All flashcards
Flashcard 1: Which direction should you wipe during perineal care for a female client?
Answer: Front to back (urethra to anus). This direction prevents contamination of the urinary tract with fecal bacteria, reducing infection risk.
Flashcard 2: What is the correct sequence for going down stairs with a cane?
Answer: Down with the cane, then weak leg, then good leg. Leading with cane and weak leg ensures support, followed by the strong leg for controlled descent.
Flashcard 3: Which bed position is safest for giving a bed bath to reduce strain and protect privacy?
Answer: Raise bed to working height and expose only the area being washed. Optimal height reduces caregiver back strain, and minimal exposure upholds client dignity.
Flashcard 4: What is the correct method to prevent injury when moving a client up in bed?
Answer: Use a drawsheet and get assistance; avoid pulling on arms. Using proper body mechanics and tools avoids shear forces and joint injuries during repositioning.
Flashcard 5: Which action is appropriate when assisting with oral care for an unconscious client?
Answer: Side-lying position; use suction and avoid fluids pooling in mouth. Side-lying facilitates drainage, while suction and fluid control prevent aspiration in non-responsive clients.
Flashcard 6: What is the safest action when a client has dysphagia and pockets food in the cheek?
Answer: Check the mouth between bites and after meals; remove pocketed food. Regular inspection prevents aspiration by removing retained food that could obstruct the airway.
Flashcard 7: Which finding requires you to stop feeding and notify the nurse immediately?
Answer: Coughing, choking, wet/gurgly voice, or respiratory distress. These symptoms indicate potential aspiration, requiring immediate intervention to ensure airway safety.
Flashcard 8: What is the minimum time a client should remain upright after a meal to reduce aspiration?
Answer: At least 30 minutes. Maintaining an upright position aids digestion and prevents reflux or aspiration of gastric contents.
Flashcard 9: Which position reduces aspiration risk when feeding a client?
Answer: Upright at 90∘ with head midline (chin slightly tucked). This position promotes effective swallowing and gravity-assisted food passage, minimizing choking hazards.
Flashcard 10: What is the most important action after retracting a foreskin for hygiene?
Answer: Return foreskin to its normal position to prevent paraphimosis. Restoring the foreskin prevents constriction, swelling, and potential circulatory compromise.
Flashcard 11: What is the correct wiping direction for perineal care for an uncircumcised male client?
Answer: From urinary meatus outward; retract then replace foreskin. This method minimizes infection by cleaning away from the meatus and ensures foreskin mobility.
Flashcard 12: What is the correct principle for cleansing during a bed bath to reduce infection risk?
Answer: Clean from cleanest to dirtiest areas. Progressing from least to most contaminated areas limits microbial spread and cross-contamination.
Flashcard 13: Which action best prevents skin breakdown during bathing and drying?
Answer: Pat skin dry and moisturize; avoid vigorous rubbing over bony areas. Gentle drying and hydration preserve skin integrity and prevent friction-induced damage.
Flashcard 14: What is the correct technique to apply antiembolism (TED) stockings?
Answer: Turn inside out to heel, place heel, then unroll; no wrinkles. This method ensures even compression, proper fit, and circulation without restricting blood flow.
Flashcard 15: Which observation indicates TED stockings are too tight and require intervention?
Answer: Cool toes, numbness/tingling, cyanosis, or delayed capillary refill. These signs suggest impaired circulation, necessitating removal to avoid tissue damage.
Flashcard 16: What is the correct action if a client begins to fall during ambulation?
Answer: Ease the client to the floor while protecting the head; call for help. Guided lowering protects vital areas, and seeking help ensures prompt medical response.
Flashcard 17: Which instruction is correct for using a cane with a weak left leg?
Answer: Hold cane in right hand; move cane with the left (weak) leg. Cane on the strong side provides balance, advancing with the weak leg for supported weight shift.
Flashcard 18: Which action best supports client autonomy during ADL care?
Answer: Offer choices and allow the client to do as much as possible. Empowering clients through decision-making and self-performance enhances their sense of control and self-esteem.
Flashcard 19: What is the correct order for donning clothing for a client with one-sided weakness?
Answer: Dress the affected side first; undress the affected side last. This sequence facilitates easier manipulation of clothing on the weaker side, reducing strain and promoting efficiency.
Flashcard 20: What is the correct sequence for applying sterile gloves during perineal care?
Answer: Sterile gloves are not used; use clean gloves for routine perineal care. Routine perineal care uses clean technique to prevent infection without necessitating sterile conditions.
Flashcard 21: What is the priority goal when assisting a client with activities of daily living (ADLs)?
Answer: Promote safe independence while maintaining dignity and privacy. This goal encourages self-reliance, minimizes risks, and respects the client's rights and personal boundaries.