NMNC 1135 Exam 1 Questions & Answers 2024/2025
What is the proper position to use for an unresponsive patient during oral care to prevent aspiration? (Select all that apply.)
a. Prone position
b. Sims' position
c. Semi-Fowler's position with head to side
d. Trendelenburg position
e. Supin...
What is the proper position to use for an unresponsive patient during oral care to prevent aspiration?
(Select all that apply.)
a. Prone position
b. Sims' position
c. Semi-Fowler's position with head to side
d. Trendelenburg position
e. Supine position - ANSWERSb,c
The student nurse is teaching a family member the importance of foot care for his or her mother, who
has diabetes. Which safety precautions are important for the family member to know to prevent
infection? (Select all that apply.)
a. Cut nails frequently.
b. Assess skin for redness, abrasions, and open areas daily.
c. Soak feet in water at least 10 minutes before nail care.
d. Apply lotion to feet daily.
e. Clean between toes after bathing. - ANSWERSb,d,e
Integrity of the oral mucosa depends on salivary secretion. Which of the following factors impairs
salivary secretion? (Select all that apply.)
a. Use of cough drops
b. Immunosuppression
c. Radiation therapy
d. Dehydration
e. Presence of oral airway - ANSWERSc,d
,A nurse is assigned to care for the following patients. Which patient is most at risk for developing skin
problems and thus requiring thorough bathing and skin care?
a. A 44-year-old female patient who has had removal of a breast lesion and is having her menstrual
period
b. A 56-year-old male patient who is homeless and admitted to the emergency department with
malnutrition and dehydration and who has an intravenous line
c. A 60-year-old female patient who experienced a stroke with right-sided paralysis and has an
orthopedic brace applied to the left leg
d. A 70-year-old patient who has diabetes and dementia and has been incontinent of stool - ANSWERSd
When the nurse is assigned to a patient who has a reduced level of consciousness and requires mouth
care, which physical assessment techniques should the nurse perform before the procedure? (Select all
that apply.)
a. Oxygen saturation
b. Heart rate
c. Respirations
d. Gag reflex
e. Response to painful stimulus - ANSWERSc,d
The American Dental Association suggests that patients who are at risk for poor hygiene use the
following interventions for oral care: (Select all that apply.)
a. Use antimicrobial toothpaste.
b. Brush teeth 4 times a day.
c. Use 0.12% chlorhexidine gluconate (CHG) oral rinses.
d. Use a soft toothbrush for oral care.
e. Avoid cleaning the gums and tongue. - ANSWERSa,c,d
While planning morning care, which of the following patients would have the highest priority to receive
his or her bath first?
a. A patient who just returned to the nursing unit from a diagnostic test
b. A patient who prefers a bath in the evening when his wife visits and can help him
c. A patient who is experiencing frequent incontinent diarrheal stools and urine
,d. A patient who has been awake all night because of pain 8/10
e. A patient with a malignant brain tumor requires oral care. The patient's level of consciousness has
declined, with the patient only being able to respond to voice commands. - ANSWERSc
Place the following steps in the correct order for administration of oral care.
a. If patient is uncooperative or having difficulty keeping mouth open, insert an oral airway.
b. Raise bed, lower side rail, and position patient close to side of bed with head of bed raised up to 30
degrees.
c. Using a brush moistened with chlorhexidine paste, clean chewing and inner tooth surfaces first.
d. For patients without teeth, use a toothette moistened in chlorhexidine rinse to clean oral cavity.
e. Remove partial plate or dentures if present.
f. Gently brush tongue, but avoid stimulating gag reflex. - ANSWERSb,e,a,c,f,d
The nurse delegates needed hygiene care for an alert elderly patient who had a stroke. Which
intervention would be appropriate for the assistive personnel to accomplish during the bath? (Select all
that apply)
a. Checking distal pulses
b. Providing range-of-motion (ROM) exercises to extremities
c. Determining type of treatment for stage 1 pressure injury
d. Changing the dressing over an intravenous site
e. Providing special skin care - ANSWERSb,e
The nurse observes an adult Middle Eastern patient attempting to bathe himself with only his left hand.
The nurse recognizes that this behavior likely relates to:
a. Obsessive-compulsive behavior.
b. Personal preferences.
c. The patient's cultural norm.
d. Controlling behaviors. - ANSWERSc
A patient receiving chemotherapy experiences stomatitis. The nurse advises the patient to use:
, a. Community mouthwash.
b. Alcohol-based mouth rinse.
c. Normal saline rinses.
d. Firm toothbrush. - ANSWERSc
A nurse is listening to a student provide instruction to a patient who is having difficulty with activities
needed to care for soft contact lenses. Which of the following statements by the nursing student might
require some correction by the nurse?
a. Use tap water to clean soft lenses.
b. Follow recommendations of lens manufacturer when inserting the lenses.
c. Keep lenses moist or wet when not worn.
d. Use fresh solution daily when storing and disinfecting lenses. - ANSWERSa
A nurse uses long firm, strokes distal to proximal while bathing a patient's legs because:
a. It promotes venous circulation.
b. It covers a larger area of the leg.
c. It completes care in a timely fashion.
d. It prevents blood clots in legs. - ANSWERSa
When a nurse delegates hygiene care for a male patient to a nurse assistant, the assistant must use an
electric razor to shave the patient with the following diagnosis:
a. Congestive heart failure
b. Pneumonia
c. Arthritis
d. Thrombocytopenia - ANSWERSd
An 88-year-old patient comes to the medical clinic regularly. During a recent visit the nurse noticed that
the patient had lost 10 lbs in 6 weeks without being on a special diet. The patient tells the nurse that he
has had trouble chewing his food. Which of the following factors are normal aging changes that can
affect an older adult's oral health?
(Select all that apply.)
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