The nurse is caring for a patient admitted with weakness and has a history of osteoporosis and obesity. What nursing intervention should the nurse implement while providing hygiene care?

Inspect the patient's feet for a diabetic ulcer.

Expose the full body to ensure efficiency.

Encourage the patient to provide self-care.

Apply baby powder to the perineal area and skin folds.

Answer and Explanation

The Correct Answer is C

A. Inspect the patient's feet for a diabetic ulcer: Patients with obesity are at increased risk for skin breakdown, and foot ulcers may go unnoticed. Early detection prevents complications.

B. Expose the full body to ensure efficiency: Patients should be kept covered as much as possible to maintain dignity, privacy, and body temperature.

C. Encourage the patient to provide self-care: If the patient is able, self-care promotes independence and helps maintain mobility.

D. Apply baby powder to the perineal area and skin folds: Powder can clump and retain moisture, leading to skin irritation and fungal infections, especially in skin folds.

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Correct Answer is A

Explanation

A. 46-year-old with a low neutrophil count: Neutrophils are essential for fighting infection. A low neutrophil count (neutropenia) significantly increases infection risk, making this the highest-priority patient.

B. 59-year-old seven days post abdominal surgery: While postoperative patients are at risk for infection, the greatest risk is within the first few days after surgery. By day seven, the risk decreases if no signs of infection are present.

C. 82-year-old with a history of leukemia ten years ago: While leukemia can affect the immune system, a history of leukemia from ten years ago is less concerning than an active condition causing immunosuppression.

D. 62-year-old on antibiotic therapy: While antibiotics can disrupt normal flora and increase the risk of infections like Clostridioides difficile, this risk is lower than that of a patient with neutropenia.

A. Call for assistance. B. Assist the patient in sitting down on the bed. C. Assess the vital signs for orthostatic hypotension. D. Notify the provider

Correct Answer is B

Explanation

A. Call for assistance. While calling for help may be necessary if the patient becomes unresponsive or falls, the priority action is to ensure their safety immediately by helping them sit down.

B. Assist the patient in sitting down on the bed. The patient is experiencing dizziness upon standing, which could indicate orthostatic hypotension or another condition. The best immediate action is to help them sit down to prevent a fall or further complications.

C. Assess the vital signs for orthostatic hypotension. While assessing for orthostatic hypotension is important, it should be done after ensuring the patient is safe by sitting them down.

D. Notify the provider. The provider may need to be informed if the dizziness persists or if there is an underlying medical issue. Still, immediate intervention (sitting the patient down) takes priority before notifying the provider.

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Laboratory Test	Reference Range	Patient Results
White Blood Cells	5,000- 10,000/mm3	9,500/mm3
Neutrophil Count	2.500-8,000/mm3	5,200/mm3
HIV	Negative	Positive

The nurse is caring for a patient admitted with weakness and has a history of osteoporosis and obesity. What nursing intervention should the nurse implement while providing hygiene care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing care for the following patients. Which patient is at highest risk of developing an infection?

Correct Answer is A

Explanation

A patient has called the nurse to help them ambulate to the bathroom. The nurse assists the patient to a dangling position on the bed and applied the gait belt. Upon standing, the patient reports that they are feeling very dizzy. What is the next best action by the nurse?

Correct Answer is B

Explanation

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