Description:a. Gloving: Healthcare workers should wear gloves when there is potential for contact with blood, bodily fluids, mucous membranes, non-intact skin, and contaminated surfaces or objects. b. Mask and Gowning: Depending on the situation, healthcare workers might need to wear masks and gowns to protect themselves from potential exposure to infectious agents. Masks can help prevent the spread of respiratory droplets that might contain pathogens, and gowns can protect the skin and clothing from contamination. c. Hand Washing: Proper hand hygiene, including regular and thorough hand washing with soap and water or using hand sanitizers, is essential to prevent the spread of infections in a healthcare setting. d. All of the above: All these precautions collectively help minimize the risk of transmitting infections between healthcare workers, patients, and the environment.

Description:Assessing gag reflex before providing oral care is very important because absence of gag reflex may lead to aspiration.

Description:In patients with diabetes mellitus, foot care is crucial due to the potential for nerve damage (neuropathy) and reduced blood circulation. Walking barefoot, especially in areas where there might be sharp objects or uneven surfaces, can increase the risk of injury and foot problems. Patients with diabetes are advised to wear appropriate footwear at all times and avoid going barefoot to prevent foot injuries and complications. So, if a patient with diabetes makes the statement mentioned in option c, the nurse should re-educate them about the importance of wearing proper footwear and avoiding going barefoot to maintain good foot health.

Description:In the context of providing a complete bed bath to a patient, all the mentioned options are important for ensuring the patient's comfort and safety, except for option c. Water temperature should not be warmer than what is comfortable for the patient and safe for their skin to avoid burns or discomfort. The recommended water temperature for a bed bath is typically around body temperature, which is approximately 37 degrees Celsius (98.6 degrees Fahrenheit). So, the nurse should ensure that the water temperature is appropriate and safe for the patient's comfort, which is different from the high temperature of 50 degrees Celsius mentioned in option c.

Description:When providing personal hygiene care to a patient, especially in scenarios where infection transmission and sterility are concerns, it's important to follow a sequence that minimizes the risk of spreading contaminants. Cleaning from less contaminated areas to more contaminated areas helps prevent the transfer of potentially harmful microorganisms. This approach is often referred to as the "clean to dirty" principle, and it helps maintain a level of cleanliness and reduces the risk of introducing pathogens into areas that are more prone to infection. So, option a is the correct choice.

Description:Unresponsive client cannot able to have oral rinse with chlorhexidine, hence swabbing or spraying with this liquid will provide good care to the oral region.

Description:All of the mentioned options (a, b, and c) are risk factors for the development of bedsores (pressure ulcers). Pressure ulcers occur when there is prolonged pressure on certain areas of the body, often in patients who are bedridden or have limited mobility. The risk factors for developing bedsores include: a. Shearing force: This occurs when the skin moves in one direction while underlying bone and tissue move in another. It can damage blood vessels and lead to tissue death. b. Moisture: Prolonged exposure to moisture, such as from sweat, urine, or wound drainage, can soften the skin and make it more susceptible to damage. c. Impaired peripheral circulation: Poor blood circulation, often due to conditions like diabetes or cardiovascular disease, can lead to reduced oxygen and nutrient supply to the skin, making it more vulnerable to injury.

Description:The old age skin has very less moisture and highly subjective to bruising, hence the frequent bathing and wiping the skin leads to unnecessary bruising and wound formation.

Description:Hair care can have a significant impact on a person's self-image and overall appearance. Maintaining clean and well-groomed hair can boost an individual's self-esteem and contribute to a positive self-image. It's important for nurses to educate clients about the psychological and emotional benefits of maintaining personal hygiene, including hair care.

Description:To prevent the development of pressure ulcers (bedsores) in bedridden patients, it's recommended to change the patient's position regularly. Changing the patient's position every 1 to 2 hours helps relieve pressure on specific areas of the body and improves blood circulation to the skin, reducing the risk of tissue damage and bedsores. Frequent repositioning, along with proper skin care and the use of appropriate support surfaces, is an essential component of preventing pressure ulcers in patients who are unable to change their positions independently.

Description:Braden scale is used to asses the patient level of risk for development of pressure ulcers. The evaluation is based on six indication sensory perception, moisture, activity, mobility, nutrition and friction or shear.

Description:Braden scale is a tool that was developed in 1987 by Barden Braden and Nancy Bergstrom. The purpose of this scale is to assess the patient for the risk of pressure ulcer (decubitus ulcer). Braden scale has following six criteria: 1. Sensory perception 2. Moisture 3. Activity 4. Mobility 5. Nutrition 6. Frication and shear

Description:Changing position is the most effective way to prevent bedsore in bed-ridden patient. It is advised to change position of a bed-ridden patient at least every 2 hours and wheelchair-bound patient at least every 15 minutes. Dry sin is more easily damaged.

Description:One of the most effective nursing interventions for the prevention of pressure sores (pressure ulcers) is to ensure that bedridden or immobile patients are regularly turned and repositioned. This helps relieve pressure on specific areas of the body, improves blood circulation to the skin, and reduces the risk of tissue damage that can lead to pressure ulcers. The other options mentioned are not directly related to pressure sore prevention: a. Frequent baths can contribute to hygiene but are not specifically focused on pressure sore prevention. b. Maintaining the patient's skin moist might be appropriate in certain situations but needs to be managed carefully to prevent skin breakdown. d. Frequent feeding is not directly related to pressure sore prevention. Regular turning and repositioning are crucial in maintaining skin integrity for patients who are at risk of developing pressure ulcers.

Description:Bedsore is considered as a contaminated wound. In this wound periphery is considered as more clean. So cleaning of the wound has to be done from outer to inner. In surgical wound cleaning has to be done from inner to outer.

Description:In the side-lying position, the sacral region (lower back) is generally not at high risk for pressure sores. The sacral area is not in direct contact with the supporting surface in the side-lying position, unlike the other mentioned areas (ear, hip, and elbow), which are more susceptible to pressure and friction. However, the sacral region can be at risk for pressure sores when the patient is lying in a supine (back-lying) position due to direct contact with the bed or chair surface.

Description:In the side-lying position, the ear is at high risk for pressure sores, especially if the patient's head remains in direct contact with the supporting surface for an extended period. The ear is a bony prominence that can experience pressure and friction against the surface, leading to tissue damage and the development of pressure ulcers. Special attention and appropriate positioning strategies are necessary to prevent pressure sores in this area.

Description:In Stage I pressure ulcers, hyperemia (excess blood in the vessels), increased skin temperature, and redness can be noticed. However, at this stage, the skin is still intact and there are no visible breaks or open sores. The affected area might feel warmer than the surrounding skin due to increased blood flow as a response to pressure. It's important to identify Stage I pressure ulcers early and take appropriate preventive measures to avoid progression to more severe stages.

Description:• The major factors contributing to pressure ulcers are friction and shearing forces, loss sensory perception, exposure to moisture, lack of activity and mobility. • Edema, chronic disease and malnutrition may indirectly contributed to pressure ulcer but shearing forces are the direct cause of pressure ulcer.

Description:The process of bone demineralization increase in immobility. Immobility causes slow bone formation while breakdown increases. That is when someone is immobile, the cell that make bone (osteoblasts) are not able to work. In addition, there is more activity of the cells that breakdown bone (osteoclasts). Moreover, during bed rest there is an increased loss of calcium and phosphorous in the urine and often blood calcium levels. Thus loss of bone calcium takes place.

Description:A flush is a sudden and temporary reddening of the skin, often due to dilation of blood vessels. It can be caused by various factors such as emotions, heat, alcohol consumption, certain medications, or underlying medical conditions. This redness occurs when blood vessels in the skin expand and allow more blood to flow through, resulting in the visible redness known as a flush.

Description:When caring for a bedsore or any wound, it's generally recommended to remove dressings when they are moist or wet to promote healing and avoid disrupting the healing process. Dressings that are dry and adherent to the wound bed can cause unnecessary trauma and pain when removed. Keeping the wound area clean, moist, and protected with appropriate dressings is important for wound healing. Options a and b are not accurate guidelines for wound care: a. Wounds should be kept in a moist but not excessively wet environment to promote healing. Excessive moisture can lead to maceration and delayed healing. b. Tight packing of wounds is generally not recommended, as it can hinder proper wound healing and increase the risk of infection.

Description:A Grade II pressure sore involves skin loss and damage that goes beyond the top-most skin layers. In a Grade II pressure sore, there is partial-thickness loss of skin involving the epidermis (top-most layer) and possibly the dermis (second layer). The sore can appear as an abrasion, blister, or shallow crater. It's important to monitor and provide appropriate care for Grade II pressure sores to prevent them from worsening.

Description:Dehydration and electrolyte imbalance are not the side effects of anesthesia. Hydration level and electrolyte balance can be maintained by adequate administration of intravenous fluid before, during and after surgery. Conditions given in other options are potential adverse effects of surgery and anesthesia.

Description:Skin turgor means the elasticity of skin. Elasticity is usually seen when the skin is well hydrated and nourished. Poor skin turgor is a late sign of dehydration.