Exam (elaborations)
Chapter 9 Hygiene and Care of the Patient’s Environment
- Course
- Nursing
- Institution
- Western Piedmont Community College
Chapter 9 Hygiene and Care of the Patient’s Environment
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Chapter 9: Hygiene and Care of the Patient’s EnvironmentMULTIPLE CHOICE
1. The nurse is preparing to bathe a patient. What should the room temperature be set at?
a. No warmer than 67° F
b. No cooler than 68° F
c. No cooler than 70° F
d. 75° F or warmer
ANS: B
The recommended room temperature is 68° to 74° F.
PTS: 1 DIF: Cognitive Level: Application REF: Page 186
OBJ: 1 | 2 | 4 TOP: Patient‘s environment
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
2. The nurse explains that the purpose of a sitz bath is to reduce inflammation in the perineal and
anal area. What is the least amount of time the nurse will instruct for a sitz bath?
a. 10 to 15 minutes
b. 20 to 30 minutes
c. 30 to 40 minutes
d. 1 hour
ANS: B
The sitz bath should last 20 to 30 minutes.
PTS: 1 DIF: Cognitive Level: Application REF: Page 191
OBJ: 2 | 3 TOP: Therapeutic baths
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
3. A patient is recovering from a hemorrhoidectomy and experiences dizziness within 5 minutes
when taking a sitz bath. What action should the nurse implement?
a. Cover the patient to prevent chilling
b. Stay with the patient until the full time for the bath has elapsed
c. Remove the patient from the sitz bath and return to bed
d. Assess vital signs every 5 minutes during the remainder of the sitz bath
ANS: C
The patient may become dizzy during a sitz bath due to dilation of the large vessels in the
abdomen. If this occurs, the patient should be removed from the sitz bath and returned to bed.
Vital signs should be assessed until they return to normal.
PTS: 1 DIF: Cognitive Level: Application REF: Page 191
OBJ: 3 TOP: Sitz bath KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
4. What should the water temperature be when preparing a tepid bath for a patient?
, a. 98.6° F
b. 100.2° F
c. 104.8° F
d. 110.4° F
ANS: A
The tepid bath is taken in water that is 98.6° F.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 191
OBJ: 4 TOP: Tepid bath KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
5. The nurse is assessing a patient‘s skin for signs of impaired skin integrity. Which finding by
the nurse is considered a major manifestation?
a. Burn
b. Laceration
c. Pressure ulcer
d. Infection
ANS: C
A major manifestation of impaired skin integrity is a pressure ulcer.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 200
OBJ: 5 TOP: Pressure ulcers
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. A nurse assesses an area of sustained redness on the coccyx area of a resident in long-term
care. What is the most likely cause of this pressure area?
a. Heat from pressure
b. Collapse of blood vessels
c. Friction from pressure
d. Collapse of skin tissue
ANS: B
A pressure ulcer occurs when there is sufficient pressure to collapse the blood vessels.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 200
OBJ: 5 TOP: Pressure ulcers
KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
7. The nurse is caring for an unconscious patient with a risk for skin impairment. How often will
the nurse plan to change the position of this patient?
a. Every 30 minutes
b. Every 60 minutes
c. Every 120 minutes
d. Every 180 minutes
ANS: C
The bedfast patient should have a position change every 2 hours (120 minutes) because skin
compromise can occur if there is unrelieved pressure during that amount of time.
PTS: 1 DIF: Cognitive Level: Application REF: Page 202 Box 9-5
OBJ: 5 TOP: Pressure ulcers
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