drains, or replace sutures/clips.

Question 24

The nurse is caring for a one year-old child who has six teeth. What is the BEST way for the nurse to give mouth care to this child?

Accepted Answer

Answer reason: For a 1-year-old, oral care should be gentle using a soft brush or cloth. Mouthwash is inappropriate, a bottle of water does not provide oral cleaning, and toothpaste/flossing are not suitable due to swallowing risk and developmental stage.

Question 25

The nurse is providing foot care instructions to a client with arterial insufficiency. The nurse would identify the need for ADDITIONAL teaching if the client stated?

Accepted Answer

Answer reason: Clients with arterial insufficiency/PVD should not self-trim corns or calluses due to poor circulation and risk of injury or infection; a podiatrist should perform this. The other statements reflect correct foot-care practices.

Question 26

The nurse is caring for a client with a pressure ulcer on the heel that is covered with black hard tissue. Which of the following would be an appropriate goal in planning care for this client?

Accepted Answer

Answer reason: A dry, intact heel eschar should be left in place as a protective cover; debride only if signs of infection or instability develop.

Question 27

The nurse is assessing a client with a stage 2 skin ulcer. Which of the following treatments is most effective to promote healing?

Accepted Answer

Answer reason: Stage 2 pressure ulcers heal best in a moist, protected environment; transparent film dressings maintain moisture and protect the wound. Dry dressings, hydrogen peroxide, or leaving open to air delay healing and can damage tissue.

Question 28

A nurse is developing a care plan for a patient at high risk for pressure injuries. Which intervention should be included?

Accepted Answer

Answer reason: Moisture-barrier creams protect the skin from breakdown caused by prolonged exposure to moisture from incontinence or perspiration, which is a major risk factor for pressure injuries. Massaging reddened areas and delaying pressure-relieving devices are harmful practices, and repositioning every 4 hours is insufficient for high-risk patients.

Question 29

Which position is used for perineal care?

Accepted Answer

Answer reason: The lithotomy position provides maximal exposure of the perineal area, allowing thorough cleansing and access for procedures such as catheterization. Supine without leg abduction limits visualization and access. Fowler’s is used primarily to improve breathing and for feeding, and Trendelenburg is for specific hemodynamic indications, not hygiene. Therefore, lithotomy is the best choice for perineal care among the options.

Question 30

Episiotomy wound should be cleaned?

Accepted Answer

Answer reason: Postpartum perineal care for an episiotomy is aimed at minimizing bacterial contamination and promoting wound healing. Nursing guidance recommends cleansing the perineal area at least twice daily and after voiding or bowel movements using warm water or sitz baths, then keeping the area dry. Once daily or every two days is inadequate for infection prevention, and every 4 hours is unnecessarily frequent without added benefit.

Question 31

A client who has had a full-thickness burn is being discharged from the hospital. Which information is most important for the nurse to provide prior to discharge?

Accepted Answer

Answer reason: For a client with a full-thickness burn, safe wound care at home is the highest-priority discharge teaching because improper dressing changes increase the risk of infection, delayed healing, and complications that can require readmission. Teaching should include hand hygiene, correct technique, frequency, signs of infection (increasing pain, erythema, purulent drainage, fever), and when to call the provider. Smoke detector maintenance and scar removal options are secondary prevention/long-term concerns, and community reintegration is important but not as immediately safety-critical as wound care.

Question 32

Which position is used for rectal examination?

Accepted Answer

Answer reason: The Sims’ (left lateral) position is commonly used for rectal examinations and procedures because it provides good access to the rectal area while maintaining patient comfort and dignity. Flexing the upper leg and slightly rotating the pelvis exposes the anus without requiring full prone positioning. Fowler’s is mainly for breathing/feeding, lithotomy is typical for vaginal/pelvic exams, and knee-chest is more often used for certain proctologic procedures but is less commonly used as the standard exam position in nursing practice.

Question 33

Fundamentals of Nursing Which position is used for rectal examinations?

Accepted Answer

Answer reason: The Sims' (left lateral) position is commonly used for rectal examinations because it provides good access to the rectal area while maintaining patient comfort and modesty. Flexing the upper leg helps relax the gluteal muscles and opens the anal area for inspection and digital examination. Supine and prone generally provide poorer access for a routine rectal exam, and lithotomy is more commonly used for pelvic/gynecologic examinations.

Question 34

A nurse is performing oral care for an unconscious client. What is the correct technique?

Accepted Answer

Answer reason: Unconscious clients require frequent, gentle oral care to maintain mucosal integrity and reduce bacterial colonization. A soft toothbrush moistened with water is effective for mechanically removing plaque and secretions without traumatizing oral tissues. A dry swab can abrade mucosa and is less effective at cleaning. Suctioning should be used as needed to reduce pooled secretions and aspiration risk, and oral care is required more often than every 24 hours.

Question 35

A nurse is teaching foot care to a client newly diagnosed with diabetes mellitus. Which of the following instructions should the nurse include?

Accepted Answer

Answer reason: Clients with diabetes are at increased risk for neuropathy and impaired circulation, so daily foot protection and skin care are essential to prevent injury and infection. Wearing clean, well-fitting cotton socks daily helps reduce moisture accumulation, friction, and skin breakdown, and supports early detection of problems. The other options are unsafe: soaking can macerate skin, rounding nail edges increases ingrown nail risk, and lotion between toes promotes moisture and fungal infection.

Question 36

A nurse aide should give an unconscious client oral hygiene at LEAST every?

Accepted Answer

Answer reason: An unconscious client cannot perform self-care and is at increased risk for xerostomia, mucosal breakdown, and aspiration-related complications, so routine oral care is required. Standard nursing assistant care commonly provides oral hygiene at least every 4 hours, with more frequent mouth care as needed for dryness, oxygen therapy, or heavy secretions. Every 6–8 hours is too infrequent to protect oral mucosa and comfort, while every 2 hours is more frequent than the usual minimum expectation.

Question 37

A patient in the early stages of amyotrophic lateral sclerosis (ALS) presents with weakness in the thenar eminence. During which ADL task would the evaluating OT most likely observe the effect on function?

Accepted Answer

Answer reason: The thenar eminence contains the primary muscles for thumb opposition and pinch strength (e.g., abductor pollicis brevis, opponens pollicis), which are critical for fine-motor precision grasp. Squeezing toothpaste onto a toothbrush requires sustained pinch and controlled thumb opposition to compress the tube and direct toothpaste accurately. In contrast, transfers and overhead dressing are primarily gross-motor tasks, and taking a sip from a glass relies more on cylindrical grasp and proximal upper-extremity control than thenar opposition.

Question 38

Which of the following is a task that nursing assistants commonly do?

Accepted Answer

Answer reason: Nursing assistants (unlicensed assistive personnel) commonly provide basic activities of daily living (ADLs), including bathing and hygiene care. Administering medications and changing sterile dressings require licensed nursing judgment/skills and are not routine CNA tasks. Tube feedings are typically outside CNA scope in many settings and, when allowed, require specific training and delegation criteria; bathing residents is the clearly appropriate common task.

Question 39

A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching?

Accepted Answer

Answer reason: Clients with HIV are at increased risk for skin breakdown and secondary infections, so maintaining meticulous hygiene is important. Daily gentle cleansing of areas prone to moisture and bacterial overgrowth (axillae and genital area) helps reduce irritation, odor, and infection risk. The other options are either incomplete (temperature once daily is not a key discharge instruction by itself), potentially unsafe (changing litter boxes increases toxoplasmosis exposure risk), or not specific enough to improve infection prevention (warm water for dishes is not necessary compared with standard dishwashing).

Question 40

Nurse Kim is providing instructions to a client who has been fitted with a behind-the-ear hearing aid. What advice should she give?

Accepted Answer

Answer reason: Behind-the-ear hearing aids should be protected from heat and moisture, and from aerosols that can clog microphone ports or damage electronic components. Hair dryers can expose the device to excessive heat, and hairspray can leave residue that interferes with function. In contrast, hearing aids should be removed before showering and before MRI due to water and strong magnetic field risks. Turning the device off while wearing it is not practical and does not address the primary care/safety teaching point.

Question 41

Nurse Megan is conducting a class on basic infant care for new parents. She explains the importance of giving a sponge bath during the first two weeks of the baby's life. What reason should she provide for this recommendation?

Accepted Answer

Answer reason: Sponge baths are recommended until the umbilical cord stump dries and falls off because soaking the stump can delay drying and separation and increase infection risk. Keeping the area clean and dry supports normal healing of the umbilical site. Once the stump detaches and the site is healed, immersion baths can be started. The other options may be true in some situations, but they are not the primary clinical reason for avoiding full baths in the first 1–2 weeks.

Question 42

A nurse is teaching foot care to a diabetic client. Which statement requires correction?

Accepted Answer

Answer reason: Clients with diabetes should avoid soaking their feet because prolonged exposure to water can dry and macerate the skin, increasing the risk of cracking, fungal infection, and skin breakdown. Reduced sensation and impaired circulation also increase the risk that unnoticed minor injuries can progress to ulcers. Instead, they should wash feet daily with lukewarm water, dry thoroughly (especially between toes), and moisturize (not between toes). The other statements reflect recommended diabetic foot care practices.

Question 43

Which solution is commonly used for tracheostomy suctioning?

Accepted Answer

Answer reason: Sterile normal saline is commonly used during tracheostomy care/suctioning to maintain sterility, rinse/clear the suction catheter, and help loosen thick secretions when needed. Distilled water is not preferred because it is not isotonic and does not match body fluids. Hydrogen peroxide and alcohol are irritating/cytotoxic to airway mucosa and are used for equipment/skin cleansing in specific contexts, not for airway suctioning.

Question 44

Which type of bed is prepared for a patient returning from surgery?

Accepted Answer

Answer reason: Postoperative bed A postoperative (surgical) bed is made to safely receive a client returning from surgery, allowing easy transfer from stretcher to bed while maintaining body alignment and protecting incisions. Linens are arranged to minimize movement and strain, and the top covers are fanfolded to permit quick positioning and assessment. This setup supports comfort, warmth, and immediate postoperative monitoring needs.

Question 45

A client receiving chemotherapy reports mouth sores and difficulty eating. Which recommendation is best?

Accepted Answer

Answer reason: Use a soft toothbrush and saline rinses. Chemotherapy can cause oral mucositis, so gentle oral care helps reduce pain, prevent infection, and promote healing while maintaining nutrition. A soft toothbrush and bland rinses (e.g., saline) are nonirritating and support mucosal integrity. Hydrogen peroxide can be too harsh and delay healing, spicy foods worsen mucosal pain, and stopping oral hygiene increases infection risk.

Question 46

A client receiving chemotherapy complains of mouth soreness. What is the most appropriate nursing intervention?

Accepted Answer

Answer reason: Chemotherapy can cause oral mucositis, so gentle, non-irritating oral care helps reduce pain, maintain mucosal integrity, and lower infection risk. Normal saline rinses are bland and safe for inflamed mucosa and can be used frequently to cleanse and moisturize the mouth. Hydrogen peroxide and citrus juices can irritate damaged mucosa, and a hard-bristled toothbrush increases trauma and bleeding risk.

Question 47

A nurse is teaching a patient with a permanent colostomy. Which statement indicates effective teaching?

Accepted Answer

Answer reason: Gentle peristomal skin care helps prevent irritation and breakdown from contact with effluent and from appliance adhesives. Mild soap and water are appropriate because harsh soaps, oils, or alcohol-based products can dry the skin and reduce pouch adherence. Daily laxatives are not routinely recommended unless prescribed, and restricting fluids increases dehydration risk rather than being a safe strategy. Continuous liquid drainage is more typical of an ileostomy; colostomy output is usually more formed depending on the stoma location.

Question 48

A nurse identifies that a client on a prolonged bed rest may be developing a pressure ulcer. Which color over the bony prominence supports this conclusion?

Accepted Answer

Answer reason: Nonblanchable erythema over a bony prominence is the classic early sign of a developing pressure injury (Stage 1). It reflects localized tissue ischemia from unrelieved pressure and shear. Blue/purple discoloration can suggest deep tissue injury but is not the typical earliest finding described in basic staging, while black indicates necrosis/eschar and yellow suggests slough, both later-stage findings.

Question 49

Which of the following nursing interventions is necessary for a client who has silver nitrate dressings applied to his burns?

Accepted Answer

Answer reason: Silver nitrate dressings must be kept continuously moist to maintain antimicrobial activity and prevent the dressing from adhering to the wound bed, which can cause trauma and pain with removal. Drying inactivates the medication and reduces its effectiveness against burn wound pathogens. Moist dressings also help support a moist wound-healing environment, which promotes epithelialization.

Question 50

A newly licensed registered nurse is tasked by a nurse educator to perform a wet-to-dry dressing change on a client with a stage 3 pressure ulcer. Which action would indicate to the nurse educator that the registered nurse is following proper technique?

Accepted Answer

Answer reason: C. The registered nurse packs wet gauze into the ulcer without overlapping it onto the skin. Wet-to-dry dressings should be lightly packed into the wound bed so the gauze contacts the tissue that requires mechanical debridement, while avoiding contact with intact periwound skin to prevent maceration and additional breakdown. Overpacking can cause pressure and impair perfusion, so placement should fill dead space without tight compression. Cleaning should proceed from the cleanest area to the dirtiest (typically center/outward), making option A incorrect. Pouring solution over an already-applied dressing (option B) and routinely soaking an adhered dressing before removal (option D) are not the key technique points for proper wet-to-dry application and can be inconsistent with intended debridement and skin protection.

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