1. A nurse is caring for a patient who has a urinary catheter and is

experiencing urinary tract infection (UTI). Which of the following

hygiene measures should the nurse implement to prevent further

infection?

a) Change the catheter every 24 hours

b) Cleanse the perineal area with soap and water twice a day

c) Use sterile technique when emptying the drainage bag

d) Keep the drainage bag below the level of the bladder*

Rationale: Keeping the drainage bag below the level of the bladder

prevents backflow of urine into the bladder, which can introduce bacteria

and cause infection. Changing the catheter every 24 hours is not necessary

and may increase the risk of infection. Cleansing the perineal area with

soap and water twice a day is not enough to prevent infection; the nurse

should cleanse the area at least every 8 hours and after each bowel

movement. Using sterile technique when emptying the drainage bag is not

required; clean technique is sufficient.

2. A nurse is teaching a patient who has diabetes mellitus about foot care.

Which of the following instructions should the nurse include in the

teaching?

a) Cut toenails straight across and file the edges*

b) Soak feet in warm water for 15 minutes daily

c) Apply lotion between the toes to prevent dryness

d) Wear shoes that are tight-fitting to prevent friction

Rationale: Cutting toenails straight across and filing the edges prevents

ingrown toenails and reduces the risk of injury and infection. Soaking feet

in warm water for 15 minutes daily can cause maceration and increase the

risk of infection. Applying lotion between the toes can create a moist

environment that promotes fungal growth. Wearing shoes that are tightfitting can cause pressure ulcers and impair circulation.

3. A nurse is assisting a patient who has limited mobility with oral

hygiene. Which of the following actions should the nurse take?

a) Position the patient in a supine position with the head of the bed flat

b) Use a hard-bristled toothbrush to remove plaque and debris

c) Brush the patient's teeth at a 45-degree angle to the gums*

d) Rinse the patient's mouth with alcohol-based mouthwash