NUR 2032 Exam 1 Test Bank Kozier & Erb’s Fundamentals of Nursing, 10/E All Chapters Completed for 2022/2023

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Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 29NUR 2032 Exam #1 Test Bank Chapter 29 Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 29 Question 1 Type: MCSA An older client ha... s an oral temperature reading of 97.2 degrees F. The nurse realizes that this client’s low temperature could be due to which observation? 1. The anxiety level of the client has increased. 2. Hormones have fluctuated in this client. 3. Muscle activity has increased during the client’s therapy session. 4. Loss of subcutaneous fat is noted. Correct Answer: 4 Rationale 1: If a client is anxious or stressed, this response stimulates the sympathetic nervous system. This in turn increases the production of epinephrine and norepinephrine, which increases metabolic and heat production, causing the temperature to rise. Rationale 2: Women experience more hormonal fluctuations than men, and this is usually true with the secretion of progesterone at the time of ovulation. Because this client is older, hormone fluctuations and ovulation will not impact the temperature. Rationale 3: Exercise, which represents hard work or strenuous activity, increases body temperature. That is not the case with this client. No reference has been made to a therapy session, and the temperature is decreased. Rationale 4: This client is older and research shows that older people are at risk for hypothermia. When one ages, subcutaneous fat is lost. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological AdaptationQSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Identify the variations in normal body temperature, pulse, respirations, and blood pressure that occur from infancy to old age. MNL Learning Outcome: 3.3.1. Explain the body’s regulation of temperature, pulse, respirations, and blood pressure. Page Number: 479 Question 2 Type: MCSA The nurse is preparing to measure a client’s temperature. What is the first thing that the nurse should do to ensure an accurate temperature reading? 1. Assess that the equipment used is working properly. 2. Place the client in a position that is most comfortable for the health care provider. 3. Take the temperature with a chemical disposable thermometer when the client is perspiring. 4. Wait at least 10 minutes before taking the temperature after a client has been smoking. Correct Answer: 1 Rationale 1: If the equipment is not working properly, no accuracy will be obtained in the readings. Rationale 2: The type of equipment or method that is chosen will dictate client position, not the position of the health care provider. Rationale 3: If the equipment is not working properly, no accuracy will be obtained in the readings. The type of equipment or method that is chosen will dictate client position, not the position of the health care provider. In order to use a chemical disposable thermometer, the client’s skin must be dry for the thermometer to adhere to the skin. Rationale 4: The recommended time to wait to assess an oral temperature is 30 minutes after one smokes, not 10 minutes. Global Rationale:Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Verbalize the steps used in: a. Assessing body temperature. MNL Learning Outcome: 3.3.1. Explain the body’s regulation of temperature, pulse, respirations, and blood pressure. Page Number: 484 Question 3 Type: MCSA The nurse needs to measure the temperature of a client who has a history of heart disease and has eaten a bowl of vegetable soup 45 minutes ago. Which site should the nurse use? 1. Axilla 2. Oral 3. Popliteal 4. Rectal Correct Answer: 2 Rationale 1: The axilla is the preferred site for newborns, not adults. Rationale 2: Body temperature is frequently measured orally even if the client has eaten or drank something cold or hot. One only needs to wait 30 minutes, and then this site can be used. Rationale 3: The popliteal site would not be used given the history of heart disease. There could be circulatory issues that might affect accurate reading because this site is much farther away from the heart.Rationale 4: The rectal site would be contraindicated in this client given the history of heart disease. With the diagnosis of heart disease, the nurse would need to assess for the presence of hemorrhoids. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Verbalize the steps used in: a. Assessing body temperature. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 482 Question 4 Type: MCSA While waiting for the physician to respond regarding a client’s elevated temperature, what can the nurse do to assist the client? 1. Bathe the client with ice water. 2. Give the client an antipyretic. 3. Increase fluid intake. 4. Lower the room temperature. Correct Answer: 3 Rationale 1: Bathing the client in ice water would lower the client’s temperature too fast, possibly causing hypothermia. Rationale 2: Giving a client an antipyretic requires a doctor’s order.Rationale 3: Elevated body temperature contributes to dehydration, which leads to body tissues drying out and malfunctioning. Rehydrating the client’s tissues will allow the temperature to return to normal. Rationale 4: Dropping the temperature of the room would lower the client’s temperature too fast, possibly causing hypothermia. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implemenation Learning Outcome: 4. Describe appropriate nursing care for alterations in vital signs. MNL Learning Outcome: 3.3.4. Compare expected and unexpected outcomes. Page Number: 481 Question 5 Type: MCSA While assessing the dorsalis pedis pulse of a client, the nurse determines that the pulse is absent. However, the extremity is warm and pink with nail beds blanching at 2 to 3 seconds of capillary refilling time. How would the nurse explain these findings? 1. A change in the client’s health status has occurred. 2. The client has thrown a blood clot in that extremity. 3. The RN’s watch has stopped working. 4. Too much pressure was applied over the pulse site. Correct Answer: 4Rationale 1: The information provided gives no indication that any health change has occurred. Rationale 2: The assessment data given (warm, pink, etc.) are not symptoms of a blood clot. Rationale 3: There is no data given in regard to equipment malfunction, such as the nurse’s watch. Rationale 4: Too firm of pressure on a pulse site will obliterate that pulse because assessing the dorsalis pedis pulse requires one to apply some pressure over the dorsalis pedis artery, making contact with the cones in the foot. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Verbalize the steps used in: b. Assessing a peripheral pulse. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 488 Question 6 Type: MCSA The RN assesses a client who is recovering from femoral popliteal bypass surgery and discovers that it is difficult to assess the dorsalis pedis pulses. Which nursing intervention would be most appropriate for the nurse to use? 1. Ask another nurse to assess the pulses. 2. Document the findings. 3. Obtain a Doppler ultrasound stethoscope. 4. Wait and try again later.Correct Answer: 3 Rationale 1: If one nurse is having difficulty with the pulse and accuracy, getting another nurse is not going to be the best choice. Rationale 2: Just documenting the findings does not address the problem of getting an accurate pulse reading. Rationale 3: Obtaining a Doppler ultrasound stethoscope is the appropriate action to take. The Doppler will ensure accuracy by helping to exclude environmental sounds. Rationale 4: Waiting until later may be harmful to the client, creating an unsafe environment. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Verbalize the steps used in: b. Assessing a peripheral pulse. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 488 Question 7 Type: MCSA When assessing a client’s peripheral pulse, the health care provider is also assessing which of the following? 1. Depth 2. Rhythm 3. Sound4. Stress Correct Answer: 2 Rationale 1: Depth is a term used when assessing edema. Rationale 2: When assessing peripheral pulses, one of the characteristics being assessed is rhythm, along with rate, volume, and equality. Rationale 3: Heart sounds are assessed with the apical pulse. Rationale 4: Stress will affect the rate of both pulse and respiration, but it is not a characteristic of pulse assessment. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. List the characteristics that should be included when assessing pulses. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 489 Question 8 Type: MCSA The nurse is going to assess the apical-radial pulse of a client with a cardiovascular disorder. Which rationale did the RN use to make this decision? 1. A forceful radial pulse is much too difficult to count correctly. 2. Both arteriole and venous sounds were heard simultaneously.3. The pulse was bounding and easily obliterated. 4. The thrust of blood from the heart is too feeble for the wave to be felt at the peripheral pulse site. Correct Answer: 4 Rationale 1: A forceful radial pulse would be ideal for assessing a client’s peripheral pulse. Rationale 2: Arteriole and venous sounds would be detected when using the Doppler, but there is no indication for Doppler use given this situation. Rationale 3: A bounding pulse is not easily obliterated. Rationale 4: Knowing there is a history of a cardiovascular disorder would alert the RN to the importance of the utmost accuracy for the client’s pulse assessment. The apical-radial pulse is used to assess this type of client due to the feebleness of the wave of blood flow felt at the peripheral sites. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify nine sites used to assess the pulse and state the reasons for their use. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 494 Question 9 Type: MCSA A client is unconscious and in respiratory distress after being in a motor vehicle crash. Which should the nurse realize as being a factor that caused a change in this client’s respiratory rate?1. Exercise 2. Increased intracranial pressure 3. Increased environmental temperature 4. Stress Correct Answer: 2 Rationale 1: Exercise increases respiration rates. Rationale 2: Factors that decrease respirations include increased intracranial pressure. Rationale 3: Increased environmental temperatures increase respiration rates. Rationale 4: Stress increases respiration rates. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Describe the mechanics of breathing and the mechanisms that control respirations. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 495 Question 10 Type: MCSA The nurse needs to assess a client’s respiratory status. Which client position would be the best for this assessment?1. Prone 2. Semi-Fowler’s 3. Side-lying 4. Supine Correct Answer: 2 Rationale 1: The prone position increases the volume of blood inside the thoracic cavity and compresses the chest, compromising the client’s respirations. Rationale 2: Persons in a semi-Fowler’s position will better aid themselves and the nurse to assess their respiratory status. Rationale 3: The side-lying position increases the volume of blood inside the thoracic cavity and compresses the chest, compromising the client’s respirations. Rationale 4: The supine position increases the volume of blood inside the thoracic cavity and compresses the chest, compromising the client’s respirations. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Verbalize the steps used in: d. Assessing respirations. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 498 Question 11 Type: MCSAA client is being treated for congestive heart failure. Which physical finding would lead the RN to believe the client’s condition has not improved? 1. Temperature of 98.6°F (37°C) 2. Moderate amount of clear thin mucus 3. Pulse oximetry reading of 96% 4. Wheezing of breath sounds in all lobes Correct Answer: 4 Rationale 1: A temperature reading of 98.6°F is a normal finding and not an indication of heart failure. Rationale 2: A moderate amount of clear mucus is a normal finding and not an indication of heart failure. Rationale 3: A pulse oximetry reading of 96% is a normal finding and not an indication of heart failure. Rationale 4: Wheezing heard when assessing breath sounds is indicative of abnormal breath sounds, which are characteristic of congestive heart failure. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Describe the mechanics of breathing and the mechanisms that control respirations. MNL Learning Outcome: 3.3.4. Compare expected and unexpected outcomes. Page Number: 497Question 12 Type: MCSA Which determinant of blood pressure would explain a client’s blood pressure reading of 120/100? 1. Blood viscosity 2. Blood volume 3. Pumping action of the heart 4. Peripheral vascular resistance Correct Answer: 4 Rationale 1: Determinants of blood pressure such as blood viscosity mainly affect the systolic reading portion of the blood pressure. Rationale 2: Determinants of blood pressure such as blood volume mainly affect the systolic reading portion of the blood pressure. Rationale 3: Determinants of blood pressure such as pumping action of the heart mainly affect the systolic reading portion of the blood pressure. Rationale 4: Peripheral vascular resistance especially affects diastolic blood pressure readings. A reading of 120/100 would be indicative of peripheral vascular resistance. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Identify the variations in normal body temperature, pulse, respirations, and blood pressure that occur from infancy to old age.MNL Learning Outcome: 3.3.4. Compare expected and unexpected outcomes. Page Number: 500 Question 13 Type: MCSA The nurse is assessing a client’s blood pressure. What should the nurse hear during phase 2 of Korotkoff’s sounds? 1. A muffled, whooshing, or swishing sound 2. Disappearance of sound 3. Faint, clear tapping sound 4. Increased intensity of sound Correct Answer: 1 Rationale 1: Phase 2 produces a muffled, whooshing, or swishing sound. Rationale 2: Phase 5, the final phase, is where the sound disappears. Rationale 3: Phase 1 of Korotkoff’s sounds starts with a faint, clear tapping sound. Rationale 4: Phase 3 is marked by an increased intensity of sound. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Verbalize the steps used in: e. Assessing blood pressure.MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 503 Question 14 Type: MCSA The nurse is preparing to assess a client’s blood pressure. Which artery will the nurse use for this assessment? 1. Brachial 2. Femoral 3. Radial 4. Ulnar Correct Answer: 1 Rationale 1: The brachial is the most common artery used to assess a blood pressure reading because it is the most accessible. Rationale 2: The femoral is not as accessible as the brachial. Rationale 3: The radial could be used but it is not as accurate as the brachial artery. Rationale 4: The ulnar could be used but it is not as accurate as the brachial artery. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Verbalize the steps used in: e. Assessing blood pressure.MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 503 Question 15 Type: MCSA In the palpatory method of blood pressure determination, instead of listening for the blood flow sounds, light to moderate pressure is used over the artery as the pressure in the cuff is released. When will the nurse read the pressure from the sphygmomanometer? 1. When the cuff is applied 2. When the cuff is being deflated 3. When the first pulsation is felt 4. When the second pulsation is felt Correct Answer: 3 Rationale 1: Assessing the pulse before the cuff is inflated is not the pressure. Rationale 2: This is not the client’s blood pressure if the cuff is just being deflated. Rationale 3: The first pulsation that is felt after the cuff is slowly deflated is the blood pressure reading that is recorded if the palpatory method is used to assess a client’s blood pressure. Rationale 4: If the second pulsation is recorded, that would be an inaccurate reading. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 3. Verbalize the steps used in: e. Assessing blood pressure. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 503 Question 16 Type: MCSA Which condition would lead the RN to choose the dorsalis pedis pulse as the site for further assessing the client’s status? 1. Altered level of consciousness 2. Decreased urine output 3. Irregular radial pulse 4. Toes cool to touch Correct Answer: 4 Rationale 1: To assess an altered level of consciousness, the nurse would most likely assess the client’s apical pulse. Rationale 2: To assess for decreased urine output, the nurse would most likely assess the apical pulse. Rationale 3: For an irregular radial pulse, the nurse would most likely assess the apical pulse. Rationale 4: The dorsalis pedis pulse site is in the foot, so this is the ideal site to assess the pulse for toes that are cool to touch. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventionsNursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify nine sites used to assess the pulse and state the reasons for their use. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 488 Question 17 Type: MCSA When assessing a client’s oxygen saturation reading, the nurse realizes that what will affect this reading? 1. Activity 2. Environmental conditions 3. Nutrition 4. Skin color Correct Answer: 1 Rationale 1: Factors affecting oxygen saturation readings are hemoglobin, circulation, and activity. If there is shivering or excessive movement of the sensor site, this will interfere with an accurate reading. Rationale 2: Environmental conditions do not affect an accurate oxygen saturation reading. Rationale 3: Nutrition does not affect an oxygen saturation reading. Rationale 4: Skin color does not affect an oxygen saturation reading. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approachesNLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Verbalize the steps used in: f. Assessing blood oxygenation using pulse oximetry. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 507 Question 18 Type: MCSA As the RN is suctioning a client, the pulse oximetry reading drops to 83%. What should the nurse do? 1. Allow the client to take some extra deep breaths. 2. Continue to suction but only intermittently. 3. Keep the catheter in place and wait a few minutes. 4. Stop suctioning and give supplemental oxygen. Correct Answer: 4 Rationale 1: Allowing the client to take a few deep breaths will help but not quickly enough to compensate for the hypoxia experienced. Rationale 2: Continuing to suction continuously or intermittently will only decrease the saturation levels more. Rationale 3: Leaving the catheter in place obstructs air flow, thus compromising an already poor situation. Rationale 4: Not only does suctioning remove secretions, but it also removes the client’s air. By stopping suctioning, the RN stops removing both. This allows the client to recoup from the procedure, and giving oxygen will also increase the saturation ability back to a normal range. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk PotentialQSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Verbalize the steps used in: f. Assessing blood oxygenation using pulse oximetry. MNL Learning Outcome: 3.3.4. Compare expected and unexpected outcomes. Page Number: 509 Question 19 Type: MCSA The RN needs vital signs assessed for four clients. Which client should the nurse address and not assign to the UAP? 1. Cardiac catheterization client returning to the nursing unit 2. COPD client on 2 Lpm oxygen via nasal cannula 3. Pneumonia client nearing discharge 4. Post-op client of 2 days from gallbladder surgery Correct Answer: 1 Rationale 1: The cardiac catheterization client will need a thorough assessment because she is just returning to the nursing unit. Invasive procedures, such as a catheterization, will need to be closely assessed. More than likely a Doppler will be needed to ensure the pedal pulse is present and stable in the extremity used during the procedure. Unlicensed personnel are not usually delegated Doppler ultrasound device use. Rationale 2: The COPD client is a chronic condition client, and her vital signs would be considered routine. Rationale 3: The client with pneumonia nearing discharge would be considered medically stable. Therefore, assisting this client is within the UAP’s capability. Rationale 4: The client who is 2 days post-op from gallbladder surgery would be considered medically stable. Therefore, assisting this client is within the UAP’s capability.Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8. Recognize when it is appropriate to delegate measurement of vital signs to unlicensed assistive personnel. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 478 Question 20 Type: MCMA Prior to assessing a client’s blood pressure, the nurse reviews factors that could affect the reading. Which factors could impact blood pressure? Standard Text: Select all that apply. 1. Stress 2. Race 3. Obesity 4. Medications 5. Employment Correct Answer: 1, 2, 3, 4 Rationale 1: Stimulation of the sympathetic nervous system increases cardiac output and vasoconstriction of the arterioles, increasing the blood pressure reading.Rationale 2: African Americans over 35 years of age tend to have higher blood pressures than do European Americans of the same age. Rationale 3: Both childhood and adult obesity predispose to hypertension. Rationale 4: Many medications, including caffeine, can increase or decrease the blood pressure. Rationale 5: Employment is not a factor that affects blood pressure. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Describe factors that affect the vital signs and accurate measurement of them. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 500 Question 21 Type: MCMA The nurse is planning to assess a client’s pulse. What characteristics should the nurse include in this assessment? Standard Text: Select all that apply. 1. Rate 2. Rhythm 3. Volume 4. Tone5. Viscosity Correct Answer: 1, 2, 3 Rationale 1: When assessing the pulse, the nurse collects data about the rate. Rationale 2: When assessing the pulse, the nurse collects data about the rhythm. Rationale 3: When assessing the pulse, the nurse collects data about the volume. Rationale 4: Tone is not a characteristic of a pulse. Rationale 5: Viscosity is not a characteristic of a pulse. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. List the characteristics that should be included when assessing pulses. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 489 Question 22 Type: MCMA When assessing a client’s respirations, the nurse realizes that the respiratory centers and chemoreceptors respond to changes in which factors? Standard Text: Select all that apply. 1. Oxygen concentration2. Carbon dioxide concentration 3. Hydrogen ions 4. Potassium level 5. Serum calcium level Correct Answer: 1, 2, 3 Rationale 1: The respiratory centers and chemoreceptors respond to changes in the concentration of oxygen. Rationale 2: The respiratory centers and chemoreceptors respond to changes in the concentration of carbon dioxide. Rationale 3: The respiratory centers and chemoreceptors respond to changes in the concentration of hydrogen ions. Rationale 4: The respiratory centers and chemoreceptors do not respond to changes in the potassium level. Rationale 5: The respiratory centers and chemoreceptors do not respond to changes in the serum calcium level. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Describe the mechanics of breathing and the mechanisms that control respirations. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 496Question 23 Type: MCMA Even though a UAP is available to assist with vital sign assessment, the nurse is going to conduct these assessments independently in which situations? Standard Text: Select all that apply. 1. Client who complains of chest pain 2. Client returning from surgery 3. Prior to administering a medication that affects blood pressure 4. Client who complains of dizziness after ambulating. 5. Client being admitted to the care area Correct Answer: 1, 2, 3, 4 Rationale 1: When a client reports symptoms such as chest pain, the nurse should conduct the assessment. Rationale 2: When a client returns from surgery, the nurse should conduct the assessment. Rationale 3: When the client is prescribed a medication that could affect the vital signs, the nurse should conduct the assessment. Rationale 4: When the client reports symptoms such as dizziness after ambulation, the nurse should conduct the assessment. Rationale 5: When the client is being admitted to a care area, the nurse could delegate the vital sign assessment to the UAP. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approachesNLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8. Recognize when it is appropriate to delegate measurement of vital signs to unlicensed assistive personnel. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 478 Question 24 Type: MCSA When documenting a client’s axillary temperature on the graphic sheet, how should the nurse identify the method of assessing the temperature? 1. AX 2. O 3. R 4. SL Correct Answer: 1 Rationale 1: When documenting the temperature in the client record, an axillary temperature should be recorded with an AX. Rationale 2: The letter O is not used when documenting a client’s temperature. Rationale 3: The letter R would indicate a rectal temperature and not an axillary temperature. Rationale 4: The letters SL are not used when documenting a client’s temperature. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered careAACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Demonstrate appropriate documentation and reporting of vital signs. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 484 Question 25 Type: MCSA The nurse assesses phase 1 Korotkoff’s sound occurring at 136 and phase 5 Korotkoff’s sound occurring at 72. How should the nurse document this client’s blood pressure reading? 1. 136/72 2. 72/136 3. 136 – 72 4. 72 – 136 Correct Answer: 1 Rationale 1: The first tapping phase 1 Korotkoff’s sound is the systolic blood pressure. The last sound heard during phase 5 Korotkoff’s sound is the diastolic blood pressure. The nurse would document the blood pressure as being 136/72. Rationale 2: The diastolic blood pressure is not documented before the systolic blood pressure. Rationale 3: The systolic blood pressure and diastolic blood pressure are not separated by a minus sign. Rationale 4: This places the diastolic reading first and uses the minus sign, which is incorrect to use. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care EnvironmentClient Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Demonstrate appropriate documentation and reporting of vital signs. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 503 Question 26 Type: MCMA A client comes to the emergency department with a temperature of 104°F. Which assessment findings should the nurse use to determine if this client is experiencing heat stroke? Standard Text: Select all that apply. 1. Delirious 2. Pale and dizzy 3. Skin warm and flushed 4. No evidence of sweating 5. Had been playing tennis in the sun Correct Answer: 1, 3, 4, 5 Rationale 1: Persons experiencing heat stroke may be delirious. Rationale 2: Heat exhaustion is a result of excessive heat and dehydration. Signs of heat exhaustion include paleness and dizziness. Rationale 3: Persons experiencing heat stroke generally have warm, flushed skin. Rationale 4: Persons experiencing heat stroke often do not sweat. Rationale 5: Persons experiencing heat stroke generally have been exercising in hot weather.Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Describe appropriate nursing care for alterations in vital signs. MNL Learning Outcome: 3.3.4. Compare expected and unexpected outcomes. Page Number: 479 Question 27 Type: MCMA The nurse determines that unlicensed assistive personnel (UAP) are not to be delegated client blood pressure measurements. What did the nurse observe to make this clinical decision? Standard Text: Select all that apply. 1. The valve on the bulb was closed. 2. The client was sitting with the legs crossed. 3. The arm was below the level of the heart. 4. The UAP waited 2 minutes before re-measuring. 5. The cuff bladder was placed over the brachial artery. Correct Answer: 2, 3 Rationale 1: The valve on the bulb needs to be closed to pump up the cuff. Rationale 2: The adult client should be sitting with both feet on the floor. Crossed legs can cause elevations in systolic and diastolic blood pressures.Rationale 3: The elbow should be slightly flexed with the palm of the hand facing up and the arm supported at heart level. The blood pressure increases when the arm is below heart level. Rationale 4: After taking a measurement, 1 to 2 minutes should transpire before making any further measurements. Rationale 5: The cuff should be placed evenly around the upper arm and the bladder center placed directly over the artery. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8. Recognize when it is appropriate to delegate measurement of vital signs to unlicensed assistive personnel. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 504 Chapter 31 Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 31 Question 1 Type: MCSA The nurse is setting up a sterile field. Which action by the nurse best exhibits surgical asepsis? 1. Disinfecting an item before adding it to a sterile field 2. Allowing sterile gloved hands to fall below the waist3. Suctioning the oral cavity of an unconscious client 4. Touching only the inside surface of the first glove while pulling it onto the hand Correct Answer: 4 Rationale 1: Disinfecting an item is an example of medical asepsis, not surgical asepsis. Rationale 2: If sterile gloved hands fall below the waist, they are considered to be unsterile. Rationale 3: Suctioning the oral cavity of a client is considered contaminating. Rationale 4: Touching only the inside surface of the first glove while pulling it onto the hand is the correct technique when applying sterile gloves. This prevents contamination of the outside of the glove, which must remain sterile. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Explain the concepts of medical and surgical asepsis. MNL Learning Outcome: 4.2.3. Apply the principles of surgical asepsis as indicated in the client’s plan of care. Page Number: 625 Question 2 Type: MCSA The nurse is using medical asepsis when providing client care. Which action did the nurse demonstrate? 1. Administering parenteral medications2. Changing a dressing 3. Performing a urinary catheterization 4. Using personal protective equipment Correct Answer: 4 Rationale 1: Administering parenteral medications requires surgical asepsis. Rationale 2: Changing a dressing requires surgical asepsis. Rationale 3: Performing a urinary catheterization requires surgical asepsis. Rationale 4: Using personal protective equipment demonstrates medical asepsis. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Explain the concepts of medical and surgical asepsis. MNL Learning Outcome: 4.2.2. Apply the principles of medical asepsis in the care of the client. Page Number: 636 Question 3 Type: MCSA The nurse is reviewing the care needs for a group of assigned clients. Which client should the nurse recognize as being most at risk for a nosocomial infection? 1. A client in the emergency department with abdominal pain 2. A 19-year-old woman in her first trimester of pregnancy3. A 72-year-old male client with COPD 4. An 86-year-old female client on steroid therapy Correct Answer: 4 Rationale 1: A client in the emergency department with abdominal pain has just arrived in the facility, and not enough time has elapsed for this client to be considered to have a nosocomial infection. If this client has an infection, it would be community acquired. Rationale 2: The 19-year-old female who is pregnant is at a low risk. Rationale 3: The 72-year-old male with COPD is at a lower risk for infection than the 82-year-old because the older client has a weakened immune system because of taking steroids. Rationale 4: The client most at risk for a nosocomial infection is the client who is 86 years old and on steroid therapy. The very old and very young are most susceptible to infections. The 86-year-old client is also on steroid therapy, which compromises the immune system. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify risks for nosocomial and health care–associated infections. MNL Learning Outcome: 4.2.4. Integrate safe practices in the care of the client to prevent the spread of infection. Page Number: 609 Question 4 Type: MCSA The nurse is preparing discharge teaching for a client recovering from surgery. What instruction is the most important for the nurse to give this client who has a surgical wound?1. Adjust the diet so it contains more fruits and vegetables. 2. Apply lubricating lotion to the edges of the wound. 3. Notify the physician of any edema, heat, or tenderness at the wound site. 4. Thoroughly irrigate the wound with hydrogen peroxide. Correct Answer: 3 Rationale 1: Increasing intake of fruits and vegetables would increase vitamin C, which helps with wound healing, but more protein would be the best choice. Rationale 2: Applying lubricating lotion to the edges of a wound would impede the healing process. Rationale 3: A client being discharged with an open surgical wound has to be instructed on the detection of infection because the skin is the first line of defense. Signs such as edema, heat, and tenderness would indicate a local infection. Rationale 4: Irrigating with hydrogen peroxide would break down good granulating tissue, so this would not increase healing. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Identify signs of localized and systemic infections and inflammation. MNL Learning Outcome: 4.2.4. Integrate safe practices in the care of the client to prevent the spread of infection. Page Number: 607 Question 5 Type: MCSAA patient is diagnosed with a systemic infection. What will the nurse most likely assess in this client? 1. Edema, rubor, heat, and pain 2. Fever, malaise, anorexia, nausea, and vomiting 3. Palpitations, irritability, and heat intolerance 4. Tingling, numbness, and cramping of the extremities Correct Answer: 2 Rationale 1: Edema, rubor, heat, and pain are symptoms of a local infection. Rationale 2: Fever, malaise, anorexia, nausea, and vomiting are symptoms of a systemic infection. Rationale 3: Palpitations, irritability, and heat intolerance are symptoms of a thyroid condition. Rationale 4: Tingling, numbness, and cramping of the extremities are symptoms of hypocalcemia. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Identify signs of localized and systemic infections and inflammation. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse’s role, and types of precautions during client care. Page Number: 610 Question 6 Type: MCSAAn older client with gallbladder disease has had a cholecystectomy. Which factor should the nurse realize would influence the development of an infection in this client? 1. Active bowel sounds 2. Dry intact skin 3. Intact mucous membranes 4. Susceptibility of the client Correct Answer: 4 Rationale 1: Active bowel sounds would indicate the body is able to defend itself against an infection. Rationale 2: Dry intact skin is a factor that would help the body defend against an infection. Rationale 3: Intact mucous membranes is a factor that would help the body defend against infection. Rationale 4: How susceptible the client is for an infection is one of the factors that influences microorganism growth. This client is 80 years old and has a surgical incision, so the first line of defense, the skin, is not intact. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Identify factors influencing a microorganism’s capability to produce an infectious process. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse’s role, and types of precautions during client care. Page Number: 620Question 7 Type: MCSA The nurse is reviewing collected data from a client. Which information should the nurse identify as a physiological barrier to defend the client’s body from microorganisms? 1. Heavy smoking 2. Moisturizing the skin 3. Breakdown of skin 4. Voiding quantity sufficient Correct Answer: 4 Rationale 1: Heavy smoking does not defend the body from microorganisms; it destroys the cilia in the nose that help to filter organisms. Rationale 2: Moisturizing the skin can allow microorganisms to enter the body. Rationale 3: Breakdown of the skin can allow microorganisms to enter the body. Rationale 4: Voiding quantity sufficient is a barrier that helps the body defend itself against microorganisms. The act of voiding flushes those organisms that might try to enter the body through the urinary meatus. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify anatomic and physiological barriers that defend the body against microorganisms.MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse’s role, and types of precautions during client care. Page Number: 607 Question 8 Type: MCSA The nurse determines that a client has active immunity to a microorganism. What did the nurse assess that caused the client to develop this type of immunity? 1. Becoming ill with tetanus and receiving tetanus toxoid 2. Having chickenpox 3. Receiving a rabies shot after being bitten by a rabid dog 4. Receiving an injection of gamma globulin Correct Answer: 2 Rationale 1: Receiving an injection for tetanus is an example of acquired passive immunity. Rationale 2: When the client has the disease, the body stimulates the process of acquired active immunity. Rationale 3: Receiving an injection for rabies is an example of artificially acquired passive immunity. Rationale 4: Receiving an injection of gamma globulin is an example of artificially acquired passive immunity. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 6. Differentiate active from passive immunity.. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse’s role, and types of precautions during client care. Page Number: 608 Question 9 Type: MCSA A client was bitten by a rabid raccoon. What care should the nurse prepare to provide to this client? 1. A tetanus toxoid injection 2. An immunization for rabies 3. An injection of immunoglobulin 4. Mother’s breast milk with antibodies in it Correct Answer: 2 Rationale 1: A tetanus toxoid injection is not specific for rabies. Rationale 2: Receiving an immunization for rabies is an example of artificially acquired passive immunity. Rationale 3: An injection of immunoglobulin is not specific for rabies. Rationale 4: Mother’s breast milk is another example of passive immunity, but not for rabies. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 6. Differentiate active from passive immunity. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse’s role, and types of precautions during client care. Page Number: 608 Question 10 Type: MCSA The nurse is planning care for a client. Which intervention would be appropriate to reduce the risk of infection? 1. Assess vital signs only once daily. 2. Raise the temperature in the client’s room. 3. Wash hands. 4. Wear a mask for all client care. Correct Answer: 3 Rationale 1: Assessing vital signs is important but should occur more frequently than once daily. Rationale 2: Raising the temperature in a client’s room would contribute to the growth of microorganisms. Rationale 3: Washing hands is always the first and best way to stop the spread of microorganisms, which cause infections. Rationale 4: Wearing a mask for all clients is not practical and is unnecessary unless a microorganism is airborne and the client is in isolation. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safetyNursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 8. Identify interventions to reduce risks for infections. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse’s role, and types of precautions during client care. Page Number: 612 Question 11 Type: MCSA The nurse wants to protect a client from developing an infection. Which action should the nurse take to break a link in the chain of infection? 1. Cover the mouth and nose when sneezing. 2. Place contaminated linens in a paper bag. 3. Use personal protective equipment (PPE) sparingly. 4. Wear gloves at all times. Correct Answer: 1 Rationale 1: Covering the mouth and nose when sneezing prevents airborne droplets from escaping into the air for others to contract in the chain of infection. Rationale 2: Placing linens in a paper bag would allow germs to come out through the bag, and the linen would act as a fomite, thus allowing the chain to continue. Rationale 3: PPE, according to OSHA standards, has to be used whenever the situation dictates, not sparingly. Rationale 4: Gloves have to be worn but are to be changed between clients and hands washed. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespanNLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Identify measures that break each link in the chain of infection. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse’s role, and types of precautions during client care. Page Number: 612 Question 12 Type: MCSA The nurse is caring for a client with hepatitis A. Which technique should the nurse use to promote proper hand-washing technique with this client? 1. Allow the water to splatter forcibly when it is turned on. 2. Clean the faucet after use. 3. Hold the hands upward under the faucet. 4. Use approximately a teaspoon of soap. Correct Answer: 4 Rationale 1: When the water is turned on, it should be adjusted so it does not splatter even if the flow is not very forceful. Rationale 2: Cleaning the faucet after use would defeat the whole purpose of washing the hands. If the sink needs cleaning, clean it before washing the hands. Rationale 3: Holding the hands upward under the faucet is incorrect. They should be held downward so the soap, germs, and water are washed downward from the hands and down the sink. Rationale 4: Approximately 1 teaspoon of soap should be used when performing proper handwashing technique. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered careAACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Verbalize the steps used in: a. Performing hand hygiene. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse’s role, and types of precautions during client care. Page Number: 615 Question 13 Type: MCSA The nurse is removing personal protective equipment. Which nursing action demonstrates the appropriate technique for removing a mask? 1. Bend the strip at the top of the mask. 2. Loop the ties over the ears. 3. Tie the strings in a bow. 4. Touch the mask by the strings only. Correct Answer: 4 Rationale 1: Bending the strip at the top of the mask is done when applying a mask. Rationale 2: Looping the ties over the ears is done when applying a mask. Rationale 3: Tying the strings in a bow under the chin is done when applying a mask. Rationale 4: Touching the mask by the strings is the appropriate intervention because the mask is considered contaminated. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered careAACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Verbalize the steps used in: b. Applying and removing a gown, face mask, eyewear, and clean gloves. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse’s role, and types of precautions during client care. Page Number: 623 Question 14 Type: MCSA The nurse is preparing to remove soiled gloves. What action should the nurse take first? 1. Drop the gloves into the appropriate waste receptacle. 2. Ease the fingers into the gloves. 3. Grasp the outside of the nondominant glove. 4. Hook the bare thumb inside the other glove. Correct Answer: 3 Rationale 1: Dropping the gloves in the appropriate waste receptacle occurs after the gloves are removed. Rationale 2: Easing the fingers into the glove is done when applying gloves. Rationale 3: In order to remove gloves after use, one must grasp the outside of the nondominant glove. Rationale 4: Hooking the bare thumb inside the other glove is done after the gloves are removed. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection ControlQSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Verbalize the steps used in: b. Applying and removing a gown, face mask, eyewear, and clean gloves. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse’s role, and types of precautions during client care. Page Number: 622 Question 15 Type: MCSA The nurse is concerned that a break occurred in a sterile field. Which action occurred that caused this break? 1. Grasping the edge of the outermost flap and opening it away from oneself 2. Keeping objects on the field 1 inch from the edge 3. Keeping the sterile field in eyesight 4. Transferring a sterile object to a sterile field with a clean gloved hand Correct Answer: 4 Rationale 1: Grasping the edge of the outermost flap and opening it away from oneself will maintain the sterility of a field. Rationale 2: Keeping objects on the field 1 inch from the edge will maintain the sterility of a field. Rationale 3: Keeping the sterile field in eyesight will maintain the sterility of a field. Rationale 4: Transferring a sterile object onto a sterile field with a gloved hand would render the field unsterile only if the gloves are not sterile. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care EnvironmentClient Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 11. Verbalize the steps used in: c. Establishing and maintaining a sterile field. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse’s role, and types of precautions during client care. Page Number: 627 Question 16 Type: MCSA A client needs to be placed in contact isolation. What items should the nurse ensure are included in this client’s room? 1. Cabinet stocked with gloves and gowns 2. Cards and records 3. Paper towels, sink, and blood pressure cuff 4. Sign on the door Correct Answer: 3 Rationale 1: A cabinet stocked with gloves and gowns would be on the outside of the room. Rationale 2: Cards and records should never be taken into an isolation room. Rationale 3: Paper towels and a sink for hand washing should be in the client’s room so they can be used before the staff leaves the room. A blood pressure cuff needs to stay in the client’s room to prevent cross contamination. Rationale 4: The sign explaining the kind of isolation should be on the outside of the door to alert the staff of what is needed to enter. Global Rationale: Cognitive Level: ApplyingClient Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Compare and contrast category-specific, disease-specific, standard, and transmission-based isolation precaution systems. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse’s role, and types of precautions during client care. Page Number: 620 Question 17 Type: MCSA The RN has just been stuck with a syringe while dropping it into a sharps container that was too full in a client’s room. What action should the nurse take first for this puncture wound? 1. Complete an injury report. 2. Encourage bleeding. 3. Initiate first aid. 4. Wash the area with soap and water. Correct Answer: 2 Rationale 1: This is not the first step. It can be done later. Rationale 2: Encouraging bleeding is the first step. Rationale 3: Initiating first aid is not the first step. Rationale 4: Washing the area with soap and water is not the first step. Global Rationale: Cognitive Level: ApplyingClient Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13. Describe the steps to take in the event of a bloodborne pathogen exposure. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse’s role, and types of precautions during client care. Page Number: 636 Question 18 Type: MCSA The nurse is preparing to leave a client’s isolation room. Which action should the nurse take first when removing a grossly soiled gown? 1. Grasp the sleeve of the dominant arm, and remove it with a gloved hand. 2. Release the neck ties of the gown and allow the gown to fall forward. 3. Untie the strings at the neck first. 4. Untie the strings at the waist first. Correct Answer: 4 Rationale 1: Gloves are not left on while taking off a soiled gown. Rationale 2: The neck ties are untied after the ties at the waist are untied. Rationale 3: To leave an isolation room where a gown has been worn, one must untie the gown at the waist first, not at the neck. Rationale 4: To leave an isolation room where a gown has been worn, one must untie the gown at the waist first, not at the neck. After the neck ties are untied, the gown is allowed to fall forward. Global Rationale:Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Verbalize the steps used in: b. Applying and removing a gown, face mask, eyewear, and clean gloves. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse’s role, and types of precautions during client care. Page Number: 622 Question 19 Type: MCSA The nurse is preparing a presentation on standard precautions. Which statement should the nurse include in the presentation? 1. Cut the needle off a syringe after using it to give a client an injection. 2. Dispose of blood-contaminated materials in a biohazard container. 3. Gloves should not be worn for client care unless body fluids are seen. 4. Wear a mask when in direct contact with all clients. Correct Answer: 2 Rationale 1: Needles should never be cut, bent, or altered in any way, as this would place the health care provider at risk of being stuck. Rationale 2: Disposal of blood-contaminated materials in a biohazard container is a standard precaution. Rationale 3: Gloves should be worn when providing client care whether body secretions are seen or not.Rationale 4: Masks need not be worn when giving routine direct client care unless the client’s condition so warrants. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Compare and contrast category-specific, disease-specific, standard, and transmission-based isolation precaution systems. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse’s role, and types of precautions during client care. Page Number: 626 Question 20 Type: MCSA A client diagnosed with tuberculosis is being admitted to a care area. Which nursing action prevents the transmission of the disease? 1. Have the client wear a mask when coming from admission. 2. Stock the supply cart at the beginning of each shift. 3. Wash the hands only after leaving the room. 4. Wear a mask when exiting the room. Correct Answer: 1 Rationale 1: When a client has an airborne disease and must go elsewhere in the hospital, the client must wear a mask.Rationale 2: Supplies to prevent transmission of disease should be stocked at the end of the shift so that adequate supplies will be available for the next health care provider. Rationale 3: Hands should be washed before and after client care. Rationale 4: The mask should be removed just as the staff leaves the client’s room, not when coming out of the room. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 9. Identify measures that break each link in the chain of infection. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse’s role, and types of precautions during client care. Page Number: 626 Question 21 Type: MCMA The nurse is concerned that a client is at risk for a nosocomial infection. What did the nurse assess to make this clinical decision? Standard Text: Select all that apply. 1. Client is receiving intravenous fluids. 2. Client has an indwelling urinary catheter. 3. Client is recovering from surgery. 4. Client is receiving pain medication.5. Client is ambulating twice a day with assistance. Correct Answer: 1, 2, 3 Rationale 1: Bacteremia can occur from an intravascular line. Rationale 2: The client could develop an infection from an invasive procedure or device such as an indwelling urinary catheter. Rationale 3: After surgery, the client’s health status is compromised, lowering the client’s defenses to fight infection. Rationale 4: Receiving pain medication does not increase the client’s risk for developing a nosocomial infection. Rationale 5: Ambulation does not increase the client’s risk for developing a nosocomial infection. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify risks for nosocomial and health care–associated infections. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse’s role, and types of precautions during client care. Page Number: 604 Question 22 Type: MCMA A client diagnosed with an infectious disease asks the nurse how the infection ―got inside‖ her body. Which responses would be appropriate for the nurse to make? Standard Text: Select all that apply.1. ―It depends on the number of organisms present to cause a disease.‖ 2. ―It depends on how aggressive the organisms are to cause a disease.‖ 3. ―It depends upon how the organisms get inside the body to cause a disease.‖ 4. ―It depends upon where the person is at the time the disease is present.‖ 5. ―It depends upon where the person works.‖ Correct Answer: 1, 2, 3, 4 Rationale 1: ―It depends on the number of organisms present to cause a disease‖ addresses the number of microorganisms present. Rationale 2: ―It depends on how aggressive the organisms are to cause a disease‖ addresses the virulence and potency of the microorganisms. Rationale 3: ―It depends upon how the organisms get inside the body to cause a disease‖ addresses the ability of the microorganisms to enter the body. Rationale 4: ―It depends upon where the person is at the time the disease is present‖ addresses the susceptibility of the host and the ability of the microorganisms to live in the host’s body. Rationale 5: ―It depends upon where the person works‖ does not explain a factor for the development of an infection. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Identify factors influencing a microorganism’s capability to produce an infectious process. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse’s role, and types of precautions during client care.Page Number: 605 Question 23 Type: MCMA The nurse determines that a client has adequate physiological barriers to defend the body against infection. What did the nurse assess in this client? Standard Text: Select all that apply. 1. Intact and dry skin 2. Intact oral mucous membranes 3. Bowel sounds present in all four quadrants 4. Nasal congestion 5. Urinary retention Correct Answer: 1, 2, 3 Rationale 1: Intact skin is the body’s first line of defense against microorganisms. Rationale 2: Intact mucous membranes are the body’s first line of defense against microorganisms. Rationale 3: Peristalsis tends to move microbes out of the body. Rationale 4: Nasal congestion would mean that the nasal passages would be ineffective in filtering microorganisms from inspired air. Rationale 5: Urinary retention would cause the urine to remain in the body, possibly leading to an infection. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safetyNursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify anatomic and physiological barriers that defend the body against microorganisms. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse’s role, and types of precautions during client care. Page Number: 607 Question 24 Type: MCSA A client is diagnosed with a communicable disease, and must be placed in isolation. The nurse should identify which diagnosis as a priority for this client? 1. Social Isolation 2. Anxiety 3. Acute Pain 4. Imbalanced Nutrition: Less Than Body Requirements Correct Answer: 1 Rationale 1: Social Isolation would be appropriate for the client who needs to be separated from others during a contagious episode. Rationale 2: Anxiety would be appropriate if the client were demonstrating apprehension regarding a change in life activities because of the communicable disease. Rationale 3: Acute Pain would be appropriate if the client were experiencing discomfort. Rationale 4: Imbalanced Nutrition: Less Than Body Requirements would be appropriate if the client were too ill to eat adequately. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered careAACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 7. Identify relevant nursing diagnoses and contributing factors for clients at risk for infection and who have an infection. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse’s role, and types of precautions during client care. Page Number: 611 Question 25 Type: MCSA A client tells the nurse that the newly diagnosed communicable disease is negatively impacting employment and causing a stressful situation at home. What diagnosis should the nurse select as a priority for this client? 1. Anxiety 2. Acute Pain 3. Social Isolation 4. Low Self-Esteem Correct Answer: 1 Rationale 1: Anxiety is appropriate because the client is discussing the impact of the communicable disease on work and home life. Rationale 2: Acute Pain is not appropriate, as the client is not experiencing discomfort. Rationale 3: Social Isolation is not appropriate, as the client has not been placed in transmission precaution at this time. Rationale 4: Low Self-Esteem is incorrect because the client is not expressing negative comments about himself. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial IntegrityClient Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 7. Identify relevant nursing diagnoses and contributing factors for clients at risk for infection and who have an infection. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse’s role, and types of precautions during client care. Page Number: 611 Question 26 Type: MCMA A client is being discharged after a surgical procedure. On what should the nurse instruct the client to reduce the risk of infection? Standard Text: Select all that apply. 1. Hand-washing technique 2. The importance of adequate nutrition 3. Covering the mouth and nose when coughing or sneezing 4. Increasing contact with others 5. Restricting rest period Correct Answer: 1, 2, 3 Rationale 1: The nurse should instruct the client on the correct hand-washing technique to reduce the risk of infection. Rationale 2: The nurse should instruct the client on the importance of adequate nutrition to reduce the risk of infection. Rationale 3: The nurse should instruct the client to cover the mouth and nose when coughing or sneezing to reduce the risk of infection.Rationale 4: The nurse should instruct the client to minimize exposure to others when recovering from surgery to reduce the risk of infection. Rationale 5: The nurse should instruct the client to get adequate rest and sleep when recovering from surgery to reduce the risk of infection. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Identify interventions to reduce risks for infections. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse’s role, and types of precautions during client care. Page Number: 611 Question 27 Type: MCSA A client in isolation ambulates with assistance to the bathroom. After toileting, what should the unlicensed assistive personnel do? 1. Assist the client with hand washing. 2. Assist the client back to bed. 3. Change the client’s bed. 4. Leave the client’s room. Correct Answer: 1 Rationale 1: The client should utilize good hand washing after going to the bathroom. The unlicensed assistive personnel should assist the client with hand washing.Rationale 2: After handwashing, the unlicensed assistive personnel should assist the client back to bed. Rationale 3: The client’s bed can be changed at any time. Rationale 4: The unlicensed assistive personnel should not leave the client’s room until the client has washed her hands and has been assisted back to bed. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Identify interventions to reduce risks for infections. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse’s role, and types of precautions during client care. Page Number: 612 Question 28 Type: MCSA While irrigating a client’s abdominal wound, the irrigate splashes into the nurse’s nose and eyes. What should the nurse do? 1. Flush the nose and eyes for 5 to 10 minutes with water or normal saline. 2. Begin HIV high-risk exposure prophylaxis within 24 hours. 3. Wash the areas with soap and water. 4. Have blood drawn for hepatitis B antibodies. Correct Answer: 1Rationale 1: After an exposure to the mucous membranes, the area should be flushed for 5 to 10 minutes with saline or water. Rationale 2: The client was not identified as being HIV-positive. Rationale 3: Washing the area with soap and water would be appropriate for a puncture or laceration. Rationale 4: Being tested for hepatitis B would be appropriate after a puncture or laceration but not for a splash to the mucous membranes. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13. Describe the steps to take in the event of a bloodborne pathogen exposure. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse’s role, and types of precautions during client care. Page Number: 636 Question 29 Type: MCMA The nurse is reviewing the agents available to disinfect the hands after providing client care. Which agents should the nurse consider using? Standard Text: Select all that apply. 1. Triclosan 2. Chlorine (bleach) 3. Isopropyl alcohol4. Hydrogen peroxide 5. Chlorhexidine gluconate Correct Answer: 1, 3, 5 Rationale 1: Triclosan is an agent that can be used on the hands as a disinfectant. Rationale 2: Chlorine bleach is used to clean blood spills. Rationale 3: Isopropyl alcohol is an agent that can be used on the hands as a disinfectant. Rationale 4: Hydrogen peroxide is used to clean surfaces. Rationale 5: Chlorhexidine gluconate is an agent that can be used on the hands as a disinfectant. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 8. Identify interventions to reduce risks for infections. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse’s role, and types of precautions during client care. Page Number: 618 Question 30 Type: SEQ The nurse needs to apply personal protective equipment before entering a client’s room. In which order should the nurse perform the following actions? Standard Text: Place the steps in the order in which they should be performed.1. Apply gloves. 2. Apply eyewear. 3. Apply the gown. 4. Apply the face mask. 5. Perform hand hygiene. Correct Answer: 5, 3, 4, 2, 1 Rationale 1: Gloves are applied last. Rationale 2: Protective eyewear is applied after the face mask. Rationale 3: The gown is applied after hand hygiene. Rationale 4: The face mask is applied after the gown. Rationale 5: Before applying personal protective equipment, hand hygiene should be performed. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Verbalize the steps used in: b. Applying and removing a gown, face mask, eyewear, and clean gloves. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse’s role, and types of precautions during client care. Page Number: 621Chapter 32 Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 32 Question 1 Type: MCSA The nurse is planning care for an older client. Which safety hazard should the nurse take into consideration when planning this care? 1. Burns 2. Drowning 3. Poisoning 4. Suffocation Correct Answer: 1 Rationale 1: Falls, burns, and pedestrian and motor vehicle crashes are safety hazards in older adults. Rationale 2: Drowning and poisoning are seen in the toddler-age client. Rationale 3: Drowning and poisoning are seen in the toddler-age client. Rationale 4: Suffocation is a hazard in newborns and infants. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 4. Identify common potential hazards throughout the life span. MNL Learning Outcome: 4.1.3. Implement safety measures throughout the life span. Page Number: 641 Question 2 Type: MCSA The nurse is preparing materials to instruct the parents of a newborn. What should the nurse identify as a safety hazard in an infant? 1. Exposure to alcohol consumption 2. Drowning 3. Pedestrian accidents 4. Suffocation in the crib Correct Answer: 4 Rationale 1: Exposure to alcohol consumption is a safety hazard to a fetus. Rationale 2: Drowning is a safety hazard in toddlers and preschoolers. Rationale 3: Pedestrian accidents are safety hazards in the older adult. Rationale 4: Suffocation in the crib is a safety hazard for both newborns and infants. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Identify common potential hazards throughout the life span.MNL Learning Outcome: 4.1.3. Implement safety measures throughout the life span. Page Number: 641 Question 3 Type: MCSA The nurse is reviewing safety hazards with a pregnant client. What should the nurse include when instructing this client about safety and the developing fetus? 1. Banging into objects 2. Bicycle rides 3. Recreational activities 4. X-rays Correct Answer: 4 Rationale 1: Banging into objects is what a toddler would be likely to do, not an expectant mother. Rationale 2: Bicycle rides and recreational activities would be good for the developing fetus; the mother should stay as active as possible during the pregnancy. Physical activity promotes good health. Rationale 3: Physical activity promotes good health. Rationale 4: Exposure to x-rays in the first trimester could cause harm to the developing fetus. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Identify common potential hazards throughout the life span.MNL Learning Outcome: 4.1.3. Implement safety measures throughout the life span. Page Number: 641 Question 4 Type: MCSA The nurse would like to improve communication among caregivers. How should the nurse use the Joint Commission 2013 National Patient Safety Goals to achieve this objective? 1. Review a list of look-alike/sound-alike drugs used in the organization. 2. Use a verification process to confirm the correct procedure. 3. Report critical results of tests and diagnostic procedures on a timely basis.. 4. Use the client’s room number as an identifier. Correct Answer: 3 Rationale 1: Annually reviewing a list of look-alike/sound-alike drugs is used to improve the safety of use of medication in an organization, not to improve communication. Rationale 2: Using a verification process to confirm that the correct procedure for the correct client is to be performed is another way to improve the accuracy of client identification. Rationale 3: Reporting critical results of tests and diagnostic procedures on a timely basis is one way the National Patient Safety Goals improve the communication among caregivers. Rationale 4: Using the client’s room number as an identifier is a passive technique that would improve the accuracy of client identification. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 3. Discuss the National Patient Safety Goals. MNL Learning Outcome: 4.2.2. Implement strategies for the maintenance of safety in the health care facility. Page Number: 645 Question 5 Type: MCSA The nurse is planning care for a client who is prone to falling. Which nursing diagnoses should the nurse use for this client? 1. Deficient Knowledge 2. Risk for Injury 3. Risk for Disuse Syndrome 4. Risk for Suffocation Correct Answer: 2 Rationale 1: Deficient Knowledge deals with injury prevention. A client who is already prone to falls may not have the cognitive ability for a knowledge deficient. Rationale 2: Risk for Injury is a state in which the individual is at risk as a result of environmental conditions such as a fall. Rationale 3: Risk for Disuse Syndrome is a deterioration of body system as the result of prescribed or unavoidable musculoskeletal inactivity. Rationale 4: Risk for Suffocation is inadequate air available for inhalation. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safetyNursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 5. Give examples of nursing diagnoses, outcomes, and interventions for a client at risk for accidental injury. MNL Learning Outcome: 4.2.2. Implement strategies for the maintenance of safety in the health care facility. Page Number: 640 Question 6 Type: MCSA The nurse is identifying care goals for a client who is prone to getting hurt. Which care goal should the nurse select for this client? 1. Assess the client’s mental status. 2. Keep the client dependent on the staff for all care. 3. Make all choices for the client. 4. Remain free from injury. Correct Answer: 4 Rationale 1: The nurse will need to assess the client’s mental status to help accomplish this goal. Rationale 2: Keeping the client dependent on the staff for care does not encourage independence. Rationale 3: Making all choices for the client does not encourage independence. Rationale 4: The major goal for a client who is at risk for injury is for the client to remain injury-free. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safetyNursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Give examples of nursing diagnoses, outcomes, and interventions for a client at risk for accidental injury. MNL Learning Outcome: 4.2.2. Implement strategies for the maintenance of safety in the health care facility. Page Number: 649 Question 7 Type: MCSA As a member of the safety committee, the nurse’s task is to identify actions to prevent falls within the organization. Which intervention should the nurse emphasize as important to prevent falls? 1. Display the phone number to the nurses’ station. 2. Keep electrical cords under the bed. 3. Keep the environment tidy. 4. Read label directions. Correct Answer: 3 Rationale 1: Displaying the phone number to the nurses’ station is a way to call for help. Rationale 2: Electrical cords should only be used if necessary, and the maintenance department can help if any of them present a hazard. Rationale 3: Keeping the environment tidy and free of clutter will go a long way in preventing falls. Rationale 4: Reading label directions will prevent the wrong use of substances given to the client, but would not directly prevent falls. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespanNLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 4.2.2. Implement strategies for the maintenance of safety in the health care facility. Page Number: 651 Question 8 Type: MCSA The home care nurse wants to ensure the safety of an older client who lives at home alone. Which intervention should the nurse identify as a way to prevent this client from falling? 1. Check vision every 5 years. 2. Exercise regularly. 3. Place socks on feet. 4. Turn the light on after getting out of bed. Correct Answer: 2 Rationale 1: Vision can be a cause of falls, but it should be checked at least once a year; every 5 years is not often enough. Rationale 2: The client needs to exercise regularly to maintain strength, flexibility, mobility, and balance, which prevents falls. Rationale 3: Older clients should have something on their feet when walking, but not socks that will allow them to fall. A nonskid-type sock or shoe will help prevent falls. Rationale 4: The client should be able to turn the light on before getting out of bed, as inadequate lighting is another cause for falls. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection ControlQSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 4.2.3. Implement safety measures throughout the life span. Page Number: 651 Question 9 Type: MCSA The mother of a 2-year-old expresses concern to the nurse that her child continually climbs out of the crib at home. What should the nurse advise the mother to do? 1. Omit the afternoon nap. 2. Place a crib net over the top of the crib. 3. Remove all objects from around the crib. 4. Restrain the child if he gets up more than once. Correct Answer: 2 Rationale 1: A child of 2 years should still be taking a nap, and that poses a dangerous situation, at naptime or bedtime, if the child is still crawling out of the crib. Rationale 2: A crib net will prevent an active child from climbing out of the crib but will allow him freedom to move about in the crib. Rationale 3: Just removing objects off the floor from around the crib would not prevent a child from climbing out of a crib. Rationale 4: Restraining the child would be dangerous and contribute even more to his determination of getting out of the crib. Global Rationale:Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 4.2.3. Implement safety measures throughout the life span. Page Number: 665 Question 10 Type: MCSA While the nurse is performing morning care, a client begins to have a seizure. What should the nurse do to help this client? 1. Insert a tongue blade into the client’s mouth. 2. Loosen any clothing around the neck and chest. 3. Restrain the client. 4. Turn the client to the supine position if possible. Correct Answer: 2 Rationale 1: Research has found that more injury can occur to the client if the caregiver tries to place anything in the mouth during the seizure. Rationale 2: Loosening any clothing around the neck and chest prevents constriction that might occur during the seizure that could compromise the airway. Rationale 3: A client should never be restrained during a seizure. The nurse should stay with the client and call for assistance, if needed.Rationale 4: If possible, the client should be turned to the lateral position, not supine, to allow for any secretions to drain out of the mouth. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Discuss implementation of seizure precautions. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 655 Question 11 Type: MCSA The nurse is considering the use of restraints for a client. In which situation can the nurse apply restraints to a client? 1. Client wanders around the care area. 2. Client is picking at the access site for intravenous infusion of chemotherapy. 3. Client needed to use the bathroom and waited for help but didn’t want to soil the bed and fell while attempting to walk to the bathroom. 4. Client does not want to stay in bed but wants to sit in the lounge with others. Correct Answer: 2 Rationale 1: Restraints cannot be used for the convenience of the care staff. Rationale 2: In this situation, the client’s actions could hinder his or her health status and a restraint would be indicated.Rationale 3: This situation would not call for the client to be restrained. The care staff needs to be more attentive to the client’s needs. Rationale 4: This client would not be a candidate for restraints. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9. Discuss the use and legal implications of restraints. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 659 Question 12 Type: MCSA The nurse is applying restraints to a client. After securing a health care provider’s order, what should the nurse do? 1. Assess the restraints every 10 minutes. 2. Pad bony prominences. 3. Secure the restraint to the side rail. 4. Tie the restraint with a square knot. Correct Answer: 2 Rationale 1: The restraints should be assessed according to agency policy but no less frequently than every 2 hours.Rationale 2: Padding bony prominences will prevent possible skin breakdown. Rationale 3: Restraints are never tied to a side rail. The ends should be secured to the part of the bed that moves to elevate the head. Rationale 4: When a restraint is secured in place, a clove-hitch knot should be used, not a square knot. The clove-hitch knot will not tighten when pulled. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12. Verbalize the steps for: c. Applying restraints. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 660 Question 13 Type: MCSA An older client diagnosed with Alzheimer’s disease continually tries to get out of bed at night. Which safety measure should the nurse consider using with this client? 1. Explain all procedures and treatments. 2. Place a bed safety monitoring device on the bed. 3. Orient the client to surroundings. 4. Use relaxation techniques. Correct Answer: 2Rationale 1: Explaining procedures would not be appropriate with this client. Rationale 2: Alzheimer’s disease causes impaired intellectual functioning, so a safety device that is weight sensitive would alert the nurse when the client is trying to get out of bed. Rationale 3: Orienting to surroundings would not be appropriate with this client. Rationale 4: Using relaxation techniques would not be appropriate with this client. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Describe alternatives to restraints. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 652 Question 14 Type: MCSA The nurse is caring for a client who is confused and wanders. Which alternative to a restraint can the nurse use for this client? 1. Assign this client to the farthest room from the nurses’ station. 2. Place a rocking chair in the client’s room. 3. Pull up all of the side rails on the bed. 4. Wedge pillows against the side rails on the bed. Correct Answer: 2Rationale 1: Assigning the client to the farthest room from the nurses’ station would be an unsafe move for the client; closer would be safer than farther. Rationale 2: Placing a rocking chair in the client’s room will help her to expend some of her energy so that she will be less inclined to walk and wander. Rationale 3: Pulling up all of the side rails is a restraint, so that action would not be an alternative. Rationale 4: Keeping pillows wedged against the side rails will not keep the client from wandering. She is not in the bed. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Describe alternatives to restraints. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 551 Question 15 Type: MCSA The nurse is identifying outcomes for an older client prone to injuries. Which outcome should the nurse identify as appropriate for this client? 1. The client will demonstrate an understanding of all limitations. 2. The client will establish a buddy system. 3. The client will make uninformed choices when addressing health issues. 4. The client will take his medication as desired.Correct Answer: 2 Rationale 1: The client may resent limitations and act out in such a way as to cause injury. Rationale 2: Establishing a buddy system provides social contact, safeguards against abuse, and offers respite for caregivers. It also provides a way for elders to be checked up on daily. Rationale 3: Making uninformed choices about one’s health would be unsafe instead of safe for the client. Rationale 4: A routine should be established for medication administration with correct dosage to prevent the possibility of overdose toxicity. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 4.2.3. Implement safety measures throughout the life span. Page Number: 666 Question 16 Type: MCSA The nurse is reviewing safety with a home-care client. What should the nurse include in this teaching? 1. Always pull a plug at the plug-in from the wall outlet. 2. Keep plants in the home.3. Use overloaded outlets when necessary. 4. Remove labels from containers and refill for recycling. Correct Answer: 1 Rationale 1: Always pull a plug at the plug-in from the wall outlet. Pulling a plug by its cord can damage the cord and plug unit, creating a dangerous situation. Rationale 2: Not knowing which plants are poisonous and which are not may pose a serious problem for children in the home. Rationale 3: Always avoid overloading outlets at any time because this can cause a fire. Rationale 4: Do not remove container labels or reuse empty containers to store different substances. Laws mandate that the labels of all substances specify an antidote. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 659 Question 17 Type: MCSAThe nurse is attending a seminar on bioterrorism. What should the nurse identify as being the highest concern for homeland security? 1. Cancer 2. Seasonal flu 3. Tuberculosis 4. Smallpox Correct Answer: 4 Rationale 1: Cancer does not pose a threat to homeland security. Rationale 2: Seasonal flu does not pose a threat to homeland security. Rationale 3: Tuberculosis does not pose a threat to homeland security. Rationale 4: Smallpox, anthrax, botulism, plague, viral hemorrhagic fevers, and tularemia are the agents that are of highest concern with bioterrorism. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 643Question 18 Type: MCSA While eating in a restaurant, a nurse notices that a customer at the next table begins to clutch his throat while eating a steak. What should the nurse do first? 1. Ask the customer if he is choking. 2. Attempt to give five back blows. 3. Perform the Heimlich maneuver. 4. Start chest compressions. Correct Answer: 1 Rationale 1: The first step is to ask if the person is choking. Rationale 2: Five back blows are reserved for an infant who is choking. Rationale 3: If he indicates he is choking, the next step would be to perform the Heimlich maneuver. Rationale 4: Chest compressions would be given if the person was unconscious; this person is not. He is clutching his throat. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism.MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 657 Question 19 Type: MCSA The nurse is admitting an older client to the care area. What can the nurse do to promote a safe environment for the client? 1. Keep clutter to a minimum in the client’s room. 2. Have the client wear terry-cloth slippers. 3. Provide adequate lighting. 4. Turn off alarms to reduce noise. Correct Answer: 3 Rationale 1: The environment should be clutter-free because any clutter can cause the client to fall. Rationale 2: Wearing terry-cloth slippers would allow the client to fall. The client should have rubber skid-resistant soles. Rationale 3: Providing adequate lighting will help prevent the client from falling. Rationale 4: Noise should be kept to a minimum, but turning off alarms would endanger a client. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 6. Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 641 Question 20 Type: MCMA The nurse is determining a client’s risk for injury. What should the nurse assess in this client? Standard Text: Select all that apply. 1. Age 2. Mobility 3. Hearing 4. Vision 5. Dietary intake Correct Answer: 1, 2, 3, 4 Rationale 1: The ability of a person to protect him- or herself from injury is dependent upon age. Rationale 2: The ability of a person to protect him- or herself from injury is dependent upon mobility. Rationale 3: The ability of a person to protect him- or herself from injury is dependent upon hearing. Rationale 4: The ability of a person to protect him- or herself from injury is dependent upon vision. Rationale 5: The ability of a person to protect him- or herself from injury is not dependent upon dietary intake. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered careAACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Describe methods to assess a client’s risk for injury. MNL Learning Outcome: 4.2.1. Recognize factors that affect client safety. Page Number: 640 Question 21 Type: MCMA An older client is observed having difficulty moving from a sitting to standing position, and has an unsteady gait. What should the nurse assess in this client to promote home safety? Standard Text: Select all that apply. 1. Presence of grab bars in the bathroom 2. Absence of scatter rugs on the floors 3. Correct use of cane to ambulate 4. Ability to stand in place for a minute before ambulating 5. Alcohol use with prescribed medications Correct Answer: 1, 2, 3 Rationale 1: For home safety, it would be beneficial for the client with difficulty moving from a sitting to standing position to have grab bars in the bathroom. Rationale 2: For home safety, it would be beneficial for the client with an unsteady gait not to have scatter rugs on the floor. Rationale 3: For home safety, it would be beneficial for the client with an unsteady gait to be able to use a cane correctly. Rationale 4: The ability to stand in place for a minute before ambulating would be applicable if the client were demonstrating signs of orthostatic hypotension. Rationale 5: The use of alcohol with prescribed medications would be beneficial if the client were prescribed sedatives or hypnotics.Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Explain interventions to prevent falls. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 641 Question 22 Type: MCSA A client is being transferred from an acute care facility to a long-term care facility. What information should the nurse provide to the long-term care facility about the client’s medications? 1. Nothing, as the medications all need to be reordered at the long-term care facility. 2. Have the client’s medication prescriptions filled before going to long-term care facility. 3. Instruct the client to tell the nurses at the long-term care facility what medications are prescribed. 4. Inform the nurse at the long-term care facility what medications the client is prescribed, and document that this information was provided. Correct Answer: 4 Rationale 1: The nurse is responsible for communicating the client’s medications to the long-term care facility, and documents this communication. Rationale 2: The client’s medications will not be filled prior to going to the long-term care facility. Rationale 3: It is not the client’s responsibility to communicate medications to the nurses at the longterm care facility.Rationale 4: The nurse should communicate the client’s medications to the nurses at the long-term care facility and document that this communication occurred. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 648 Question 23 Type: MCSA A client is prescribed seizure precautions. The nurse places functioning oral suction equipment in the client’s room for what reason? 1. Suctioning might be needed to prevent the aspiration of oral secretions. 2. The client has difficulty swallowing liquids. 3. There was a spare oral suction set up, and the nurse did not want to return it to the engineering department. 4. It helps when the client is brushing her teeth. Correct Answer: 1Rationale 1: When implementing seizure precautions, the nurse should place oral suction equipment in the client’s room because suctioning might be needed to prevent aspiration of oral secretions. Rationale 2: If the client were having difficulty swallowing liquids, oral suction already would be in the client’s room. Rationale 3: Placing a piece of equipment in a client’s room that is not needed is not a good utilization of resources. Rationale 4: Having oral suction equipment available for teeth brushing is not the best use of the equipment. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 8. Discuss implementation of seizure precautions. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 655 Question 24 Type: MCSA The nurse is evaluating teaching provided to a client about home safety. Which observation indicates that teaching has been effective? 1. Smoke alarm functioning with new batteries installed 2. Scatter rugs located in the kitchen and bathroom only 3. Cord for a space heater stretched across a hallway4. Light bulbs burned out in the bathroom and living room Correct Answer: 1 Rationale 1: The installation and use of a smoke alarm in the home would indicate that home safety instruction has been effective. Rationale 2: Scatter rugs would indicate that instruction on home safety has not been effective. Rationale 3: Cords for appliances stretching across major walkways would indicate that instruction on home safety has not been effective. Rationale 4: Inadequate lighting in major rooms of the home would indicate that instruction on home safety has not been effective. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 6. Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 656 Question 25 Type: MCSA The nurse is installing a bed safety-monitoring device for a client. What should the nurse do after testing the device and alarm sound? 1. Place the leg band on the client with the leg in a straight horizontal position.2. Place the sensor under the mattress near the shoulder region. 3. Set a time delay for 30 seconds. 4. Connect the sensor pad to the control unit. Correct Answer: 1 Rationale 1: After testing the device and alarm sound, the nurse should place the leg band on the client with the leg in a straight horizontal position. Rationale 2: The sensor should be placed under the mattress at the buttocks area, not the shoulder area. Rationale 3: Time delays should be between 1 and 12 seconds. Rationale 4: Connecting the sensor pad to the control unit is the last step when installing the bed safety-monitoring device. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12. Verbalize the steps for: a. Using a bed or chair exit safety monitoring device. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 653 Question 26 Type: SEQ A client is prescribed to have wrist restraints applied. Place in order the steps the nurse will take to apply these restraints.Standard Text: Click and drag the options below to move them up or down. Choice 1. Pad bony prominences on the wrist. Choice 2. Apply the padded portion of the restraint around the wrist. Choice 3. Pull the tie of the restraint through the slit in the wrist restraint and ensure that it is not too tight. Choice 4. Attach the other end of the restraint to the movable portion of the bed frame using a halfbow knot. Correct Answer: 1, 2, 3, 4 Rationale 1: Prior to applying the wrist restraint, the client’s bony prominences should be padded. Rationale 2: The nurse should apply the padded portion of the restraint around the wrist. Rationale 3: The nurse should then pull the tie of the restraint through the slit in the wrist restraint and ensure that it is not too tight. Rationale 4: The nurse should then attach the other end of the restraint to the movable portion of the bed frame using a half-bow knot. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12. Verbalize the steps for: c. Applying restraints. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 664 Question 27Type: MCSA The nurse is identifying activities and skills to delegate to unlicensed assistive personnel (UAP). Which action can the nurse safely delegate? 1. Provide oral fluids to a newly extubated client. 2. Irrigate the indwelling urinary catheter of a client recovering from prostate surgery. 3. Apply a wrist restraint to a client. 4. Administer oral pain medication to a client before the client attends physical therapy. Correct Answer: 3 Rationale 1: Providing oral fluid to a newly extubated client should be done first by the nurse, so the client can be assessed for ability to safely swallow. Rationale 2: Irrigating an indwelling urinary catheter is beyond the scope for UAP. Rationale 3: Application of ordered restraints and their temporary removal for skin monitoring and care may be delegated to UAP who have been trained in their use. Rationale 4: Administering medication is beyond the scope for UAP. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13. Recognize when it is appropriate to delegate using a bed or chair exit safety monitoring device, implementing seizure precautions, and applying restraints of clients to unlicensed assistive personnel. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment.Page Number: 663 Question 28 Type: MCSA A client is prescribed seizure precautions. What can the nurse safely delegate to UAP to complete when implementing the precautions? 1. Placing a tongue blade at the head of the bed 2. Padding the client’s bed 3. Installing oxygen 4. Checking the oral suction apparatus Correct Answer: 2 Rationale 1: Tongue blades are not used as part of seizure precautions, and should not be placed at the head of the bed. Rationale 2: The nurse can safely delegate the padding of the bed to UAP. Rationale 3: The nurse should install the oxygen. Rationale 4: The nurse should check the oral suction apparatus. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13. Recognize when it is appropriate to delegate using a bed or chair exit safety monitoring device, implementing seizure precautions, and applying restraints of clients to unlicensed assistive personnel.MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 654 Question 29 Type: MCSA After ambulating a client to the bathroom, the unlicensed assistive personnel did not reattach the client’s bed safety-monitoring device, and the client fell out of bed. What should the nurse document? 1. Client fell out of bed; bed safety-monitoring device malfunctioning. 2. Client fell out of bed; client removed leg band of bed safety-monitoring device. 3. Client fell out of bed; no observable injuries. 4. Client fell out of bed; bed safety-monitoring device not activated. Correct Answer: 4 Rationale 1: The bed safety device was not activated. It was not malfunctioning. Rationale 2: The client did not remove the leg band of the monitoring device. Rationale 3: The nurse needs to report the fall to the primary care physician. Rationale 4: The nurse needs to document what occurred with the client and why. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14. Demonstrate appropriate documentation and reporting of using a bed or chair exit safety monitoring device, seizure precautions, and applying restraints.MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 654 Question 30 Type: MCMA A client who is on seizure precautions experiences a seizure while ambulating in the room. What should the nurse include in this client’s documentation? Standard Text: Select all that apply. 1. Who assisted the client back to bed 2. Location of the seizure 3. Duration of the seizure 4. Status of airway and use of oxygen 5. Who discovered the client Correct Answer: 2, 3, 4 Rationale 1: It is not important for the nurse to name the individuals who assisted the client back to bed. Rationale 2: Documentation should include where the client was when the seizure occurred. Rationale 3: Documentation should include the duration of the seizure. Rationale 4: Documentation should include the status of the client’s airway and use of oxygen. Rationale 5: It is not important for the nurse to name the individual who found the client having a seizure. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered careAACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14. Demonstrate appropriate documentation and reporting of using a bed or chair exit safety monitoring device, seizure precautions, and applying restraints. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 655 Question 31 Type: MCMA The nurse is preparing to assess a client who has a history of falls. Which methods should the nurse use to assess this client’s risk for injury? Standard Text: Select all that apply. 1. Cognitive awareness 2. Mobility 3. Nursing history 4. Physical examination 5. Health status Correct Answer: 3, 4 Rationale 1: Cognitive awareness, mobility, and health status are factors affecting safety. Rationale 2: Cognitive awareness, mobility, and health status are factors affecting safety. Rationale 3: A nursing history and physical examination are methods to assess a client at risk for injury. Rationale 4: A nursing history and physical examination are methods to assess a client at risk for injury. Rationale 5: Cognitive awareness, mobility, and health status are factors affecting safety. Global Rationale:Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 643 Question 32 Type: MCMA The nurse is appointed to be a member of committee whose focus is to identify and address workplace safety issues. Which issues should the nurse recommend for analysis by this committee? Standard Text: Select all that apply. 1. Lifting clients 2. Inadequate lighting 3. Bending and walking 4. Exposure to infectious agents 5. Exposure to hazardous medications Correct Answer: 1, 3, 4, 5 Rationale 1: The U.S. Bureau of Labor Statistics (2012) reports that nursing has many hazards. Some of the hazards include lifting.Rationale 2: Inadequate lighting would be a safety issue in a home or community neighborhood. Rationale 3: The U.S. Bureau of Labor Statistics (2012) reports that nursing has many hazards. Some of the hazards include bending and walking. Rationale 4: The U.S. Bureau of Labor Statistics (2012) reports that nursing has many hazards. Some of the hazards include exposure to infectious agents. Rationale 5: The U.S. Bureau of Labor Statistics (2012) reports that nursing has many hazards. Some of the hazards include exposure to hazardous compounds. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 642 Question 33 Type: MCMA During a home visit, the nurse determines that a toddler is at risk for injury. What did the nurse assess to identify this client’s risk? Standard Text: Select all that apply. 1. Unscreened windows2. Electrical outlets uncovered 3. Yard with a built-in pool unfenced 4. Cleaning solution in the bottom cabinet 5. Pots on stove with handles turned inward Correct Answer: 1, 2, 3, 4 Rationale 1: Unscreened windows would be a safety hazard for a toddler. Rationale 2: Uncovered electrical outlets would be a safety hazard for a toddler. Rationale 3: Having a backyard pool without a fence is a safety hazard for a toddler. Rationale 4: Cleaning solution in the bottom cabinet can be easily reached by a toddler, creating a safety hazard. Rationale 5: Pots on stove with the handles turned inward is the appropriate way to maintain safety in a home with a toddler. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 647Chapter 33 Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 33 Question 1 Type: MCSA The nurse is preparing to provide morning care to a client. What should the nurse explain to the client as the reason for a daily bath? 1. Assess skin integrity 2. Develop a nurse–client relationship 3. Moisturize the skin 4. Stimulate circulation Correct Answer: 4 Rationale 1: Giving a bath to a client will allow the nurse to assess the skin but this is not the most important purpose. Rationale 2: Giving a bath to a client will allow the nurse to develop a nurse–client relationship but this is not the most important purpose. Rationale 3: Giving a bath to a client will allow the nurse to moisturize the skin but this is not the most important purpose. Rationale 4: The three major reasons for a bath are to remove waste products such as perspiration, stimulate circulation, and refresh the client. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferencesNLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Identify the purposes of bathing. MNL Learning Outcome: 4.4.1. Describe the hygienic practices implemented in bathing a client. Page Number: 674 Question 2 Type: MCSA The nurse is preparing to bath a client on the first postoperative day. Which nursing intervention should take priority? 1. Apply lotion to the extremities. 2. Change the water when it becomes cold. 3. Raise side rails when gathering supplies. 4. Remove the soiled dressing during the bath. Correct Answer: 3 Rationale 1: Applying lotion to the skin would be performed before or after, not during, the bath. Rationale 2: Changing the water needs to be done before it becomes cold, but it is not a priority. Rationale 3: Raising the side rails would take priority when planning care. This is a safety issue, and safety is second on Maslow’s hierarchy of needs. The client is only 1 day postop and may still be sedated, posing a risk for a potential fall. Rationale 4: A dressing change would be performed before or after, not during, the bath and only with a doctor’s order. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experienceAACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Compare and contrast the task-centered approach and the person-centered approach to bathing. MNL Learning Outcome: 4.4.1. Describe the hygienic practices implemented in bathing a client. Page Number: 677 Question 3 Type: MCMA A client who is ambulatory is able to get out of bed for morning care. What should the nurse assess before assisting the client out of the bed to change the linen? Standard Text: Select all that apply. 1. Pulse 2. Respirations 3. Urine output 4. Blood pressure 5. Mobility status Correct Answer: 1, 2, 4, 5 Rationale 1: When changing the linen of an unoccupied bed the nurse should assess the client’s pulse. Rationale 2: When changing the linen of an unoccupied bed the nurse should assess the client’s respirations. Rationale 3: Urine output does not need to be assessed prior to assisting a client out of the bed to change the linen. Rationale 4: When changing the linen of an unoccupied bed the nurse should assess the client’s blood pressure. Rationale 5: When changing the linen of an unoccupied bed the nurse should assess the client’s mobility status.Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15. Verbalize the steps used in: h. Changing an unoccupied bed. MNL Learning Outcome: 4.4.1. Describe the hygienic practices implemented in bathing a client. Page Number: 710 Question 4 Type: MCSA The nurse is shampooing a client’s hair. Which assessment finding should the nurse consider as expected? 1. Dry, dark, thin 2. Smooth, taut, shiny 3. Smooth texture and not oily or dry 4. Tender, warm scalp Correct Answer: 3 Rationale 1: The hair should not be dry or thin. This could be a sign of alopecia. Darkness would depend on hair color through the gene pool. Rationale 2: Skin is assessed as being smooth, taut, or shiny, not hair. Rationale 3: The hair should be smooth in texture and neither oily nor dry. Rationale 4: A tender, warm scalp could indicate a problem, so this would not be normal.Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify normal and abnormal assessment findings while providing hygiene care. MNL Learning Outcome: 4.4.4. Implement hygienic practices for the care of the feet, hair, mouth, eyes, and ears. Page Number: 700 Question 5 Type: MCSA The nurse identifies the diagnosis Self-Care Deficit related to cognitive impairment as appropriate for a client. What should the nurse select as an expected outcome for this client? 1. The client will be able to name the staff that works on the day shift. 2. The client will eliminate safety hazards in her environment. 3. The client, with supervision, will brush her teeth. 4. The nurse will stress the importance of adequate fluid intake. Correct Answer: 3 Rationale 1: Cognitive impairment limits the client’s ability to understand and comprehend; therefore, naming the staff is not within the client’s realm of understanding. Rationale 2: Cognitive impairment limits the client’s ability to understand and comprehend; therefore, eliminating safety hazards is not within the client’s realm of understanding.Rationale 3: A client with cognitive impairment would be able to brush her teeth but only with supervision. The client would not voluntarily brush her teeth without prompting from the staff. Rationale 4: Cognitive impairment limits the client’s ability to understand and comprehend; therefore, stressing adequate fluid intake is not within the client’s realm of understanding. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Apply the nursing process to common problems related to hygienic care of the: skin, feet, nails, mouth, hair, eyes, and ears. MNL Learning Outcome: 4.4.4. Implement hygienic practices for the care of the feet, hair, mouth, eyes, and ears. Page Number: 672 Question 6 Type: MCSA The nurse is reviewing assigned clients for morning care needs. Which situation could pose a threat to one client’s personal hygiene? 1. A client has a newly formed ileostomy. 2. A client performs meticulous foot care. 3. A German client refuses to bathe everyday. 4. The room temperature is set at 72°F. Correct Answer: 1Rationale 1: Some of the factors that influence one’s personal hygiene are social practices, body image, knowledge of physical condition, and cultural variables. A client who has had an ileostomy has had a body image change, which can greatly influence whether he will care for it or rely on others. This can pose a threat if the client chooses not to care for it. Rationale 2: Performing meticulous foot care does not pose a threat to one’s hygiene. Rationale 3: Bathing every other day does not pose a threat to one’s hygiene. Rationale 4: Room temperature of 72°F does not pose a threat to one’s hygiene. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Identify factors influencing personal hygiene. MNL Learning Outcome: 4.4.2. Recognize factors that influence hygienic practices. Page Number: 699 Question 7 Type: MCSA The nurse is preparing to provide hygienic care to a client. On what will the nurse focus this care? 1. Clothes 2. Family 3. Hair 4. NutritionalCorrect Answer: 3 Rationale 1: Hygienic care does not include care of the client’s clothes. Rationale 2: Hygienic care does not include care to the client’s family. Rationale 3: Hygiene care consists of skin, hair, hands, feet, eyes, nose, mouth, back, and perineum. Rationale 4: Hygienic care does not include the client’s nutritional status. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Describe hygienic care that nurses provide to clients. MNL Learning Outcome: 4.4.4 Implement hygienic practices for the care of the feet, hair, mouth, eyes, and ears. Page Number: 669 Question 8 Type: MCSA A client needs to have soft contact lenses removed. What should the nurse do when removing the lenses? 1. Gently pinch the lens and lift it out. 2. Have the client look up. 3. Pull the lower eyelid upward.4. Use the pad of the ring finger. Correct Answer: 1 Rationale 1: Gently pinching the lens and lifting it out is one of the correct steps for removing a client’s soft contact lenses. Rationale 2: The nurse should have the client look straight ahead, not up. Rationale 3: The upper eyelid is pulled down gently. Rationale 4: The nurse would use the pad of the index finger, not the ring finger. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Identify the steps in removing contact lenses. MNL Learning Outcome: 4.4.4 Implement hygienic practices for the care of the feet, hair, mouth, eyes, and ears. Page Number: 703 Question 9 Type: MCSA The nurse is caring for a client with diabetes. What should the nurse include as foot care for this client? 1. Cut toenails in a rounded shape and file. 2. Dry toes thoroughly.3. Wash feet with water at a temperature of 90°F to 98.6°F. 4. Inspect feet thoroughly once a week. Correct Answer: 2 Rationale 1: Toenails should be cut straight across, and nurses do not cut diabetic clients’ toenails. Only a podiatrist should handle this task. Rationale 2: Toes should be dried thoroughly after being washed to impede fungal growth and prevent maceration. Rationale 3: The water to wash the feet should be 100°F to 110°F. Rationale 4: Feet should be inspected each day, not once a week, for early detection of any problems. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 15. Verbalize the steps used in: c. Providing foot care. MNL Learning Outcome: 4.4.4 Implement hygienic practices for the care of the feet, hair, mouth, eyes, and ears. Page Number: 686 Question 10 Type: MCSA A client has the nursing diagnosis Risk for Impaired Skin Integrity related to immobility. Which nursing intervention should be identified for this client’s problem?1. Encourage the client to eat at least 40% of meals. 2. Keep linens dry and wrinkle-free. 3. Restrict fluid intake. 4. Turn client every 3 hours. Correct Answer: 2 Rationale 1: For nutritional support to promote healthy tissue, clients should consume more than 40% of their meals. Rationale 2: Keeping linens dry and wrinkle-free will prevent pressure areas. Rationale 3: Fluids should not be restricted unless some other physical condition dictates. The skin should be kept hydrated. Rationale 4: To relieve pressure, the client should be turned every 2 hours, not every 3. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Apply the nursing process to common problems related to hygienic care of the: skin, feet, nails, mouth, hair, eyes, and ears. MNL Learning Outcome: 4.4.4 Implement hygienic practices for the care of the feet, hair, mouth, eyes, and ears. Page Number: 686 Question 11 Type: MCSAUnlicensed assistive personnel are caring for a client’s ears. What information should be reported to the nurse? 1. Excessive earwax 2. Loud talking 3. Presence of a hearing aid 4. Presence of any drainage Correct Answer: 4 Rationale 1: Excess earwax is not an immediate problem. Rationale 2: Loud talking could be an indication the client is hard of hearing, which is not an immediate threat. Rationale 3: The presence of a hearing aid should already be noted on the client’s admission assessment. Rationale 4: The health care provider should report any drainage from the ears to the nurse. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify normal and abnormal assessment findings while providing hygiene care. 16. Recognize when it is appropriate to delegate hygiene skills for clients to unlicensed assistive personnel. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices.Page Number: 704 Question 12 Type: MCSA A client’s hearing aid needs to be removed. What action should the nurse perform? 1. Assist the client with removal when necessary. 2. Instruct the client to remove the aid in the sunroom. 3. Leave the aid in place when bathing. 4. Send the aid home with the family. Correct Answer: 1 Rationale 1: The small size of hearing aids may make it difficult for older adults to manipulate, so they may need assistance in the aid’s removal. Rationale 2: Clients are instructed not to remove their aids in common rooms like a sunroom. Rationale 3: The removal of the aid is necessary before bathing so that it is not damaged. Rationale 4: The aid should always be stored in the client’s bedside table—not sent home with the family—so it is available for later use. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12. Describe the steps for removing, cleaning, and inserting hearing aids.MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 704 Question 13 Type: MCSA A client’s hearing aid needs to be cleaned. What action should the nurse take to complete this task? 1. Clean with a dry, soft cloth. 2. Leave the battery in place when not in use. 3. Store the aid in the bathroom cabinet. 4. Use alcohol to remove any earwax. Correct Answer: 1 Rationale 1: It is recommended by the manufacturers to clean the aid with a dry, soft cloth to prevent any damage to the aid. Rationale 2: The aid should be turned off and the battery removed to preserve the life of the battery. Rationale 3: The aid should be stored in a safe place where it will not get damaged. It should not be stored in the bathroom cabinet. Rationale 4: Alcohol is not recommended to be used on an aid because it could damage the aid. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 12. Describe the steps for removing, cleaning, and inserting hearing aids. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 705 Question 14 Type: MCSA The nurse is making a client’s bed. What safety measure should the nurse implement at this time? 1. Begin at the head and move toward the foot, loosening bottom linens. 2. Miter corners at the head of the bed. 3. Place the soiled sheet in a laundry bag. 4. Prepare the client. Correct Answer: 3 Rationale 1: Beginning at the head and moving toward the foot, loosening the bottom linens, provides maximum work space. Rationale 2: Mitering the corners at the head of the bed prevents linens from becoming easily loosened. Rationale 3: Placing the soiled sheet in the laundry bag reduces the spread of microorganisms, which is a safety measure for both the nurse and client. Rationale 4: Preparing the client readies the client for the procedure. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventionsNursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14. Identify safety and comfort measures underlying bed-making procedures. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 680 Question 15 Type: MCMA The nurse is preparing to remove ticks from a client’s scalp. Which actions should the nurse perform to safely remove these pathogens from the client? Standard Text: Select all that apply. 1. Grasp the tick with blunt tweezers. 2. Apply heat to the tick with a match. 3. Wash the area with antibacterial soap. 4. Pull the tick away in a perpendicular movement. 5. Apply petroleum jelly to the surface of the tick. Correct Answer: 1, 3, 4 Rationale 1: To remove a tick, grasp the tick as close to the skin as possible with blunt tweezers. Rationale 2: Applying heat to the tick with a match is a dangerous practice and should not be done. Rationale 3: After the tick is removed, wash the area with antibacterial soap. Rationale 4: Gently pull the tick away using a perpendicular motion. Rationale 5: Applying petroleum jelly to the surface of the tick is an ineffective approach to remove a tick. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection ControlQSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Apply the nursing process to common problems related to hygienic care of the: skin, feet, nails, mouth, hair, eyes, and ears. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 698 Question 16 Type: MCSA The nurse is making an occupied bed. Which step will provide comfort for the client during this linen change? 1. Allow for a toe pleat. 2. Place a bath blanket over the client. 3. Slide the mattress to the head of the bed. 4. Raise the side rail. Correct Answer: 1 Rationale 1: Allowing for a toe pleat provides for client comfort. Rationale 2: Placing the bath blanket over the client prevents unnecessary exposure. Rationale 3: Sliding the mattress to the head of the bed makes it easier to tuck in the linens. Rationale 4: Raising the side rail maintains client safety. Global Rationale: Cognitive Level: Applying Client Need: Physiological IntegrityClient Need Sub: Basic Care and Comfort QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14. Identify safety and comfort measures underlying bed-making procedures. 15. Verbalize the steps used in: i. Changing an occupied bed. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 711 Question 17 Type: MCSA The nurse is preparing to shave a client. Which action step should the nurse consider when providing this care? 1. Assist the client to a prone position. 2. Pull the skin taut with the dominant hand. 3. Rinse the razor after each stroke. 4. Use long strokes. Correct Answer: 3 Rationale 1: Assist the client to a sitting position—not a prone position—because this is a more natural position. Rationale 2: The skin should be pulled taut with the nondominant hand—not the dominant hand— because this provides uniform shaving. Rationale 3: Rinsing the razor after each stroke keeps the cutting edge clean. Rationale 4: Short strokes should be used—not long strokes—because this provides for a closer shave without irritation. Global Rationale:Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Apply the nursing process to common problems related to hygienic care of the: skin, feet, nails, mouth, hair, eyes, and ears. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 702 Question 18 Type: MCSA The nurse is preparing to provide a client with mouth care. What should the nurse do to ensure safe handling of the client’s dentures? 1. Clean biting surfaces. 2. Place a washcloth in the bowl of the sink. 3. Replace the upper dentures first. 4. Rinse dentures thoroughly with hot water. Correct Answer: 2 Rationale 1: Cleansing biting surfaces prevents bacteria, odor, and stain formation. Rationale 2: Placing a washcloth in the bowl of the sink serves as a cushion for the dentures if accidentally dropped. Rationale 3: Replacing the upper dentures first promotes comfort.Rationale 4: Dentures should be rinsed thoroughly with tepid water, not hot water, because extreme temperatures will harm dentures. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15. Verbalize the steps used in: e. Providing special oral care. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 695 Question 19 Type: MCSA A connection on a client’s intravenous solution was dislodged and solution saturated the client’s gown and bed linens. The nurse will provide which type of hygienic care to the client? 1. Hour-of-sleep care 2. As-needed care 3. Early morning care 4. Morning care Correct Answer: 2 Rationale 1: Hour-of-sleep care includes providing for elimination needs, washing the face and hands, oral care, and a back massage.Rationale 2: As-needed care is provided as required by the client. Because the intravenous solution has saturated the gown and bed linens, this is the type of care the client needs at this time. Rationale 3: Early morning care is provided to clients as they awaken in the morning and consists of aiding to void, washing the face and hands, and providing oral care. Rationale 4: Morning care is usually after breakfast and includes providing for elimination needs, a bath or shower, perineal care, back massage, and oral, nail, and hair care. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe hygienic care that nurses provide to clients. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 670 Question 20 Type: MCSA A client tells the nurse that bathing is done at the sink in the bathroom at home because it is difficult to physically lift the legs to get into the shower. The nurse identifies which factor as influencing this client’s hygienic practice? 1. Religion 2. Personal preference 3. Culture 4. Health and energyCorrect Answer: 4 Rationale 1: The client’s inability to lift the legs to get into the shower is not a religious practice. Rationale 2: The client’s inability to lift the legs to get into the shower is not a personal preference. Rationale 3: The client’s inability to lift the legs to get into the shower is not a cultural preference. Rationale 4: Ill people or those with neuromuscular disorders may not be able to perform hygienic care. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Identify factors influencing personal hygiene. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 670 Question 21 Type: MCSA During the morning bath of a client, the nurse identifies areas of erythema below the client’s breasts. What should the nurse do to enhance comfort and healing for the client? 1. Wash the skin carefully. 2. Apply alcohol-free lotion. 3. Wash the area without soap.4. Remove hair in the area. Correct Answer: 1 Rationale 1: For areas of erythema, the nurse should wash the area carefully to remove microorganisms. Rationale 2: Alcohol-free lotion would be applicable for excessively dry skin areas. Rationale 3: Washing without soap would be applicable for excessively dry skin areas. Rationale 4: Removing the hair would be applicable for hirsutism. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Apply the nursing process to common problems related to hygienic care of the: skin, feet, nails, mouth, hair, eyes, and ears. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 671 Question 22 Type: MCSA While providing a complete bed bath to a client, the nurse discovers abrasions along the client’s back and upper buttock area. What should the nurse do to help this client? 1. Apply antiseptic spray to the abrasions. 2. Do not wash the client with soap.3. Find assistance to help with the remainder of the bath. 4. Apply alcohol-free lotion to the abrasions. Correct Answer: 3 Rationale 1: Applying antiseptic spray would be applicable for areas of erythema but not for abrasions. Rationale 2: Avoiding soap would be applicable for excessively dry skin. Rationale 3: Because the client has abrasions over the back and upper buttock area, the nurse should lift and not pull or slide the client. The nurse needs to find assistance to help with the remainder of the bath. Rationale 4: Applying alcohol-free lotion would be applicable for excessively dry skin but not for abrasions. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Apply the nursing process to common problems related to hygienic care of the: skin, feet, nails, mouth, hair, eyes, and ears. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 671 Question 23 Type: MCMAThe nurse wants to assess a client during the morning bath. What will the nurse be able to assess during this time? Standard Text: Select all that apply. 1. Skin status 2. Financial status 3. Psychosocial needs 4. Learning needs 5. Physical conditions Correct Answer: 1, 3, 4, 5 Rationale 1: Assessment of the skin can be done during the morning bath. Rationale 2: The client’s financial status is an area not usually assessed during the morning bath. Rationale 3: The client’s psychosocial needs can be assessed during the morning bath. Rationale 4: The client’s learning needs regarding hygienic care can be assessed during the morning bath. Rationale 5: Assessing the client’s physical conditions can be done during the morning bath. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify normal and abnormal assessment findings while providing hygiene care.MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 672 Question 24 Type: MCMA A client is prescribed bed rest with bathroom privileges. Which types of bath would be appropriate for this client? Standard Text: Select all that apply. 1. Shower 2. Tub bath 3. Self-help bed bath 4. Therapeutic bath 5. Partial bath Correct Answer: 3, 5 Rationale 1: Getting into and out of a shower might be too strenuous for a client prescribed bed rest with bathroom privileges. Rationale 2: Getting into and out of a bathtub might be too strenuous for a client prescribed bed rest with bathroom privileges. Rationale 3: Because the client is prescribed bed rest with bathroom privileges, the self-help bed bath would be appropriate because the client can independently wash with some help from the nurse. Rationale 4: A therapeutic bath is for some physical effect and not used routinely for morning care. Rationale 5: Because the client is prescribed bed rest with bathroom privileges, the partial bath would be appropriate because the client can independently wash with some help from the nurse to wash the back area. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and ComfortQSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Describe various types of baths. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 671 Question 25 Type: MCSA A client with a skin rash is prescribed a bath in which medication is added to the bath water. The nurse should plan for the client to receive which type of bath? 1. Shower 2. Tub 3. Partial 4. Complete Correct Answer: 2 Rationale 1: A shower would not permit the medication to be in contact with the client’s skin long enough. Rationale 2: Therapeutic baths are given for physical effects, such as to soothe irritated skin or to treat an area. Medications may be placed in the water. A therapeutic bath is generally taken in a tub one-third or one-half full. The client remains in the bath for a designated time, often 20 to 30 minutes. If the client’s back, chest, and arms are to be treated, these areas need to be immersed in the solution. Rationale 3: A partial bath would not permit the medication to be in contact with the client’s skin long enough. Rationale 4: A complete bath would not permit the medication to be in contact with the client’s skin long enough.Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Apply the nursing process to common problems related to hygienic care of the: skin, feet, nails, mouth, hair, eyes, and ears. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 675 Question 26 Type: MCSA A client tells the nurse that she does not want to get into the tub for a morning bath. The client has not been bathed for several days. What should the nurse do? 1. Assign UAP the task of giving the client a bath. 2. Skip the client’s bath and document ―refused‖ in the medical record. 3. Ask the client the usual way bathing occurs at home. 4. Tell the client that a bath is needed and ignore the client’s comment. Correct Answer: 3 Rationale 1: Assigning a UAP the task of giving the client a bath is following the task-centered approach. Rationale 2: Skipping the client’s bath and documenting ―refused‖ is not following a client-centered approach.Rationale 3: To provide a person-centered approach to bathing, the nurse should ask the client to describe the usual way bathing occurs at home. Rationale 4: Telling the client that a bath is needed and ignoring the client’s comment is not following a client-centered approach. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Compare and contrast the task-centered approach and the person-centered approach to bathing. MNL Learning Outcome: 4.4.2 Recognize factors that influence hygienic practices. Page Number: 674 Question 27 Type: MCSA An older client tells the nurse that showers are not taken because of a previous fall. What can the nurse do to support the client’s bathing needs? 1. Obtain a shower chair and assist the client in the shower. 2. Document that the client ―refused‖ a morning bath in the medical record. 3. Tell the client that shower shoes can be worn to prevent falls. 4. Hold the client during the shower. Correct Answer: 1Rationale 1: To provide person-centered care with bathing, the nurse should obtain a shower chair. This should eliminate the client’s fear of falling when in the shower. Rationale 2: The client did not refuse a morning bath but rather explained why showers are not used. Rationale 3: Shower shoes may not be sufficient to eliminate the client’s fear of falling when in the shower. Rationale 4: The nurse would not be able to hold the client during the shower. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13. Discuss factors that support a positive and safe environment for the client. MNL Learning Outcome: 4.4.2 Recognize factors that influence hygienic practices. Page Number: 675 Question 28 Type: MCMA The nurse is preparing to provide a morning bath to a client diagnosed with dementia. What can the nurse do to ensure a positive bathing experience for the client? Standard Text: Select all that apply. 1. Move slowly. 2. Be flexible. 3. Help the client feel in control.4. Avoid stopping once the bath is started. 5. Be prepared. Correct Answer: 1, 2, 3, 5 Rationale 1: When bathing a client with dementia, the nurse should move slowly. Rationale 2: When bathing a client with dementia, the nurse should be flexible to adapt the approach to meet the needs of the client. Rationale 3: When bathing a client with dementia, the nurse should offer the client choices in order for the client to feel in control. Rationale 4: When bathing a client with dementia, the nurse should stop if the client begins to feel distressed. Rationale 5: When bathing a client with dementia, the nurse should be prepared with all items prior to starting the bath. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Describe guidelines for bathing persons with dementia. MNL Learning Outcome: 4.4.2 Recognize factors that influence hygienic practices. Page Number: 681 Question 29 Type: MCSAA client has hard contact lenses. What should the nurse do to assist the client in the care of the lenses? 1. Pinch the lenses out of the client’s eyes to remove. 2. Remove both of the client’s lenses before storing in the appropriate storage cup. 3. Document when the lenses need to be removed and cleaned every 2 weeks. 4. Ask the client how many hours the lenses are worn each day. Correct Answer: 4 Rationale 1: Hard contact lenses are not removed by pinching. Rationale 2: The nurse should remove one lens at a time and store in the appropriate storage cup. Rationale 3: Hard contact lenses should be removed and cleaned every day, not every 2 weeks. Rationale 4: Hard contact lenses should only be worn for 12 to 14 hours. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Discuss the different types of contact lenses. MNL Learning Outcome: 4.4.2 Recognize factors that influence hygienic practices. Page Number: 703 Question 30 Type: MCSADuring an assessment, the nurse learns a client has soft contact lenses that have not been removed or cleaned for weeks. What should the nurse do? 1. Nothing, because these types of lenses can be worn for months. 2. Remove the client’s lenses, wrap in tissue, and place in the bedside table. 3. Assist the client to remove and clean the contacts. 4. Ask the physician for ophthalmology consult because the client will need help removing the lenses. Correct Answer: 3 Rationale 1: This type of lens should not be worn for more than 30 days. Rationale 2: The lenses should not be wrapped in tissue because this will cause the lenses to dry out and not be able to be worn or used. Rationale 3: Most eye specialists recommend that soft contact lenses be removed and cleaned every week. The nurse should assist the client to remove and clean the contacts. Rationale 4: The client does not need ophthalmology consult. The nurse can help the client remove the lenses. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Discuss the different types of contact lenses. 10. Identify the steps in removing contact lenses. MNL Learning Outcome: 4.4.2 Recognize factors that influence hygienic practices. Page Number: 703Question 31 Type: SEQ The nurse is assisting a client in removing soft contact lenses. Place in order the steps the nurse should take to help this client. Standard Text: Click and drag the options below to move them up or down. Choice 1. Using the pad of the index finger of the other hand, move the lens down to the sclera. Choice 2. Have the client look forward. Choice 3. Apply gloves. Choice 4. Gently pinch the lens between the pads of the thumb and index finger. Choice 5. Retract the lower lid with one hand. Correct Answer: 3, 2, 5, 1, 4 Rationale 1: The nurse should use the pad of the index finger of the other hand to move the lens down to the sclera. Rationale 2: The nurse should ask the client to look forward. Rationale 3: The first step is for the nurse to apply gloves. Rationale 4: The nurse should gently pinch the lens between the pads of the thumb and index finger to remove the lens. Rationale 5: The nurse should retract the lower lid with one hand. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventionsNursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Identify the steps in removing contact lenses. MNL Learning Outcome: 4.4.2 Recognize factors that influence hygienic practices. Page Number: 703 Question 32 Type: MCSA The client has a hearing aid with an earpiece that is connected by a cord to a receiver that the client keeps in a shirt pocket. The nurse would document this as which type of hearing aid? 1. Body hearing aid 2. In-the-canal aid 3. Completely-in-the-canal aid 4. Eyeglasses aid Correct Answer: 1 Rationale 1: A body hearing aid is a pocket-sized aid that clips onto a shirt pocket. The case, containing the microphone and amplifier, is connected by a cord to the receiver, which snaps into the earpiece. Rationale 2: An in-the-canal aid is a hearing aid that fits directly into the client’s ear and is barely visible. It is not connected to a receiver worn by the client. Rationale 3: A completely-in-the-canal aid is a hearing aid that fits inside the client’s ear canal and is not visible. It is not connected to a receiver worn by the client. Rationale 4: An eyeglass aid has a hearing aid attached to the eyeglasses and is not connected to a receiver worn by the client. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experienceAACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11. Discuss the different types of hearing aids. MNL Learning Outcome: 4.4.2 Recognize factors that influence hygienic practices. Page Number: 705 Question 33 Type: MCSA The nurse has delegated the making of unoccupied beds to unlicensed assistive personnel. What should the nurse assess regarding client safety once the beds are completed? 1. Folding of the top sheet 2. Direction of the pillow 3. Call light being readily available 4. Presence of mitered corners Correct Answer: 3 Rationale 1: The folding of the top sheet is not important for client safety. Rationale 2: The direction of the pillow is not important for client safety. Rationale 3: The nurse should assess for the call light being readily available while the client is out of the bed. Rationale 4: The presence of mitered corners is not important for client safety. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection ControlQSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14. Identify safety and comfort measures underlying bed-making procedures. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 712 Question 34 Type: MCMA A client recovering from acute illness has just received a tub bath. When documenting the bath, what should the nurse include? Standard Text: Select all that apply. 1. Client’s ability to maintain a conversation during the procedure 2. Client’s tolerance of the procedure 3. Condition and integrity of the skin 4. Client strength 5. Percentage of bath done without assistance Correct Answer: 2, 3, 4, 5 Rationale 1: It is not necessary for the nurse to document if the client was maintaining a conversation during the bath. Rationale 2: When evaluating the client’s bath, the nurse should include the client’s tolerance of the procedure. Rationale 3: When evaluating the client’s bath, the nurse should include the condition and integrity of the client’s skin. Rationale 4: When evaluating the client’s bath, the nurse should include the client’s strength.Rationale 5: When evaluating the client’s bath, the nurse should include the percentage of the bath done without assistance. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 17. Demonstrate appropriate documentation and reporting of hygiene skills. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 675 Question 35 Type: MCSA The nurse has completed foot care for a client as part of routine morning care. What should the nurse document about the procedure? 1. The condition of the skin and nails 2. Nothing unless a problem is noted 3. The amount of time taken on foot care 4. The client’s comments about the foot care Correct Answer: 2 Rationale 1: The nurse does not need to document the condition of the skin and nails unless a problem is noted. Rationale 2: Foot care is not generally recorded unless problems are noted.Rationale 3: The nurse does not need to document the amount of time taken on foot care. Rationale 4: The nurse does not need to document the client’s comments about the foot care. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 17. Demonstrate appropriate documentation and reporting of hygiene skills. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 686 [Show More]

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