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RNSG 1105: Nursing Skills Exam 2 Review (Module 6)
1. Remember you always start out with: educating your patient & telling them what you are going to do
2. Always remember: cultural differences (like when they want a bath or not--only have to give it if they have an
infection/skin breakdown & they need a bath)
3. Standard Precautions (medical asepsis): Handwashing and gloves (non ster- ile) any time the nurse may come into
contact with: blood body fluids secretions / excretions non-intact skin mucous membranes
4. When to wear gloves/not in reference to hygiene: wear gloves for soiled linens
5. Wash with antimicrobial soap: when there is visible contamination & handling bodily fluids (before putting on
new gloves) at beginning and end of shifts, before and after wearing gloves for patient care or handling contaminated patient items.
6. Use Alcohol-based hand rubs: when hands are not considered contaminated Ex. Before and after taking vital signs
7. Hand hygiene: Before & after care Before & after
each patient wear gloves for soiled linens
8. Rationale for Personal Hygiene: Stimulates circulation: distal to proximal gentle strokes and warm water stimulate
2 / circulation and promote venous return. Helps improve self-image: Promote patient independence encourage them to do what they can. Opportunity for Assessment: patient condition, psychosocial / learning needs, signs of skin breakdown. Nurse-Patient Relationship: Caring Behaviors strengthen the Helping Relationship
9. If they want to shower, first assess: their mobility (wrap IV before shower)
10. Complete bath:
11. Partial (Assisted) Bath:
12. Know the performance checklists for the baths: what to wash first, etc
13. Patient becomes short of breath while taking a bath: let them rest
14. Face: Clean the eye from the inner canthus to the outer canthus using a wet, warm washcloth; cotton ball; or
compress. Use a protective shield if necessary to keep the lids closed when the blink reflex is absent. Wiping from inner to outer canthus prevents plugging / contaminating the naso- lacrimal duct and HAI eye infection). A warm wet cloth or compress (NO SOAP) should be used to remove excess secretions from the eyes; boric acid not necessary and might damage eye leading to entry point for infection.
15. Ears: turn it off first
Clean the patient's external ear with a washcloth-covered finger. ONLY the external ear (front and back) is washed; at least daily with a washcloth-covered finger; sharp objects could injure the ear. Q tips or cotton swabs cause cerumen (ear wax) to become packed further into the inner ear.
4 / Pull skin taut and lightly shave in the direction hair grows. Apply after shave to reduce razor burn Use safety razor only once then discard
21. How to Shave with an Electric Razor: Used for patients on blood thinners or who have bleeding problems
Shave against the direction hair grows Clean blade head with alcohol between uses Apply after shave
22. Hair Care: Daily Brushing distributes natural hair oils and stimulates circulation.
23. TED Hose Purpose: to prevent venous stasis--blood pooling in legs to prevent thrombophlebitis--
vein inflammation to prevent deep vein thrombosis (DVT)--a blood clot that could break loose and create an embolus
24. TED Hose Application: Elasticized stockings: graduated degrees of pressure, ankle up.
Optimum amount of pressure = Proper fit. free of wrinkles. length and circumference measured for correct size. (too tight--if not monitored, can cut off circulation, too large--patients wasting money, too small--can cause DVT) Patient SHOULD ambulate with them on
1. Insert hand into stocking as far as the heal pocket
2. Grasp the center of the heel pocket and turn stocking inside out to heel area
3. Carefully position stocking over foot and heel. Be sure heel is centered in heel pocket.
4. Begin pulling body of stocking up around the ankle and calf..
5. Smooth stocking up to just below knee. If measured properly, the stocking will fit smoothly. Be sure not to roil down
top of stocking (acts like a tourniquet)
25. TED Hose Neuromuscular Checks: Assess: NEURO-VASCULAR checks Q 8 and PRN.
5 / Neuro- (nerves) Wiggle toes Numbness / tingling / swelling. Vascular (circulation) Toes warm and pink ((or normal for ethnicity) Capillary refill < 3 secs.(press on toe nail and begin counting)
- Remove Q SHIFT: Assess for signs of skin breakdown or DVT then reapply. Capillary refill assesses how quickly circulation returns to the toe nail or skin after it is pressed hard enough to cause blanching. Counting is One one thousand, Two one thousand, etc. If the blanched area becomes pink again within 3 seconds Cap Refill is said to be good (< 3 sec.). Longer than that indicates poor circulation. Be sure to check chart for prior assessments to identify changes. If your findings are new, may need to recheck the fit. Any change in circulation is important to report to the HCP and document. It is best to replace the TEDs at the end of the bath before getting the patient out of bed. Their lower legs may swell upon becoming dependent (lower that the trunk of the body). If this happens, you will need to put them back in bed and elevate their legs for at least 20 minutes to resolve swelling before reapplying the TEDs. Get 2 pairs of TEDs for your patient. That way you can rinse out the old ones and put on fresh ones each day with their bath. Patients can take their TEDs home with them when they are discharged
26. Sequential Compression Device (SCD): Plastic sleeve wrapped around leg, Velcro fastening
Connected to pump, alternately inflates / deflates sleeve (ankle to top) Enhances venous blood return and prevents venous stasis. ONLY for bed, DON'T AMBULATE with them on.
27. Gown on and off:
28. Correct way to shave:
7 / The correct way to trim nails is to cut them straight across and away from the end of the nail bed. Cutting them too short can cause ingrown toenails.
31. Male Perineal Care: Remember "Clean to Dirty"
Uncircumcised male patient (teenage and older) retract foreskin to wash the glans. IMPORTANT Pull foreskin back into place Immediately to prevent constriction of the shaft, edema, & serious tissue damage. Indwelling Foley catheter: Clean the first several inches of the catheter tubing from the meatus toward the drainage bag. To prevent dislodging the catheter, hold it between two fingers at the meatus as you are wiping.
32. Female Perineal care: Clean front to back to prevent carrying organisms from the anal area back over the genital
area. If there is an indwelling catheter, clean several inches of the tubing while holding it where it exits the meatus toward the drainage bag.
33. Condom Catheter: Safer alternative to indwelling catheter (Foley) for male incontinence. (NPSG 7: Prevent
CAUTI)
Leave 1 to 2 inches (2.5 to 5 cm) of space between tip of penis and end of condom sheath. Ensure the tubing is not kinked or twisted. Hang the drainage bag on the bed frame below the bladder. If your patient is uncircumcised, be sure the foreskin is pulled forward before applying the condom. Put the tape in a spiral around the penis and never wrap the actual penis without the condom on it bc it cuts off circulation.
34. Rationale for Changing Linen: Psychological : Promotes Comfort Patient feels comfortable and
refreshed. Physiological : Preserve Skin Integrity Food Crumbs, rough seams and wrinkles cause skin irritation and contribute to pressure sores/decubitus.
8 / Safety / Environmental: "Break the chain" Soiled linens are a Reservoir for microorganisms.
35. Maintain Asepsis: Hand Hygiene - wear gloves for soiled linens Uniform - Keep soiled linen
away from your uniform. Linen - Place soiled linen in bag or hamper, never on floor. Microorganisms - Never shake or fluff, always fold / unfold linen - air currents spread microorganisms. Contamination - Do not touch your hair / body while making bed.
36. Maintain Safety: Bed Locked first Working
Height Get Help if needed Side Rails up Maintain Proper Body Mechanics
37. ambulating specifics what to do with the IV and foley:
38. Review performance checklists on everything:
39. What is the proper position to use for an unresponsive patient during oral care to prevent aspiration?: Sim's
position Semi-Fowler's position with head to the side.
40. 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.): Assess skin for redness, abrasions, and open areas daily. Apply lotion to the feet daily.
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48. An 88-year-old patient comes to the medical clinic regular. 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 again changes that can affect an older adult's oral health? (Select all that apply.): Dentures do not always got properly. Many older adults are edentulous, and remaining teeth are often decayed.
49. 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. Place the following steps in the correct order for administration of oral care.: 1. Raise bed, lower side rail, and position patient close to side of bed with head of bed raised up 30 degrees.
2. Remove partial plate or dentures if present.
3. If patient is uncooperative or having difficulty keeping mouth open, insert an oral airway.
4. Using a brush moistened with chlorhexidine past, clean chewing and inner tooth surfaces first.
5. Gently brush tongue but avoid stimulating gag reflex.
6. For patients without teeth, use a toothlette moistened in chlorhexidine rinse to clean oral cavity.
50. The nurse delegates needed hygiene care for an elderly stroke patient. Which intervention would be
appropriate of the nursing assistive personnel to accomplish during the bath?: Providing range-of-motion (ROM) exercises to extremities.
51. 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:: The patient's cultural norm.
52. When a nurse delegates hygiene care for a male patient to a nursing assistive personnel, the NAP must use
11 / an electric razor to shave the patient with the following diagnosis:: Thrombocytopenia
53. A patient receiving chemotherapy experiences stomatitis. The nurse advis- es the patient to use:: Normal
saline rinses.
