Which substance will the home care nurse instruct a client to use after laryngectomy to
cleanse the stoma site?
Sterile saline
Steroid cream
Oil-based lubricant
Mild soap and water - Answer Mild soap and water
Nurs 204 Actual Exam with Questions and
Solutions
Which substance will the home care nurse instruct a client to use after laryngectomy to
cleanse the stoma site?
Sterile saline
Steroid cream
Oil-based lubricant
Mild soap and water - Answer Mild soap and water
So close! Rationale Mild soap and water are used to cleanse the stoma site. Sterile
saline, a humidifier, or pans of water can be used to humidify the air entering the stoma.
There is no need to use steroid cream at the site unless instructed by the health care
provider. Non—oil-based, rather than oil-based, lubricants can be used as needed for
lubrication of the site.
Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when
four or five consecutive questions have the same letter or number for the correct
answer. Next @ @ Sterile saline
NOTES
Rationale, The nurse should follow protective isolation precautions for the 20-year-old
patient who is suffering from leukemia and has undergone stem cell transplantation.
- Leukemia patients usually have a compromised immune system. Protective isolation
precautions such as positive pressure rooms and respiratory masks are used in patients
with compromised immune function.
- The nurse should follow airborne precautions while caring for a patient with chicken
pox because the mode of transmission of the infection is airborne. The nurse should
,follow contact precautions while caring for a patient with herpes simplex infection
because the infection is transmitted through direct or indirect contact. The nurse should
follow droplet precautions while caring for a patient with meningococcal sepsis because
the mode of infection transmission is droplets. - Answer
While providing a complete bed bath for a patient, which techniques of physical
assessment would the nurse use to evaluate the skin?
Inspection and palpation
Palpation and percussion
Percussion and auscultation
Auscultation and inspection - Answer Inspection and palpation
Rationale While performing a complete bed bath, the nurse has the opportunity to
observe the patient's body to assess for any signs of disease. Through inspection and
palpation, the nurse notes the color, texture, warmth, and intactness of the skin.
Through deep palpation, the nurse may identify the size and shape of the organs as well.
Percussion is a method of physical examination that involves tapping on a body surface
to determine its underlying structure. Auscultation is used to listen to the internal
sounds of the body. The nurse does not use percussion and auscultation while providing
a complete bed bath to the patient.
Test-Taking Tip: Eliminating a component of a choice eliminates that choice. For this
question, if you know that percussion is not a technique used to evaluate the skin, you
can eliminate two choices: palpation and percussion, as well as percussion and
auscultation. If you know auscultation is not a correct response, you can eliminate two
choices also. Just knowing those two terms are incorrect gives you the answer! p. 513
Next
, While teaching a group of student nurses, the nurse educator reports, "This technique
of back massage should not be used over the kidney area." Which technique is the nurse
describing?
So close! Rationale Tapotement is a massage technique in which the back of the patient
is massaged using the palm or ulnar side of the hand. This technique is not performed
over the kidneys because it may cause pain or discomfort to the patient. Petrissage is a
massaging technique that stimulates deep muscle tissue through the use of kneading
motions with the thumbs and fingers. Effleurage is a series of massage strokes that
employs long hand movements along the length of the back muscle. Petrissage and
effeurage can be done over the kidney area. Aromatherapy is not a type of massage.
This helps the patient relax and relieve stress by using the sense of smell.
When assessing a patient reporting a toothache, the nurse finds that the patient holds
the toothbrush bristles at a 45-degree angle when brushing the gum line. The patient
also brushes teeth from the crown to the gum line. On examination, the mucous
membranes of the patient's mouth are dry. Which information would the nurse provide
the patient about oral care?
Use lemon-glycerin preparations.
Brush the teeth from the gum line to the crown.
Hold the toothbrush bristles at a 90-degree angle to the gum line.
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