TEST BANK for Clinical Nursing Skills 3rd Edition A Concept-Based Approach by Barbara Callahan. Pear

Clinical Nursing Skills: A Concept-Based Approach, 3rd Edition Chapter 1 Assessment 1) A client on the medical/surgical unit complains of sudden chest pains. Which is the first action the nurse will implement?

A) Call the health care provider.

B) Administer pain medication.

C) Reassess a new set of vital signs.

D) Turn client from supine to lateral.

Answer: C Explanation: A) The nurse will need to reassess the client first, before calling the healthcare provider.

B) The nurse will need to reassess the client first, before administering pain medication.

C) The nurse needs to implement a new set of vital signs first when there is a change in condition.

D) The nurse will need to reassess the client first, before moving the client, to avoid making the change in client's condition worse.

Page Ref: 3 Cognitive Level: Applying Client Need/Sub: Reduction of Risk Potential: System Specific Assessments Standards: Nursing Process: Implementation | Learning Outcome: 1.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Relationship Centered Care

2) The nurse is observing the UAP taking the temperature of an unconscious client. Which route will the nurse question the UAP using?

A) Oral B) Rectal C) Scanner D) Tympanic 1

Answer: A Explanation: A) The temperature of an unconscious client is never taken by mouth. The rectal, tympanic, or scanner method is preferred.

B) The rectal, tympanic, or scanner method is preferred.

C) The rectal, tympanic, or scanner method is preferred.

D) The rectal, tympanic, or scanner method is preferred.

Page Ref: 24 Cognitive Level: Remembering Client Need/Sub: Management of Care: Assignment, Delegation, and Supervision Standards: Nursing Process: Evaluation | Learning Outcome: 1.1 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety 3) The nurse is changing a 2-month-old client's diaper and notes the client feels warm to touch.

Which is the best method for checking this baby's temperature?

A) Oral B) Rectal C) Axillary D) Tympanic membrane Answer: C Explanation: A) Oral is used for age 3 or older.

B) The rectal route is the least desirable.

C) The tympanic membrane route may be more accurate in determining temperature in febrile newborns or infants.

D) The tympanic membrane may be used for 3 months or older.

Page Ref: 29 Cognitive Level: Understanding Client Need/Sub: Reduction of Risk Potential: Diagnostic Tests Standards: Nursing Process: Evaluating | Learning Outcome: 1.2 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety

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4) A client comes in with exacerbation of chronic obstructive pulmonary disease (COPD). Which noninvasive diagnostic test will the nurse implement to know that the client is receiving enough oxygen?

A) Chest x-ray B) Pulse oximeter C) Arterial blood gasses D) Assessment of respiratory rate Answer: B Explanation: A) A chest x-ray is not an intervention a nurse completes.

B) A pulse oximeter provides a noninvasive method of measuring oxygenation, or oxygen saturation, in the blood and provides a pulse reading, which is especially helpful for the client with a respiratory illness or disease.

C) Arterial blood gases are an invasive diagnostic test.

D) Assessing a respiratory rate is important for the nurse to implement; however, it is not a diagnostic test.

Page Ref: 21 Cognitive Level: Applying Client Need/Sub: Reduction of Risk Potential: Diagnostic Tests Standards: Nursing Process: Implementation | Learning Outcome: 1.3 | QSEN Competencies: Informatics AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety 5) Which is the most important question the nurse should ask a client before performing a routine musculoskeletal assessment?

A) "Do you exercise every day?"

B) "Do you have a history of any sports injuries?"

C) "Do you take a hot bath to relax your muscles?"

D) "Do you want pain medication before I begin?"

Answer: B Explanation: A) Knowing if a client exercises is an important question but knowing if there are any sports injuries to know about first, is most important before doing a routine musculoskeletal 3

assessment.

B) It is important to note if the client has a history of any sports injuries first to know what the client will or will not be able to do during a routine musculoskeletal assessment.

C) Knowing if the client takes a hot bath to relax the muscles is not the most important to ask before performing a routine musculoskeletal assessment.

D) To know if a client is experiencing any pain is an important question; however, this question is assuming the client is in pain by asking if the client wants a pain medication before beginning a routine musculoskeletal assessment.

Page Ref: 62 Cognitive Level: Analyzing Client Need/Sub: Safety and Infection Control: Accident/Error/Injury Prevention Standards: Nursing Process: Assessment | Learning Outcome: 1.5 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety

6) A client's daughter mentions to the nurse that her mom seems to have a decline in mental status and seems to be forgetting many things in their conversation since this hospitalization.

Which is the best response by the nurse?

A) "Give your mom time, because it will take her a little longer when answering questions."

B) "Let me check the cranial nerve function to see if there is a defect in her mental status."

C) "You do not need to worry. This decline is part of the normal process of aging."

D) "If you bring some things from her home, it might reduce the confusion."

Answer: D Explanation: A) This is expected to give some older adults time to respond, but the daughter is concerned about her forgetting, not the length of the response.

B) Cranial nerve function is an assessment of the cranial nerves and not the mental status of a client.

C) A decline in mental status is not a normal result of aging, so this response is not true.

D) The stress of being in unfamiliar situations can cause confusion in some older adults.

Page Ref: 68 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: Therapeutic Environment 4

Standards: Nursing Process: Planning | Learning Outcome: 1.6 | QSEN Competencies: PatientCentered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Context and Environment 7) The nurse coming on duty received in report that the client's lung sounds were clear to auscultation in all lobes. The nurse coming on heard moderate-intensity and moderate-pitch "blowing" sounds between the scapulae and lateral to the sternum at the first and second intercostal spaces when doing her own assessment. Which should the nurse do next?

A) Encourage the client to cough and deep breathe.

B) Notify the healthcare provider of abnormal breath sounds.

C) Document assessment findings as normal breath sounds.

D) Raise the head of the bed to allow maximum air excursion.

Answer: C Explanation: A) The nurse would implement this if these were adventitious lung sounds; however, these are bronchovesicular sounds.

B) The nurse would notify the healthcare provider if these were adventitious lung sounds; however, these are bronchovesicular sounds.

C) This is correct, because these are bronchovesicular sounds.

D) The nurse would implement this if these were adventitious lung sounds; however, these are bronchovesicular sounds.

Page Ref: 88 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.7 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Context and Environment

8) A new client came to the clinic complaining of shortness of breath and fever. How long should the triage nurse count the peripheral pulse?

A) 15 seconds 5

B) 30 seconds C) 1 minute D) 2 minutes Answer: C Explanation: A) Count for a full minute if taking a client's pulse for the first time.

B) Count for a full minute if taking a client's pulse for the first time.

C) Count for a full minute if taking a client's pulse for the first time.

D) Count for a full minute if taking a client's pulse for the first time.

Page Ref: 19 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.8 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety 9) Prior to administering digoxin, which should the nurse assess first?

A) Temperature B) Apical pulse C) Respiratory rate D) Pain using a pain scale Answer: B Explanation: A) The nurse should assess the apical pulse before the administration of a medication that could affect the cardiovascular systems, such as before giving a digitalis preparation.

B) The nurse should assess the apical pulse before the administration of a medication that could affect the cardiovascular systems, such as before giving a digitalis preparation.

C) The nurse should assess the apical pulse before the administration of a medication that could affect the cardiovascular systems, such as before giving a digitalis preparation.

D) The nurse should assess the apical pulse before the administration of a medication that could affect the cardiovascular systems, such as before giving a digitalis preparation.

Page Ref: 3 6

Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety

10) When measuring the newborn during a general assessment, which is the correct assessment?

A) Wrap the tape measure around the head below the ears.

B) Wrap the tape measure around the head starting at the nose.

C) Wrap the tape measure around the abdomen at the umbilicus.

D) Wrap the tape measure around the chest below the nipple line.

Answer: C Explanation: A) When measuring the head circumference, wrap the tape around the head at the supraorbital prominence above the eyebrows, above the ears, and around the occipital prominence.

B) When measuring the head circumference, wrap the tape around the head at the supraorbital prominence above the eyebrows, above the ears, and around the occipital prominence.

C) Correct. When measuring the abdomen circumference, wrap the tape around the abdomen at the level of the umbilicus.

D) When measuring the chest circumference, wrap the tape measure around the chest, placed just under the axilla and at the nipple line.

Page Ref: 9 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety

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11) Which would cause an erroneously low blood pressure during a general assessment for an adult client?

A) Bladder to cuff ratio too wide B) Arm unsupported C) Cuff wrapped too loosely D) Arm below heart level Answer: A Explanation: A) The width of the bladder cuff needs to be 40% of the circumference or 20% wider than the diameter of the midpoint.

B) If the arm is unsupported, it will cause an erroneously high blood pressure.

C) If the cuff is wrapped too loosely, it will cause an erroneously high blood pressure.

D) If the arm is below heart level, it will cause an erroneously high blood pressure.

Page Ref: 15 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety

12) Based on the information provided, which client should the nurse see first?

A) Infant respirations 38/min B) 2-year-old pulse 112/min C) 6-year-old axillary temperature 97.5°F D) 10-year-old blood pressure 138/88 Answer: D Explanation: A) An infant's respiration range is 20-40/min.

B) A 2-year-old child's pulse range is 70-120/min.

C) A 6-year-old child's temperature range is 98.6°F but axillary is 1°F lower than oral.

D) A 10-year-old child's blood pressure range is systolic 95-116 and diastolic 60-70. This is much higher than the range for the age of this client.

Page Ref: 15 10

Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety 13) Which is the best route to check a temperature for a client who is diaphoretic? Select all that apply.

A) Oral B) Rectal C) Axillary D) Tympanic E) Heat sensitive Answer: A, B, D Explanation: A) Oral does not interfere with diaphoresis because the probe is in the mouth.

B) Rectal does not interfere with diaphoresis because the probe is in the rectum.

C) Axillary might be wet and cause an error in the reading temperature.

D) Tympanic does not interfere with diaphoresis because the probe is in the ear. However, do not use if ear is draining or infected.

E) Heat sensitive might have areas of the skin that are wet and cause an error in reading temperature.

Page Ref: 26, 28 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety

14) Which is the best response by the nurse when explaining to the client as to why the stethoscope is warmed up before placing it on the abdomen?

A) "I might hear a friction rub with a cold stethoscope."

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B) "A nice nurse will put a warm stethoscope on your abdomen."

C) "A cold stethoscope may cause your abdominal muscles to contract."

D) "Warming up the stethoscope will help with the digestion of your food."

Answer: C Explanation: A) The nurse might hear a friction rub due to an inflammation, infection, or abdominal growth, not from a cold stethoscope.

B) Warming up a stethoscope can be nice for client's comfort; however, it is to decrease the abdominal muscles to contract, otherwise the nurse might hear unnecessary contractions.

C) A cold stethoscope may cause your abdominal muscles to contract which the nurse might hear with a cold stethoscope.

D) Warming up the stethoscope has no effect with digestion of food. A warm stethoscope will decrease the abdominal muscles to contract, so the nurse will not hear any unnecessary noises.

Page Ref: 31 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety 15) Which are signs and symptoms of colon cancer? Select all that apply.

A) Weight gain B) Rectal bleeding C) Unusual cough D) Change in bowel function E) Decrease medication absorption Answer: B, D Explanation: A) Weight loss, not gain, is a sign and symptom of colon cancer.

B) Correct.

C) Unusual cough is more a sign and symptom of a lung infection or lung cancer.

D) Correct E) A decrease in medication absorption often occurs with aging, not colon cancer.

Page Ref: 34 10

Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety

16) Which is the appropriate way to hold the ear when inspecting the tympanic membrane of a 2year-old client?

A) Pull the pinna up and back.

B) Pull the pinna up and forward.

C) Pull the pinna down and back.

D) Pull the pinna down and forward.

Answer: C Explanation: A) Pulling the pinna up and back will straighten the ear canal for a client greater than 3 years old.

B) Pulling the pinna up and forward will not allow sufficient visualization of the ear.

C) Pulling the pinna down and back will straighten the ear canal for a client less than 3 years old.

D) Pulling the pinna down and forward will not allow sufficient visualization of the ear.

Page Ref: 43 Cognitive Level: Applying 17) Which does the nurse observe during the assessment while documenting a Tanner Stage 5?

A) There is no pubic hair except for fine body hair.

B) Pubic hair is developing along the labia.

C) Pubic hair distribution extends to umbilicus.

D) Pubic hair appears on the inner aspect of the thigh.

Answer: D Explanation: A) No pubic hair is Tanner Stage 1.

B) Pubic hair developing along the labia is Stage 2.

C) Pubic hair distribution extends to umbilicus is Stage 5 but for men only.

D) Pubic hair appears on the inner aspect of the thigh for Stage 5.

Page Ref: 51 10

Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety

18) The UAP notifies the nurse of these vital signs for a client on the medical-surgical unit: temperature 97.6°F, respirations 22, pulse 122, and BP 98/72. Which is the best action the nurse should do next?

A) Ask the UAP to reassess the client.

B) Inform the UAP to document these vital signs.

C) Reassess the client to validate these vital signs.

D) Notify the healthcare provider of these vital signs.

Answer: C Explanation: A) UAP cannot assess or reassess as evaluation of data.

B) These vital signs are abnormal; the nurse needs to reassess the client to validate these findings.

C) The nurse needs to reassess the client to validate these findings.

D) The nurse will notify the healthcare provider of these vital signs after the nurse reassesses the client to validate these findings.

Page Ref: 2 Cognitive Level: Analyzing 19) Which does the nurse observe for an adult client who has a negative Babinski response?

A) All toes turn inward.

B) All toes curve upward.

C) All toes spread outward.

D) All toes bend downward.

Answer: D Explanation: A) This is not in relation to the Babinski response; it could be another problem.

B) A positive Babinski response is when the toes spread outward and the big toe moves upward and backward.

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C) A positive Babinski response is when the toes spread outward and the big toe moves upward and backward.

D) All toes bend downward for a negative Babinski response on an adult.

Page Ref: 70 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety

20) Before completing a blood pressure on an adult, which should the nurse do next after introducing self?

A) Provide privacy.

B) Perform handwashing.

C) Identify the client with two identifiers.

D) Explain what he or she will be doing with the client.

Answer: C Explanation: A) Need to identify the right client before providing privacy so you know you are in the right room.

B) Need to identify the right client before performing handwashing so you know you are in the right room.

C) The nurse needs to identify the right client before doing anything else after introducing self.

D) The nurse needs to identify the right client before explaining the procedure so the client knows why the nurse is in the room.

Page Ref: 14 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety 10

21) The nurse is completing an assessment on a client who just received morphine. Which is the nurse's highest priority?

A) Pain level B) Respirations C) Temperature D) Blood pressure Answer: B Explanation: A) Pain level has already been assessed because the client just received morphine and it is too early to reassess pain.

B) Respirations are highest priority after administering morphine because morphine can cause respiratory depression.

C) The temperature of a client is not affected by morphine or pain.

D) Blood pressure can change because of the client's pain; however, the highest priority for this client is respirations because morphine was just administered.

Page Ref: 23 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety

22) After receiving shift report, which of the following clients should the nurse assess first?

A) Kussmaul respirations B) Blood glucose of 144 C) Pain level 6 out of 10 D) Temperature is 101.8°F Answer: A Explanation: A) This client is probably experiencing diabetic ketoacidosis or going into shock and needs to be reassessed immediately.

B) The glucose is elevated in this client, but the Kussmaul breathing has a higher priority.

C) The pain level is moderate pain.

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D) The temperature is elevated, but Kussmaul breathing has a higher priority.

Page Ref: 91 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety 23) Which task can the nurse delegate to the UAP? A) Administration of medication B) Recording findings from a sponge bath C) Teaching a client how to take own vital signs D) Assessing a client in the medical-surgical unit for two days Answer: B Explanation: A) Administration of medication requires licensed personnel to administer.

B) A UAP can record the findings from a sponge bath because the skin is observed during a UAP's usual care.

C) UAPs cannot teach clients because this is outside their scope of practice.

D) Assessing is outside the UAP's scope of practice.

Page Ref: 79 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety

24) Which statement made by the UAP is best in understanding the teaching from the nurse?

A) "I will clean the site after applying the sensor."

B) "I will move the adhesive toe or finger sensor once a shift."

C) "I will remove any fingernail polish when using a pulse oximeter."

D) "I will use the side of the finger rather than perpendicular to the nail bed."

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Answer: D Explanation: A) The site needs to be cleaned before applying the sensor.

B) The adhesive toe or finger sensor needs to be moved every four hours.

C) The UAP needs to remove dark fingernail polish.

D) Correct. The side of the finger is an alternate use if the client has dark fingernail polish on the fingernail.

Page Ref: 21 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety

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Clinical Nursing Skills: A Concept-Based Approach, 3e (Pearson) Chapter 2 Caring Interventions 1) The nurse is observing a UAP performing a bed bath for a client. Which action by the UAP requires the nurse to intervene?

A) Washing the client's arms from wrists to shoulders.

B) Washing the client's eyes and face first before the rest of the body.

C) Washing, rinsing, and drying the client's leg from thigh to ankle.

D) Washing the client's back and then the perineum.

Answer: C Explanation: The correct method in performing a bed bath is washing, rinsing, and drying the client's leg from ankle to thigh.

Page Ref: 95-100 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Intervention | Learning Outcome: 2.3 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

2) The nurse delegates soft contact lens care to a UAP. Which action by the UAP requires the nurse to intervene?

A) Placing the client in semi-Fowler's position.

B) Placing the client's removed disposable lenses in the trash.

C) Placing the gloved thumb and forefinger directly on the soft lens on top of the eyeball.

D) Placing the gloved thumb on the client's lower eyelid and gloved index finger on the client's upper lid, pressing lightly on the eyeball.

Answer: D Explanation: Placing the gloved thumb on the client's lower eyelid and gloved index finger on the client's upper lid, pressing lightly on the eyeball is the technique to remove rigid contact lenses, not soft lenses.

Page Ref: 110 Cognitive Level: Analyzing 17

Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Intervention | Learning Outcome: 2.3 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 3) The nurse determines some client care tasks can be delegated to the UAP. Which task should not be delegated?

A) Performing foot care for a client with diabetes.

B) Changing an occupied bed for a client with multiple intravenous medications infusing.

C) Performing a bath for a newborn with an unhealed umbilical cord.

D) Oral care for an unconscious client.

Answer: A Explanation: The registered nurse should perform foot care for the client with diabetes.

Page Ref: 111 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Intervention | Learning Outcome: 2.3 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

4) When teaching the client about foot care, which statement will the nurse include in the teaching?

A) "Use creams or lotions on the feet and in between the toes after showering."

B) "While sitting, cross your legs at the knees instead of the ankles."

C) "Avoid using pumice stones on the feet to decrease callouses."

D) "When your feet are cold, place them on a hot water bottle to warm them."

Answer: C Explanation: The client should avoid using pumice stones on the feet because these can injure the feet.

Page Ref: 111 Cognitive Level: Applying 18

Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Intervention | Learning Outcome: 2.3 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 5) Prior to delegating hearing aid care to a UAP, what is the nurse's PRIORITY? A) Determine the UAP's knowledge of the procedure.

B) Inform the UAP of what to report back to the nurse.

C) Discuss relevant client health information necessary for the task.

D) Provide the UAP with guidance on where to find supplies necessary for the task.

Answer: A Explanation: Prior to delegation, the nurse must first determine the UAP's knowledge of the procedure.

Page Ref: 117 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Intervention | Learning Outcome: 2.3 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 6) A client places one hearing aid in the ear and tells the nurse, "I hear a whistling sound." Which actions will the nurse take in response to the client's statement? Select all that apply.

A) Turn the volume of the hearing aid up.

B) Check the battery inside the hearing aid.

C) Turn the volume of the hearing aid down.

D) Ensure the ear canal is not blocked with wax.

E) Check that the earmold is attached to the receiver.

Answer: C, E Explanation: Turning the volume of the hearing aid down will decrease the client's distress.

Checking that the earmold is attached to the receiver troubleshoots the whistling noise.

Page Ref: 117 19

Cognitive Level: Applying Client Need/Sub: Basic Care and Comfort: Assistive Devices Standards: Nursing Process: Intervention | Learning Outcome: 2.3 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 7) A nurse cares for a client who receives new hearing aids for the first time. Which statements will the nurse include when teaching the client about the hearing aids? Select all that apply.

A) "Push the earmold slightly backward and pull out to remove it."

B) "Rotate the earmold slightly forward and pull out to remove it."

C) "If the hearing aid is not used for several days, be sure to turn the device off."

D) "If the earmold is detachable, soak it in isopropyl alcohol weekly to disinfect it."

E) "Blow any excess moisture through the opening of the earpiece when cleaning it."

Answer: B, E Explanation: The nurse will instruct the client to rotate the earmold slightly forward and pull it out to remove it.

To remove excess moisture, the client can be instructed to blow any excess moisture through the opening of the earpiece.

Page Ref: 116 Cognitive Level: Applying Client Need/Sub: Basic Care and Comfort: Assistive Devices Standards: Nursing Process: Intervention | Learning Outcome: 2.3 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 8) The nurse is performing hearing aid care for a client and notes the hearing aid has "TM" near its on/off switch. What is the nurse's understanding of the meaning of "TM"?

A) Transmitting mode B) Tympanic membrane C) Telephone/microphone D) Tympanic/microphone 20

Answer: B Explanation: "T/M" on the hearing aid stands for telephone/microphone, not tympanic membrane.

Page Ref: 116 Cognitive Level: Remembering Client Need/Sub: Basic Care and Comfort: Assistive Devices Standards: Nursing Process: Assessment | Learning Outcome: 2.3 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 9) A nurse is providing oral care to an older adult. What findings does the nurse recognize are normal findings in this client? Select all that apply.

A) Dry mouth B) Gingivitis C) Jaw bone loss D) Receding gums E) Tooth root decay Answer: A, D, E Explanation: Dryness of the oral mucosa is a common finding among many older adults.

Receding gums is a common finding among many older adults.

Tooth root decay is common in some older adults, often due to receding gums.

Page Ref: 122 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Aging Process Standards: Nursing Process: Assessment | Learning Outcome: 2.3 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 10) The nurse is making an occupied bed. In which order should the nurse perform when removing the top linens and adding the bath blanket?

A) Spread the bath blanket over the top sheet.

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B) Remove the spread and the blanket.

C) Reach under the bath blanket, grasp top edge of sheet.

D) Ask the client to hold the top edge of the bath blanket.

E) Pull the sheet from under the bath blanket.

Answer: B, A, D, C, E Explanation: A) Spreading the bath blanket over the top sheet happens after the nurse removes the spread and blanket (top linens).

B) Removing the spread and blanket is the first step in the procedure.

C) After removing the spread and the blanket, spreading the bath blanket on the top sheet, asking the client to hold the top edge of the bath blanket, the nurse will reach under the bath blanket and grasp the top edge of the sheet.

D) After removing the spread and the blanket, spreading the bath blanket on the top sheet, the nurse will ask the client to hold the top edge of the bath blanket.

E) After removing the spread and the blanket, spreading the bath blanket on the top sheet, asking the client to hold the top edge of the bath blanket, the nurse will reach under the bath blanket and grasp the top edge of the sheet. Finally, the nurse will pull the sheet from under the bath blanket.

Page Ref: 104 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 2.1 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 11) The nurse prepares to make an unoccupied bed. Place the steps in correct order of how the nurse will remove the soiled linens.

A) Detach the call bell and any drainage tubes from the bed linens.

B) Loosen all the bedding systematically.

C) Roll all soiled linens inside the bottom sheet.

D) Remove the incontinent pad and discard.

E) Remove the pillowcases and fold reusable linens.

Answer: A, B, E, D, C Explanation: A) The first step to make an unoccupied bed is to detach the call bell and any drainage tubes from the bed linens.

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B) The second step when making an unoccupied bed is loosening all the bedding systematically.

C) The final step when making an unoccupied bed is rolling all soiled linens inside the bottom sheet.

D) Removing the incontinent pad and discarding it occurs after detaching the call bell, loosening the bedding, and removing the pillowcases.

E) Removing the pillowcases occurs after detaching the call bell and loosening all bedding systematically.

Page Ref: 106 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 2.1 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 12) The nurse prepares to perform oral care for a client with dentures. Place the steps in correct order for how the nurse will remove the client's dentures.

A) Use gauze to grasp upper plate at the front teeth with the thumb and second finger.

B) Lift the lower plate and remove without stretching the lip.

C) Move the denture up and down slightly.

D) Don gloves E) Place the upper plate in the denture cup.

F) Place the lower plate in the denture cup.

Answer: D, A, C, E, B, F Explanation: A) The correct steps to remove the client's dentures is as follows: Don gloves, use gauze to grasp the upper plate at the front teeth with the thumb and second finger, move the denture up and down slightly, place the upper plate in the denture cup. Next, lift the lower plate and remove it without stretching the lip. Finally, place the lower plate in the denture cup.

B) The correct steps to remove the client's dentures is as follows: Don gloves, use gauze to grasp the upper plate at the front teeth with the thumb and second finger, move the denture up and down slightly, place the upper plate in the denture cup. Next, lift the lower plate and remove it without stretching the lip. Finally, place the lower plate in the denture cup.

C) The correct steps to remove the client's dentures is as follows: Don gloves, use gauze to grasp the upper plate at the front teeth with the thumb and second finger, move the denture up and 23

down slightly, place the upper plate in the denture cup. Next, lift the lower plate and remove it without stretching the lip. Finally, place the lower plate in the denture cup.

D) The correct steps to remove the client's dentures is as follows: Don gloves, use gauze to grasp the upper plate at the front teeth with the thumb and second finger, move the denture up and down slightly, place the upper plate in the denture cup. Next, lift the lower plate and remove it without stretching the lip. Finally, place the lower plate in the denture cup.

E) The correct steps to remove the client's dentures is as follows: Don gloves, use gauze to grasp the upper plate at the front teeth with the thumb and second finger, move the denture up and down slightly, place the upper plate in the denture cup. Next, lift the lower plate and remove it without stretching the lip. Finally, place the lower plate in the denture cup.

F) The correct steps to remove the client's dentures is as follows: Don gloves, use gauze to grasp the upper plate at the front teeth with the thumb and second finger, move the denture up and down slightly, place the upper plate in the denture cup. Next, lift the lower plate and remove it without stretching the lip. Finally, place the lower plate in the denture cup.

Page Ref: 119 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 2.2 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 13) The nurse prepares to mix two medications (vial A and B) in one syringe. Place the steps in correct order for how the nurse will perform the procedure.

A) Inject a volume of air equal to the volume of medication to be withdrawn into vial A. B) Withdraw the required amount of medication from vial B. C) Draw up a volume of air equal to the volume of medications to be withdrawn from both vials A and B. D) Withdraw the needle from vial A and inject the remaining air into vial B. E) Withdraw the required amount of medication from vial A. Answer: C, A, D, B, E Explanation: A) Mixing two medications from two vials in one syringe has the following steps: After performing appropriate hand hygiene, draw up a volume of air equal to the volume of medications to be withdrawn from both vials A and B. Inject a volume of air equal to the volume 24

of medication to be withdrawn into vial A. Next withdraw the needle from vial A and inject the remaining air into vial B. Finally, withdraw the required amount of medication from vial A. B) Mixing two medications from two vials in one syringe has the following steps: After performing appropriate hand hygiene, draw up a volume of air equal to the volume of medications to be withdrawn from both vials A and B. Inject a volume of air equal to the volume of medication to be withdrawn into vial A. Next withdraw the needle from vial A and inject the remaining air into vial B. Finally, withdraw the required amount of medication from vial A. C) Mixing two medications from two vials in one syringe has the following steps: After performing appropriate hand hygiene, draw up a volume of air equal to the volume of medications to be withdrawn from both vials A and B. Inject a volume of air equal to the volume of medication to be withdrawn into vial A. Next withdraw the needle from vial A and inject the remaining air into vial B. Finally, withdraw the required amount of medication from vial A. D) Mixing two medications from two vials in one syringe has the following steps: After performing appropriate hand hygiene, draw up a volume of air equal to the volume of medications to be withdrawn from both vials A and B. Inject a volume of air equal to the volume of medication to be withdrawn into vial A. Next withdraw the needle from vial A and inject the remaining air into vial B. Finally, withdraw the required amount of medication from vial A. E) Mixing two medications from two vials in one syringe has the following steps: After performing appropriate hand hygiene, draw up a volume of air equal to the volume of medications to be withdrawn from both vials A and B. Inject a volume of air equal to the volume of medication to be withdrawn into vial A. Next withdraw the needle from vial A and inject the remaining air into vial B. Finally, withdraw the required amount of medication from vial A. Page Ref: 134 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Intervention | Learning Outcome: 2.7 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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14) The nurse delegates oral care of an unconscious client on supplemental oxygen to the UAP. Which action by the UAP requires the nurse to intervene?

A) Placing a bite block in the client's mouth.

B) Applying petroleum-based moisturizer to the client's lips.

C) Positioning the client in side-lying position with head of bed lowered.

D) Using a separate moistened swab for the inside of each cheek.

Answer: B Explanation: Applying petroleum-based moisturizer to the client's lips will require nursing intervention because these products may increase the risk of fire for clients with oxygen. Waterbased moisturizers should be used instead.

Page Ref: 117 Cognitive Level: Applying Client Need/Sub: Reduction of Risk Potential: Therapeutic Procedures Standards: Nursing Process: Intervention | Learning Outcome: 2.2 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

15) The nurse understands that, in addition to the five client rights of medication administration, there are now more rights for safe medication administration. Which rights are the new rights for safe medication administration? Select all that apply.

A) Right documentation B) Right dose C) Right time D) Right route E) Right reason Answer: A, E Explanation: Right documentation is a new right for safe medication administration.

Right reason is a new right for safe medication administration.

Page Ref: 128 AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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Cognitive Level: Understanding Client Need/Sub: Pharmacological and Parenteral Therapies: Medication Administration Standards: Nursing Process: Intervention | Learning Outcome: 2.4 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 16) The nurse is acting as preceptor for a novice nurse. Which action by the novice nurse requires the nurse preceptor to intervene?

A) Labeling medications placed in a medication cup.

B) Removing prepackaged medication and placing in a medication cup.

C) Keeping narcotics separated from other medications that need to be administered.

D) Breaking scored tablets as needed for correct dosage.

Answer: B Explanation: The nurse should leave prepackaged medications in their original package to ensure proper labeling and to maintain sanitary approaches.

Page Ref: 151 Cognitive Level: Applying Client Need/Sub: Pharmacological and Parenteral Therapies: Medication Administration Standards: Nursing Process: Intervention | Learning Outcome: 2.4 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 17) The nurse performs a skin assessment while bathing an older adult client. Which lifespan considerations regarding skin characteristics are more common in the older adult? Select all that apply.

A) Dry skin B) Itchy skin C) Poor healing D) Increased risk of water retention E) Increased risk of trauma AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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Answer: A, B, C, E Explanation: The older adult client is at increased risk for dry skin due to a decrease in endocrine secretion and decreased elastin.

The older adult client is at increased risk for itchy skin due to a decrease in endocrine secretion and decreased elastin.

The older adult client is at increased risk for poor healing due to inadequate nutrition, compromised immunity, poor hydration, and decreased mobility, among other factors.

The older adult client is at an increased risk of trauma due to fall, immobility, and decreased ability to heal, among others.

Page Ref: 102 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Aging Process Standards: Nursing Process: Assessment | Learning Outcome: 2.3 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 18) The nurse prepares to administer an intermittent intravenous solution using a secondary administration set. Place the steps of assembling the secondary infusion in correct order.

A) Insert the secondary tubing needleless cannula into the distal primary tubing port located above the infusion pump.

B) Hang the secondary container above the level of the primary bag.

C) Attach the appropriate label to the secondary tubing.

D) Lower medication bag to clear tubing and back-prime tubing.

E) Close the clamp on the secondary infusion tubing and spike the medication infusion bag.

Answer: E, A, B, D, C Explanation: A) The correct steps of assembling the secondary infusion is as follows: Close the clamp on the secondary infusion tubing and spike the medication infusion bag; insert the secondary tubing needleless cannula into the distal primary tubing port located above the infusion pump; hang the secondary container above the level of the primary bag; lower AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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medication bag to clear tubing and back-prime tubing; Attach the appropriate label to the secondary tubing.

B) The correct steps of assembling the secondary infusion is as follows: Close the clamp on the secondary infusion tubing and spike the medication infusion bag; insert the secondary tubing needleless cannula into the distal primary tubing port located above the infusion pump; hang the secondary container above the level of the primary bag; lower medication bag to clear tubing and back-prime tubing; Attach the appropriate label to the secondary tubing.

C) The correct steps of assembling the secondary infusion is as follows: Close the clamp on the secondary infusion tubing and spike the medication infusion bag; insert the secondary tubing needleless cannula into the distal primary tubing port located above the infusion pump; hang the secondary container above the level of the primary bag; lower medication bag to clear tubing and back-prime tubing; Attach the appropriate label to the secondary tubing.

D) The correct steps of assembling the secondary infusion is as follows: Close the clamp on the secondary infusion tubing and spike the medication infusion bag; insert the secondary tubing needleless cannula into the distal primary tubing port located above the infusion pump; hang the secondary container above the level of the primary bag; lower medication bag to clear tubing and back-prime tubing; Attach the appropriate label to the secondary tubing.

E) The correct steps of assembling the secondary infusion is as follows: Close the clamp on the secondary infusion tubing and spike the medication infusion bag; insert the secondary tubing needleless cannula into the distal primary tubing port located above the infusion pump; hang the secondary container above the level of the primary bag; lower medication bag to clear tubing and back-prime tubing; Attach the appropriate label to the secondary tubing.

Page Ref: 179-180 Cognitive Level: Analyzing Client Need/Sub: Pharmacological and Parenteral Therapies: Medication Administration Standards: Nursing Process: Intervention | Learning Outcome: 2.8 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 19) A novice nurse instructs a client on the use of sublingual nitroglycerin. Which statement by AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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the novice nurse requires intervention by the nurse preceptor?

A) "Be sure to take the medication prior to the start of your pain."

B) "Do not chew or swallow the tablet."

C) "The tablet may cause burning or tingling as it dissolves."

D) "Be sure to sit down when you decide to take the medication."

Answer: A Explanation: Nitroglycerin is taken at the onset of the client's symptoms, not prior to.

Page Ref: 156 Cognitive Level: Applying Client Need/Sub: Pharmacological and Parenteral Therapies: Medication Administration Standards: Nursing Process: Intervention | Learning Outcome: 2.5 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 20) A nurse mixes two insulins in one syringe for a client with diabetes. Which action by the nurse is incorrect?

A) Injecting a volume of air equal to the volume of medication to be withdrawn into the first vial.

B) Drawing up air in the syringe equal to the dose of both insulins.

C) Gently shaking the vials in order to ensure medication has dissolved.

D) Withdrawing the needle from the first vial and injecting the remaining air into the second vial.

Answer: C Explanation: Shaking the insulins is not recommended because it will cause the medication to become frothy and difficult to measure. Instead, the nurse should gently roll the insulins in order to mix them.

Page Ref: 134-135 Cognitive Level: Applying Client Need/Sub: Pharmacological and Parenteral Therapies: Medication Administration AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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Standards: Nursing Process: Intervention | Learning Outcome: 2.7 | QSEN Competencies: Evidence-Based Practice AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 21) While giving the client a bath, the nurse notes the client has facial acne. What statement by the nurse will not be included when teaching the client about this condition?

A) "Use cool water when cleansing your face to close the pores."

B) "Wash your face frequently to remove oil and dirt."

C) "Avoid using oil-based creams on your face."

D) "Do not squeeze the lesions on your face."

Answer: A Explanation: The nurse should instruct the client to use soap and warm water to cleanse the face.

Page Ref: 102 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: Nursing Process: Intervention | Learning Outcome: 2.3 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

22) The nurse is caring for an older adult client and performs a bed bath and linen change. Which action by the nurse poses an increase of injury in the client?

A) Washing the client with a washcloth.

B) Pulling linens underneath the client.

C) Assisting the client to turn in bed.

D) Covering the client with warm linens.

Answer: B Explanation: The nurse should be most cautious when pulling linens underneath an older adult client. This increases the risk of skin impairment because some older adults can be more prone to AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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injury of the skin.

Page Ref: 109 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 2.3 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 23) The nurse cares for a client who wears soft contact lenses for vision correction. Which statement will the nurse include when teaching the client about care of the lenses?

A) "If you do not have saline solution, saliva works to cleanse the lenses."

B) "If you wear disposable lenses, it is acceptable to cleanse them and wear them again."

C) "If you are removing the lens, place your thumb and forefinger directly on the lens."

D) "If you wear disposable lenses, be sure to cleanse the lens container daily."

Answer: C Explanation: When instructing the client to remove the soft lens, the nurse should tell the client to place the thumb and forefinger directly on the lens and squeeze gently.

Page Ref: 110 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: Nursing Process: Intervention | Learning Outcome: 2.3 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 24) The nurse prepares to perform a z-track injection to a client. Place the steps of the procedure in correct order.

A) Maintain displacement and insert needle at a 90-degree angle.

B) Inject medication slowly, keeping skin taut.

C) Pull skin 2.5–3.8 cm (1–1. in.) laterally away from the injection site.

D) Withdraw needle.

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E) Release retracted skin.

Answer: C, A, B, D, E Explanation: A) The injection technique of a z-track injection include the following steps: Pull skin 2.5–3.8 cm (1–1. in.) laterally away from the injection site; maintain displacement and insert needle at a 90-degree angle; inject medication slowly, keeping skin taut; withdraw the needle; release the retracted skin.

B) The injection technique of a z-track injection include the following steps: Pull skin 2.5–3.8 cm (1–1. in.) laterally away from the injection site; maintain displacement and insert needle at a 90-degree angle; inject medication slowly, keeping skin taut; withdraw the needle; release the retracted skin.

C) The injection technique of a z-track injection include the following steps: Pull skin 2.5–3.8 cm (1–1. in.) laterally away from the injection site; maintain displacement and insert needle at a 90-degree angle; inject medication slowly, keeping skin taut; withdraw the needle; release the retracted skin.

D) The injection technique of a z-track injection include the following steps: Pull skin 2.5–3.8 cm (1–1. in.) laterally away from the injection site; maintain displacement and insert needle at a 90-degree angle; inject medication slowly, keeping skin taut; withdraw the needle; release the retracted skin.

E) The injection technique of a z-track injection include the following steps: Pull skin 2.5–3.8 cm (1–1. in.) laterally away from the injection site; maintain displacement and insert needle at a 90-degree angle; inject medication slowly, keeping skin taut; withdraw the needle; release the retracted skin.

Page Ref: 170 Cognitive Level: Analyzing Client Need/Sub: Pharmacological and Parenteral Therapies: Medication Administration Standards: Nursing Process: Intervention | Learning Outcome: 2.4 | QSEN Competencies: Evidence-Based Practice AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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Clinical Nursing Skills: A Concept-Based Approach, 3e (Pearson) Chapter 3 Comfort

1) The nurse cares for a neonate who appears in pain. The neonate has tight facial muscles, loud and shrill cry, rapid breathing, tense extremities and is thrashing about. Using the NIPS pain scale, which number will the nurse give the neonate?

A) 5 B) 6 C) 7 D) 8 Answer: C Explanation: The Neonatal Infant Pain Scale (NIPS) is a standardized pain scale used for assessing pain in neonates up to 6 weeks of age. The scale is based on facial expressions, cry, breathing patterns, arm and leg movements, and state of arousal. Tight facial muscles (1 point), loud and shrill cry (2 points), rapid breathing (1 point), tense extremities (2 points), and increased movement (1 point) equal 7 points.

Page Ref: 192 Cognitive Level: Analyzing Client Need/Sub: Reduction of Risk Potential: System Specific Assessments Standards: Nursing Process: Assessment | Learning Outcome: 2.3 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

2) The nurse sets up a PCA pump for a postoperative client. Which safety parameters will the nurse use? Select all that apply.

A) Dose volume limits.

B) Partial dose settings.

C) Dosage limits.

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D) Lockout interval.

E) Re-programming alarm settings.

Answer: A, C, D Explanation: Dose volume limit parameters limit the amount of drug that the client can receive when the client pushes the control button. This is an important safety parameter the nurse will use.

Dosage limits set the dosage limits as specified on the order. This is an important safety parameter the nurse will use.

The lockout interval is set in order to ensure that doses are not administered too frequently. This is an important safety parameter the nurse will use.

Page Ref: 204-205 Cognitive Level: Understanding Client Need/Sub: Safety and Infection Control: Safe Use of Equipment Standards: Nursing Process: Intervention | Learning Outcome: 3.5 | QSEN Competencies: Safety 3) The nurse cares for a client who requires a PCA for pain control. The health care provider has ordered a loading dose for the client. Place the steps in order for the nurse to provide the loading dose by PCA pump.

A) Set the safety parameters.

B) Press the loading dose control button.

C) Set the volume to be delivered.

D) Set the pump for a lockout time of zero minutes.

Answer: D, C, B, A Explanation: A) When providing the loading dose by PCA pump, the nurse must first set the pump for a lockout time of zero minutes. Next, the nurse will set the volume to be delivered and press the loading dose control button. Finally, the nurse will set the safety parameters.

B) When providing the loading dose by PCA pump, the nurse must first set the pump for a lockout time of zero minutes. Next, the nurse will set the volume to be delivered and press the loading dose control button. Finally, the nurse will set the safety parameters.

C) When providing the loading dose by PCA pump, the nurse must first set the pump for a AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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lockout time of zero minutes. Next, the nurse will set the volume to be delivered and press the loading dose control button. Finally, the nurse will set the safety parameters.

D) When providing the loading dose by PCA pump, the nurse must first set the pump for a lockout time of zero minutes. Next, the nurse will set the volume to be delivered and press the loading dose control button. Finally, the nurse will set the safety parameters.

Page Ref: 111 Cognitive Level: Analyzing Client Need/Sub: Pharmacological and Parenteral Therapies: Pharmacological Pain Management Standards: Nursing Process: Intervention | Learning Outcome: 3.5 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

4) The nurse is caring for a client in acute pain. When assessing the client's quality of pain, which statement will the nurse use?

A) "How long have you been having pain?"

B) "Is the pain better or worse at certain times of the day or night?"

C) "What words would you use to describe your pain?"

D) "Have you noticed any time during the day or night that the pain is better or worse?"

Answer: C Explanation: Quality of pain may be assessed by asking the client, "What words would you use to describe your pain?"

Page Ref: 195 Cognitive Level: Applying Client Need/Sub: Basic Care and Comfort: Non-Pharmacological Comfort Interventions Standards: Nursing Process: Assessment | Learning Outcome: 3.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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5) A nurse assesses a client who is experiencing acute pain. Which aspects of the pain assessment are gathered first before the detailed assessment? Select all that apply.

A) Location B) Provocation C) Intensity D) Quality E) Radiation Answer: A, C, D Explanation: For clients experiencing acute or severe pain, the nurse may focus on determining location, intensity, and quality–and quickly follow with an intervention. Clients with less severe or chronic pain can usually provide a more detailed description, and the nurse can obtain a comprehensive pain assessment.

For clients experiencing acute or severe pain, the nurse may focus on determining location, intensity, and quality–and quickly follow with an intervention. Clients with less severe or chronic pain can usually provide a more detailed description, and the nurse can obtain a comprehensive pain assessment.

For clients experiencing acute or severe pain, the nurse may focus on determining location, intensity, and quality–and quickly follow with an intervention. Clients with less severe or chronic pain can usually provide a more detailed description, and the nurse can obtain a comprehensive pain assessment.

Page Ref: 194 Cognitive Level: Remembering Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Intervention | Learning Outcome: 3.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

6) The nurse is caring for a client who is using a TENS unit for pain management. Which statements will the nurse use when teaching the client about this therapy? Select all that apply.

A) "Make sure and cover the unit while showering or bathing."

B) "When turning the unit on, make sure the amplitude control is set to 5."

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C) "With the unit off, plug the lead wires into the battery-operated unit at one end, leaving the electrodes at the other end."

D) "Increase the amplitude until you feel discomfort and then decrease the amplitude until you feel comfortable."

E) "Wash, rinse, and dry the area where you would like to apply the electrodes."

Answer: C Explanation: The nurse should instruct the client that, with the TENS unit off, plug the lead wires into the battery-operated unit at one end, leaving electrodes at the other end.

Page Ref: 201 Cognitive Level: Applying Client Need/Sub: Basic Care and Comfort: Assistive Devices Standards: Nursing Process: Intervention | Learning Outcome: 3.6 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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7) The nurse cares for a client who wants to try biofeedback for relief of chronic pain. What advantages to this therapy does the nurse recognize? Select all that apply.

A) Increases circulation and endorphins.

B) Completely controlled by the client.

C) Rapid pain relief.

D) Redirects energy flow through pressure on meridian points.

E) Promotes stress reduction as well as pain relief.

Answer: B, E Explanation: Biofeedback is an electric monitoring device that feeds back effect of behavior so the client can control internal processes (such as the heart rate). Advantages to biofeedback include the fact that it is completely controlled by the client and it promotes stress reduction as well as pain relief. Massage increases circulation and endorphins. Ice therapy promotes rapid pain relief and acupressure redirects energy flow through pressure on meridian points.

Biofeedback is an electric monitoring device that feeds back effect of behavior so the client can control internal processes (such as the heart rate). Advantages to biofeedback include the fact that it is completely controlled by the client and it promotes stress reduction as well as pain relief. Massage increases circulation and endorphins. Ice therapy promotes rapid pain relief and acupressure redirects energy flow through pressure on meridian points.

Page Ref: 203 Cognitive Level: Remembering Client Need/Sub: Basic Care and Comfort: Assistive Devices Standards: Nursing Process: Assessment | Learning Outcome: 3.6 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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8) The nurse cares for a client with chronic pain who asks the nurse about using acupressure for pain relief. Which statements will the nurse include in the teaching regarding how this treatment works for pain relief. Select all that apply.

A) "The pressure compresses and splints irritated nerve endings."

B) "It redirects energy flow through pressure on meridian points."

C) "The therapy restores structural integrity and balance."

D) "The therapy reduces pain and increases endorphins."

E) "It manipulates muscles and realigns spinal column nerve function."

Answer: B, D Explanation: Acupressure is a therapy based on the traditional Chinese method of acupuncture.

This method involves using specific points located on meridians at various places on the body.

This therapy reduces pain and increases endorphins. Acupressure does not compress nerve endings. Chiropractic care restores structural integrity and balance as well as manipulates muscles and realigns spinal column nerve function.

Acupressure is a therapy based on the traditional Chinese method of acupuncture. This method involves using specific points located on meridians at various places on the body. This therapy reduces pain and increases endorphins. Acupressure does not compress nerve endings.

Chiropractic care restores structural integrity and balance as well as manipulates muscles and realigns spinal column nerve function.

Page Ref: 203 Cognitive Level: Applying Client Need/Sub: Basic Care and Comfort: Non-Pharmacological Comfort Interventions Standards: Nursing Process: Intervention | Learning Outcome: 3.6 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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9) The nurse prepares to apply dry heat to a client's extremity in an effect to reduce pain. Which variables does the nurse recognize affects physiological tolerance to heat and cold? Select all that apply.

A) Body part location B) Size of the exposed body part C) Individual tolerance D) Intactness of skin E) Gender Answer: A, B, C, D Explanation: Body part location affects the physiological tolerance to heat and cold. For example, the back of the hand and foot are not very temperature sensitive. In contrast, the inner aspect of the wrist and forearm, the neck, and the perineal area are temperature sensitive.

The size of the exposed body part affects the physiological tolerance to heat and cold. The larger the area exposed to heat and cold is, the lower is the tolerance.

Individual tolerance affects the physiological tolerance to heat and cold. The very young and the very old have the least physiological tolerance.

Injured areas of the skin are more susceptible to temperature variations versus intact skin.

Page Ref: 207 Cognitive Level: Understanding Client Need/Sub: Physiological Adaptation: Pathophysiology Standards: Nursing Process: Assessment | Learning Outcome: 3.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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10) The nurse is caring for five clients with acute pain. When considering the use of heat and cold therapy, which medical conditions will the nurse determine require special precautions?

Select all that apply.

A) Diabetes B) Venous insufficiency C) Asthma D) Congestive heart failure E) Arterial disease Answer: A, B, D, E Explanation: Clients with peripheral vascular disease (peripheral arterial disease and venous insufficiency), congestive heart failure, and diabetes require special precautions during heat and cold therapy because these clients lack the normal ability to dissipate heat via the blood circulation, which puts them at risk for tissue damage with heat applications. Cold applications are contraindicated for these clients. Clients with asthma do not require special precautions.

Clients with peripheral vascular disease (peripheral arterial disease and venous insufficiency), congestive heart failure, and diabetes require special precautions during heat and cold therapy because these clients lack the normal ability to dissipate heat via the blood circulation, which puts them at risk for tissue damage with heat applications. Cold applications are contraindicated for these clients. Clients with asthma do not require special precautions.

Clients with peripheral vascular disease (peripheral arterial disease and venous insufficiency), congestive heart failure, and diabetes require special precautions during heat and cold therapy because these clients lack the normal ability to dissipate heat via the blood circulation, which puts them at risk for tissue damage with heat applications. Cold applications are contraindicated for these clients. Clients with asthma do not require special precautions.

Clients with peripheral vascular disease (peripheral arterial disease and venous insufficiency), congestive heart failure, and diabetes require special precautions during heat and cold therapy because these clients lack the normal ability to dissipate heat via the blood circulation, which puts them at risk for tissue damage with heat applications. Cold applications are contraindicated for these clients. Clients with asthma do not require special precautions.

Page Ref: 208 Cognitive Level: Applying Client Need/Sub: Physiological Adaptation: Pathophysiology 42

Standards: Nursing Process: Assessment | Learning Outcome: 3.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 11) A nurse cares for a 13-year-old adolescent with a terminal illness. Which client statement does the nurse expect to hear from this client regarding death and dying?

A) "I will go to sleep for a long time and then wake up."

B) "I know that people die with my disease but I won't die."

C) "I wonder what happens to people after death."

D) "I know people die but I will defy my own death."

Answer: D Explanation: An adolescent client fears a lingering death, often fantasizing that death may be defied by acting in reckless behavior (substance abuse, dangerous driving).

Page Ref: 223 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: End of Life Care Standards: Nursing Process: Assessment | Learning Outcome: 3.7 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

12) The nurse cares for a client who needs a PCA pump for control of postoperative pain. Which task can the nurse delegate to the unlicensed assistive personnel (UAP)?

A) Pushing the client button if the client is unable.

B) Silencing the pump alarm while waiting for the nurse.

C) Reporting specific client observations.

D) Asking the client about level of pain.

Answer: C Explanation: The nurse may delegate the UAP to report specific client observations (such as reporting inadequate pain control). Pushing the client's PCA button is administering an intravenous medication and is a task for the nurse only. The UAP should not silence the PCA pump or determine the client's pain level because these involve assessment of the client's clinical 43

situation and should not be performed by unlicensed personnel.

Page Ref: 204 Cognitive Level: Applying Client Need/Sub: Management of Care: Assignment, Delegation, and Supervision Standards: Nursing Process: Intervention | Learning Outcome: 3.5 | QSEN Competencies: Teamwork and Collaboration AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 13) The nurse cares for an older adult client who will have heat and cold therapy to assist with pain. Which lifespan considerations does the nurse consider when using this treatment for the client? Select all that apply.

A) Skin cells proliferate quicker as one ages.

B) Sensitivity to pain decreases as one ages.

C) Skin becomes thinner as one ages.

D) Moisture in the skin decreases as one ages.

E) Skin burns easier as one ages.

Answer: B, C, D, E Explanation: Older adults have a reduced sensitivity to pain, and therefore may not feel untoward effects of heat and cold treatment.

Older adult have thinner skin.

Temperature should be reduced when using heat therapy because older adult patient's skin burns more easily.

Because skin is thinner, skin burns easier as one ages.

Page Ref: 218 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Aging Process Standards: Nursing Process: Assessment | Learning Outcome: 3.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

14) The nurse is caring for a client with acute pain and uses the FLACC pain assessment. Which 44

clinical scenario does the nurse recognize as LEAST appropriate for use of the FLACC pain assessment?

A) Situations where clients self-report pain.

B) Situations requiring rapid pain assessment.

C) Clients who are asleep.

D) Clients who are children.

Answer: B Explanation: The FLACC pain assessment requires observation of the client for at least 5 minutes before a determination regarding the pain can be made.

Page Ref: 117 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 3.3 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 15) The nurse is preparing to use a disposable hot pack on the client for pain relief. Which action will the nurse prioritize as an appropriate task for the UAP? A) Observing the site of application and reporting abnormal findings.

B) Assessing the client's level of pain.

C) Determining if the client requires additional therapy.

D) Documenting the client's response to therapy.

Answer: A Explanation: Application of various heat therapies may be delegated to the UAP. Assessing, determining additional therapy, and documenting response to therapy are all reserved for the nurse only. The UAP may observe the site of the application and report abnormal findings.

Page Ref: 213 Cognitive Level: Analyzing Client Need/Sub: Management of Care: Establishing Priorities Standards: Nursing Process: Intervention | Learning Outcome: 3.4 | QSEN Competencies: Teamwork and Collaboration AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice 45

NLN Competencies: Nursing Judgment

16) The nurse assesses a toddler for pain using the FLACC scale. The nurse notes the client is crying steadily with a quivering chin, is kicking, is shifting back and forth, and is difficult to console. What number does the nurse document for the client's pain, based on the FLACC scale?

A) 8 B) 9 C) 10 D) 11 Answer: B Explanation: The FLACC behavioral pain assessment may be used to help the nurse determine the client's level of pain. Assessment is based on findings of the face, legs, activity, cry, and consolability. A steady cry (2) with quivering chin (2), kicking (2), shifting back and forth (1), and difficult to console (2) results in a FLACC score of 9.

Page Ref: 192 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 3.2 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 17) The nurse is caring for a client in acute pain and plans to use a pain scale tool for assessment.

What is the major advantage in using this tool?

A) It allows organization in the assessment process.

B) It works with the same efficacy among the entire population.

C) It allows for variation among various cultures.

D) It can always be performed quickly.

Answer: A Explanation: The major advantage of a standardized pain scale tool for assessment of the client's pain is that it allows the nurse to stay organized in the assessment process. While efficient in assessing a client's pain, the tool does not factor in cultural variances and perceptions of pain.

Most tools may be performed quickly, however is not universally true.

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Page Ref: 102 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 3.2 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

18) The nurse is caring for a client who is dying. When prioritizing care, which intervention will the nurse provide to meet the client's physiological needs?

A) Encourage frequent ambulation and deep breathing.

B) Initiate total nutrition intravenously.

C) Administer curative medications.

D) Encourage favorite foods as tolerated.

Answer: D Explanation: Encouraging favorite foods as tolerated is an important nursing intervention the nurse will perform for the dying client.

Page Ref: 220 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: End of Life Care Standards: Nursing Process: Intervention | Learning Outcome: 3.8 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 19) The nurse prepares to perform a pain assessment and chooses to use a standardized pain assessment tool. Place the steps in order for the use of the standardized pain assessment tool.

A) Assess the client's physiological response to pain.

B) Assess the client's perception of pain.

C) Perform a focused assessment.

D) Document the findings.

Answer: B, A, C, D Explanation: A) The steps to performing a pain assessment using a standardized pain assessment 47

tool is as follows: Assess the client's perception of pain (including location, intensity, and quality), assess the client's physiological response to pain (i.e., changes in vital signs), perform a focused assessment, and document the findings.

B) The steps to performing a pain assessment using a standardized pain assessment tool is as follows: Assess the client's perception of pain (including location, intensity, and quality), assess the client's physiological response to pain (i.e., changes in vital signs), perform a focused assessment, and document the findings.

C) The steps to performing a pain assessment using a standardized pain assessment tool is as follows: Assess the client's perception of pain (including location, intensity, and quality), assess the client's physiological response to pain (i.e., changes in vital signs), perform a focused assessment, and document the findings.

D) The steps to performing a pain assessment using a standardized pain assessment tool is as follows: Assess the client's perception of pain (including location, intensity, and quality), assess the client's physiological response to pain (i.e., changes in vital signs), perform a focused assessment, and document the findings.

Page Ref: 195 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 3.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 20) The nurse prepares to apply a TENS unit on a client who is experiencing pain. Place the steps of this procedure in the correct order.

A) With the unit off, plug the lead wires into the unit.

B) Insert the battery and test for functioning.

C) Turn the unit on and ensure the amplitude is set to zero.

D) Apply the electrodes to the client.

E) Increase the amplitude until the client notes discomfort.

F) Slowly decrease the amplitude until the client notes a pleasant sensation.

Answer: B, A, D, C, E, F Explanation: A) Application of the TENS unit is as follows: Insert the battery and test for 48

functioning; with the unit off, plug the lead wires into the unit; apply the electrodes to the client; turn the unit on and ensure the amplitude is set to zero; increase the amplitude until the client notes discomfort; slowly decrease the amplitude until the client notes a pleasant sensation.

B) Application of the TENS unit is as follows: Insert the battery and test for functioning; with the unit off, plug the lead wires into the unit; apply the electrodes to the client; turn the unit on and ensure the amplitude is set to zero; increase the amplitude until the client notes discomfort; slowly decrease the amplitude until the client notes a pleasant sensation.

C) Application of the TENS unit is as follows: Insert the battery and test for functioning; with the unit off, plug the lead wires into the unit; apply the electrodes to the client; turn the unit on and ensure the amplitude is set to zero; increase the amplitude until the client notes discomfort; slowly decrease the amplitude until the client notes a pleasant sensation.

D) Application of the TENS unit is as follows: Insert the battery and test for functioning; with the unit off, plug the lead wires into the unit; apply the electrodes to the client; turn the unit on and ensure the amplitude is set to zero; increase the amplitude until the client notes discomfort; slowly decrease the amplitude until the client notes a pleasant sensation.

E) Application of the TENS unit is as follows: Insert the battery and test for functioning; with the unit off, plug the lead wires into the unit; apply the electrodes to the client; turn the unit on and ensure the amplitude is set to zero; increase the amplitude until the client notes discomfort; slowly decrease the amplitude until the client notes a pleasant sensation.

F) Application of the TENS unit is as follows: Insert the battery and test for functioning; with the unit off, plug the lead wires into the unit; apply the electrodes to the client; turn the unit on and ensure the amplitude is set to zero; increase the amplitude until the client notes discomfort; slowly decrease the amplitude until the client notes a pleasant sensation.

Page Ref: 201 Cognitive Level: Analyzing Client Need/Sub: Basic Care and Comfort: Non-Pharmacological Comfort Interventions Standards: Nursing Process: Intervention | Learning Outcome: 3.6 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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Clinical Nursing Skills: A Concept-Based Approach, 3e (Pearson) Chapter 4 Elimination 1) The nurse prepares to obtain a urine sample from a client's closed drainage system. Place the procedure steps in the correct order.

A) Disinfect the needle insertion site.

B) Insert the needle at a 30-to 40-degree angle.

C) Unclamp the catheter.

D) Transfer the urine to the specimen container.

E) Withdraw the required amount of urine.

F) Clamp the drainage tubing at least 8 cm (3 in.) below the sampling port for 30 minutes.

Answer: F, A, B, E, C, D Explanation: A) The procedure for obtaining a urine sample from a closed drainage system is as follows: clamp the drainage tubing at least 8 cm (3 in.) below the sampling port for 30 minutes; disinfect the needle insertion site; insert the needle at a 30-to 40-degree angle; withdraw the required amount of urine; unclamp the catheter; transfer the urine to the specimen container.

B) The procedure for obtaining a urine sample from a closed drainage system is as follows: clamp the drainage tubing at least 8 cm (3 in.) below the sampling port for 30 minutes; disinfect the needle insertion site; insert the needle at a 30-to 40-degree angle; withdraw the required amount of urine; unclamp the catheter; transfer the urine to the specimen container.

C) The procedure for obtaining a urine sample from a closed drainage system is as follows: clamp the drainage tubing at least 8 cm (3 in.) below the sampling port for 30 minutes; disinfect the needle insertion site; insert the needle at a 30-to 40-degree angle; withdraw the required amount of urine; unclamp the catheter; transfer the urine to the specimen container.

D) The procedure for obtaining a urine sample from a closed drainage system is as follows: clamp the drainage tubing at least 8 cm (3 in.) below the sampling port for 30 minutes; disinfect the needle insertion site; insert the needle at a 30-to 40-degree angle; withdraw the required amount of urine; unclamp the catheter; transfer the urine to the specimen container.

E) The procedure for obtaining a urine sample from a closed drainage system is as follows: clamp the drainage tubing at least 8 cm (3 in.) below the sampling port for 30 minutes; disinfect the needle insertion site; insert the needle at a 30-to 40-degree angle; withdraw the required amount of urine; unclamp the catheter; transfer the urine to the specimen container.

F) The procedure for obtaining a urine sample from a closed drainage system is as follows: 1

clamp the drainage tubing at least 8 cm (3 in.) below the sampling port for 30 minutes; disinfect the needle insertion site; insert the needle at a 30-to 40-degree angle; withdraw the required amount of urine; unclamp the catheter; transfer the urine to the specimen container.

Page Ref: 234 Cognitive Level: Analyzing Client Need/Sub: Safety and Infection Control: Safe Use of Equipment Standards: Nursing Process: Intervention | Learning Outcome: 4.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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2) The nurse prepares to obtain a urine specimen from a client's indwelling catheter. What is the nurse's understanding of the purpose of clamping the indwelling catheter prior to collection of urine?

A) Decreases client discomfort.

B) Increases urine production.

C) Promotes sterile collection.

D) Eases technique of procedure.

Answer: C Explanation: Clamping the client's indwelling catheter promotes the sterile collection of urine because sterile urine collects in the tube, allowing for sterile collection. Clamping the tube does not increase or decrease the client's discomfort, increase urine production, or ease technique of the procedure.

Page Ref: 247 Cognitive Level: Understanding Client Need/Sub: Safety and Infection Control: Safe Use of Equipment Standards: Nursing Process: Intervention | Learning Outcome: 4.1 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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3) A nurse prepares to administer a warm water enema to a client. Place the steps of the procedure in correct order.

A) Raise the solution container.

B) Open the clamp.

C) Encourage the client to retain the solution.

D) Lift the upper buttock, insert the tube slowly.

E) Assist the client to the left lateral position with right leg flexed.

F) Allow the solution to run through the tubing to remove air.

Answer: F, E, D, A, B, C Explanation: A) The steps of the warm water enema administration is as follows: Allow the solution to run through the tubing to remove air; assist the client to the left lateral position with the right leg flexed; lift the upper buttock and insert the tube slowly; raise the solution container and open the clamp; encourage the client to retain the solution.

B) The steps of the warm water enema administration is as follows: Allow the solution to run through the tubing to remove air; assist the client to the left lateral position with the right leg flexed; lift the upper buttock and insert the tube slowly; raise the solution container and open the clamp; encourage the client to retain the solution.

C) The steps of the warm water enema administration is as follows: Allow the solution to run through the tubing to remove air; assist the client to the left lateral position with the right leg flexed; lift the upper buttock and insert the tube slowly; raise the solution container and open the clamp; encourage the client to retain the solution.

D) The steps of the warm water enema administration is as follows: Allow the solution to run through the tubing to remove air; assist the client to the left lateral position with the right leg flexed; lift the upper buttock and insert the tube slowly; raise the solution container and open the clamp; encourage the client to retain the solution.

E) The steps of the warm water enema administration is as follows: Allow the solution to run through the tubing to remove air; assist the client to the left lateral position with the right leg flexed; lift the upper buttock and insert the tube slowly; raise the solution container and open the clamp; encourage the client to retain the solution.

F) The steps of the warm water enema administration is as follows: Allow the solution to run through the tubing to remove air; assist the client to the left lateral position with the right leg flexed; lift the upper buttock and insert the tube slowly; raise the solution container and open the 4

clamp; encourage the client to retain the solution.

Page Ref: 269 Cognitive Level: Analyzing Client Need/Sub: Safety and Infection Control: Safe Use of Equipment Standards: Nursing Process: Intervention | Learning Outcome: 4.3 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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4) The registered nurse acts as preceptor to a novice nurse who is placing an indwelling urinary catheter for a client. Which action by the novice nurse requires intervention by the preceptor?

A) Removing and discarding clean gloves after opening the drainage package.

B) Cleansing the urethral meatus before removing the catheter from the protective sleeve.

C) Donning sterile gloves prior to attaching the catheter to the drainage system.

D) Lubricating the tip of the catheter before inserting the tip of the prefilled syringe into the catheter side arm.

Answer: B Explanation: The nurse should remove the catheter from the protective sleeve prior to cleansing the urethral meatus. This action will require intervention by the nurse preceptor.

Page Ref: 250 Cognitive Level: Applying Client Need/Sub: Safety and Infection Control: Safe Use of Equipment Standards: Nursing Process: Intervention | Learning Outcome: 4.8 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

5) When placing the client on a bedpan, which position will the nurse place the client?

A) High-Fowler's B) Semi-Fowler's C) Upright D) Supine Answer: B Explanation: The semi-Fowler's position alleviates back strain and permits a more normal position for elimination. High-Fowler's upright, and supine positions are not the best position for the client on a bedpan.

Page Ref: 240 Cognitive Level: Remembering Client Need/Sub: Basic Care and Comfort: Elimination Standards: Nursing Process: Intervention | Learning Outcome: 4.2 | QSEN Competencies: Patient-Centered Care 6

AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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6) A nurse attempts to obtain a urine sample from a client's ileal conduit. After correct sterile catheterization, no urine output is noted. How should the nurse respond?

A) Contact the health care provider.

B) Reinsert the catheter.

C) Ask the client to drink water.

D) Advance the catheter further in the stoma.

Answer: C Explanation: After correct sterile catheterization of an ileal conduit, if no urine is obtained, the nurse should ask the client to drink water in order to produce urine.

Page Ref: 235 Cognitive Level: Applying Client Need/Sub: Safety and Infection Control: Safe Use of Equipment Standards: Nursing Process: Intervention | Learning Outcome: 4.8 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 7) When auscultating a client's AV fistula, the nurse notes a whooshing sound. What term is used to describe this finding?

A) Bruit B) Murmur C) Gallop D) Click Answer: A Explanation: The whooshing sound heard on auscultation of a patent AV fistula is called bruit.

The other answer choices represent abnormal heart tones, not the sound of a patent AV fistula.

Page Ref: 286 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 4.7 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice 8

NLN Competencies: Nursing Judgment

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8) An uncircumcised male client needs to provide a clean-catch urine sample. Which client teaching will the nurse provide the client regarding the procedure? Select all that apply.

A) Retract the foreskin slightly.

B) Pull the foreskin over the meatus.

C) Use a circular motion to clean the meatus.

D) Use each towelette only once, then discard.

E) Void a small amount prior to collecting the sample.

Answer: A, C, D, E Explanation: When instructing the uncircumcised male on the proper technique of a clean-catch urine sample, the nurse will instruct the client to retract the foreskin slightly, use a circular motion to clean the meatus, use each towelette only once, and void a small amount prior to collecting the sample. Pulling the foreskin over the meatus is not correct and the nurse will not instruct the client to do this.

When instructing the uncircumcised male on the proper technique of a clean-catch urine sample, the nurse will instruct the client to retract the foreskin slightly, use a circular motion to clean the meatus, use each towelette only once, and void a small amount prior to collecting the sample.

Pulling the foreskin over the meatus is not correct and the nurse will not instruct the client to do this.

When instructing the uncircumcised male on the proper technique of a clean-catch urine sample, the nurse will instruct the client to retract the foreskin slightly, use a circular motion to clean the meatus, use each towelette only once, and void a small amount prior to collecting the sample.

Pulling the foreskin over the meatus is not correct and the nurse will not instruct the client to do this.

When instructing the uncircumcised male on the proper technique of a clean-catch urine sample, the nurse will instruct the client to retract the foreskin slightly, use a circular motion to clean the meatus, use each towelette only once, and void a small amount prior to collecting the sample.

Pulling the foreskin over the meatus is not correct and the nurse will not instruct the client to do this.

Page Ref: 233 Cognitive Level: Applying Client Need/Sub: Reduction of Risk Potential: Diagnostic Tests Standards: Nursing Process: Intervention | Learning Outcome: 4.8 | QSEN Competencies: 10

Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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9) When assessing the client's AV fistula, the nurse notes vibration at the fistula site. How should the nurse respond to this finding?

A) Contact the health care provider.

B) Ask the client how long this has occurred.

C) Determine when the fistula was placed.

D) Document the finding.

Answer: D Explanation: Vibration of the AV fistula is known as "thrill" and is a normal finding of the AV fistula. The nurse should document the finding. The nurse does not need to contact the health care provider, ask the client how long this has occurred, or determine when the fistula was placed.

Page Ref: 207 Cognitive Level: Understanding Client Need/Sub: Physiological Adaptation: Pathophysiology Standards: Nursing Process: Assessment | Learning Outcome: 3.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

10) A nurse performs a sterile urine specimen collection from an ileal conduit. Which action by the nurse is incorrect and may lead to inaccurate results?

A) Removing the collection pouch prior to obtaining the sample.

B) Inserting the tip of the catheter into the stoma approximately 4 cm (1.5 inches).

C) Obtaining the sample from the collection pouch.

D) Placing towels around the stoma.

Answer: C Explanation: The nurse should not use the collection pouch to obtain the urine sample because this may contain bacteria and is not an accurate representation of a sterile urine specimen.

Page Ref: 235 Cognitive Level: Applying Client Need/Sub: Reduction of Risk Potential: Diagnostic Tests Standards: Nursing Process: Intervention | Learning Outcome: 4.8 | QSEN Competencies: 12

Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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11) The home care nurse prepares to drain the fluid of a client with continuous ambulatory peritoneal dialysis (CAPD). Place the steps in correct order of the procedure to drain the fluid.

A) Attach the sterile bag and transfer set to the catheter.

B) Place the bag on a low stool or table below the client's abdomen.

C) Unclamp the tubing and allow fluid to drain.

D) Reclamp the tubing.

E) Don gloves and uncap the catheter.

Answer: E, A, B, C, D Explanation: A) The correct procedure to drain the peritoneal fluid of a client with CAPD is as follows: Don gloves and uncap the catheter maintaining surgical asepsis; attach the sterile bag and transfer set to the catheter; place the bag on a low stool or table below the client's abdomen; unclamp the tubing and allow fluid to drain; reclamp the tubing.

B) The correct procedure to drain the peritoneal fluid of a client with CAPD is as follows: Don gloves and uncap the catheter maintaining surgical asepsis; attach the sterile bag and transfer set to the catheter; place the bag on a low stool or table below the client's abdomen; unclamp the tubing and allow fluid to drain; reclamp the tubing.

C) The correct procedure to drain the peritoneal fluid of a client with CAPD is as follows: Don gloves and uncap the catheter maintaining surgical asepsis; attach the sterile bag and transfer set to the catheter; place the bag on a low stool or table below the client's abdomen; unclamp the tubing and allow fluid to drain; reclamp the tubing.

D) The correct procedure to drain the peritoneal fluid of a client with CAPD is as follows: Don gloves and uncap the catheter maintaining surgical asepsis; attach the sterile bag and transfer set to the catheter; place the bag on a low stool or table below the client's abdomen; unclamp the tubing and allow fluid to drain; reclamp the tubing.

E) The correct procedure to drain the peritoneal fluid of a client with CAPD is as follows: Don gloves and uncap the catheter maintaining surgical asepsis; attach the sterile bag and transfer set to the catheter; place the bag on a low stool or table below the client's abdomen; unclamp the tubing and allow fluid to drain; reclamp the tubing.

Page Ref: 281 Cognitive Level: Analyzing Client Need/Sub: Safety and Infection Control: Safe Use of Equipment Standards: Nursing Process: Intervention | Learning Outcome: 4.6 | QSEN Competencies: 14

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12) The nurse prepares to remove a client's indwelling urinary catheter. Which technique will the nurse use when performing this procedure? Select all that apply.

A) Aspirate the balloon vigorously.

B) Withdraw all the fluid from the balloon.

C) Detach the catheter from the client's skin.

D) Use clean gloves instead of sterile gloves.

E) Place a towel between the client's legs.

Answer: B, C, D, E Explanation: When removing the client's indwelling urinary catheter, the nurse will withdraw all the fluid from the balloon and detach the catheter from the client's skin. The procedure should be performed using clean gloves instead of sterile gloves and a towel should be placed between the client's legs. Aspirating the balloon vigorously may collapse the inflation lumen and prevent balloon deflation.

When removing the client's indwelling urinary catheter, the nurse will withdraw all the fluid from the balloon and detach the catheter from the client's skin. The procedure should be performed using clean gloves instead of sterile gloves and a towel should be placed between the client's legs. Aspirating the balloon vigorously may collapse the inflation lumen and prevent balloon deflation.

When removing the client's indwelling urinary catheter, the nurse will withdraw all the fluid from the balloon and detach the catheter from the client's skin. The procedure should be performed using clean gloves instead of sterile gloves and a towel should be placed between the client's legs. Aspirating the balloon vigorously may collapse the inflation lumen and prevent balloon deflation.

When removing the client's indwelling urinary catheter, the nurse will withdraw all the fluid from the balloon and detach the catheter from the client's skin. The procedure should be performed using clean gloves instead of sterile gloves and a towel should be placed between the client's legs. Aspirating the balloon vigorously may collapse the inflation lumen and prevent balloon deflation.

Page Ref: 246-247 Cognitive Level: Applying Client Need/Sub: Safety and Infection Control: Safe Use of Equipment Standards: Nursing Process: Intervention | Learning Outcome: 4.8 | QSEN Competencies: 16

Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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13) The nurse prepares to perform an indwelling urinary catheterization for a client who will undergo surgery. Place the steps of client positioning and sterile glove donning in the correct order.

A) Open the drainage package, maintaining sterility.

B) Position the client.

C) Remove and discard gloves; perform hand hygiene.

D) Open the catheterization kit; apply sterile gloves.

Answer: B, A, C, D Explanation: A) The pre-procedure steps of indwelling urinary catheterization includes: Positioning the client; opening the drainage package, ensuring sterility; removing and discarding gloves, performing hand hygiene; opening the catheterization kit and applying sterile gloves.

B) The pre-procedure steps of indwelling urinary catheterization includes: Positioning the client; opening the drainage package, ensuring sterility; removing and discarding gloves, performing hand hygiene; opening the catheterization kit and applying sterile gloves.

C) The pre-procedure steps of indwelling urinary catheterization includes: Positioning the client; opening the drainage package, ensuring sterility; removing and discarding gloves, performing hand hygiene; opening the catheterization kit and applying sterile gloves.

D) The pre-procedure steps of indwelling urinary catheterization includes: Positioning the client; opening the drainage package, ensuring sterility; removing and discarding gloves, performing hand hygiene; opening the catheterization kit and applying sterile gloves.

Page Ref: 249 Cognitive Level: Analyzing Client Need/Sub: Safety and Infection Control: Safe Use of Equipment Standards: Nursing Process: Intervention | Learning Outcome: 4.8 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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14) The nurse cares for a client who requires hemodialysis and has an arteriovenous fistula.

Which statements will the nurse include when teaching the client safety precautions for the AV fistula? Select all that apply.

A) "Keep the AV fistula dry and avoid washing with soap."

B) "Do not wear constrictive clothing or jewelry."

C) "Avoid lifting heaving objects with the extremity that has the AV fistula."

D) "Avoid lying on the extremity with the AV fistula."

E) "Immediately report swelling or discoloration."

Answer: B, C, D, E Explanation: Safety precautions for the AV fistula include: avoiding constrictive clothing or jewelry, avoiding heaving lifting or lying on the extremity with the AV fistula, and immediately reporting swelling or discoloration of the extremity with the AV fistula. The AV fistula can be cleansed with soap and water.

Safety precautions for the AV fistula include: avoiding constrictive clothing or jewelry, avoiding heaving lifting or lying on the extremity with the AV fistula, and immediately reporting swelling or discoloration of the extremity with the AV fistula. The AV fistula can be cleansed with soap and water.

Safety precautions for the AV fistula include: avoiding constrictive clothing or jewelry, avoiding heaving lifting or lying on the extremity with the AV fistula, and immediately reporting swelling or discoloration of the extremity with the AV fistula. The AV fistula can be cleansed with soap and water.

Safety precautions for the AV fistula include: avoiding constrictive clothing or jewelry, avoiding heaving lifting or lying on the extremity with the AV fistula, and immediately reporting swelling or discoloration of the extremity with the AV fistula. The AV fistula can be cleansed with soap and water.

Page Ref: 286 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Self-Care Standards: Nursing Process: Intervention | Learning Outcome: 4.7 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 19

15) The home care nurse cares for a client who requires continuous ambulatory peritoneal dialysis (CAPD) at home. Place the steps in correct order for infusing the dialysate.

A) Warm the dialysate.

B) Add medications to the dialysate as ordered.

C) Connect tubing to dialysate bag.

D) Perform hand hygiene and don gloves.

E) Hang the dialysate bag above the client's shoulder and open the clamp.

Answer: A, D, B, C, E Explanation: A) Infusion of the dialysate using CAPD is a sterile technique with steps as follows: Warm the dialysate; perform hand hygiene for 3 minutes using antibacterial soap, then don gloves; add medications to the dialysate as ordered, using sterile technique; connect the tubing to the dialysate bag; hang the dialysate bag above the client's shoulder and open the clamp.

B) Infusion of the dialysate using CAPD is a sterile technique with steps as follows: Warm the dialysate; perform hand hygiene for 3 minutes using antibacterial soap, then don gloves; add medications to the dialysate as ordered, using sterile technique; connect the tubing to the dialysate bag; hang the dialysate bag above the client's shoulder and open the clamp.

C) Infusion of the dialysate using CAPD is a sterile technique with steps as follows: Warm the dialysate; perform hand hygiene for 3 minutes using antibacterial soap, then don gloves; add medications to the dialysate as ordered, using sterile technique; connect the tubing to the dialysate bag; hang the dialysate bag above the client's shoulder and open the clamp.

D) Infusion of the dialysate using CAPD is a sterile technique with steps as follows: Warm the dialysate; perform hand hygiene for 3 minutes using antibacterial soap, then don gloves; add medications to the dialysate as ordered, using sterile technique; connect the tubing to the dialysate bag; hang the dialysate bag above the client's shoulder and open the clamp.

E) Infusion of the dialysate using CAPD is a sterile technique with steps as follows: Warm the dialysate; perform hand hygiene for 3 minutes using antibacterial soap, then don gloves; add medications to the dialysate as ordered, using sterile technique; connect the tubing to the dialysate bag; hang the dialysate bag above the client's shoulder and open the clamp.

Page Ref: 282 Cognitive Level: Analyzing Client Need/Sub: Safety and Infection Control: Safe Use of Equipment 20

Standards: Nursing Process: Intervention | Learning Outcome: 4.5 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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16) The nurse is planning care for a client who receives peritoneal dialysis. Which nursing diagnosis will the nurse determine is PRIORITY? A) Knowledge deficit B) Risk for infection C) Impaired skin integrity D) Fluid volume excess Answer: B Explanation: The client who receives peritoneal dialysis is at increased risk for infection, which can be serious or evenly deadly to the client. This is the priority nursing intervention.

Page Ref: 227 Cognitive Level: Analyzing Client Need/Sub: Safety and Infection Control: Safe Use of Equipment Standards: Nursing Process: Planning | Learning Outcome: 4.5 | QSEN Competencies: PatientCentered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 17) The nurse cares for a client with an AV fistula for hemodialysis. Which assessments will the nurse perform when assessing the AV fistula? Select all that apply.

A) Palpation B) Auscultation C) Inspection D) Percussion Answer: A, B, C Explanation: Inspection, palpation (feeling for thrill or vibration), and auscultation (listening for bruit) of the AV site are all assessments the nurse will perform. Percussion is not indicated when assessing the AV site.

Inspection, palpation (feeling for thrill or vibration), and auscultation (listening for bruit) of the AV site are all assessments the nurse will perform. Percussion is not indicated when assessing the AV site.

Inspection, palpation (feeling for thrill or vibration), and auscultation (listening for bruit) of the AV site are all assessments the nurse will perform. Percussion is not indicated when assessing 22

the AV site.

Page Ref: 286 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 4.7 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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18) The nurse teaches a client with a peritoneal dialysis catheter about the signs and symptoms of peritonitis. Which teaching statements will the nurse include? Select all that apply.

A) "Monitor your temperature and report any fever."

B) "Monitor your urine output and report any decrease in output."

C) "Report any nausea or vomiting you may have."

D) "Monitor the insertion site and report any redness."

E) "Report any abdominal pain you may have."

Answer: A, C, D, E Explanation: The nurse should teach the client with a peritoneal dialysis catheter to report any signs and symptoms of peritonitis. These include: fever, nausea, vomiting, redness at the insertion site, or abdominal pain. Decreased urinary output is not uncommon in a client receiving peritoneal dialysis and is not a sign or symptom of peritonitis.

The nurse should teach the client with a peritoneal dialysis catheter to report any signs and symptoms of peritonitis. These include: fever, nausea, vomiting, redness at the insertion site, or abdominal pain. Decreased urinary output is not uncommon in a client receiving peritoneal dialysis and is not a sign or symptom of peritonitis.

The nurse should teach the client with a peritoneal dialysis catheter to report any signs and symptoms of peritonitis. These include: fever, nausea, vomiting, redness at the insertion site, or abdominal pain. Decreased urinary output is not uncommon in a client receiving peritoneal dialysis and is not a sign or symptom of peritonitis.

The nurse should teach the client with a peritoneal dialysis catheter to report any signs and symptoms of peritonitis. These include: fever, nausea, vomiting, redness at the insertion site, or abdominal pain. Decreased urinary output is not uncommon in a client receiving peritoneal dialysis and is not a sign or symptom of peritonitis.

Page Ref: 281 Cognitive Level: Applying Client Need/Sub: Physiological Adaptation: Pathophysiology Standards: Nursing Process: Intervention | Learning Outcome: 4.6 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 24

19) The nurse plans to assist in the transfer of the client to a bedside commode. Place the procedure steps in the correct order.

A) Place slippers on the client.

B) Place commode at the foot of the bed.

C) Raise the client's head of the bed and move client to the edge of the bed.

D) Safely transfer the client to the commode.

E) Cover client with bath blanket as needed for warmth.

Answer: B, A, C, D, E Explanation: A) The correct steps for the transfer to bedside commode is as follows: Place the commode at the foot of the bed, ensuring the wheels are locked; place slippers on the client; raise the client's head of the bed and move the client to the edge of the bed; safely transfer the client to the commode using proper body mechanics; cover the client with a bath blanket as needed for warmth.

B) The correct steps for the transfer to bedside commode is as follows: Place the commode at the foot of the bed, ensuring the wheels are locked; place slippers on the client; raise the client's head of the bed and move the client to the edge of the bed; safely transfer the client to the commode using proper body mechanics; cover the client with a bath blanket as needed for warmth.

C) The correct steps for the transfer to bedside commode is as follows: Place the commode at the foot of the bed, ensuring the wheels are locked; place slippers on the client; raise the client's head of the bed and move the client to the edge of the bed; safely transfer the client to the commode using proper body mechanics; cover the client with a bath blanket as needed for warmth.

D) The correct steps for the transfer to bedside commode is as follows: Place the commode at the foot of the bed, ensuring the wheels are locked; place slippers on the client; raise the client's head of the bed and move the client to the edge of the bed; safely transfer the client to the commode using proper body mechanics; cover the client with a bath blanket as needed for warmth.

E) The correct steps for the transfer to bedside commode is as follows: Place the commode at the foot of the bed, ensuring the wheels are locked; place slippers on the client; raise the client's head of the bed and move the client to the edge of the bed; safely transfer the client to the commode using proper body mechanics; cover the client with a bath blanket as needed for warmth.

Page Ref: 244 Cognitive Level: Analyzing Client Need/Sub: Basic Care and Comfort: Mobility/Immobility 25

Standards: Nursing Process: Intervention | Learning Outcome: 4.2 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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20) The nurse prepares to change a client's fecal ostomy pouch. Which assessments regarding the stoma are PRIORITY? Select all that apply.

A) Skin around the stoma.

B) Location of the stoma.

C) Appearance of the stoma.

D) Date of stoma placement.

E) Complications during placement of stoma.

Answer: A, B, C Explanation: When assessing the stoma of a client with a fecal ostomy pouch, the priority assessment includes assessing the skin around the stoma, the appearance of the stoma itself, and the location of the stoma. The date the stoma was placed as well as any complications during the placement of the stoma are not priority when changing the fecal ostomy pouch.

When assessing the stoma of a client with a fecal ostomy pouch, the priority assessment includes assessing the skin around the stoma, the appearance of the stoma itself, and the location of the stoma. The date the stoma was placed as well as any complications during the placement of the stoma are not priority when changing the fecal ostomy pouch.

When assessing the stoma of a client with a fecal ostomy pouch, the priority assessment includes assessing the skin around the stoma, the appearance of the stoma itself, and the location of the stoma. The date the stoma was placed as well as any complications during the placement of the stoma are not priority when changing the fecal ostomy pouch.

Page Ref: 272 Cognitive Level: Analyzing Client Need/Sub: Reduction of Risk Potential: Potential for Complications from Surgical Procedures and Health Alterations Standards: Nursing Process: Assessment | Learning Outcome: 4.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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Clinical Nursing Skills: A Concept-Based Approach, 3e (Pearson) Chapter 5 Fluids and Electrolytes

1) The nurse prepares to change the client's central line dressing. Place the steps of the procedure in correct order.

A) Remove the old dressing.

B) Remove and discard gloves; perform hand hygiene.

C) Don a mask and have the client don a mask.

D) Apply the new dressing.

E) Cleanse the site.

Answer: C, A, B, E, D Explanation: A) The correct steps for performing a central line dressing change is as follows: don a mask and have the client don a mask; remove the old dressing; remove and discard gloves; perform hand hygiene; cleanse the site; apply the new dressing.

B) The correct steps for performing a central line dressing change is as follows: don a mask and have the client don a mask; remove the old dressing; remove and discard gloves; perform hand hygiene; cleanse the site; apply the new dressing.

C) The correct steps for performing a central line dressing change is as follows: don a mask and have the client don a mask; remove the old dressing; remove and discard gloves; perform hand hygiene; cleanse the site; apply the new dressing.

D) The correct steps for performing a central line dressing change is as follows: don a mask and have the client don a mask; remove the old dressing; remove and discard gloves; perform hand hygiene; cleanse the site; apply the new dressing.

E) The correct steps for performing a central line dressing change is as follows: don a mask and have the client don a mask; remove the old dressing; remove and discard gloves; perform hand hygiene; cleanse the site; apply the new dressing.

Page Ref: 297 Cognitive Level: Analyzing Client Need/Sub: Safety and Infection Control: Safe Use of Equipment Standards: Nursing Process: Intervention | Learning Outcome: 5.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice 1

NLN Competencies: Nursing Judgment

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2) The nurse prepares to administer a medication through the client's central line. Per hospital policy, the nurse must use heparin to keep the line patent. Place the steps in the correct order for administering medication through the central line.

A) Administer the medication.

B) Flush the catheter with 5-mL saline.

C) Flush the catheter with heparin.

D) Flush the catheter with 10-mL saline.

Answer: D, A, B, C Explanation: A) The process to administer medication through the central line is as follows: flush the catheter with 10-mL saline; administer the medication; flush the catheter with 5-mL saline; flush the catheter with heparin.

B) The process to administer medication through the central line is as follows: flush the catheter with 10-mL saline; administer the medication; flush the catheter with 5-mL saline; flush the catheter with heparin.

C) The process to administer medication through the central line is as follows: flush the catheter with 10-mL saline; administer the medication; flush the catheter with 5-mL saline; flush the catheter with heparin.

D) The process to administer medication through the central line is as follows: flush the catheter with 10-mL saline; administer the medication; flush the catheter with 5-mL saline; flush the catheter with heparin.

Page Ref: 302 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Intervention | Learning Outcome: 5.8 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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3) The nurse cares for a client who is sedated, intubated, mechanically ventilated, and has a central line. While repositioning the client, the central line is disrupted. Place the steps in correct order in response to the clinical scenario.

A) Place the client in supine position.

B) Clamp the affected lumen with a soft-tipped clamp.

C) Place a strip of tape over the catheter.

D) Notify the health care provider.

Answer: A, C, B, D Explanation: A) If a central line is disrupted, the nurse should first have the client perform the Valsalva maneuver. However, this client is unable to do so. In this case, the correct steps are as follows: place the client in supine position; place a strip of tape over the catheter; clamp the affected lumen with a soft-tipped clamp; notify the health care provider.

B) If a central line is disrupted, the nurse should first have the client perform the Valsalva maneuver. However, this client is unable to do so. In this case, the correct steps are as follows: place the client in supine position; place a strip of tape over the catheter; clamp the affected lumen with a soft-tipped clamp; notify the health care provider.

C) If a central line is disrupted, the nurse should first have the client perform the Valsalva maneuver. However, this client is unable to do so. In this case, the correct steps are as follows: place the client in supine position; place a strip of tape over the catheter; clamp the affected lumen with a soft-tipped clamp; notify the health care provider.

D) If a central line is disrupted, the nurse should first have the client perform the Valsalva maneuver. However, this client is unable to do so. In this case, the correct steps are as follows: place the client in supine position; place a strip of tape over the catheter; clamp the affected lumen with a soft-tipped clamp; notify the health care provider.

Page Ref: 301 Cognitive Level: Analyzing Client Need/Sub: Reduction of Risk Potential: Potential for Complications from Surgical Procedures and Health Alterations Standards: Nursing Process: Intervention | Learning Outcome: 5.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 4

4) The nurse is teaching a client on the importance of monitoring intake and output at home.

Which statement will the nurse include in the client teaching?

A) "Weigh at two different times during the day in order to see a change."

B) "If your weight goes up more than one pound in a day, contact your health care provider."

C) "If you notice sticky mucus membranes, contact your health care provider."

D) "Weigh with two different scales in order to compare results."

Answer: C Explanation: Sticky mucus membranes may indicate a fluid volume deficit and the client should report this finding to the health care provider. The nurse should teach the client to weigh at the same time during the day, using the same scale, wearing similar clothing in order to provide accurate weights. The nurse will teach the client that if their weight goes up by more than 0.9-1.3 kg (2-3 lb.) per day to contact the health care provider.

Page Ref: 295 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Intervention | Learning Outcome: 5.6 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

5) The nurse is assisting the health care provider insert a central line for the client. During the procedure, the client reports sudden shortness of breath and the client's SpO2 falls to 88% on room air. Which actions will the nurse take? Select all that apply.

A) Place the client in the left side-lying position.

B) Lower the client's head of the bed.

C) Raise the client's head of the bed.

D) Apply 100% oxygen via mask.

E) Prepare for intubation and mechanical ventilation.

Answer: A Explanation: The client is likely experiencing an air embolism, a potential complication of central line placement. The nurse should place the client in the left Trendelenburg position (sidelying) with the head of bed lowered. Additionally, the nurse will apply 100% oxygen via mask.

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Although the client is experiencing shortness of breath, the nurse will not yet prepare for intubation and mechanical ventilation.

Page Ref: 302 Cognitive Level: Analyzing Client Need/Sub: Reduction of Risk Potential: Potential for Complications from Surgical Procedures and Health Alterations Standards: Nursing Process: Intervention | Learning Outcome: 5.2 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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6) The nurse plans teaching for the client on methods of encouraging fluid intake. Which statements will the nurse include? Select all that apply.

A) "Consume 180 mL of water daily."

B) "Limit your alcohol intake."

C) "Avoid excess amounts of fluids high in salt."

D) "Moderate caffeine intake is acceptable."

E) "Consume 6-8 glasses of water daily."

Answer: B, C, E Explanation: When teaching a client on methods of encouraging fluid intake, the nurse will suggest the client consume 6-8 glasses of water daily, and avoid excess amounts of fluids high in salt. 180 mL of fluid is not enough fluid intake daily and caffeine promotes diuresis, which is counter-productive to fluid intake.

When teaching a client on methods of encouraging fluid intake, the nurse will suggest the client consume 6-8 glasses of water daily, and avoid excess amounts of fluids high in salt. 180 mL of fluid is not enough fluid intake daily and caffeine promotes diuresis, which is counter-productive to fluid intake.

When teaching a client on methods of encouraging fluid intake, the nurse will suggest the client consume 6-8 glasses of water daily, and avoid excess amounts of fluids high in salt. 180 mL of fluid is not enough fluid intake daily and caffeine promotes diuresis, which is counter-productive to fluid intake.

Page Ref: 295 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: Nursing Process: Intervention | Learning Outcome: 5.6 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

7) The nurse prepares to insert an intravenous catheter in an older adult client. Which action should the nurse take?

A) Use a tourniquet prior to assessing the insertion site.

B) Keep a tourniquet applied until the infusion set is attached.

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C) Insert the catheter in a distal vein.

D) Insert the catheter in a proximal vein.

Answer: C Explanation: Older adult clients' veins are fragile and roll easily, and frequently the needle punctures the wall of the vessel. The nurse should insert a small-gauge, short catheter in the distal vein first to preserve proximal vessel. A tourniquet may not be necessary and if used, should be applied loosely for a short period of time.

Page Ref: 306 Cognitive Level: Applying Client Need/Sub: Reduction of Risk Potential: Therapeutic Procedures Standards: Nursing Process: Intervention | Learning Outcome: 5.5 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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8) The nurse is caring for a client who is receiving intravenous therapy with an infusion pump.

An occlusion alarm sounds. Which things will the nurse check? Select all that apply.

A) IV site B) Pinched tubing C) Closed clamp D) Client positioning E) Bubbles in the tubing Answer: A, B, C, D Explanation: An occlusion alarm is a common alarm that sounds on the infusion pump. This occurs when the pump cannot maintain delivery in the face of increasing resistance. The nurse should check the IV site for infiltration, pinched tubing, clamps for closures, and the client positioning. Bubbles in the tubing causes an air in the tubing warning.

An occlusion alarm is a common alarm that sounds on the infusion pump. This occurs when the pump cannot maintain delivery in the face of increasing resistance. The nurse should check the IV site for infiltration, pinched tubing, clamps for closures, and the client positioning. Bubbles in the tubing causes an air in the tubing warning.

An occlusion alarm is a common alarm that sounds on the infusion pump. This occurs when the pump cannot maintain delivery in the face of increasing resistance. The nurse should check the IV site for infiltration, pinched tubing, clamps for closures, and the client positioning. Bubbles in the tubing causes an air in the tubing warning.

An occlusion alarm is a common alarm that sounds on the infusion pump. This occurs when the pump cannot maintain delivery in the face of increasing resistance. The nurse should check the IV site for infiltration, pinched tubing, clamps for closures, and the client positioning. Bubbles in the tubing causes an air in the tubing warning.

Page Ref: 306 Cognitive Level: Remembering Client Need/Sub: Pharmacological and Parenteral Therapies: Parenteral/Intravenous Therapies Standards: Nursing Process: Assessment | Learning Outcome: 5.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 9

9) The nurse prepares to change the client's central line dressing and replace the injection cap.

Which position will the nurse place the client?

A) Supine B) Upright C) High-Fowler's D) Side-lying Answer: A Explanation: The client should be positioned in the supine position because head of bed elevation increases the chances of an air embolism forming. Upright, high-Fowler's, and sidelying positions are not the correct positioning when changing the client's central line dressing and replacing the caps.

Page Ref: 297 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Aging Process Standards: Nursing Process: Assessment | Learning Outcome: 5.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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10) The nurse needs to obtain blood samples from the client's central line for blood analysis.

Place the steps of the procedure in correct order.

A) Withdraw 10 mL of blood and discard.

B) Flush with 5 mL normal saline.

C) Inject 5mL heparin.

D) Draw up the required blood and transfer to the appropriate containers.

E) Clean the infusion access port according to policy for 10 seconds.

F) Clean the infusion access port according to policy for 30 seconds.

Answer: F, A, D, E, B, C Explanation: A) The steps of obtaining blood for analysis while drawing from a central line is as follows: clean the infusion access port according to policy for 30 seconds; withdraw 10 mL of blood and discard; draw up the required blood and transfer to the appropriate containers; clean the infusion access port according to policy for 10 seconds; flush with 5 mL normal saline; inject 5 mL heparin.

B) The steps of obtaining blood for analysis while drawing from a central line is as follows: clean the infusion access port according to policy for 30 seconds; withdraw 10 mL of blood and discard; draw up the required blood and transfer to the appropriate containers; clean the infusion access port according to policy for 10 seconds; flush with 5 mL normal saline; inject 5 mL heparin.

C) The steps of obtaining blood for analysis while drawing from a central line is as follows: clean the infusion access port according to policy for 30 seconds; withdraw 10 mL of blood and discard; draw up the required blood and transfer to the appropriate containers; clean the infusion access port according to policy for 10 seconds; flush with 5 mL normal saline; inject 5 mL heparin.

D) The steps of obtaining blood for analysis while drawing from a central line is as follows: clean the infusion access port according to policy for 30 seconds; withdraw 10 mL of blood and discard; draw up the required blood and transfer to the appropriate containers; clean the infusion access port according to policy for 10 seconds; flush with 5 mL normal saline; inject 5 mL heparin.

E) The steps of obtaining blood for analysis while drawing from a central line is as follows: clean the infusion access port according to policy for 30 seconds; withdraw 10 mL of blood and discard; draw up the required blood and transfer to the appropriate containers; clean the infusion 11

access port according to policy for 10 seconds; flush with 5 mL normal saline; inject 5 mL heparin.

F) The steps of obtaining blood for analysis while drawing from a central line is as follows: clean the infusion access port according to policy for 30 seconds; withdraw 10 mL of blood and discard; draw up the required blood and transfer to the appropriate containers; clean the infusion access port according to policy for 10 seconds; flush with 5 mL normal saline; inject 5 mL heparin.

Page Ref: 304 Cognitive Level: Analyzing Client Need/Sub: Pharmacological and Parenteral Therapies: Central Venous Access Devices Standards: Nursing Process: Intervention | Learning Outcome: 5.8 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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11) Calculate the flow rate of the following intravenous therapy prescription: 3 liters 09.% normal saline over 24 hours.

A) 125 mL/hr B) 100 mL/hr C) 250 mL/hr D) 90 mL/hr Answer: A Explanation: The formula for calculating flow rate is as follows: = mL/hr 3L =

= 125 mL/hr

Page Ref: 308 Cognitive Level: Analyzing Client Need/Sub: Pharmacological and Parenteral Therapies: Dosage Calculation Standards: Nursing Process: Intervention | Learning Outcome: 5.3 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

12) The nurse is setting up an intravenous infusion for a client and the nurse has set the IV pump according to the health care provider's orders. How will the nurse best verify that the drops/minute rate is correct?

A) Verify the tubing size and adjust accordingly.

B) Verify the flow rate on the infusion pump.

C) Count the drops in the drip chamber for 6 seconds and multiply by 10.

D) Count the drops in the drip chamber for 15 seconds and multiply by 4.

Answer: D Explanation: In order to verify that the drops/minute rate is correct, the nurse will count the drops in the drip chamber for 15 seconds and multiply by 4. Counting the drops for 6 seconds is not long enough and is not accurate. The other answer choices do not verify that the drops/minute rate is correct.

Page Ref: 309 13

Cognitive Level: Analyzing Client Need/Sub: Pharmacological and Parenteral Therapies: Dosage Calculation Standards: Nursing Process: Intervention | Learning Outcome: 5.3 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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13) The nurse cares for a client with a PICC line that requires a dressing change. Place the procedure steps in the correct order the nurse will perform.

A) Remove old transparent dressing.

B) Discard old dressing and gloves.

C) Perform hand hygiene and don clean gloves.

D) Assess the exit site.

E) Perform hand hygiene and don sterile gloves.

F) Clean the exit site and catheter with antimicrobial swabs; allow to dry.

G) Place securement device and cover exit site with transparent dressing.

Answer: C, A, D, B, E, F, G Explanation: A) The correct steps to perform a PICC dressing change is as follows: Perform hand hygiene and don clean gloves; remove old transparent dressing; assess the exit site; discard the old dressing and gloves; perform hand hygiene and don sterile gloves; clean the exit site and catheter with antimicrobial swabs and allow to dry; place securement device and cover exit site with a transparent dressing.

B) The correct steps to perform a PICC dressing change is as follows: Perform hand hygiene and don clean gloves; remove old transparent dressing; assess the exit site; discard the old dressing and gloves; perform hand hygiene and don sterile gloves; clean the exit site and catheter with antimicrobial swabs and allow to dry; place securement device and cover exit site with a transparent dressing.

C) The correct steps to perform a PICC dressing change is as follows: Perform hand hygiene and don clean gloves; remove old transparent dressing; assess the exit site; discard the old dressing and gloves; perform hand hygiene and don sterile gloves; clean the exit site and catheter with antimicrobial swabs and allow to dry; place securement device and cover exit site with a transparent dressing.

D) The correct steps to perform a PICC dressing change is as follows: Perform hand hygiene and don clean gloves; remove old transparent dressing; assess the exit site; discard the old dressing and gloves; perform hand hygiene and don sterile gloves; clean the exit site and catheter with antimicrobial swabs and allow to dry; place securement device and cover exit site with a transparent dressing.

E) The correct steps to perform a PICC dressing change is as follows: Perform hand hygiene and don clean gloves; remove old transparent dressing; assess the exit site; discard the old dressing 15

and gloves; perform hand hygiene and don sterile gloves; clean the exit site and catheter with antimicrobial swabs and allow to dry; place securement device and cover exit site with a transparent dressing.

F) The correct steps to perform a PICC dressing change is as follows: Perform hand hygiene and don clean gloves; remove old transparent dressing; assess the exit site; discard the old dressing and gloves; perform hand hygiene and don sterile gloves; clean the exit site and catheter with antimicrobial swabs and allow to dry; place securement device and cover exit site with a transparent dressing.

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G) The correct steps to perform a PICC dressing change is as follows: Perform hand hygiene and don clean gloves; remove old transparent dressing; assess the exit site; discard the old dressing and gloves; perform hand hygiene and don sterile gloves; clean the exit site and catheter with antimicrobial swabs and allow to dry; place securement device and cover exit site with a transparent dressing.

Page Ref: 328 Cognitive Level: Analyzing Client Need/Sub: Pharmacological and Parenteral Therapies: Central Venous Access Devices Standards: Nursing Process: Intervention | Learning Outcome: 5.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 14) The nurse removes a client's intravenous catheter and notes the tip of the catheter is broken.

The nurse palpates the client's arm and feels the broken piece. Which action should the nurse take?

A) Apply ice to the insertion site.

B) Raise the client's arm above the heart.

C) Apply a pressure dressing on the insertion site.

D) Apply a tourniquet above the insertion site.

Answer: D Explanation: If the broken piece of a catheter is palpated, the nurse should apply a tourniquet above the tourniquet to decrease the risk of the piece migrating to the heart or lunges. The other answer choices do not represent adequate action to take when an intravenous catheter is broken.

Page Ref: 306 Cognitive Level: Applying Client Need/Sub: Reduction of Risk Potential: Potential for Complications from Surgical Procedures and Health Alterations Standards: Nursing Process: Intervention | Learning Outcome: 5.2 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 17

15) The nurse administers intravenous fluid therapy using a Dial-A-Flo device. What is a disadvantage of this device that the nurse recognizes?

A) It does not control the size of the drops delivered.

B) It does not allow for a fixed flow rate.

C) It does not allow a specified number of drops in the drip chamber.

D) It does not allow visual calculation of the flow rate.

Answer: A Explanation: The Dial-A-Flo device is a gravity-control infusion device that has a manual controller with a dial that allows for a fixed flow rate. Because the device cannot control the size of the drops dispensed, it is not as accurate as an IV pump. This device allows a specified number of drops in the drip chamber and allows for visual calculation of the flow rate.

Page Ref: 307 Cognitive Level: Understanding Client Need/Sub: Pharmacological and Parenteral Therapies: Medication Administration Standards: Nursing Process: Assessment | Learning Outcome: 5.3 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 16) The nurse cares for a client with a central venous catheter. Which action by the nurse is incorrect when maintaining the client's central line?

A) Wiping the access port with an antimicrobial swab for 30 seconds.

B) Using a 5-mL syringe to flush the catheter.

C) Flushing the catheter before and after each dose of medication.

D) Using a push-pause-push motion to flush the catheter.

Answer: B Explanation: When maintaining the client's central line, the nurse will use a 10-mL syringe instead of 5-mL because smaller syringes can exert too much pressure, which can damage the catheter. The nurse will wipe the access port with an antimicrobial swab for at least 30 seconds, will flush the catheter before and after each dose of medication, using a push-pause-push motion to flush the catheter.

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Cognitive Level: Applying Client Need/Sub: Pharmacological and Parenteral Therapies: Central Venous Access Devices Standards: Nursing Process: Intervention | Learning Outcome: 5.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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17) A nurse attempts to flush the lumen of a triple lumen central catheter and notes severe resistance to flushing. Which diagnostic procedure does the nurse anticipate when assessing the correct placement of the central line?

A) Chest CT B) Fluoroscopy C) Chest X-ray D) Endoscopy Answer: C Explanation: The nurse should anticipate the health care provider ordering a chest X-ray when determining the placement of the client's central line. The chest CT may be performed; however, this is not the most likely diagnostic test. Fluoroscopy will be performed if an occlusion is suspected. Endoscopy is performed when there are issues with the upper or lower GI system.

Page Ref: 302 Cognitive Level: Understanding Client Need/Sub: Pharmacological and Parenteral Therapies: Central Venous Access Devices Standards: Nursing Process: Assessment | Learning Outcome: 5.8 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 18) The nurse cares for a client with an intravenous infusion of D5NS. Which complications will the nurse closely monitor the client for? Select all that apply.

A) Increased serum sodium B) Decreased serum potassium C) Fluid overload D) Hypotension E) Increased serum chloride Answer: A, C, E Explanation: D5NS is a hypertonic intravenous solution, which promotes osmosis of fluid out of the cells. Complications of D5NS therapy is hypernatremia (elevated serum sodium), fluid overload, and hyperchloremia (increased serum chloride). Hypotension and hypokalemia (decreased serum potassium) are not complications of D5NS therapy.

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D5NS is a hypertonic intravenous solution, which promotes osmosis of fluid out of the cells.

Complications of D5NS therapy is hypernatremia (elevated serum sodium), fluid overload, and hyperchloremia (increased serum chloride). Hypotension and hypokalemia (decreased serum potassium) are not complications of D5NS therapy.

D5NS is a hypertonic intravenous solution, which promotes osmosis of fluid out of the cells.

Complications of D5NS therapy is hypernatremia (elevated serum sodium), fluid overload, and hyperchloremia (increased serum chloride). Hypotension and hypokalemia (decreased serum potassium) are not complications of D5NS therapy.

Page Ref: 314 Cognitive Level: Analyzing Client Need/Sub: Pharmacological and Parenteral Therapies: Medication Administration Standards: Nursing Process: Assessment | Learning Outcome: 5.2 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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19) The nurse cares for a client with a triple lumen central line who develops a fever, which the nurse suspects is from the central line. Which nursing actions are appropriate? Select all that apply.

A) Replace the infusing TPN with normal saline.

B) Change the IV tubing.

C) Remove the IV using sterile technique.

D) Change the IV dressing.

E) Culture the insertion site using sterile technique.

Answer: A, B, D, E Explanation: If the nurse suspects the central line may be the cause of infection, the nurse will replace any nutrition or blood infusing with normal saline, change both the IV tubing and dressing, and culture the insertion site using sterile technique. The nurse will not remove the IV without the order of the health care provider.

If the nurse suspects the central line may be the cause of infection, the nurse will replace any nutrition or blood infusing with normal saline, change both the IV tubing and dressing, and culture the insertion site using sterile technique. The nurse will not remove the IV without the order of the health care provider.

If the nurse suspects the central line may be the cause of infection, the nurse will replace any nutrition or blood infusing with normal saline, change both the IV tubing and dressing, and culture the insertion site using sterile technique. The nurse will not remove the IV without the order of the health care provider.

If the nurse suspects the central line may be the cause of infection, the nurse will replace any nutrition or blood infusing with normal saline, change both the IV tubing and dressing, and culture the insertion site using sterile technique. The nurse will not remove the IV without the order of the health care provider.

Page Ref: 302 Cognitive Level: Applying Client Need/Sub: Pharmacological and Parenteral Therapies: Central Venous Access Devices Standards: Nursing Process: Intervention | Learning Outcome: 5.5 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 22

20) A novice nurse performs care of a client's central line. Which action by the novice nurse requires intervention by the nurse preceptor?

A) Changing a clean gauze dressing that is 48 hours old.

B) Changing a clean transparent dressing that is 72 hours old.

C) Scrubbing the insertion site with antimicrobial solution for 30 seconds.

D) Placing an impregnated antimicrobial dressing on the insertion site.

Answer: B Explanation: Care of the central line involves ensuring sterile technique and replacing dressings when needed. A clean and intact transparent dressing may be left in place for up to 7 days. A gauze dressing for a central line needs to be replaced after 48 hours, even if the dressing is dry and intact. Scrubbing the insertion site with antimicrobial solution for 30 seconds and placing an impregnated antimicrobial dressing on the insertion site are both correct actions when caring for a client's central line.

Page Ref: 301 Cognitive Level: Applying Client Need/Sub: Pharmacological and Parenteral Therapies: Central Venous Access Devices Standards: Nursing Process: Intervention | Learning Outcome: 5.4 | QSEN Competencies: Evidence-Based Practice AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 21) After removing a client's intravenous catheter from the upper extremity, the nurse notes the client has persistent bleeding despite applying firm pressure. Which action will the nurse take?

A) Hold the client's arm above the level of the heart.

B) Place the client's arm in the dependent position.

C) Lower the client's head of the bed.

D) Apply a tourniquet to the client's arm.

Answer: A Explanation: If bleeding persists after applying firm pressure, the nurse should hold the client's arm above the level of the heart to decrease blood flow to the extremity. The other answer choices do not decrease the risk for bleeding and may make the client's condition worse.

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Cognitive Level: Applying Client Need/Sub: Physiological Adaptation: Unexpected Response to Therapies Standards: Nursing Process: Intervention | Learning Outcome: 5.2 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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22) The nurse attempts to secure and stabilize an IV catheter and dressing of an older adult client. Which nursing action is appropriate?

A) Use roll-type gauze to cover the IV site.

B) Apply skin protector solution prior to dressing the IV site.

C) Use extra tape to attach to the client's skin.

D) Apply lotion to the client's skin prior to dressing the IV site.

Answer: B Explanation: Securing and stabilizing an IV catheter and dressing of an older adult client can be challenging due to the client's fragile skin. The nurse should apply a skin protector solution prior to dressing the IV site to help protect the skin. Additionally, the nurse should use stretch mesh gauze to cover the site, not roll-type gauze. The nurse should avoid using tape as this increases the risk of injury. Application of lotion would impair, not improve, securing and stabilizing an IV catheter and dressing.

Page Ref: 306 Cognitive Level: Applying Client Need/Sub: Reduction of Risk Potential: Therapeutic Procedures Standards: Nursing Process: Intervention | Learning Outcome: 5.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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23) The nurse cares for a client with traumatic injuries due to a motor vehicle accident. The nurse wants to increase the intravenous flow rate of intravenous fluids infusing. Which actions will the nurse take? Select all that apply.

A) Insert a large bore IV catheter.

B) Warm the IV fluid prior to infusing.

C) Cool the IV fluid prior to infusing.

D) Insert a long IV catheter.

E) Use a macrodrip IV tubing set.

Answer: A, B, E Explanation: There are situations where intravenous fluid therapy needs to be infused rapidly.

Methods to improve the rapid infusion of intravenous fluids include inserting a large bore IV catheter, warming the IV fluid, and using a macrodrip IV tubing set (which will provide larger drops of fluid per minute). Cool fluid infuses slower, as do longer IV catheters (due to increased resistance).

There are situations where intravenous fluid therapy needs to be infused rapidly. Methods to improve the rapid infusion of intravenous fluids include inserting a large bore IV catheter, warming the IV fluid, and using a macrodrip IV tubing set (which will provide larger drops of fluid per minute). Cool fluid infuses slower, as do longer IV catheters (due to increased resistance).

There are situations where intravenous fluid therapy needs to be infused rapidly. Methods to improve the rapid infusion of intravenous fluids include inserting a large bore IV catheter, warming the IV fluid, and using a macrodrip IV tubing set (which will provide larger drops of fluid per minute). Cool fluid infuses slower, as do longer IV catheters (due to increased resistance).

Page Ref: 306 Cognitive Level: Applying Client Need/Sub: Pharmacological and Parenteral Therapies: Medication Administration Standards: Nursing Process: Intervention | Learning Outcome: 5.2 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 26

Clinical Nursing Skills: A Concept-Based Approach, 3e (Pearson) Chapter 6 Infection

1) The nurse is caring for a client in isolation. The nurse needs to remove the isolation gown and gloves after leaving the client's room. Place the steps in correct order for removing PPE. A) Remove gloves.

B) Use the nondominant hand to pull sleeve wristlet over the dominant hand.

C) Grasp outside of gown through the sleeves at shoulders.

D) Using the dominant hand and grasping the clean part of the wristlet, pull sleeve wristlet over the nondominant hand.

E) Fold gown inside out and discard.

F) Pull gown down over the arms.

Answer: A, D, B, C, F, E Explanation: A) The process of removing gloves and gown is as follows: Remove gloves; using the dominant hand and grasping the clean part of the wristlet, pull sleeve wristlet over the nondominant hand; use the nondominant hand to pull sleeve wristlet over the dominant hand; grasp the outside of the gown through the sleeves at the shoulders; pull the gown down over the arms; fold gown inside out and discard.

B) The process of removing gloves and gown is as follows: Remove gloves; using the dominant hand and grasping the clean part of the wristlet, pull sleeve wristlet over the nondominant hand; use the nondominant hand to pull sleeve wristlet over the dominant hand; grasp the outside of the gown through the sleeves at the shoulders; pull the gown down over the arms; fold gown inside out and discard.

C) The process of removing gloves and gown is as follows: Remove gloves; using the dominant hand and grasping the clean part of the wristlet, pull sleeve wristlet over the nondominant hand; use the nondominant hand to pull sleeve wristlet over the dominant hand; grasp the outside of the gown through the sleeves at the shoulders; pull the gown down over the arms; fold gown inside out and discard.

D) The process of removing gloves and gown is as follows: Remove gloves; using the dominant hand and grasping the clean part of the wristlet, pull sleeve wristlet over the nondominant hand; use the nondominant hand to pull sleeve wristlet over the dominant hand; grasp the outside of the gown through the sleeves at the shoulders; pull the gown down over the arms; fold gown inside 1

out and discard.

E) The process of removing gloves and gown is as follows: Remove gloves; using the dominant hand and grasping the clean part of the wristlet, pull sleeve wristlet over the nondominant hand; use the nondominant hand to pull sleeve wristlet over the dominant hand; grasp the outside of the gown through the sleeves at the shoulders; pull the gown down over the arms; fold gown inside out and discard.

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F) The process of removing gloves and gown is as follows: Remove gloves; using the dominant hand and grasping the clean part of the wristlet, pull sleeve wristlet over the nondominant hand; use the nondominant hand to pull sleeve wristlet over the dominant hand; grasp the outside of the gown through the sleeves at the shoulders; pull the gown down over the arms; fold gown inside out and discard.

Page Ref: 347 Cognitive Level: Analyzing Client Need/Sub: Safety and Infection Control: Standard Precautions/Transmission-Based Precautions/Surgical Asepsis Standards: Nursing Process: Intervention | Learning Outcome: 6.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 2) The nurse caring for a client in an isolation environment decides to change the isolation mask.

What is the most likely reason the nurse changes the mask?

A) The effectiveness of the mask decreased.

B) The mask became soiled by the client.

C) The mask was too uncomfortable.

D) The mas did not seal properly.

Answer: A Explanation: An isolation mask should be changed every 30 minutes or sooner because the moisture that accumulates in it decreases its effectiveness. The other answer choices may occur; however, these are not the most likely reason the nurse changes the mask.

Page Ref: 358 Cognitive Level: Understanding Client Need/Sub: Safety and Infection Control: Standard Precautions/Transmission-Based Precautions/Surgical Asepsis Standards: Nursing Process: Intervention | Learning Outcome: 6.4 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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3) The nurse exits a client's room who is in isolation precautions. The nurse must remove both protective eyewear and a face mask. Place the steps in the correct order of removing the PPE. A) Untie the upper strings of the mask.

B) Dispose of the mask.

C) Remove the protective eyewear.

D) Untie the lower strings of the mask.

Answer: C, D, A, B Explanation: A) When removing protective eyewear and face mask, the following steps should be followed: Remove the protective eyewear; untie the lower strings of the mask; untie the upper strings of the mask; remove the mask.

B) When removing protective eyewear and face mask, the following steps should be followed: Remove the protective eyewear; untie the lower strings of the mask; untie the upper strings of the mask; remove the mask.

C) When removing protective eyewear and face mask, the following steps should be followed: Remove the protective eyewear; untie the lower strings of the mask; untie the upper strings of the mask; remove the mask.

D) When removing protective eyewear and face mask, the following steps should be followed: Remove the protective eyewear; untie the lower strings of the mask; untie the upper strings of the mask; remove the mask.

Page Ref: 359 Cognitive Level: Analyzing Client Need/Sub: Safety and Infection Control: Standard Precautions/Transmission-Based Precautions/Surgical Asepsis Standards: Nursing Process: Intervention | Learning Outcome: 6.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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4) The nurse prepares to enter the room of a child who requires isolation precautions. Which actions will the nurse take to ease the child's fears? Select all that apply.

A) Introduce self before donning a mask, if possible.

B) Encourage the child to play with the equipment.

C) Visit the client frequently.

D) Group nursing tasks to decrease contact.

E) Encourage the child to walk the halls frequently.

Answer: A, B, C Explanation: A child on isolation precautions is often scared of health care providers and the equipment used for isolation. In order to ease the child's fears, the nurse should introduce herself or himself before donning a mask, if possible. Encouraging the child to play with the equipment may decrease the child's fear and the nurse should visit the client frequently to establish rapport and get the child use to the nurse. Decreasing contact increases the child's social isolation and is not recommended. The child requires isolation precautions and walking the halls may not be appropriate.

A child on isolation precautions is often scared of health care providers and the equipment used for isolation. In order to ease the child's fears, the nurse should introduce herself or himself before donning a mask, if possible. Encouraging the child to play with the equipment may decrease the child's fear and the nurse should visit the client frequently to establish rapport and get the child use to the nurse. Decreasing contact increases the child's social isolation and is not recommended. The child requires isolation precautions and walking the halls may not be appropriate.

A child on isolation precautions is often scared of health care providers and the equipment used for isolation. In order to ease the child's fears, the nurse should introduce herself or himself before donning a mask, if possible. Encouraging the child to play with the equipment may decrease the child's fear and the nurse should visit the client frequently to establish rapport and get the child use to the nurse. Decreasing contact increases the child's social isolation and is not recommended. The child requires isolation precautions and walking the halls may not be appropriate.

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Precautions/Surgical Asepsis Standards: Nursing Process: Intervention | Learning Outcome: 6.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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5) The nurse cares for a client with bacterial meningitis. Which isolation precaution will the nurse apply?

A) Standard B) Contact C) Droplet D) Airborne Answer: C Explanation: Bacterial meningitis is transmitted by contact with tiny droplets of mucus or airway secretions from talking, coughing and sneezing and the nurse will implement droplet precautions.

The other answer choices are not correct.

Page Ref: 345 Cognitive Level: Remembering Client Need/Sub: Safety and Infection Control: Standard Precautions/Transmission-Based Precautions/Surgical Asepsis Standards: Nursing Process: Intervention | Learning Outcome: 6.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 6) A home care nurse is providing teaching to a client regarding infection control precautions at home. Which statement will the nurse including in the teaching?

A) "Discard used dressings in a biohazard bag."

B) "Clothing soiled with blood can be laundered with the rest of your clothing."

C) "Disinfect reusable equipment and supplies with a bleach solution."

D) "If supplies need refrigeration, keep in the door of the fridge away from the light."

Answer: C Explanation: The home care nurse will provide infection control teaching to clients and it is important to understand home care instructions for infection control. Teach the client to disinfect reusable equipment and supplies with a bleach solution. Used dressings should be discarded in the regular trash. Clothing soiled with blood or fluid should be laundered separately from the rest of the laundry. If supplies need refrigeration, the supplies should be kept in a bag and placed in 7

the refrigerator.

Page Ref: 351 Cognitive Level: Applying Client Need/Sub: Safety and Infection Control: Standard Precautions/Transmission-Based Precautions/Surgical Asepsis Standards: Nursing Process: Intervention | Learning Outcome: 6.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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7) The nurse reviews the various isolation environments to prevent the spread of disease. What basic preventive practices are implemented with all clients and others to ensure disease transmission does not happen?

A) Standard B) Reverse C) Droplet D) Airborne Answer: A Explanation: Standard precautions (previously known as universal precautions) are the basic preventive practices that are implemented with all clients and others to prevent the spread of disease. Reverse isolation is known as neutropenic isolation and occurs when a client is severely immunocompromised. Droplet precautions are implemented when conditions may be spread by respiratory droplets in the air. Airborne precautions are implemented when conditions my be spread by the air.

Page Ref: 340 Cognitive Level: Remembering Client Need/Sub: Safety and Infection Control: Standard Precautions/Transmission-Based Precautions/Surgical Asepsis Standards: Nursing Process: Assessment | Learning Outcome: 6.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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8) The nurse is caring for a client with cancer who is neutropenic. Which guidelines will the nurse follow regarding neutropenic precautions? Select all that apply.

A) Ensure the client does not receive any visitors.

B) Do not allow the client to receive fresh flowers.

C) Inspect the client's food trays to ensure no fresh vegetables are given.

D) Keep the client's door closed.

E) Ensure the client wears an N95 mask when outside of the room.

Answer: B, C, D Explanation: A client who is neutropenic has a decreased level of neutrophils, which increases the client's risk for infection. The nurse should make sure the client does not receive fresh flowers or eats raw vegetables because these pose an increased risk of infection for the neutropenic client. Additionally, the nurse should keep the client's door closed. The neutropenic client may receive visitors; however, these should be limited to immediate family only and these visitors must comply with the neutropenic precautions. The client who is neutropenic should wear a regular surgical mask when outside the room; an N95 mask is not necessary.

A client who is neutropenic has a decreased level of neutrophils, which increases the client's risk for infection. The nurse should make sure the client does not receive fresh flowers or eats raw vegetables because these pose an increased risk of infection for the neutropenic client.

Additionally, the nurse should keep the client's door closed. The neutropenic client may receive visitors; however, these should be limited to immediate family only and these visitors must comply with the neutropenic precautions. The client who is neutropenic should wear a regular surgical mask when outside the room; an N95 mask is not necessary.

A client who is neutropenic has a decreased level of neutrophils, which increases the client's risk for infection. The nurse should make sure the client does not receive fresh flowers or eats raw vegetables because these pose an increased risk of infection for the neutropenic client.

Additionally, the nurse should keep the client's door closed. The neutropenic client may receive visitors; however, these should be limited to immediate family only and these visitors must comply with the neutropenic precautions. The client who is neutropenic should wear a regular surgical mask when outside the room; an N95 mask is not necessary.

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Precautions/Surgical Asepsis Standards: Nursing Process: Intervention | Learning Outcome: 6.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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9) The nurse cares for an older adult and recognizes the client is at increased risk for developing infection. Which condition poses the greatest risk of infection in the client?

A) Diabetes mellitus B) Eczema C) Glaucoma D) Emphysema Answer: A Explanation: Diabetes mellitus, often found in older adult clients, increases the risk of infection and delayed healing. Eczema, glaucoma, and emphysema are common in the older adult; however, these do not pose the greatest risk of infection in the client.

Page Ref: 351 Cognitive Level: Understanding Client Need/Sub: Physiological Adaptation: Pathophysiology Standards: Nursing Process: Assessment | Learning Outcome: 6.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 10) The nurse cares for a client who acquires a healthcare-associated infection while in an isolation environment. Which action will the infection control nurse take that best responds to the client's condition?

A) Plan staff education on isolation precautions and proper hand hygiene.

B) Ask the client if he or she is performing hand hygiene.

C) Examine isolation equipment outside the client's room.

D) Plan staff education on the identification of client's at greatest risk for infection.

Answer: A Explanation: Staff education is the priority when a client acquires a healthcare-associated infection while in an isolation environment. The priority teaching is on the proper use of isolation precautions and correct hand hygiene. Education on identification of client's at greatest risk is not the priority because infection control always begins with proper hand hygiene. Asking the client if he or she is performing hand hygiene does not help respond to the client's condition and the scenario does not indicate if the client is able to perform this action. While it is not 12

inappropriate to examine isolation equipment, this intervention is not the best response to the client's condition and is not the correct answer choice.

Page Ref: 360 Cognitive Level: Applying Client Need/Sub: Safety and Infection Control: Standard Precautions/Transmission-Based Precautions/Surgical Asepsis Standards: Nursing Process: Assessment | Learning Outcome: 6.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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11) The nurse must remove soiled equipment from a client's isolation room. Place the steps in correct order of how the nurse will remove the equipment.

A) Place equipment in an isolation bag.

B) Wash equipment with an antimicrobial agent.

C) Perform hand hygiene and don gloves.

D) Remove the isolation bag.

Answer: C, B, A, D Explanation: A) The process to remove soiled equipment from a client's isolation room is as follows: Perform hand hygiene and don gloves; wash equipment with an antimicrobial agent; place the equipment in an isolation bag; remove the isolation bag.

B) The process to remove soiled equipment from a client's isolation room is as follows: Perform hand hygiene and don gloves; wash equipment with an antimicrobial agent; place the equipment in an isolation bag; remove the isolation bag.

C) The process to remove soiled equipment from a client's isolation room is as follows: Perform hand hygiene and don gloves; wash equipment with an antimicrobial agent; place the equipment in an isolation bag; remove the isolation bag.

D) The process to remove soiled equipment from a client's isolation room is as follows: Perform hand hygiene and don gloves; wash equipment with an antimicrobial agent; place the equipment in an isolation bag; remove the isolation bag.

Page Ref: 353-354 Cognitive Level: Analyzing Client Need/Sub: Safety and Infection Control: Standard Precautions/Transmission-Based Precautions/Surgical Asepsis Standards: Nursing Process: Intervention | Learning Outcome: 6.2 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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12) The nurse cares for a client with norovirus. Which action by the nurse regarding the isolation precautions should the nurse perform?

A) Using an alcohol-based hand sanitizer after leaving the client's room.

B) Placing the client in a negative-pressure room.

C) Using soap and water only when leaving the client's room.

D) Donning sterile gloves when entering the client's room.

Answer: C Explanation: Enteric contact precautions are used for clients with active infection of pathogens such as C.difficile, rotavirus, or norovirus in the intestinal tract. The pathogens are transmitted in the client's stool. Healthcare personnel must only perform soap and water hand washing instead of using an alcohol-based hand rub because the alcohol is not effective in removing the pathogens from the hands. Placing the client in a negative-pressure room and donning sterile gloves when entering the client's room are not appropriate.

Page Ref: 344 Cognitive Level: Applying Client Need/Sub: Safety and Infection Control: Standard Precautions/Transmission-Based Precautions/Surgical Asepsis Standards: Nursing Process: Intervention | Learning Outcome: 6.3 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 13) A staff nurse asks the charge nurse the difference between airborne and droplet precautions.

How will the charge nurse respond?

A) "Droplet precautions require the use of an N95 mask, while airborne precautions do not."

B) "Airborne precautions require the use of an N95 mask, while droplet precautions do not."

C) "They are actually the same except some agencies use different terms for these precautions."

D) "Droplet precautions are considered one-tier and airborne precautions are considered twotier."

Answer: B Explanation: Both droplet and airborne precautions are two-tier transmission-based precautions.

Airborne precautions require the use of an N95 mask, while droplet precautions do not. Airborne illnesses are transmitted through the air while droplet-transmitted illnesses are transmitted 15

through droplets from secretions in the airway. These precautions are not the same.

Page Ref: 345 Cognitive Level: Analyzing Client Need/Sub: Safety and Infection Control: Standard Precautions/Transmission-Based Precautions/Surgical Asepsis Standards: Nursing Process: Intervention | Learning Outcome: 6.2 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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14) The nurse cares for a group of clients with infectious diseases or conditions. Which conditions can the nurse use a waterless antiseptic gel for hand hygiene? Select all that apply.

A) Clostridium difficile B) Hepatitis B C) Norovirus D) Staphylococcus aureus E) Escherichia coli Answer: B, D, E Explanation: Waterless antiseptic hand gels are appropriate for most viruses and bacteria.

Hepatitis B, Staphylococcus aureus, and Escherichia coli are all killed by these hand gels.

However, C. difficile and Norovirus are not killed by these hand gels and are only eliminated with traditional hand washing with soap and water.

Waterless antiseptic hand gels are appropriate for most viruses and bacteria. Hepatitis B, Staphyloccus aureus, and Escherichia coli are all killed by these hand gels. However, C. difficile and Norovirus are not killed by these hand gels and are only eliminated with traditional hand washing with soap and water.

Waterless antiseptic hand gels are appropriate for most viruses and bacteria. Hepatitis B, Staphyloccus aureus, and Escherichia coli are all killed by these hand gels. However, C. difficile and Norovirus are not killed by these hand gels and are only eliminated with traditional hand washing with soap and water.

Page Ref: 343 Cognitive Level: Applying Client Need/Sub: Safety and Infection Control: Standard Precautions/Transmission-Based Precautions/Surgical Asepsis Standards: Nursing Process: Assessment | Learning Outcome: 6.3 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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15) The nurse is caring for a client suspected of having tuberculosis. The nurse must don an N95 particulate mask. Place the steps in correct order for donning this mask.

A) Position the mask over the mouth and nose.

B) Pull the strap over the head.

C) Pull the shorter strap over the head, below the ears.

D) Hold the mask in the hands with the nosepiece towards the fingertips.

Answer: D, A, B, C Explanation: A) When donning an N95 particulate mask, the nurse will first hold the mask in the hands with the nosepiece towards the fingertips. Next, the nurse will position the mask over the mouth and nose. Next, the nurse will first pull the strap over the head. Finally, the nurse will pull the shorter strap over the head, below the ears.

B) When donning an N95 particulate mask, the nurse will first hold the mask in the hands with the nosepiece towards the fingertips. Next, the nurse will position the mask over the mouth and nose. Next, the nurse will first pull the strap over the head. Finally, the nurse will pull the shorter strap over the head, below the ears.

C) When donning an N95 particulate mask, the nurse will first hold the mask in the hands with the nosepiece towards the fingertips. Next, the nurse will position the mask over the mouth and nose. Next, the nurse will first pull the strap over the head. Finally, the nurse will pull the shorter strap over the head, below the ears.

D) When donning an N95 particulate mask, the nurse will first hold the mask in the hands with the nosepiece towards the fingertips. Next, the nurse will position the mask over the mouth and nose. Next, the nurse will first pull the strap over the head. Finally, the nurse will pull the shorter strap over the head, below the ears.

Page Ref: 358 Cognitive Level: Analyzing Client Need/Sub: Safety and Infection Control: Standard Precautions/Transmission-Based Precautions/Surgical Asepsis Standards: Nursing Process: Intervention | Learning Outcome: 6.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 18

16) The nurse needs to remove an isolation gown that slips over the head. How will the nurse remove the gown?

A) Pull the shoulders forward to loosen the Velcro at the neck.

B) Tear the gown at the neck.

C) Pull the sleeves over the hands to loosen the gown.

D) Pull the gown over the head inside out.

Answer: A Explanation: Some isolation gowns slip over the head instead of tying at the neck. When removing this type of gown, the nurse will pull the shoulders of the gown forward to loosen the Velcro at the neck. The nurse will then remove the gown in the manner as if the gown were tied in the back.

Page Ref: 347 Cognitive Level: Analyzing Client Need/Sub: Safety and Infection Control: Standard Precautions/Transmission-Based Precautions/Surgical Asepsis Standards: Nursing Process: Assessment | Learning Outcome: 6.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 17) A novice nurse works with a nurse preceptor on a busy medical surgical unit. Which action by the novice nurse requires intervention by the nurse preceptor when observing the novice nurse performing hand hygiene?

A) Washing hands with warm soapy water for 15 seconds.

B) Using a waterless foam sanitizer before entering the room of a client.

C) Cleaning under the fingernails with an orangewood stick.

D) Drying hands thoroughly with fingers pointing up.

Answer: A Explanation: The novice nurse should wash hands with warm soapy water for at least 20 seconds, not 15. Inadequate washing time decreases the efficacy of hand hygiene. Using a waterless foam sanitizer before entering the room of a client, cleaning under the fingernails with an orangewood stick, and drying hands thoroughly with fingers pointing up are all correct 19

methods in hand hygiene.

Page Ref: 342 Cognitive Level: Applying Client Need/Sub: Safety and Infection Control: Standard Precautions/Transmission-Based Precautions/Surgical Asepsis Standards: Nursing Process: Intervention | Learning Outcome: 6.3 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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18) The nurse teaches an older adult client on methods of infection control. Which statement, specific to this client population, will the nurse include in the teaching?

A) "Ensure increased protein intake in order to maintain immune function."

B) "Inflammatory response increases with age."

C) "Immune function remains unchanged with age."

D) "Ensure adequate protein intake in order to maintain immune function."

Answer: D Explanation: In order to promote methods of infection control in the older adult, the nurse will encourage adequate (not increased) protein intake in an effort to maintain immune function."

Inflammatory response decreases, not increases with age and immune function decreases with ages as well.

Page Ref: 351 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Aging Process Standards: Nursing Process: Intervention | Learning Outcome: 6.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 19) The nurse is removing gloves after performing client care activities. Place the steps in correct order for removing gloves.

A) Pull off one glove by touching the outside of the glove at the cuff.

B) Slip one finger of ungloved hand under glove cuff of other hand.

C) Pull down and off so both gloves are removed as one.

D) Roll up glove and place in gloved hand.

Answer: A, D, B, C Explanation: A) When removing gloves, pull off one glove by touching the outside of the glove at the cuff; roll up the glove and place in the gloved hand; slip one finger of the ungloved hand under the glove cuff of the other hand; pull down and off so both gloves are removed as one.

B) When removing gloves, pull off one glove by touching the outside of the glove at the cuff; roll up the glove and place in the gloved hand; slip one finger of the ungloved hand under the glove cuff of the other hand; pull down and off so both gloves are removed as one.

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C) When removing gloves, pull off one glove by touching the outside of the glove at the cuff; roll up the glove and place in the gloved hand; slip one finger of the ungloved hand under the glove cuff of the other hand; pull down and off so both gloves are removed as one.

D) When removing gloves, pull off one glove by touching the outside of the glove at the cuff; roll up the glove and place in the gloved hand; slip one finger of the ungloved hand under the glove cuff of the other hand; pull down and off so both gloves are removed as one.

Page Ref: 359 Cognitive Level: Analyzing Client Need/Sub: Safety and Infection Control: Standard Precautions/Transmission-Based Precautions/Surgical Asepsis Standards: Nursing Process: Intervention | Learning Outcome: 3.7 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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20) The nurse is removing gloves after performing client care activities. Place the steps in correct order for removing gloves.

A) Pull off one glove by touching the outside of the glove at the cuff.

B) Slip one finger of ungloved hand under glove cuff of other hand.

C) Pull down and off so both gloves are removed as one.

D) Roll up glove and place in gloved hand.

Answer: A, D, B, C Explanation: A) When removing gloves, pull off one glove by touching the outside of the glove at the cuff; roll up the glove and place in the gloved hand; slip one finger of the ungloved hand under the glove cuff of the other hand; pull down and off so both gloves are removed as one.

B) When removing gloves, pull off one glove by touching the outside of the glove at the cuff; roll up the glove and place in the gloved hand; slip one finger of the ungloved hand under the glove cuff of the other hand; pull down and off so both gloves are removed as one.

C) When removing gloves, pull off one glove by touching the outside of the glove at the cuff; roll up the glove and place in the gloved hand; slip one finger of the ungloved hand under the glove cuff of the other hand; pull down and off so both gloves are removed as one.

D) When removing gloves, pull off one glove by touching the outside of the glove at the cuff; roll up the glove and place in the gloved hand; slip one finger of the ungloved hand under the glove cuff of the other hand; pull down and off so both gloves are removed as one.

Page Ref: 359 Cognitive Level: Analyzing Client Need/Sub: Safety and Infection Control: Standard Precautions/Transmission-Based Precautions/Surgical Asepsis Standards: Nursing Process: Intervention | Learning Outcome: 3.7 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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Clinical Nursing Skills: A Concept-Based Approach, 3e (Pearson) Chapter 7 Intracranial Regulation

1) The nurse is completing a Glasgow Coma Scale reassessment of a client who fell down a flight of stairs 8 hours ago. On admission, the client displayed spontaneous eye opening. The nurse does not see this response at this time and knows to do which to know if the client responds at the next level of eye opening?

A) Provide painful stimuli to evoke eye opening.

B) Request the client speak his own name.

C) Tell the client to "open his eyes" or to look at the nurse.

D) Ask the client to squeeze the nurse's hand.

Answer: C Explanation: If the client doesn't spontaneously open his eyes, the nurse should ask the client to open his eyes.

Page Ref: 363 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 7.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

2) The charge nurse in a long-term care facility is called to assess an older adult client diagnosed with Alzheimer disease who has fallen and has a head laceration. The nurse is aware that the Glasgow Coma Scale is not an accurate tool to assess this client's level of consciousness because of which reason?

A) The client is in a long-term care facility.

B) The client is an older adult.

C) The client has a head laceration.

D) The client has been diagnosed with Alzheimer disease.

Answer: D Explanation: The client's Alzheimer disease hampers the nurse's ability to fully assess the 1

client's responses on the Glasgow Coma Scale.

Page Ref: 363 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 7.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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3) The nurse notes that an elderly resident of a long-term care facility has fallen and the client is unable to say whether or not he hit his head. Which are the first signs that the nurse will note if this client has sustained a closed head injury? Select all that apply.

A) Spontaneous vomiting B) Bradycardia C) Vertigo D) Headache E) Widened pulse pressure Answer: A, C, D Explanation: Vomiting without nausea is an early sign of ICP. Vertigo is an early sign of ICP. Headache is an early sign of ICP. Page Ref: 366 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 7.3 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

4) The nurse is caring for an older adult client who is being observed after sustaining a minor head injury. The client's only complaints related to the head injury are headache and dizziness.

Which interventions would be most helpful to this client in preventing a possible increase in intracranial pressure?

A) Place the client in a room near the nurse's station.

B) Encourage the client to visit with friends and family to prevent boredom.

C) Dim the lights in the room and encourage the client to rest.

D) Place the client in a supine position with both legs elevated slightly.

Answer: C Explanation: The client should be encouraged to rest and the environment should encourage that rest.

Page Ref: 366 2

Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 7.3 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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5) The nurse is caring for an older adult client who sustained a closed head injury approximately 4 hours ago. At the time of the injury, the client denied any pain or other symptoms. Which statement by the client would cause the MOST concern to the nurse?

A) "Who are you? Why do you keep asking me my name?"

B) "I wish the nurses would stop coming in and shining a light in my eyes. It's annoying."

C) "This is so silly. I really don't see why all of this is necessary."

D) "Please let me go home. I will come back if I have any problems."

Answer: A Explanation: A very early sign of increased ICP is a slight change in level of consciousness. The client does not appear to recognize the nurse or understand why the assessments are being done.

Page Ref: 366 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 7.3 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

6) The nurse instructs the UAP to hold the infant in a side-lying position in preparation for a lumbar puncture. The nurse shows the UAP how to flex the infant so that the spine is exposed and curved. Which explanation is the BEST to help the UAP understand why this position must be maintained?

A) "This position decreases pain for the infant while this procedure is performed."

B) "This position must be maintained because it gives the healthcare provider the best access to the infant's spinal column."

C) "This is the position in which the healthcare provider requested that the infant be placed."

D) "This position prevents contamination of the lumbar puncture site if the infant urinates or defecates during the procedure."

Answer: B Explanation: Flexing the infant's spine by holding the neck and the legs is the best way to ensure that the healthcare provider has the best and safest access to the infant's spinal column.

Page Ref: 367 3

Cognitive Level: Remembering Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 7.2 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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7) While holding a 2-year-old child in a flexed position for a lumbar puncture, the nurse monitors which vital sign to detect any abnormality caused by the child's position?

A) Temperature B) Heart rate C) Respirations D) Blood pressure Answer: C Explanation: Respirations may be affected because the child's flexed position may impair the ability to adequately breathe.

Page Ref: 368 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessment | Learning Outcome: 7.2 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

8) The charge nurse is preparing to assign a staff member to assist the healthcare provider planning to perform a lumbar puncture on a 9-month-old infant who is irritable and has an elevated temperature. Which staff member would be the best one to assist in this procedure?

A) An RN who graduated from nursing school 6 weeks ago B) A UAP with 9 years of experience in caring for elderly clients C) A UAP with 2 years of experience on a pediatric unit D) An LPN who has been licensed for 4 years but has only worked on the unit for 2 weeks Answer: C Explanation: The UAP has 2 years of experience working with infants and children and would be the best choice for holding the infant during the procedure.

Page Ref: 369 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 7.2 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 5

9) The nurse working in the emergency department is preparing to determine the level of consciousness on a client who was involved in a motor vehicle accident with a possible head injury. Which client precondition would prevent the nurse from using the Glasgow Coma Score?

A) The client is blind.

B) The client is deaf.

C) The client had a previous brain attack.

D) The client has diabetes mellitus.

Answer: B Explanation: It would be very difficult for the nurse to use the GCS in a client who is deaf because the tool requires the client to hear the nurse and respond.

Page Ref: 363 Cognitive Level: Applying Client Need/Sub: Physiologic Integrity: Basic Care and Comfort Standards: Nursing Process: Assessment | Learning Outcome: 7.7 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 10) The nurse enters a client's room with a suspected head injury in preparation for completing a neurological assessment that includes a Glasgow Coma Score (GCS). Upon entering the room and turning on a light, the nurse notes that the client doesn't open his eyes immediately. Which is the nurse's next action?

A) Complete the client's vital signs and recheck the client in 30 minutes.

B) Gently touch the client's arm to see if the client spontaneously awakens.

C) Turn the light off, leave the room, and document that the client is sleeping.

D) Vigorously rub the client's sternum to determine if the client responds to painful stimuli.

Answer: B Explanation: The nurse should first attempt to gently awaken the client because it is the normal sleeping time. If the client awakens with this, the nurse would continue with the GCS and neuro check.

Page Ref: 363 Cognitive Level: Applying 6

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 7.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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11) The intensive care unit nurse is preparing to assess the level of consciousness of a client who is intubated and has both hands restrained to prevent the client from pulling out the endotracheal tube. The client's injury occurred due to a stabbing incident that ultimately caused the client to fall and hit his head. Which item related to the client will cause the nurse to report an incomplete Glasgow Coma Score (GCS)?

A) The client is intubated.

B) The client's hands are restrained.

C) The client was stabbed.

D) The client fell and hit his head.

Answer: A Explanation: Because the client is intubated, the nurse will be unable to get a verbal response, which is a part of the GCS. Page Ref: 363 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 7.7 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 12) The nurse is caring for a client diagnosed with diabetic ketoacidosis and notes that the client's level of consciousness appears to be deteriorating. The nurse is aware that which assessments are a component of both the Glasgow Coma Score and the Full Outline of UnResponsiveness (FOUR Score) Coma Scale? Select all that apply.

A) Brainstem reflexes B) Ability to follow verbal commands C) Abnormal breathing patterns D) Pupil size E) Types of motor responses Answer: B, E Explanation: Both the FOUR Coma Scale and the GCS use the client's ability to follow commands as a component of the assessment.

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Motor response is a component of both the GCS and the FOUR Coma Scale.

Page Ref: 363 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 7.7 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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13) Prior to beginning to assist a healthcare provider with a lumbar puncture on an adult client, the nurse asks another nurse to also assist in the procedure for what reason?

A) To administer pain medication to the client B) To encourage the client to lie as still as possible C) To ensure that the healthcare provider maintains sterile technique D) To take over holding the client when the first nurse gets tired Answer: B Explanation: Providing encouragement to the client helps the client hold still, which is necessary for safety in the procedure.

Page Ref: 368 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Intervention | Learning Outcome: 7.8 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 14) The nurse is instructing a UAP in the technique of assisting a client to stay in the proper position for a lumbar puncture. The nurse will know that the UAP is doing it correctly if the UAP holds which parts of the client's body immediately before the procedure begins?

A) Behind the client's neck and knees B) Behind the client's neck and feet C) Under the client's arms and knees D) Around the client's neck and behind the knees Answer: A Explanation: The UAP stands in front of the client and places the hands behind the client's neck and knees with the client in a fetal position.

Page Ref: 368 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Intervention | Learning Outcome: 7.8 | QSEN Competencies: Patient-Centered Care 10

AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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15) The healthcare provider is preparing to perform a lumbar puncture on a 5-year-old child and requests that the child be placed in a sitting position. How will the nurse assist the child to maintain this position?

A) Tell the child to curl up in a ball and grab onto his feet and hold very still.

B) Inform the healthcare provider that the child is too young to do the procedure in a sitting position and that the procedure must be performed with the child lying down.

C) Assist the child to curl the body over a pillow and help the child stay in this position by stabilizing the child's neck with one hand and the child's knees with another hand.

D) Request another nurse assist so that one nurse can hold the child's neck and head in the curved position and the other nurse can assist the child to hold the knees steady.

Answer: D Explanation: For a child to be assisted to maintain the seated position for a lumbar puncture, it requires at least two people: one to help the child hold still at the head and the other to help the child hold still at the knees.

Page Ref: 368 Cognitive Level: Remembering Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Intervention | Learning Outcome: 7.8 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 16) The nurse is talking to parents of a 6-month-old infant who will have a lumbar puncture to rule out meningitis. The mother tells the nurse that she refuses to leave the baby and that no one will touch her child unless she is there. Which is the nurse's BEST response to this mother?

A) "We can't take the chance that you will faint during the procedure. We are here to care for your child, not you."

B) "I realize that you are upset, but this is a sterile procedure and there is an increased chance your child will get an infection if you insist on staying in the room."

C) "I know this must be stressful with your child so sick. Would you like to help hold her in the correct position or would you just like to talk quietly to her during the procedure?"

D) "Our facility's policy is that no one can be in the room except for medical personnel. Besides, 12

you don't want your baby to blame you for all of this."

Answer: C Explanation: If the parent would like to be present, the nurse should give the parent the choice of what he or she would like to do to assist with the procedure.

Page Ref: 367 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Intervention | Learning Outcome: 7.8 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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17) The nurse is caring for an older adult client who has been diagnosed with a closed head injury. The healthcare provider decides to monitor the client's intracranial pressure (ICP) using an ICP transducer system. The nurse will place the client in which position to prevent compromise of the client's condition?

A) Left lateral, bed flat B) Supine, head midline, head of bed elevated 30 degrees C) Right lateral, head of bed elevated 60 degrees D) Supine, head midline, bed in Trendelenburg Answer: B Explanation: The best position for the client who has an ICP transducer system to monitor the client's intracranial pressure is supine, head midline, and the head of the bed elevated 15 to 30 degrees. This position prevents compression of blood vessels in the neck and obstruction of venous blood flow.

Page Ref: 365 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Intervention | Learning Outcome: 7.6 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 18) The nurse is caring for a client with a diagnosed head injury who has an ICP transducer system to monitor the client's intracranial pressure. Which sign on the ICP monitor indicates that the client's condition is worsening?

A) Narrow amplitude waveform B) Appearance of plateau waveforms C) Increased ICP for 2 minutes D) ICP pressure of 4-20 Answer: B Explanation: The appearance of plateau waveforms is indicative of a worsening condition of the client.

Page Ref: 366 14

Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 7.6 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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19) The nurse is caring for a client with a diagnosed closed head injury that requires intracranial pressure monitoring. Which signs/symptoms indicate that the client's intracranial pressure is rising? Select all that apply.

A) The nurse notes "Doll's eyes" when assessing the client's pupils.

B) The nurse documents eupnea in respect to respiratory effort.

C) The nurse finds that all extremities are flaccid.

D) The nurse notes that blood pressure is stable.

E) The nurse documents that the client is in a comatose state.

Answer: A, C, E Explanation: Doll's eyes is a pupillary sign that indicates a worsening ICP. Flaccid extremities are a sign of worsening ICP. A comatose state indicates worsening ICP. Page Ref: 366 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 7.6 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 20) The nurse is assisting with a lumbar puncture of an infant who is irritable and feverish. The manometer indicates increased intracranial pressure and the cerebral spinal fluid appears cloudy.

The nurse will institute which interventions as a result of these findings?

A) Prepare to send the infant for a CT scan to look for an area of bleeding.

B) Assess the infant's anterior fontanel for any bulging.

C) Place the child in respiratory isolation because of possible meningitis.

D) Administer an antipyretic and prepare to send the infant home.

Answer: C Explanation: The presence of cloudy fluid is indicative of infection, so the child should be placed in isolation until the type of infection can be determined.

Page Ref: 368 Cognitive Level: Analyzing 16

Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 7.5 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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Clinical Nursing Skills: A Concept-Based Approach, 3e (Pearson) Chapter 8 Metabolism

1) The nurse is interviewing a client with a suspected endocrine disorder. Which question by the nurse would BEST obtain subjective data related to this client's possible diagnosis?

A) "I noticed that your blood pressure is 97/76 today. Was it this low the last time your blood pressure was measured?"

B) "Can you tell me more about the tingling you are experiencing in your feet?"

C) "Your skin appears very tanned. Did you recently go to the beach?"

D) "Does your face twitch when you touch your cheek?

Answer: B Explanation: A client's description of a tingling feeling is subjective data.

Page Ref: 374 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Assessment | Learning Outcome: 8.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

2) The client calls the clinic complaining of an unusual problem. Which client statement to the nurse is most suggestive of a subjective symptom related to an endocrine problem?

A) "I don't have as much energy as I used to. I get out of breath going up stairs."

B) "Recently I have noticed little purple spots on my legs."

C) "All I want to eat are salty things and I'm adding salt to everything I eat."

D) "My belly seems to be growing bigger every day and it's hard to breathe."

Answer: C Explanation: Salt cravings is suggestive of Addison disease, an endocrine disorder.

Page Ref: 374 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Assessment | Learning Outcome: 8.1 | QSEN Competencies: 1

Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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3) The nurse is conducting an initial assessment of a client diagnosed with an endocrine disorder and identifies which signs and symptoms as subjective, as opposed to objective symptoms?

Select all that apply.

A) There is 2+ edema present in both hands and feet.

B) The client complains of feeling tired most of the time.

C) The client states that he can't see as well as before.

D) The client's vision measured as 20/200.

E) The client reports very dry skin.

Answer: B, C, E Explanation: A complaint of feeling tired is subjective.

Complaining of decreased visual acuity is a subjective symptom.

Client report of dry skin is a subjective symptom.

Page Ref: 374 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Assessment | Learning Outcome: 8.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

4) A client calls the clinic and asks to speak to the nurse. The client states, "I don't understand why you keep telling me that my thyroid is overactive when my TSH level is so low." How does the nurse BEST explain this to the client?

A) "You are correct. We should have said that your thyroid was underactive, not overactive."

B) "I will recheck your lab reports to make sure that they are correct."

C) "Well, that's just the way it works. You just have to know what the number means."

D) "TSH stands for thyroid stimulating hormone, so if it is low it means that your thyroid is working hard and producing more hormone than it needs to."

Answer: D Explanation: Explaining to the client the relationship between TSH and thyroid function is the best response to the client who asks about a lab test.

Page Ref: 375 3

Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Intervention | Learning Outcome: 8.2 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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5) The nurse is discussing issues related to childbearing with a woman who has a low prolactin level and knows that this woman may experience difficulty related to which childbearing activity?

A) Becoming pregnant B) Staying pregnant C) Giving birth D) Breastfeeding Answer: D Explanation: Prolactin is released by the anterior pituitary and enables the client to breastfeed.

Page Ref: 373 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Intervention | Learning Outcome: 8.2 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

6) The charge nurse is discussing the endocrine system and the new nurse correctly identifies which organ as the one that influences the release of hormones into the portal circulation?

A) Hypothalamus B) Pituitary gland C) Pancreas D) Adrenal gland Answer: A Explanation: The hypothalamus is responsible for releasing hormones in the portal circulation.

Page Ref: 373 Cognitive Level: Remembering Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Assessment | Learning Outcome: 8.2 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 5

7) A client diagnosed with acromegaly is scheduled for a growth hormone test. When the client arrives for the test, the nurse notes that the client appears to have been crying. The nurse shares with the client this observation and the client begins to cry again and tells the nurse about some serious family problems. Which should the nurse do at this time in relation to the client's growth hormone test?

A) After the client's growth hormone test has been completed, discuss with the client possible resources available to assist with the family problems that the client is experiencing.

B) Explain to the client that the growth hormone test will not be accurate if performed when the client is emotionally upset, so the test needs to be rescheduled.

C) Wait until the client calms down to have the test performed.

D) Report to the healthcare provider that the client's emotional state must be taken into account when interpreting the growth hormone test.

Answer: B Explanation: The growth hormone test should be rescheduled because the result will be inaccurate if the client is not fasting or well rested, or is physical or emotionally stressed.

Page Ref: 375 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 8.2 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

8) The healthcare provider has ordered a radioactive iodine (RA) uptake exam for a client who has complained of constipation, fatigue, and weight gain. The client asks the nurse to explain again why this test has been ordered in relation to these symptoms. Which is the nurse's BEST response to this client?

A) "This test is used to check all of the endocrine glands that could cause you to have these symptoms."

B) "Your symptoms are related to possible problems with your adrenal gland, so this test will evaluate if this is the problem."

C) "Your symptoms are suggestive of a thyroid problem. Iodine is taken up exclusively by the 6

thyroid gland, so it is used to evaluate if this gland is responsible for your problems."

D) "The pituitary gland puts out iodine that is taken up by the thyroid, so this test will tell if your thyroid is producing enough of this."

Answer: C Explanation: Iodine is taken up by the thyroid, so the RA uptake test is done to see if the thyroid is functioning properly.

Page Ref: 376 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Intervention | Learning Outcome: 8.2 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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9) The nurse is caring for a client with a large abdomen. Which assessment technique would assist the nurse in determining whether the client is experiencing ascites or the large abdomen is related to obesity?

A) Weigh the client weekly.

B) Check the client's feet for pedal edema.

C) Measure the client's abdomen daily.

D) Measure the amount of food the client eats with each meal.

Answer: C Explanation: Frequent measurement of abdominal girth allows the nurse to see if the abdomen is growing quickly, which is seen in ascites but not in obesity.

Page Ref: 378 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Assessment | Learning Outcome: 8.3 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

10) The nurse is caring for a client who is experiencing both decreased appetite and shortness of breath related to ascites. A paracentesis has been scheduled for this client. Immediately prior to the procedure, the nurse accompanies the client to the bathroom so the client can void. Which would be the nurse's BEST action when the client reports an inability to void?

A) Request that the healthcare provider (HCP) postpone the procedure until the client can void.

B) Explain to the healthcare provider that extra caution must be taken during the paracentesis because the client couldn't void before the procedure.

C) Ask the healthcare provider for a one-time order of an in-and-out catheterization.

D) Ask the client to try the void again because the paracentesis cannot be performed until the client's bladder is empty.

Answer: C Explanation: Requesting that the HCP order a one-time bladder catheterization allows the nurse to empty the client's bladder and the paracentesis to be performed.

Page Ref: 379 8

Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 8.4 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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11) The nurse is caring for a client who just had 1,500 mL of fluid removed during a paracentesis. The client asks the nurse why his belly still feels so big even though that large amount of fluid was removed. Which is the nurse's BEST answer to this client?

A) "The skin of your belly stretched while you had fluid in your abdomen and it will take a while for your belly to return to its normal size."

B) "Only a certain amount of fluid can be removed from our abdomen at a time to prevent your body from going into shock."

C) "Removing that much fluid helps to get rid of the excess fluid. Now the rest of the fluid will drain into your lymphatic system."

D) "It was important to limit the amount of fluid that was removed to prevent infection from occurring."

Answer: B Explanation: Draining very large amounts of fluid can cause hypovolemia, which could then lead to shock so the amount of fluid drained during a paracentesis is limited to 1,500 mL. Page Ref: 379 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Intervention | Learning Outcome: 8.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

12) The nurse is discussing glucose control with a client who reports consistently elevated capillary blood glucose levels. The client appears unconcerned and says, "I don't see why this is Standards: Nursing Process: Intervention | Learning Outcome: 8.5 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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a problem. I feel fine." Which is the nurse's BEST response to this client?

A) "That's good. I'm glad that nothing has happened to you yet."

B) "Most people with diabetes never develop complications."

C) "I know you say you that you feel fine but you don't know just how sick you are."

D) "While you may feel good right now, complications usually appear after many years of poor glucose control."

Answer: D Explanation: Informing the client that complications will occur years from now is important to help the client understand why glucose control must be established now.

Page Ref: 384 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance

Standards: Nursing Process: Intervention | Learning Outcome: 8.5 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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13) The client diagnosed with diabetes mellitus calls the nurse to complain about dizziness that occurs upon standing. The nurse informs the client that this may be caused by which initial complication related to diabetes mellitus?

A) Hypertension B) Impaired peripheral circulation C) Diabetic autonomic neuropathy D) Diabetic nephropathy Answer: C Explanation: Neuropathy caused by diabetes leads to postural hypotension, which causes the client to have dizziness when standing.

Page Ref: 384 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Intervention | Learning Outcome: 8.5 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

14) The nurse is caring for a client who has just been diagnosed with diabetes mellitus. The client tells the nurse that she went to the doctor with symptoms of a urinary tract infection and ended up being admitted with diabetes mellitus. She then tells the nurse that her father had diabetes and he ended up dying with kidney failure. The client says, "It looks like that's what is going to happen to me. My kidneys are already messed up." Which is the nurse's BEST response to this client's statement?

Standards: Nursing Process: Intervention | Learning Outcome: 8.5 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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A) "It does appear that your disease is progressing quite quickly. Do you have anyone in your family who would donate a kidney for you?"

B) "I wouldn't worry about that right now. Your first job is to get used to having diabetes."

C) "Have you had any other symptoms of kidney failure such as edema or high blood pressure?"

D) "Your current infection was caused by the diabetes, but watching your blood sugar in the future will help prevent complications."

Answer: D Explanation: The nurse is correct to help the client see the connection between good blood sugar control and prevention of complications.

Page Ref: 384 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: Nursing Process: Intervention | Learning Outcome: 8.5 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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15) The nurse is observing a client obtain a capillary blood specimen for glucose and notes that the client actively squeezes the finger after piercing it with a lancet and then places a drop of blood on the test strip. The meter shows the blood glucose as 126 mg/dl. How does the nurse interpret these results?

A) The blood sugar is within normal limits for a client with diabetes mellitus.

B) The blood sugar result may be incorrect. The milking of the finger caused the test to read lower than it should.

C) The client should be treated for hypoglycemia because the milking of the finger caused the test to read higher than it should.

D) The client should be instructed to apply pressure to the fingertip when obtaining a capillary blood glucose instead of squeezing the finger.

Answer: B Explanation: The blood sugar reading may be lower than the actual result because of the squeezing or milking of the finger that the client performed after piercing the skin with the lancet.

Page Ref: 381 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 8.6 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

16) The client tells the nurse that he doesn't check his blood sugar as often as he should because his fingers are so sore from pricking them. How can the nurse assist this client to be more compliant with his blood sugar monitoring?

A) Push the injector as far into the finger as possible to ensure that an adequate drop is obtained with the first prick.

B) Hang the hand to be used below the waist for a minute to make sure the site that is chosen will have adequate blood supply for the test.

C) For best results, choose the pad of the finger for the test.

D) Allow two or three drops of blood to fall, wipe them away, and then place the next drop of 14

blood on the test strip.

Answer: B Explanation: Hanging the hand below the waist will increase blood supply to the finger chosen for the blood sample and will make obtaining the correct size blood sample easier for the client.

Page Ref: 381 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Intervention | Learning Outcome: 8.6 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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17) Place in correct order the steps for obtaining capillary blood glucose sampling.

A) Cleanse the side of the client's finger.

B) Apply the blood to the test strip.

C) Pierce the skin with a lancet.

D) Calibrate the blood glucose meter.

E) Apply clean gloves.

F) Wipe away the first drop of blood.

Answer: D, A, E, C, F, B Explanation: A) Cleansing the site is completed after the glucometer is calibrated.

B) Application of blood to the test strip is the last step in capillary blood glucose sampling.

C) Piercing the skin with a lancet is completed after putting on clean gloves.

D) Calibrating the glucometer is the first step in the process to ensure the result is correct.

E) Clean gloves are applied immediately before piercing the skin.

F) The first drop of blood is wiped away before applying the blood to the test strip.

Page Ref: 380-81 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Intervention | Learning Outcome: 8.6 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

18) The nurse in the clinic receives a call from a client diagnosed with diabetes mellitus who states his blood sugar is 275 mg/dl and he doesn't feel well. Which is the first thing the nurse should tell the client to do?

A) Obtain a urine specimen and check it for ketones.

B) Immediately go to the emergency department to be admitted.

C) Drink a large beverage that has sugar and electrolytes and recheck the blood sugar.

D) Ask the client if he has a headache or irritability.

Answer: A Explanation: The client has developed hyperglycemia and also states he doesn't feel well, so the nurse should first have the client check his urine for ketones to see if he is developing diabetic 16

ketoacidosis.

Page Ref: 383 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Intervention | Learning Outcome: 8.7 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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19) A nurse is shopping and notes an individual who is acting oddly. The nurse notes that the person is sweating and appears confused. The nurse approaches the individual, helps him find a seat, and takes the pulse, which is increased. The person complains of a headache. Which is this nurse's first action in assisting this individual?

A) Ask for someone in the store to call for emergency assistance.

B) Ask the individual if he has any hard candy in his pocket.

C) Lie the individual on the floor and raise the individual's feet above the heart.

D) Determine if the store has an automated external defibrillator (AED).

Answer: B Explanation: By asking the person if hard candy is in the pocket, the nurse can immediately give the person a quick source of glucose and begin raising the blood sugar.

Page Ref: 383 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Intervention | Learning Outcome: 8.7 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

20) The nurse is working with a client who has just been diagnosed with diabetes mellitus and informs the client to adhere to which principles that will be most helpful at preventing complications of this disease? Select all that apply.

A) Monitor your blood glucose levels at least once each week.

B) Make sure to take your oral antidiabetic medications as ordered.

C) Exercise at least an hour a day.

D) Make sure that meals and snacks are eaten at regular times.

E) See your healthcare provider (HCP) regularly even if you don't feel ill.

Answer: B, D, E Explanation: Oral antidiabetic drugs or insulin need to be taken as prescribed to prevent complications.

Food intake should be regulated so that it matches the insulin or oral antidiabetic medications that are taken.

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It is important for the client to see the HCP regularly to ensure that complications are not developing or to catch early signs of complications.

Page Ref: 383 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Intervention | Learning Outcome: 8.8 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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21) The nurse is talking to a client who has come to the clinic for a fasting blood sugar to monitor the client's blood sugar. The nurse notes that the client is wearing new tennis shoes.

Which statement by the client about the shoes would indicate that the client needs further instruction about diabetic foot care?

A) "I am careful to measure the temperature of the water before I get in the bathtub to make sure I don't hurt my feet."

B) "I am so excited about my new shoes. They are a little tight, but the more I wear them the more they will loosen up."

C) "I make sure that my sock don't fit too tightly around my leg."

D) "I am a little worried about cutting my toenails correctly, so I'm going to go to the podiatrist to make sure there is no problem."

Answer: B Explanation: The individual with diabetes should not wear shoes that are too tight because it may cause a blister or a sore that will be difficult to heal.

Page Ref: 384 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Intervention | Learning Outcome: 8.8 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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Clinical Nursing Skills: A Concept-Based Approach, 3e (Pearson) Chapter 9 Mobility

1) The nurse observes the unlicensed assistive person (UAP) perform range-of-motion (ROM) exercises to a client's leg. The nurse knows that UAP is correctly performing abduction of the hip when which set of motions is completed?

A) The UAP moves the leg to the side away from the body.

B) The UAP moves the leg from the side of the body across and in front of the other leg.

C) The UAP bends the knee and brings the heel toward the back of the thigh.

D) The UAP moves the foot down and away from the leg.

Answer: A Explanation: Abduction is the movement of a limb away from the medial plane of the body so abduction of the leg would be movement to the side away from the body.

Page Ref: 391 Cognitive Level: Remembering Client Need/Sub: Physiologic Integrity: Basic Care and Comfort Standards: Nursing Process: Intervention | Learning Outcome: 9.2 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential VI: Interprofessional Communication and Collaboration for Improving Patient Health Outcomes NLN Competencies: Nursing Judgment

2) The UAP is caring for a 79-year-old client who is immobilized and is preparing to complete range-of-motion (ROM) exercises. The nurse cautions the UAP to avoid which motion in an elderly client?

A) Flexion B) Extension C) Hyperextension D) Abduction Answer: C Explanation: Hyperextension should be avoided in the elderly because joints become joints become less flexible with age and hypertension may cause pain or nerve damage.

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Page Ref: 391 Cognitive Level: Remembering Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Intervention | Learning Outcome: 9.2 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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3) The nurse is teaching a group of newly hired UAP's about proper body mechanics and instructs them to use which most important piece of equipment to ensure that proper body mechanics are used?

A) Gait belt B) Assistive moving device C) Additional staff D) No special equipment is required Answer: D Explanation: No special equipment is required to do proper body mechanics but the healthcare worker must know what equipment is available to assist with safe movement of a client.

Page Ref: 388 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 9.1 | QSEN Competencies: Teamwork and Collaboration AACN Ess. Comps.: Essential II: Basic Organizational and Systems Leadership for Quality Care and Patient Safety NLN Competencies: Nursing Judgment

4) The nurse is observing an unlicensed assistant person (UAP) make an occupied bed and will provide correction if the UAP uses which technique with body mechanics?

A) The UAP stands close to the bed while making it.

B) The UAP pulls the client to move him in the bed.

C) The UAP distributes weigh evenly between both feet.

D) The UAP carries the clean sheets and blankets close to the body.

Answer: B Explanation: Pulling an object (or client) to move it puts a strain on a person's back. The UAP should push to move the object using the legs.

Page Ref: 401 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 9.1 | QSEN Competencies: Safety 3

AACN Ess. Comps.: Essential II: Basic Organizational and Systems Leadership for Quality Care and Patient Safety NLN Competencies: Human Flourishing

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5) The charge nurse is making assignments for the nursing unit and knows that which healthcare worker is responsible for ensuring that staff use proper body mechanics in caring for assigned clients?

A) The charge nurse B) The education director C) The client's healthcare provider D) All healthcare personnel Answer: D Explanation: All healthcare personnel are responsible for using proper body mechanics when caring for clients.

Page Ref: 388 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Planning | Learning Outcome: 9.1 | QSEN Competencies: Teamwork and Collaboration AACN Ess. Comps.: Essential II: Basic Organizational and Systems Leadership for Quality Care and Patient Safety NLN Competencies: Nursing Judgment

6) The nurse attempts to meet the developmental needs of a four-year-old child while doing range of motion (ROM) exercises by doing what with the child?

A) Explaining why the ROM exercises must be done.

B) Promising the child, a treat after ROM exercises are completed.

C) Turning the ROM exercises into a game.

D) Asking the child's parents to complete the ROM exercises.

Answer: C Explanation: Turning the ROM exercise experience into a game will meet the child's developmental needs and elicit the most cooperation from the child.

Page Ref: 393 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Intervention | Learning Outcome: 9.2 | QSEN Competencies: 5

Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Human Flourishing

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7) The nurse has completed discharge teaching about range-of-motion exercises with an elderly client that are to be completed at home. The nurse explains that these exercises are important to complete for what reason?

A) ROM exercises will help the client maintain necessary muscle mass.

B) ROM exercises prevent the elderly client from becoming depressed.

C) ROM exercises increase the elderly client's dependent behaviors.

D) ROM exercises causes an elderly client to use proper body mechanics.

Answer: A Explanation: ROM exercises will help prevent a loss of muscle mass which could lead to difficulties performing activities requiring strength.

Page Ref: 394 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Intervention | Learning Outcome: 9.2 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 8) The nurse is observing a UAP assist a client with a vascular problem back into bed. The nurse would intervene if the UAP placed this client in what position in the bed?

A) Low-Fowler B) Semi-Fowler C) Orthopneic position D) Elevate knee-gatch position Answer: D Explanation: The elevate knee-gatch bed position is contraindicated in clients with vascular problems because it will put pressure on the blood vessels at the back of the knee.

Page Ref: 403 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Intervention | Learning Outcome: 9.3 | QSEN Competencies: Patient-Centered Care 7

AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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9) The nurse is preparing to place a client with COPD in the orthopneic bed position and will place what item in front of this client that is necessary to maintain this position?

A) Wheelchair B) Stationary chair C) Over the bed table D) Client's urinal Answer: C Explanation: An overbed table is necessary when the client is in the orthopneic position because it assists the client with exhalation.

Page Ref: 403 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Intervention | Learning Outcome: 9.2 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

10) The nurse is caring for a client who is complaining of esophageal reflux symptoms. After administering the prescribed medication, the nurse will place the client in what bed position to assist in providing comfort to this client?

A) Semi-Fowlers B) Reverse Trendelenburg C) Trendelenburg D) High-Fowler Answer: B Explanation: Reverse Trendelenburg places the client in position with the bed tilted down starting at the head of the bed. This allows gravity to assist with keeping gastric contents in the stomach and out of the esophagus.

Page Ref: 404 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Intervention | Learning Outcome: 9.3 | QSEN Competencies: 9

Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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11) The nurse and the UAP are preparing to logroll a client who has a spinal injury. The nurse will ask the UAP to obtain what assistive device prior to beginning the procedure?

A) Trochanter roll B) Hydraulic lift C) Friction-reducing device D) Foot board Answer: C Explanation: A friction-reducing device is necessary to pull the client to the side of the bed prior to logrolling the client.

Page Ref: 410 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Assessment | Learning Outcome: 9.4 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

12) The nurse is caring for a client with limited movement who weighs 415 pounds and will plan to use which assistive device when moving this client up in bed?

A) Mechanical lift B) Turn sheet C) Fiction-reducing device D) Pull sheet Answer: A Explanation: A mechanical lift is necessary to move an obese client up in the bed because the client's weight and immobility will require the nurse to lift more than 35 pounds of the client's weight.

Page Ref: 413 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Assessment | Learning Outcome: 9.4 | QSEN Competencies: Patient-Centered Care 11

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13) The nurse and the UAP are preparing to move a client from the bed to a chair for the first time using a hydraulic lift. What is the first thing the nurse should do prior to beginning this procedure?

A) Place the canvas sling under the client's thighs.

B) Place the client in the supine position.

C) Lock the wheels of the client's bed.

D) Demonstrate the use of the hydraulic lift to the client.

Answer: D Explanation: Prior to using the hydraulic lift with a client for the first time, the nurse should demonstrate the use of the lift to calm any anxieties the client may have about the lift.

Page Ref: 396 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Intervention | Learning Outcome: 9.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 14) The nurse is caring for a client who uses a hydraulic lift to be moved out of the bed. What is the nurse's first action prior to starting this procedure?

A) Perform hand hygiene.

B) Request help from another staff member.

C) Roll the client to the side to position the sling.

D) Demonstrate the use of the hydraulic lift to the client.

Answer: B Explanation: A minimum of 2 healthcare workers is required to safely move a client with a hydraulic lift. The nurse should first obtain assistance.

Page Ref: 397 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 9.5 | QSEN Competencies: Safety AACN Ess. Comps.: Essential II: Basic Organizational and Systems Leadership for Quality 13

Care and Patient Safety NLN Competencies: Nursing Judgment

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15) The nurse is preparing to assist a client with ambulation and knows a gait belt may not be appropriate to use for a client with which condition?

A) A client wearing a knee brace.

B) A client who uses a walker for ambulation.

C) A client who has a large abdominal incision.

D) A client who has vertigo.

Answer: C Explanation: A gait belt may not be appropriate for a client who has an abdominal incision because of the pressure is may put on the incision.

Page Ref: 396 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 9.4 | QSEN Competencies: Safety AACN Ess. Comps.: Essential II: Basic Organizational and Systems Leadership for Quality Care and Patient Safety NLN Competencies: Nursing Judgment

16) The nurse is watching an unlicensed assistive person (UAP) prepare to move an eighteenmonth-old toddler from the pediatric unit to the radiology unit. The nurse will stop the UAP if the UAP chooses which form of transport?

A) The child's crib B) Pediatric wheelchair C) Walking while holding the mother's hand D) Stretcher Answer: D Explanation: A stretcher is not a safe form of transport because a mobile toddler could possibly fall off of it.

Page Ref: 412 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 9.6 | QSEN Competencies: Safety AACN Ess. Comps.: Essential II: Basic Organizational and Systems Leadership for Quality 15

Care and Patient Safety NLN Competencies: Nursing Judgment

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17) The nurse is preparing to transport a six-month-old infant to the radiology department. What measures will the nurse institute to safely complete this procedure? Select all that apply.

A) Ensure the parents stay in the infant's room.

B) Unhook all monitors and IV lines prior to transporting the infant.

C) Use a high-top crib for transporting.

D) Cover the infant with a blanket.

E) Ensure the infant's hands are washed before transport begins.

Answer: C, D Explanation: A high-top crib ensures the infant can't fall during transport.

Infant is kept covered to prevent hypothermia from occurring.

Page Ref: 412 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 9.6 | QSEN Competencies: Safety AACN Ess. Comps.: Essential II: Basic Organizational and Systems Leadership for Quality Care and Patient Safety NLN Competencies: Nursing Judgment

18) The nurse will stand where when preparing to ambulate a client who uses crutches?

A) On the client's affected side and slightly behind.

B) On the client's strong side and slightly ahead.

C) On the client's affected side and directly next to the client.

D) On the client's strong side and directly next to the client.

Answer: A Explanation: The nurse stands behind the client and toward the affected side to provide support if the client loses balance.

Page Ref: 416 Cognitive Level: Remembering Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 9.7 | QSEN Competencies: Safety AACN Ess. Comps.: Essential II: Basic Organizational and Systems Leadership for Quality Care and Patient Safety 17

NLN Competencies: Nursing Judgment

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19) The nurse is aware that which client would best be able to handle a three-point gait using crutches?

A) A 76-year-old client who complains of pain in both knees.

B) A 25-year-old client with a broken right ankle.

C) A 19-year-old client with a broken right tibia and a sprained left foot.

D) A 55-year-old client with a fractured left patella and a right foot laceration.

Answer: B Explanation: The three-point gait requires that the client must bear the entire body weight on the unaffected leg. A young person whose only injury is a broken right ankle would be able to do this.

Page Ref: 417 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Assessment | Learning Outcome: 9.7 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 20) The nurse is aware that clients who use the swing-to-gait for ambulation on a regular basis are at risk for development of which problem?

A) Atrophy of the arm muscles B) Fractures of the feet C) Atrophy of the leg muscles D) Sciatic nerve injury Answer: C Explanation: Prolonged use of the swing-to-gait can cause atrophy of unused muscles, the legs.

Page Ref: 418 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 9.7 | QSEN Competencies: PatientCentered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice 19

NLN Competencies: Nursing Judgment

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21) The nurse is caring for a client who was placed in skeletal traction 48 hours ago for treatment of a serious femur fracture. The nurse will check the client's neurovascular status of the client's affected foot how often?

A) Every 30 minutes B) Every 1 hour C) Every 4 hours D) Every 24 hours Answer: C Explanation: The client's neurovascular status is checked every 4 hours while the client remains in traction.

Page Ref: 423 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Intervention | Learning Outcome: 9.8 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

22) The nurse is preparing to conduct an hourly assessment of a client who was placed in skin traction approximately 6 hours ago and has been stable since that time. The plan is to check the client's vital signs, pain level and complete what other assessments? Select all that apply.

A) Neurovascular assessment of the unaffected leg.

B) Skin integrity of both heels.

C) Massage the skin of the buttocks with a dry washcloth.

D) Ensure traction weight is correctly placed.

E) Ensure client's shoulders and hips are in alignment.

Answer: B, D, E Explanation: Check the skin integrity of any area exposed to the surface of the bed like the heels.

The nurse should ensure that the weights are hanging properly, not sitting on the floor.

The body alignment shoulders and hips in alignment) should be checked often.

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Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 9.8 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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23) The nurse has asked the unlicensed assistive person (UAP) to provide personal care to the client who is in skin traction and will ensure that UAP knows to place the client in what position?

A) Semi-Fowler B) Low-Fowler C) Lateral D) Supine Answer: D Explanation: The client in skin traction must be maintained in the supine position to maintain body alignment and proper traction.

Page Ref: 428 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 9.8 | QSEN Competencies: Safety AACN Ess. Comps.: Essential VI: Interprofessional Communication and Collaboration for Improving Patient Health Outcomes NLN Competencies: Nursing Judgment

24) The nurse is preparing to do pin site care for a client in skeletal traction. It is noted that the site appears red and feels warm to the touch. What actions will the nurse perform in taking care of this situation? Select all that apply.

A) Notify the healthcare provider.

B) Refrain from disturbing the crusts around the pin until the healthcare provider can observe it.

C) Expect to obtain a culture and sensitivity specimen from the pin site.

D) Remove the client's traction weights until the healthcare provider sees the client.

E) Check the client's vital signs.

Answer: A, C, E Explanation: The healthcare provider should be notified immediately once an infection is suspected.

A culture and sensitivity of the drainage is obtained so antibiotic sensitivity can be determined.

The nurse should take the client's temperature to monitor for signs of systemic infection.

Page Ref: 429 12

Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 9.8 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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Clinical Nursing Skills: A Concept-Based Approach, 3e (Pearson) Chapter 10 Nutrition

1) The nurse is teaching about nutritional requirements of the newborn to his new parents. The nurse should recognize that the parents need further instruction when which statement is made?

A) "I will only feed my baby as much formula as he wants to eat at each feeding."

B) "I will mix rice cereal in my baby's bottle before he goes to bed so he will sleep better."

C) "I will hold my baby while I feed him and for about 15 minutes after he eats."

D) "I will wash my hands before I mix my baby's formula."

Answer: B Explanation: Solid foods including rice cereal shouldn't be introduced until the baby is at least 6 months old.

Page Ref: 439-440 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 10.1 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

2) The nurse is teaching a group of toddler parents about snack foods that are safe for this age group and should include which food in this teaching?

A) Grapes B) Popcorn C) Corn chips D) Applesauce Answer: D Explanation: Applesauce is safe because it is easily swallowed and is not a choking hazard.

Page Ref: 440 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 10.1 | QSEN Competencies: 1

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3) The nurse is working with a group of parents of toddlers and should know that further instruction is needed when which statement is heard?

A) "I carefully cut up all of my child's food so he can easily eat it."

B) "I put food on my toddler's plate but I don't get upset if he doesn't eat it all."

C) "I promise my toddler that he can have a cookie if he does what I ask him to do."

D) "I allow my child to help me cook even though it gets pretty messy."

Answer: C Explanation: Food should never be used as a bribe.

Page Ref: 440 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 10.1 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 4) The nurse knows that which setting would be most effective in assisting teenagers to eat a more nutritious diet?

A) In a small group of their peers B) At the hospital cafeteria C) At a table with parents D) Served to each teenager privately Answer: A Explanation: Teenagers are influenced the most by their own peer group.

Page Ref: 440 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 10.1 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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5) The nurse is performing a nutritional assessment of an older adult client who has reported a 10-pound weight loss in the last 6 weeks with no history of dieting. If no disease process is found, the nurse is aware that weight loss can result from what issue for this age group?

A) The client attends a daily meal program for senior citizens.

B) The client appears to have loose, ill-fitting dentures.

C) The client lives with a daughter who fixes dinner every night.

D) The client has a regular elimination schedule.

Answer: B Explanation: Loose or ill-fitting dentures may cause the client to avoid chewing foods, which can lead to decreased intake and weight loss.

Page Ref: 444 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 10.2 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

6) The nurse is caring for a client who is in the midst of a 24-hour urine collection for urinary nitrogen and would know which test will help determine if the client has an adequate intake of what nutrient?

A) Carbohydrates B) Fats C) Proteins D) Sugars Answer: C Explanation: The 24-hour urinary nitrogen test is done to measure inadequate protein intake.

Page Ref: 445 Cognitive Level: Remembering Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 10.2 | QSEN Competencies: Client-Centered Care 4

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7) The nurse is completing an anthropometric measurement of an individual and should use which instruments to complete this assessment?

A) Yard stick and scale B) Yard stick and tape measure C) Tape measure and ruler D) Tape measure and skinfold caliper Answer: D Explanation: Anthropometric measurements require a tape measure to measure circumference of the upper arm and a skinfold caliper to measure skinfold thickness of the triceps muscle.

Page Ref: 444 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 10.2 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

8) The nurse is completing an admission assessment of a bedridden client and will use which technique to measure the height of this client?

A) Place the client in a bed sling and use a tape measure to measure the client's length.

B) Ask the client to fully extend both arms out to the sides of the body and measure the arm span.

C) Assist the client to a sitting position and measure the length of the client's spine and double the number.

D) Using a tape measure, measure around the client's fist and multiply by 5.

Answer: B Explanation: The best way to estimate height in a bedridden client is to measure the client's arm span.

Page Ref: 444 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Assessment | Learning Outcome: 10.2 | QSEN Competencies: 6

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9) The nurse is working with a group of parents who have children that are extremely picky eaters and tells them that which makes the biggest impact on a child's lifetime eating habits?

A) Peer groups as teenagers B) Being breastfed as an infant C) Habits learned as a young child D) Lessons on nutrition taught in middle school Answer: C Explanation: The biggest impact on a child's lifetime eating habits are the habits learned as a young child.

Page Ref: 440 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 10.3 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 10) The nurse is assisting a client with swallowing difficulties to eat and should encourage the client to put how much food on the spoon at one time?

A) 1/4 tsp B) 1 tsp C) 1 tbs D) 3 tbs Answer: B Explanation: The client should be instructed to take 1/2 to 1 tsp with each bite to avoid choking but be large enough for chewing.

Page Ref: 441 Cognitive Level: Remembering Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Intervention | Learning Outcome: 10.4 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice 8

NLN Competencies: Nursing Judgment

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11) The nurse observes a client with dysphagia who is eating and should discourage which activity?

A) Using a straw B) Using a spoon to eat a milkshake C) Using a towel under the plate D) Sitting at a 90-degree angle in bed Answer: A Explanation: The use of a straw increases the risk of aspiration and should be discouraged.

Page Ref: 442 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Intervention | Learning Outcome: 10.4 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

12) The nurse is feeding a client with dementia and should assist swallowing with which nursing action?

A) Encourage the client to drink water between each bite.

B) Stroke the client in a downward motion under the chin.

C) Blow softly in the client's face to encourage swallowing.

D) Tell the client to quickly take bites to facilitate swallowing.

Answer: B Explanation: Gently stroking the client under the chin in a downward motion during swallowing helps to cue the client to swallow.

Page Ref: 442 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 10.4 | QSEN Competencies: Safety AACN Ess. Comps.: Essential II: Basic Organizational and Systems Leadership for Quality Care and Patient Safety 10

NLN Competencies: Nursing Judgment

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13) The nurse has just finished inserting a nasogastric tube into a client that will be used for enteral feeding and knows that prior to starting the feeding, tube placement will best be confirmed using which method?

A) Determining the presence of carbon dioxide B) Ensuring that the gastric aspirate has a pH higher than 7 C) Obtaining an x-ray to confirm placement D) Inserting 30 mL of air into the tube and listening over the stomach for the whoosh Answer: C Explanation: An x-ray is the best way to confirm tube placement because all nasogastric tubes are marked to be seen on x-ray.

Page Ref: 459 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 10.5 | QSEN Competencies: Evidence-Based Practice AACN Ess. Comps.: Essential II: Basic Organizational and Systems Leadership for Quality Care and Patient Safety NLN Competencies: Nursing Judgment

14) The nurse is caring for a client who will be receiving continuous enteral feeding through a nasogastric feeding tube. The nurse is aware that which is the most dangerous complication associated with improper nasogastric tube placement?

A) Diarrhea B) Vomiting C) Pneumonia D) Dehydration Answer: C Explanation: Aspiration pneumonia is by far the most dangerous complication associated with feeding a client when the feeding tube is improperly placed.

Page Ref: 459 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control 12

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15) The nurse has just completed insertion of a nasogastric tube that is needed for gastric lavage of a client. Radiographic confirmation of placement is not possible at this time, so the nurse should use which method to best determine tube placement?

A) Aspirate gastric contents and determine the bilirubin level.

B) Observe for signs of respiratory distress.

C) Determine that the pH of the gastric aspirate is below 4.

D) Detect for carbon dioxide and determine the gastric pH. Answer: D Explanation: If an x-ray confirmation is not available, the nurse should use two different methods such as lack of respiratory distress and acid gastric aspirate.

Page Ref: 459 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Intervention | Learning Outcome: 10.5 | QSEN Competencies: Evidence-Based Practice AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 16) The nurse is preparing to insert a nasogastric tube into a newborn and plans to use which landmark to ensure that the tube reaches into the infant's stomach?

A) The tip of the xiphoid process B) Midway between the nipples C) Midway between the xiphoid and the umbilicus D) The top of the symphysis pubis Answer: C Explanation: In a newborn, the length of the NG tube is measured from the nose to the tip of the earlobe to a point midway between the umbilicus and the xiphoid process.

Page Ref: 461 Cognitive Level: Remembering Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Intervention | Learning Outcome: 10.5 | QSEN Competencies: Evidence-Based Practice 14

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17) The nurse is caring for a client receiving enteral nutrition through a syringe. Midway through the feeding, the client complains of gas pains. Which is the nurse's best action at this time?

A) Contact the healthcare provider.

B) Clamp the tubing going to the client for a short time to see if symptoms are relieved.

C) Stop the feeding and remove the nasogastric tube.

D) Continue the feeding while reassuring the client that this is a common issue related to enteral feedings.

Answer: B Explanation: If a client complains of flatus, cramps, or vomiting during a syringe feeding, the nurse should pinch or clamp the tubing to stop the flow for a minute.

Page Ref: 454 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Intervention | Learning Outcome: 10.6 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

18) The nurse has just begun a new enteral feeding on a client using a closed system of formula.

The nurse labels the bag with the time and date it was begun (1300 hours on 12/6) knowing that this will mean the feeding tubing set will need to be changed at which time and date?

A) 1300 hours on 12/7 B) 0100 hours on 12/7 C) 1300 hours on 12/8 D) 1300 hours on 12/9 Answer: A Explanation: Whether using a closed or an open system, the feeding tubing set is usually changed every 24 hours to reduce the risk of contamination.

Page Ref: 454 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 10.6 | QSEN Competencies: 16

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19) The nurse is caring for a client receiving total parenteral nutrition and will instruct the unlicensed assistive person (UAP) to complete which assessment every 4 hours?

A) Blood pressure B) Pulse C) Temperature D) Pain level Answer: C Explanation: The client receiving TPN is at a high risk for infection, so temperature assessment should be completed at least every 4 hours.

Page Ref: 467 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessment | Learning Outcome: 10.7 | QSEN Competencies: Safety AACN Ess. Comps.: Essential VI: Interprofessional Communication and Collaboration for Improving Patient Health Outcomes NLN Competencies: Nursing Judgment

20) The nurse started a lipid infusion on a client approximately 1 hour ago and will observe for which signs and symptoms related to lipid side effects? Select all that apply.

A) Dizziness B) Peripheral neuropathy C) Nausea D) Joint pain E) Headache F) Insomnia Answer: A, C, E Explanation: Dizziness is an IV lipid side effect.

Nausea and vomiting are known IV lipid side effects.

Headache is a known IV lipid side effect.

Page Ref: 464 Cognitive Level: Analyzing 18

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 10.8 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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21) The nurse is preparing to infuse intravenous lipids on a client and should utilize which safety considerations when completing this action?Select all that apply.

A) Perform hand hygiene prior to touching any of the equipment.

B) Swab the stopper of the IV bottle with alcohol and immediately spike the bottle.

C) Hang the IV bottle of lipids approximately 18 inches above the IV site.

D) Piggyback the lipids into the port closest to the client.

E) Set the pump for 100 mL/hour.

Answer: A, D Explanation: Hand hygiene should always be performed prior to beginning any procedure. In addition, the nurse will wear clean gloves when hanging the infusion.

The lipids should be piggybacked into the port closest to the client.

Page Ref: 463-464 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Intervention | Learning Outcome: 10.8 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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Clinical Nursing Skills: A Concept-Based Approach, 3e (Pearson) Chapter 11 Oxygenation

1) The nurse has been asked to obtain a sputum specimen from a client who is in the first postoperative day after a surgical gastric resection for stomach cancer. The nurse will ensure that which item is provided to the client to ensure an effective sputum collection?

A) Supplemental oxygen B) Folded bath blanket C) Peak expiratory flow meter D) Sterile applicator stick Answer: B Explanation: A folded bath blanket will be used by the client to hold against the abdomen to allow for effective coughing.

Page Ref: 476 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Intervention | Learning Outcome: 11.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

2) After completing instructions for collecting a sputum specimen to the client, the nurse observes the client remove the lid of the specimen container and spit into the cup. Which is the nurse's next best action?

A) Ask the client if the specimen obtained was sputum or saliva.

B) Explain to the client that the specimen will have to be obtained by suctioning.

C) Provide the client with a new specimen container and explain again how to obtain the specimen.

D) Send the specimen to the lab as obtained but label it as saliva.

Answer: C Explanation: The nurse should explain again how to obtain the specimen and give the client a new specimen container.

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Page Ref: 476 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Intervention | Learning Outcome: 11.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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3) The nurse is assisting a client in obtaining a sputum specimen. After a deep cough, the client produces approximately 1/2 tsp of sputum. Which is the nurse's next action?

A) Assist the client to cough again and produce more sputum.

B) Send the specimen to the lab.

C) Allow the client to rest for one hour and then ask the client to cough again.

D) Ask the client to walk around for 30 minutes and try again to produce sputum.

Answer: A Explanation: A sputum specimen requires 1-2 tsp of sputum, so the nurse should assist the client to repeat the coughing to produce additional sputum.

Page Ref: 476 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Intervention | Learning Outcome: 11.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

4) The nurse is preparing to assist a client in obtaining a sputum specimen and should place the client in which position?

A) Low Fowler's B) Side-lying C) Semi-Fowler's D) Trendelenburg Answer: C Explanation: Semi-Fowler's position allows for maximum lung ventilation and expansion. Other positions that would be effective would be high Fowler's, or sitting on the side of a bed or in a chair.

Page Ref: 476 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Intervention | Learning Outcome: 11.1 | QSEN Competencies: Patient-Centered Care 3

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5) The nurse should encourage the client to use incentive spirometry prior to which procedure?

A) Ambulating the client B) Preparing the client for a rest period C) Removing the client's meal tray D) Obtaining a sputum specimen Answer: D Explanation: The deep breathing that is completed with incentive spirometry may help a client prepare for obtaining a sputum specimen.

Page Ref: 479 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Intervention | Learning Outcome: 11.2 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 6) The nurse observes a client using the incentive spirometer and s that further instruction is required when the client performs which action?

A) Exhales before placing the incentive spirometer to the lips B) Seals the lips tightly around the mouthpiece of the incentive spirometer C) Inhales quickly, causing the spirometer balls to snap to the top of the incentive spirometer D) Attempts to cough productively after using the incentive spirometer Answer: C Explanation: The client should inhale slowly, not quickly, and deeply to ensure maximal lung expansion.

Page Ref: 479 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 11.2 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 5

7) The nurse should know that which takes priority in assisting the client to effectively use a volume-oriented incentive spirometer?

A) The spirometer must be held in an upright position.

B) A nose clip must be used for effective inhalation.

C) The procedure must be repeated every 15 minutes to be effective.

D) Clean the spirometer in the dishwasher when used at home.

Answer: A Explanation: A volume-oriented incentive spirometer must be used in an upright position to function correctly.

Page Ref: 479 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 10.1 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

8) The nurse is caring for a 4-year-old postoperative client who has been unable to understand the use of the incentive spirometer. The nurse should choose which activity that will assist the child to perform the same action as the spirometer?

A) Blowing out candles B) Sucking on a straw C) Filling up a balloon D) Using bubbles Answer: B Explanation: Incentive spirometry focuses on inhalation, which is the action that sucking on a straw will imitate.

Page Ref: 480 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Intervention | Learning Outcome: 11.2 | QSEN Competencies: Patient-Centered Care 6

AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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9) The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen and should intervene if which delivery device is being used by the client?

A) Nasal cannula B) Continuous positive airway pressure (CPAP) C) Bilevel positive airway pressure (BiPAP) D) Venturi face mask Answer: D Explanation: A Venturi face mask provides oxygen concentrations from 24% to 50% with flow rates from 4-10 L/min, which would be too high for a client with COPD and may cause the client's breathing stimuli to be suppressed.

Page Ref: 486 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 11.3 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

10) The nurse is caring for a group of clients with respiratory disorders and should know that which client should not be placed on continuous positive airway pressure (CPAP) to assist with respiratory distress?

A) The client with chronic obstructive pulmonary disease (COPD) who is complaining of shortness of breath B) The client whose respirations have fallen to 8/minute after receiving morphine sulfate C) The client who experiences apnea during sleep D) The client who is experiencing wheezing and is having difficulty moving air adequately Answer: B Explanation: CPAP should never be used on clients receiving opioids because it causes the pharynx to relax and contributes to further airway obstruction.

Page Ref: 487 Cognitive Level: Analyzing 8

Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessment | Learning Outcome: 11.3 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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11) The nurse is caring for a client who was just placed on supplemental oxygen per nasal cannula and should contact the healthcare provider if which assessment data are noted at the next assessment? Select all that apply.

A) The client complains of feeling anxious and restless.

B) Skin color is pink and warm to touch.

C) The heart rate is 82.

D) The respiratory rate is 36.

E) The client is using accessory muscles to breathe.

Answer: A, D, E Explanation: Feelings of anxiety and restlessness are signs of hypoxia and should be reported.

A respiratory rate of 36 indicates the client is breathing abnormally fast and it should be reported.

The use of accessory muscles to breathe indicates difficulty breathing and should be reported.

Page Ref: 488 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 11.3 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

12) The nurse is caring for a client who is exhibiting severe respiratory distress and is receiving supplemental oxygen through a nonrebreather mask. While assessing the client, the nurse notes that the bag attached to the mask is deflated. Which is the nurse's best action?

A) Document it as functioning normally.

B) Decrease the flow of oxygen to the mask.

C) Increase the flow of oxygen to the mask.

D) Prepare for endotracheal intubation.

Answer: C Explanation: If the bag is completely deflated, the nurse should increase the flow of oxygen to the mask and then contact the healthcare provider.

Page Ref: 486 10

Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 11.3 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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13) The nurse is caring for a client with pneumonia and should be most concerned about which assessment?

A) The client cannot remember which day it is.

B) The client's heart rate has risen from 72 to 78 bpm.

C) The client's pulse oximetry has decreased from 99% to 97%.

D) The client respiratory rate has risen from 16 to 20 breaths per minute.

Answer: A Explanation: One of the early signs of hypoxia is confusion and should be reported immediately.

Page Ref: 488 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessment | Learning Outcome: 11.4 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 14) The nurse is caring for a client with a respiratory disorder and should alert the healthcare provider if the client displays which signs or symptoms that indicate early hypoxia? Select all that apply.

A) Headache B) Nausea C) Heart rate of 52 D) Respiratory rate of 30 E) Blurred vision F) Hemoglobin of 17.3 mg/dl Answer: A, D, E Explanation: Headache is an early sign of hypoxia.

Tachypnea is an early sign of hypoxia.

Visual disturbances are an early sign of hypoxia.

Page Ref: 490 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential 12

Standards: Nursing Process: Assessment | Learning Outcome: 11.4 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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15) The nurse has just completed insertion of a nasal trumpet to assist in protecting a responsive client's airway and should place the client in which position to maintain the airway?

A) Supine with the head to the side B) Side-lying with chin positioned closest to the chest C) Prone with head to the side D) Side-lying with head slightly tilted up and centered on the pillow Answer: D Explanation: The client should be positioned in a side-lying position with the head slightly tilted up to maintain and open airway and to allow for adequate drainage of secretions.

Page Ref: 494 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 11.5 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 16) The nurse is preparing to insert an oropharyngeal airway in an unresponsive client and should do which to ensure the airway is inserted correctly?

A) Using a tongue depressor, push the tongue to the side of the mouth when inserting the airway.

B) Begin the procedure by inserting the airway upside down and then rotating it to the correct position.

C) Position the airway in a downward position and then rotate it upward as it passes by the back of the throat.

D) Refrain from taping the bottom of the airway to prevent esophageal injury when the client swallows.

Answer: B Explanation: The procedure is begun with the airway curved upward (upside down) and then rotated 180 degrees.

Page Ref: 495 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential 14

Standards: Nursing Process: Intervention | Learning Outcome: 11.5 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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17) The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is experiencing increasing respiratory difficulty. The client has refused being placed on a mechanical ventilator and the nurse is aware that which would provide possible respiratory assistance to this client?

A) Place an endotracheal tube without the use of a mechanical ventilator.

B) Provide supplemental oxygen using a Venturi face mask.

C) Put a nonrebreather mask on the client to help him breathe.

D) Place the client on a bilevel positive airway pressure (BiPAP) machine.

Answer: D Explanation: The use of a CPAP or BiPAP machine may provide an appropriate alternative to intubation.

Page Ref: 496 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 11.5 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 18) The nurse is observing a new mother use a bulb syringe to suction her newborn's nose and mouth and should provide further instruction if the mother performs which action?

A) The mother begins the procedure by suctioning the infant's nose.

B) The mother deflates the bulb before placing the tip of the bulb syringe in the infant's nose.

C) The mother releases the bulb and removes the bulb syringe from the infant's nose.

D) The mother washes the bulb syringe with soap and water and then allows it to air dry.

Answer: A Explanation: The mother should be taught to suction the infant's mouth before suctioning the infant's nose to prevent aspiration of secretions in the throat.

Page Ref: 499 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Intervention | Learning Outcome: 11.6 | QSEN Competencies: 16

Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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19) The nurse is preparing to do tracheostomy care for a client and should know that which must be present at the bedside before beginning this procedure?

A) One pair of sterile gloves B) Obturator C) Full-strength hydrogen peroxide D) Sterile water Answer: B Explanation: The nurse must have an obturator at the bedside in case the trach tube is inadvertently dislodged. The obturator will allow the tube to be reinserted immediately.

Page Ref: 505 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 11.7 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

20) The nurse is caring for an older adult client who had a tracheostomy placed 3 days ago and should know that which issue will take priority when caring for this client?

A) Reducing the client's anxiety concerning self-care of the tracheostomy B) Reassuring the client that the tracheostomy is a temporary measure C) Ensuring that the skin around the client's tracheostomy stoma is assessed frequently D) Referring the client to a support group for individuals with tracheostomies Answer: C Explanation: The nurse should place priority on caring for the skin around the client's stoma because older adults are more prone to skin breakdown.

Page Ref: 508 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 11.7 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice 18

NLN Competencies: Nursing Judgment

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21) The nurse is preparing to provide tracheostomy care to a 6-month-old infant and should know that which takes priority when performing this procedure?

A) Teaching the parents how to perform the procedure B) Ensuring that a second person is available to assist with the procedure C) Completing the procedure while the infant is asleep to minimize traumatizing the infant D) Use clean rather than sterile procedure because the infant will be going home with the tracheostomy Answer: B Explanation: An assistant should always be present while trach care is performed in an infant or child.

Page Ref: 508 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 11.7 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

22) The nurse is preparing to perform tracheostomy care on an alert, cooperative adult client and should request an assistant prior to which step?

A) An assistant is not required when performing tracheostomy care in a cooperative, alert adult client.

B) The assistant is required prior to pouring liquids into the sterile container.

C) The assistant is required prior to removing the inner cannula.

D) The assistant is required prior to removing and placing new tracheostomy ties.

Answer: D Explanation: The nurse requires assistance prior to changing the ties of the trach tube because it is at this time that the entire trach could be dislodged.

Page Ref: 508 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 11.7 | QSEN Competencies: 20

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23) The nurse is caring for a client who had a chest tube inserted 48 hours ago. During the first AM assessment, the nurse noted there was intermittent bubbling of the water in the water-seal chamber. When assessing the client 2 hours later, the nurse notes that the water is now continuously bubbling. Which is the nurse's priority action at this time?

A) Document the presence of the bubbling.

B) Immediately contact the healthcare provider.

C) Instruct the client to perform deep-breathing exercises.

D) Disconnect the chest tube from the drainage system and place the chest tube in a new chest tube drainage system.

Answer: B Explanation: Because continuous bubbling in the water-seal chamber indicates a possible break in the system, the nurse should immediately notify the healthcare provider and follow any orders received.

Page Ref: 510 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessment | Learning Outcome: 11.8 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 24) The nurse is caring for a client who has a chest tube. Upon assessment, the nurse notes that there is continuous bubbling of water in the suction container of the chest tube but very little if any bubbling in the water seal chamber. Which is the nurse's best action at this time?

A) Contact respiratory therapy for immediate assistance.

B) Reposition the client to the affected side.

C) Auscultate the client's lungs, paying close attention to the area near the chest tube.

D) Wait 15 minutes and reassess the client.

Answer: C Explanation: Auscultation of the client's lungs should be the nurse's first action because the nurse needs to know if there continues to be lack of air movement (tube is blocked) or possible healing of air leak before contacting the healthcare provider.

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Page Ref: 510 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 11.8 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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Clinical Nursing Skills: A Concept-Based Approach, 3e (Pearson) Chapter 12 Perfusion

1) A nurse is providing care to a client on complete bed rest. Which is the best explanation by the nurse as to the function of sequential compression devices?

A) "Inflatable compartments compress legs in a graduated sequential fashion."

B) "An air compressor fills an inflatable sleeve, then allows the air to drain out of the sleeve."

C) "Proper measurement will provide adequate pressure on the legs to facilitate venous return."

D) "The function is to promote circulation in the upper legs."

Answer: A Explanation: The compartment closest to the foot inflates first and the compartment closest to the thigh inflates last. The highest pressure is in the first compartment and the lowest in the last one. This creates a "milking" action to empty deeper veins of the lower leg to promote optimal blood flow.

Page Ref: 12 Cognitive Level: Analyzing Client Need/Sub: Basic Care and Comfort: Mobility/Immobility Standards: Nursing Process: Planning | Learning Outcome: 12.1 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety

2) The nurse is reading a 12-lead recording. Which lead will the nurse review as the best for monitoring atrial functioning?

A) Lead I B) Lead II C) Lead aVL D) Lead aVF Answer: B Explanation: Lead II records activity between the arm and leg, and is best for monitoring atrial functioning.

Page Ref: 16 Cognitive Level: Applying 1

Client Need/Sub: Reduction of Risk Potential: Diagnostic Tests Standards: Nursing Process: Evaluation | Learning Outcome: 12.3 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety

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3) How will the nurse know that the electrodes have been placed properly?

A) Lights on the box come on when electrodes are placed properly.

B) Follow the picture on the box for proper placement of electrodes.

C) Call the base station to run an ECG strip to check the signal of transmission.

D) Electrodes are placed correctly unless notified by the monitoring station.

Answer: C Explanation: The nurse needs to call and have the base station run an ECG strip to check the clarity of transmission when applying electrodes on a client being monitored by telemetry.

Page Ref: 19 Cognitive Level: Understanding Client Need/Sub: Reduction of Risk Potential: Diagnostic Tests Standards: Nursing Process: Evaluating | Learning Outcome: 12.2 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety 4) The nurse is placing electrodes on a client. Which is the correct placement of a 3-lead telemetry?

A) RA (white)-below right clavicle; LA (black)-below left clavicle; LL (red)-left lowest rib cage area B) RA (white)-right wrist; LA (black)-left wrist; LL (red)-left leg C) RA (green)-right lowest rib cage; LA (brown)-midaxillary line; LL (red) left lowest rib cage D) RA (green)-below right clavicle; LA (black)-below left clavicle; LL (red)-left leg Answer: A Explanation: The correct placement for the 3-lead telemetry is RA (white)-below right clavicle; LA (black)-below left clavicle; LL (red)-left lowest rib cage area.

Page Ref: 19 Cognitive Level: Remembering Client Need/Sub: Physiological Adaptation: Hemodynamics Standards: Nursing Process: Implementation | Learning Outcome: 12.3 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety 3

5) How should the nurse calculate the heart rate from a rhythm strip?

A) Count the number of R waves in 30 large blocks and multiply by 10.

B) Count the number of small squares in a 3-second period and multiply by 0.20.

C) Count the number of large squares and multiply by 3.

D) Count the number of P waves in a 0.04 second and multiply by 5.

Answer: A Explanation: Thirty large blocks equal a 6-second period, then multiply by 10 to obtain the heart rate. A normal rate is 60-100 beats/min.

Page Ref: 20 Cognitive Level: Remembering Client Need/Sub: Reduction of Risk Potential: Diagnostic Tests Standards: Nursing Process: Evaluation | Learning Outcome: 12.3 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety

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6) The nurse is providing care to a client with a history of a diagnosis of heart disease who has been placed on a telemetry monitor. The nurse observes an irregular rhythm on the monitor.

Which is the first action the nurse should implement?

A) Immediately initiate cardioversion.

B) Place oxygen on the client.

C) Administer calcium channel blockers.

D) Complete a cardiac assessment.

Answer: D Explanation: Need to assess the client first to determine whether the abnormal rhythm is potentially life threatening or if there is something wrong with the telemetry monitor.

Page Ref: 21 Cognitive Level: Analyzing Client Need/Sub: Physiological Adaptation: Hemodynamics Standards: Nursing Process: Assessment | Learning Outcome: 12.3 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety 7) Which dysrhythmia is considered life threatening?

A) P wave normal; atrial rate > 100; QRS complex width 0.06—0.08 second B) P wave normal; atrial rate< 60; QRS complex width 0.08 second C) P wave none identifiable; atrial rate disorganized activity greater 350 beats/min; QRS complex width irregular D) P wave none; atrial rate cannot differentiate; ventricular rate 130—250 beats/min Answer: D Explanation: This is ventricular tachycardia.

Page Ref: 22 Cognitive Level: Understanding Client Need/Sub: Reduction of Risk Potential: Diagnostic Tests Standards: Nursing Process: Assessment | Learning Outcome: 12.4 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice 5

NLN Competencies: Quality and Safety

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8) The nurse observes an irregular chaotic rhythm. Which arrhythmia should the nurse document?

A) Ventricular tachycardia B) Ventricular fibrillation C) Atrial flutter D) Atrial fibrillation Answer: B Explanation: Ventricular fibrillation is an irregular, totally chaotic rhythm with fibrillating waves only.

Page Ref: 23 Cognitive Level: Analyzing Client Need/Sub: Physiological Adaptation: Unexpected Response to Therapies Standards: Nursing Process: Assessment | Learning Outcome: 12.4 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety

9) The nurse is providing care to a client with a history of a diagnosis of organic heart disease.

The nurse received a phone call from the telemetry base station and reported a reading of ventricular rate <40 beats/min from the Purkinje fibers. After the nurse checks the client, what should the nurse do next?

A) Prepare the client for pacemaker insertion.

B) Start CPR at 100 chest compressions/minute.

C) Administer oxygen to maintain tissue perfusion.

D) Assign the UAP to monitor the client.

Answer: A Explanation: The client is in third-degree heart block. Need to prepare client for a pacemaker insertion.

Page Ref: 24 Cognitive Level: Analyzing Client Need/Sub: Physiological Adaptation: Unexpected Response to Therapies Standards: Nursing Process: Implementation | Learning Outcome: 12.4 | QSEN Competencies: 7

Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety

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10) The nurse is providing care to a client with an arrhythmia. For which arrhythmia will the nurse administer prescribed digoxin?

A) Atrial fibrillation B) Atrial flutter C) Premature ventricular contractions D) Sinus bradycardia Answer: A Explanation: Digoxin is used to treat atrial fibrillation.

Page Ref: 23 Cognitive Level: Applying Client Need/Sub: Pharmacological and Parenteral Therapies: Medication Administration Standards: Nursing Process: Implementation | Learning Outcome: 12.4 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety

11) A client asked the nurse "Why do I need to have this transcutaneous pacemaker?" Which is the most appropriate response by the nurse?

A) "It provides close monitoring by your healthcare provider."

B) "It delivers impulses and transmissions to the myocardium."

C) "It is for an emergency when you have an irregular rhythm."

D) "It is for symptomatic bradycardia that is unresponsive to atropine."

Answer: D Explanation: This does explain why the client needs this transcutaneous pacemaker.

Page Ref: 29 Cognitive Level: Analyzing Client Need/Sub: Physiological Adaptation: Hemodynamics Standards: Nursing Process: Implementation | Learning Outcome: 12.5 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety 9

12) A nurse is providing care to a client with a temporary pacemaker. The nurse observes a spike on the ECG. What should the nurse do first?

A) Notify the healthcare provider that the client is having an arrhythmia.

B) Document the client's rhythm, pacing spikes, and post strip in the client's chart.

C) Complete the pain assessment because this is an irregular finding and causes pain.

D) Delegate this client to the UAP until the temporary pacemaker is not needed.

Answer: B Explanation: This nurse needs to document the findings because this is a normal response to a client who has a temporary pacemaker.

Page Ref: 27 Cognitive Level: Applying Client Need/Sub: Physiological Adaptation: Unexpected Response to Therapies Standards: Nursing Process: Implementation | Learning Outcome: 12.6 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety 13) The nurse is providing care to a client who has signs of pacemaker failure. Which will the nurse document for pacemaker failure? Select all that apply.

A) Bradycardia B) Bradypnea C) Decreased urine output D) Increased blood pressure E) Increase in temperature Answer: A, C Explanation: A decrease in cardiac output causes a decrease in urine output (CO = HR × SV).

The pacemaker functions to keep the heart rate above 60 beats/min. Bradycardia is less than 60 beats/min (CO = HR × SV).

Page Ref: 28 Cognitive Level: Analyzing Client Need/Sub: Physiological Adaptation: Unexpected Response to Therapies Standards: Nursing Process: Implementation | Learning Outcome: 12.6 | QSEN Competencies: 10

Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety

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14) The nurse is administering a blood transfusion to a client. Which should the nurse implement first when a client is complaining of chills and back pain within the first 15 minutes of this transfusion?

A) Infuse normal saline.

B) Give the client a blanket.

C) Stop the infusion.

D) Notify the charge nurse.

Answer: C Explanation: The nurse needs to stop the transfusion immediately at the first sign of an infusion reaction and reassess the client.

Page Ref: 6 Cognitive Level: Applying Client Need/Sub: Pharmacological and Parenteral Therapies: Blood and Blood Products Standards: Nursing Process: Evaluation | Learning Outcome: 12.7 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety

15) A client receiving a blood transfusion begins to have difficulty breathing and complains of itchiness. What action should the nurse instruct a new graduate RN to take first?

A) Stop the infusion.

B) Call a code blue.

C) Reassess the client.

D) Administer albuterol.

Answer: A Explanation: The nurse needs to stop the transfusion immediately at the first sign of an infusion reaction and reassess the client.

Page Ref: 6 Cognitive Level: Applying Client Need/Sub: Pharmacological and Parenteral Therapies: Blood and Blood Products Standards: Nursing Process: Implementation | Learning Outcome: 12.7 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice 12

NLN Competencies: Quality and Safety

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16) The client diagnosed with anemia has the following lab results: hemoglobin 7.8 g/dL, platelets 150,000, white blood cells 4.7, and hematocrit 23.4%. Which lab result indicates the transfusion worked after receiving 2 units of packed red blood cells?

A) Hemoglobin 11 g/dL B) Platelets 130,000 C) White blood cells 5.3 D) Hematocrit 15% Answer: A Explanation: The hemoglobin increased, which indicates that the transfusion worked.

Page Ref: 3 Cognitive Level: Applying Client Need/Sub: Pharmacological and Parenteral Therapies: Blood and Blood Products Standards: Nursing Process: Implementation | Learning Outcome: 12.7 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety

17) Before removing a unit of blood from the blood bank, what should the nurse ask first?

A) Verify the client's name, date of birth, and blood type.

B) Review the signed consent form in the client's EMR. C) Ask if any family members had a reaction to a blood transfusion.

D) Administer prescribed premedications before starting the blood transfusion.

Answer: B Explanation: The nurse is aware that the blood is only good for 30 minutes at room temperature after leaving the blood blank, so the consent form needs to be signed before picking up the blood, in case the client refuses the transfusion.

Page Ref: 5 Cognitive Level: Analyzing Client Need/Sub: Pharmacological and Parenteral Therapies: Blood and Blood Products Standards: Nursing Process: Implementation | Learning Outcome: 12.7 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice 14

NLN Competencies: Quality and Safety

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18) A new nurse asks the RN why blood needs to be hung within 30 minutes after leaving the blood bank. Which is the most appropriate answer by the nurse?

A) "Coagulation occurs faster the warmer the blood gets."

B) "Rejection occurs when the blood is not administered cold."

C) "Risk for bacterial growth occurs as it gets warmer."

D) "An allergy will occur if administered when cold."

Answer: C Explanation: As blood warms, the risk of bacterial growth increases. Make sure the unit of blood is left at room temperature for no more than 30 minutes before starting the transfusion.

Page Ref: 5 Cognitive Level: Analyzing Client Need/Sub: Pharmacological and Parenteral Therapies: Blood and Blood Products Standards: Nursing Process: Implementation | Learning Outcome: 12.7 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety 19) The nurse receives a prescription to administer blood stat to a client receiving total parenteral nutrition (TPN). Which is the first action the nurse should implement?

A) Administer the blood.

B) Take vital signs.

C) Start a new IV line.

D) Premedicate the client.

Answer: C Explanation: Need a new IV line with a #18 or #20 gauge because TPN or any other solution is not compatible with blood unless it is normal saline. If unable to start an IV, will need to request another PICC line for the blood.

Page Ref: 3 Cognitive Level: Applying Client Need/Sub: Pharmacological and Parenteral Therapies: Blood and Blood Products Standards: Nursing Process: Implementation | Learning Outcome: 12.7 | QSEN Competencies: Safety 16

AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety

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20) The RN is precepting a new graduate RN who is preparing to transfuse blood. For which action by the new graduate nurse will the nurse intervene immediately?

A) Starts blood transfusion immediately upon return to unit B) Primes infusion set with normal saline solution C) Educates the client about possible side effects D) Reviews client chart for history of allergies Answer: A Explanation: Blood must be verified by two RNs and not just by one RN before transfusion begins.

Page Ref: 5 Cognitive Level: Applying Client Need/Sub: Pharmacological and Parenteral Therapies: Blood and Blood Products Standards: Nursing Process: Implementation | Learning Outcome: 12.7 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety

21) The nurse is providing care to a client who has a sequential compression device (SCD) on both legs and is complaining of numbness and tingling in the left leg. Which is the first action the nurse should implement?

A) Assess capillary refill in the toes on the left foot.

B) Remove the SCD unit from left leg.

C) Notify the healthcare provider.

D) Administer pain medication.

Answer: B Explanation: The nurse needs to remove the SCD unit when the client is complaining of numbness and tingling to assess that leg.

Page Ref: 13 Cognitive Level: Analyzing Client Need/Sub: Basic Care and Comfort: Mobility/Immobility Standards: Nursing Process: Implementation | Learning Outcome: 12.8 | QSEN Competencies: Safety 18

AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety

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Clinical Nursing Skills: A Concept-Based Approach, 3e (Pearson) Chapter 13 Perioperative Care

1) The nurse has just completed teaching a client about postoperative leg exercises to prevent which postoperative complication?

A) Pneumonia B) Pulmonary embolism C) Atelectasis D) Ileus Answer: B Explanation: Leg exercises help to prevent the formation of blood clots that could become a pulmonary embolism.

Page Ref: 570 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Reduction of Risk Potential Standards: Nursing Process: Intervention | Learning Outcome: 13.2 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

2) The nurse is preparing four older adult patients for surgery and knows that which client is at highest risk for postoperative pressure wound development?

A) The client who regularly attends the local senior center for socialization and meals and takes diphenhydramine (Benadryl) at night for sleep B) The client who walks one mile every other day and takes ibuprofen twice a day for arthritis in his knees C) The client who babysits every day and takes prednisone daily for allergies D) The client who drives a bus every week and takes fluoxetine (Prozac) for anxiety Answer: C Explanation: Prednisone can cause increased bruising and skin breakdown and will increase the client's risk for pressure wound development.

Page Ref: 571 1

Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 13.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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3) The circulating nurse calls for a "time out" prior to the onset of a surgical procedure and knows that which client will not have a visible mark at the site of surgery?

A) The client who is having a right bunionectomy B) The client who is having a left knee replacement C) The client who is having removal of a melanoma on the right arm D) The client who is having a splenectomy Answer: D Explanation: Single-organ surgeries such as a splenectomy do not need to be marked.

Page Ref: 582 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 13.1 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 4) The nurse is conducting preoperative teaching for a 78-year-old client who will be having outpatient cataract surgery. Which statement by the nurse indicates the best approach to safely teaching this client?

A) "Be at the eye surgery center at 6 AM, wear loose-fitting clothes, and make sure that you bring someone with you who can take you home."

B) "Please do not eat or drink anything after 10 PM the night before surgery."

C) "Please read this information about cataract surgery and I'll be back in a few minutes to answer any questions you may have."

D) "I see that your spouse had a cataract removed with us last year. Everything will be about the same for your surgery."

Answer: B Explanation: The nurse is giving the client one instruction at a time to allow time for the information to be processed or repeated.

Page Ref: 571 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Reduction of Risk Potential 3

Standards: Nursing Process: Intervention | Learning Outcome: 13.1 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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5) The nurse is performing a surgical hand scrub prior to entering the operating room. The circulating nurse will stop the nurse and reinstruct on proper hand scrubbing if the nurse does which action?

A) After wetting the hands and forearms, the nurse holds the hands above the level of the elbows.

B) The nurse spends 25 to 30 seconds rubbing soap on the tops and palms of hands using an upand-down motion.

C) The nurse keeps the arms elevated and backs into the operating room.

D) The nurse uses a sterile towel to dry one hand from fingers to the elbow and then picks up a second sterile towel for the other hand.

Answer: B Explanation: This must be corrected. Circular strokes clean more effectively. Rubbing is necessary but an up-and-down motion will not provide effective cleaning.

Page Ref: 572-573 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 13.3 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 6) The nurse is preparing to complete hand hygiene using an alcohol-based rub and knows that how much hand rub product will be required for adequate hand cleansing?

A) 0.5-1.5 mL B) 2-4 mL C) 5-6 mL D) 8-10 mL Answer: C Explanation: It takes approximately 6 mL for adequate hand cleansing.

Page Ref: 573 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control 5

Standards: Nursing Process: Intervention | Learning Outcome: 13.3 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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7) The nurse is caring for a client who had abdominal surgery three days ago. The client is able to drink fluids but is reluctant to eat anything for fear of nausea and vomiting. The nurse encourages the client to try and eat to prevent which postoperative complication?

A) Dehydration B) Pneumonia C) Urinary retention D) Delayed wound healing Answer: D Explanation: Adequate nutrition is needed to support wound healing and muscle strength.

Page Ref: 571 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Intervention | Learning Outcome: 13.2 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

8) The nurse is preparing a sterile field prior to a wet to dry dressing change and notices that the corner of the sterile drape is damp. What is the nurse's best action at this time?

A) Continue with the procedure because the dampness is in the area already considered to be contaminated.

B) Put down a fresh drape but use the liquids that have already been poured.

C) Begin the procedure from the beginning, including pouring fresh liquids.

D) Wait 5 minutes to see if the damp area will move into the area considered sterile. If the sterile area becomes damp, begin again with fresh supplies.

Answer: C Explanation: Once there is the possibility of contamination, fresh supplies must be used.

Page Ref: 577 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 13.4 | QSEN Competencies: Safety 7

AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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9) The nurse has been asked to assist a healthcare provider with a sterile procedure at the client's bedside. The nurse enters the client's room to find a non-covered sterile field set out on the client's bedside table but the healthcare provider has left the room. What should the nurse do at this time?

A) Nothing; it is not the nurse's responsibility.

B) Leave the room and wait until the healthcare provider enters the room again before reentering.

C) Ask the client how long the healthcare provider has been out of the room.

D) Request that the healthcare provider set up a new sterile field.

Answer: D Explanation: An unobserved sterile field is now considered contaminated and should be discarded and a fresh one laid out.

Page Ref: 576 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 13.4 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

10) The nurse enters a room in preparation for a sterile dressing change. Which must the nurse do before preparing the sterile field?

A) Turn the room fan off.

B) Open the blinds in the room.

C) Request the client perform hand hygiene.

D) Increase the temperature in the room 10 degrees to prevent chilling the client.

Answer: A Explanation: The room fan should be turned off because air movement should be minimized to prevent airborne contamination.

Page Ref: 577 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 13.4 | QSEN Competencies: 9

Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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11) The nurse is preparing a client for surgery and asks the client to remove his dentures and place them in the specified cup at the bedside. The client states, "Why are you asking me to do this? The last time I had surgery I got to keep my dentures in my mouth." Which is the nurse's best response to this client statement?

A) "You may have thought you kept them in. I'm guessing your dentures were removed after you went to sleep and were returned to your mouth before you were completely awake."

B) "Some anesthesiologists allow a client to keep a full set of dentures in the mouth if a specific type of anesthesia is given."

C) "I've never heard of anyone keeping their dentures in for surgery. You must remove them."

D) "I'm sorry that you don't want to do this. You must take them out or your surgery will be canceled."

Answer: B Explanation: Some anesthesiologists allow clients to wear a full set of dentures if anesthesia is administered by mask.

Page Ref: 582 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Intervention | Learning Outcome: 13.8 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

12) The nurse is caring for a client who is being prepared for surgery. Due to a motorcycle crash 10 years ago, the client has a prosthetic right arm, prosthetic left leg, prosthetic left eye, and wears hearing aids. The client also wears a wedding ring that cannot easily be removed from the client's finger. Which statement by the nurse indicates the proper way of preparing the client for surgery?

A) "Please remove your hearing aids and your prosthetic leg, arm, and eye. I am going to securely tape your ring in place. " B) "Please remove your hearing aids and prosthetic leg and arm. I will place tape over your left eye and tape on your ring to hold them both in place during the surgery."

C) "I need for you to remove your hearing aids, and all of your prosthetics. I am going to get 11

some oil to put on your finger because your ring must be removed prior to surgery."

D) "I'm sure you know the drill because you have had many surgeries before. Please remove anything that is not your original equipment."

Answer: A Explanation: The hearing aids and prosthetics must be removed but the ring may be securely taped in place.

Page Ref: 582 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 13.5 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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13) The nurse is caring for a client who had a knee replacement completed 2 days ago. When changing the knee dressing, the nurse notes that the incision appears red and feels warm to the touch. The client's temperature is now 100.6 degrees F and the client states that the knee hurts worse now than it did the day after surgery. After calling the surgeon, the nurse anticipates which to be ordered for this client?

A) Keep the client NPO and prepare for the client to be returned to surgery.

B) Restart the client's IV and give fluids and pain medication.

C) Culture any drainage that is present and administer fluids and antibiotics.

D) Provide anticoagulant therapy and place the client on oxygen.

Answer: C Explanation: Any drainage should be cultured and antibiotics and possibly fluids will be started.

Page Ref: 569 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessment | Learning Outcome: 13.6 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

14) The nurse is preparing to change the dressing of a surgical client and will be alert for which signs or symptoms of a wound infection? Select all that apply.

A) Cool to the touch B) Redness C) Serosanguinous drainage D) Client temperature of 101 degrees F E) Pain rating of 2 out of 10 Answer: B, D Explanation: Redness at the incision site is an indication of a wound infection.

Fever or elevated client temperature is an indication of a wound infection.

Page Ref: 569 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control 13

Standards: Nursing Process: Intervention | Learning Outcome: 13.6 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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15) Immediately prior to placing the client on a gurney for surgery, the nurse asks the client to remove the partial plate dentures. The client becomes upset and states, "No one can see me without my teeth. I am so embarrassed by the way I look without them." What is the nurse's best response to the client?

A) "I realize this is hard for you to do. I will ask the nurse in surgery to remove them for you after you go to sleep."

B) "Why don't you take them out and drape this washcloth over your face so no one can see you without your teeth?"

C) "Leaving your teeth in during surgery may cause injury to you or your teeth. Here is the cup for your dentures. Take them out right before surgery and then you can place them back in your mouth as soon as you wake up."

D) "This is just something you have to put up with when you have surgery. No one knows you here so it won't be that embarrassing."

Answer: C Explanation: Explaining the reason for removing the dentures is important. Then, giving a safe option of the client is important also.

Page Ref: 583 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 13.8 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

16) The nurse is caring for an older adult client who is being prepared for abdominal surgery.

During the preoperative assessment, the nurse notes that the client has a nonproductive cough but all lung sounds appear normal. With regard to this finding, which preoperative teaching will take priority with this client?

A) Postoperative nutrition B) Pursed-lip breathing C) Use of incentive spirometer D) Bed leg exercises 15

Answer: C Explanation: Use of the incentive spirometer would take priority because it causes the client to take deep breaths and would help prevent the development of pneumonia in the older adult client.

Page Ref: 571 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 13.2 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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17) The nurse is researching the literature to determine the best method to perform hand hygiene to prevent a postsurgical wound infection and has determined that which method has been determined to be the best?

A) Hand hygiene using a surgical scrub brush and very hot water works best to prevent infection.

B) Performing hand hygiene using an alcohol-based rub has been shown as the best method to prevent postoperative infection.

C) Prior to surgery, washing the hands with soap and water and finishing with an alcohol-based hand wash is the best method to prevent infection.

D) Research has not determined whether hand washing with soap or the use of alcohol-based hand hygiene is better at preventing infection.

Answer: D Explanation: Research has shown that surgical hand antisepsis is necessary but it does not state which method has an advantage over the other.

Page Ref: 574 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 13.3 | QSEN Competencies: Evidence-Based Practice AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

18) The nurse is preparing a client for inguinal hernia surgery, which will require hair to be removed from the inguinal region. The nurse informs the client that this hair removal is completed at what time in relation to the surgery?

A) The nurse will instruct the client on completing a preoperative shave with a safety razor on the night prior to the surgery.

B) The nurse will instruct the client to complete the preoperative shave with a safety razor on the morning of the surgery prior to coming to the hospital.

C) The nurse will explain that the preoperative shave will be completed using an electric clipper after the client arrives at the hospital the morning of surgery.

D) The nurse will tell the client that the preoperative shave will be completed by the surgeon in the operating room immediately prior to the beginning of the surgery.

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Answer: C Explanation: The hair is removed as close to the surgery as possible, using a clipper or scissors or depilatory cream.

Page Ref: 575 Cognitive Level: Remembering Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 13.6 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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19) The nurse is preparing to do preoperative teaching for a client who will have abdominal surgery. Which preoperative teaching will the nurse emphasize for this client to assist the client with early ambulation? Select all that apply.

A) How to get out of bed after surgery B) Requesting pain medication before the pain is severe C) Using an incentive spirometer D) How to turn in bed to prevent skin breakdown E) Splinting the incision before coughing Answer: A, B Explanation: In an effort to promote early ambulation, it is important for the nurse to teach the client how to get out of bed.

The client needs to understand that pain control is necessary so that the client will be able to ambulate after surgery.

Page Ref: 569-570 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 13.7 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

20) The nurse is preparing the room for a client who is having surgery to repair a tibial fracture.

In an effort to promote early ambulation, the nurse will have which safest assistive device available for the client?

A) Cane B) Walker C) Crutches D) Wheelchair Answer: B Explanation: A walker would be the safest device for the client to have that would support early ambulation.

Page Ref: 570 19

Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 13.7 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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Clinical Nursing Skills: A Concept-Based Approach, 3e (Pearson) Chapter 14 Reproduction

1) The certified nurse-midwife (CNM) is doing the first prenatal assessment on a client who states she believes she is 6 weeks pregnant. Which assessment finding by the CNM would indicate that this is the correct gestational age?

A) The fundus is palpable just above the symphysis.

B) Chadwick's sign is noted.

C) The fetal heart rate is obtained with a fetoscope.

D) Colostrum is able to be expressed from the nipple.

Answer: B Explanation: Chadwick's sign (bluish color of the cervix) may be seen at 4 to 6 weeks.

Page Ref: 589, 590 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 14.1 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

2) The nurse is discussing anticipated weight gain with a client who has a BMI of 32. Which statement by the client indicates understanding of the topic?

A) "I know that because I am overweight that my baby already has access to sufficient nutrients Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 14.1 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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and I should attempt to keep my weight stable through the pregnancy."

B) "No matter what you weigh when you are pregnant, you should attempt to gain 25 to 30 lb so that my baby will be born healthy."

C) "I will need to watch what I eat and make sure that I am eating a nutritious diet and I will try and limit by weight gain to less than 20 lb."

D) "I will limit what I eat while I am pregnant so I can begin to lose weight and to ensure that my baby is not born fat."

Answer: C Explanation: An obese woman should watch her diet to ensure that the calories she consumes are the most nutritious and attempt to limit weight gain to 15 to 20 lb.

Page Ref: 589

Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 14.1 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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3) A 16-year-old client comes to the prenatal clinic and is very concerned about a black line that has appeared on her abdomen. Which statement by the nurse will be most helpful to this client concerning this issue?

A) "This line occurs depending upon the sex of your baby. I don't want to tell you which one in case you don't know the gender of your baby yet."

B) "This line indicates that you are getting too much iron in your diet. You need to reduce the amount of red meat you are eating."

C) "This line is called the linea nigra and is related to the increase in your hormones during pregnancy."

D) "Please don't be worried about this. It is normal and it will go away after you have your baby."

Answer: C Explanation: The linea nigra is related to increased hormone levels and should fade considerably after the birth of the baby.

Page Ref: 589 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 14.1 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 14.1 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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4) The nurse is assessing a client who is 36 weeks pregnant. Her current pulse is 101 bpm, which represents an increase of 10 bpm since her first assessment at 9 weeks of gestation. Which is the nurse's best action related to this assessment finding?

A) Document the finding, because it is considered within normal limits.

B) Retake the pulse in 15 minutes and ask the client to lie quietly during this time.

C) Teach the client to take her pulse and to record it twice a day.

D) Report the assessment finding to the healthcare provider (HCP) immediately.

Answer: A Explanation: An increase in the pulse rate of approximately 10 bpm during pregnancy is considered normal and should be documented.

Page Ref: 589

Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 14.1 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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5) The nurse is caring for a woman who has been diagnosed with preeclampsia and has been placed on intravenous magnesium sulfate to prevent seizures. After checking the patellar deep tendon reflex, the nurse documents the response as 2+. Which is the nurse's next action after this assessment?

A) Immediately discontinue the magnesium sulfate because the patellar response indicates hyporeflexia.

B) Check the deep tendon reflex in the biceps to see if it agrees with the patella.

C) Turn the client on her side to prevent aspiration during the anticipated seizure.

D) Ensure that the IV site is patent and that the magnesium sulfate is infusing adequately.

Answer: B Explanation: It is common for the nurse to check two different reflexes, so the nurse would assess another reflex after assessing the patella.

Page Ref: 594 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 14.2 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

6) The nurse is assessing a pregnant client who is at 29 weeks gestation. The nurse notes that the client's blood pressure is 160/90 and documents that the clonus was noted after assessing the patellar reflex. Which assessment findings led the nurse to document this finding?

A) There was no response when the area directly above the knee was struck with the percussion hammer.

B) The nurse noted an extension of the leg when the percussion hammer touched the area above the knee.

C) The client complained of pain when the foot was dorsiflexed.

D) The client's foot tapped against the nurse's hand when it was dorsiflexed.

Answer: D Explanation: When the foot taps or jerks against the hand of the nurse who dorsiflexes the client's foot, it indicates clonus and may indicate severe hyperreflexia.

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Page Ref: 593-94 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 14.2 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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7) The nurse is performing the first Leopold maneuver on a client of 34 weeks gestation and notes the presence of fetal bottom and legs. The nurse knows that this maneuver would indicate which for this client?

A) The fetus' head is in the pelvis but positioned in a posterior fashion.

B) The fetus is in a breech position and a caesarean section may be required at birth.

C) The fetus' size does not match its gestational age.

D) The fetus is in position for immediate delivery and the healthcare provider should be notified immediately.

Answer: B Explanation: The presence of bottom and feet indicates that the fetus is in a breech position and a caesarean section may be necessary at birth.

Page Ref: 590 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 14.3 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

8) The nurse is admitting a client to the labor and delivery unit who states she is at 39 weeks and began having steady contractions approximately 6 hours ago. Which assessment findings discovered during the nurse's vaginal examination would indicate that this client will deliver within the next few hours? Select all that apply.

A) The client's cervix is dilated 7 centimeters.

B) The client's cervix is effaced 20%.

C) The presenting part of the fetus is at -4 station.

D) The client's membranes appear to have ruptured.

E) There is the presence of a bloody show on the nurse's gloved hand.

Answer: A, D, E Explanation: Cervical dilation of 7 cm indicates that labor is progressing and birth can be expected within the next few hours.

Ruptured membranes indicate that birth will occur soon.

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Bloody show on the nurse's glove indicates that the client's mucous plug has been lost and is indicative that the client is in the active stage of labor.

Page Ref: 607-8 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 14.3 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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9) The nurse assesses the fundus of a client who delivered 6 hours ago and notes that it is 2 centimeters above the umbilicus and is displaced to the right. Which is the nurse's best action at this time?

A) Begin to massage the fundus.

B) Attempt to move the fundus back to midline.

C) Request the client go to the bathroom and void.

D) Determine if this client has had more than one child in the last 3 years.

Answer: C Explanation: A fundus that is elevated and displaced to the right indicates that the client's bladder may be full. The nurse should ask the client to void and then check again.

Page Ref: 617 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 14.3 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

10) The nurse receives a call from a primapara who is at 37 weeks gestation. The client states, "I just wanted to let you know that we are on our way to the hospital. All of a sudden, my belly dropped so I know that I will be delivering the baby very soon." Which is the nurse's best response to this client?

A) "Just stay home because there is no way to tell when your labor will start."

B) "If you would like to come in and be checked that will be fine, but this drop only indicates your baby is getting ready for labor, not that it will start soon."

C) "I think you need to come in because once the head drops, labor can begin at any minute."

D) "I can't stop you from coming in, but I don't recommend it. You are just going to have a long wait for nothing."

Answer: B Explanation: This response gives the control to the client and explains what has just occurred.

Page Ref: 591 Cognitive Level: Understanding 6

Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 14.3 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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11) The nurse is caring for a client who is in active labor and has just had an amniotomy. The nurse notes that the fetal heart rate has decreased from 140 bpm immediately prior to the amniotomy to 95 bpm. Upon vaginal examination, the nurse feels a portion of the umbilical cord in the vagina. Which is the nurse's next action in caring for this client?

A) Carefully push the umbilical cord back into the vagina with a sterile gauze.

B) Immediately place the client in reverse Trendelenburg and prepare to move the client to the operating room for a caesarean section.

C) Assist the client to the knee-chest position and notify the healthcare provider.

D) Place oxygen on the client at 2 L/min per nasal cannula and turn the client to the left side.

Answer: C Explanation: If the umbilical cord is palpated in the vagina, the nurse should assist the client to the knee-chest position as quickly as possible and hold pressure on the presenting part to keep it off the cord and notify the healthcare provider.

Page Ref: 612 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 14.3 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

12) The nurse is using a Doppler for obtaining the fetal heart tone of a client who is at 28 weeks gestation and obtains a rate of 98 bpm. Which is the nurse's next action for this client?

A) Take the client's pulse while monitoring the fetal heart rate.

B) Massage the client's abdomen and retake the fetal heart tone.

C) Distract the client and retake the fetal heart tone.

D) Request the healthcare provider (HCP) assess the client for possible fetal compromise.

Answer: A Explanation: When obtaining the fetal heart rate, the nurse should be prepared to compare the client's heart rate with the fetal heart rate obtained. If they are the same, the Doppler is actually hearing the client's heart rate.

Page Ref: 602 8

Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 14.4 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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13) The nurse is caring for a client who is 6 cm dilated with a fetus who has been diagnosed with a serious congenital heart defect. The client has rejected the use of continuous fetal monitoring so the nurse will use the Doppler and monitor the fetal heart rate (FHR) at what frequency?

A) Every 45 minutes B) Every 30 minutes C) Every 15 minutes D) Every 5 minutes Answer: C Explanation: The high-risk client in the first stage of labor should have the FHR monitored every 15 minutes.

Page Ref: 608 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 14.4 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

14) The nurse is caring for a client at 33 weeks gestation who is being monitored for possible preeclampsia. The nurse prepares to check the client's patellar deep tendon reflex and places the client in which position?

A) Ask the client to lay on her left side with the right leg slightly bent and the nurse supporting the client's knee.

B) Request the client lie on her back with the knees bent and the nurse supports on the legs.

C) Sit the client up in bed with the knees bent and the feet resting on the bed.

D) Assist the client to a chair next to the bed and ask the client to cross her legs.

Answer: B Explanation: To elicit a patellar deep tendon reflex on an inpatient, the client is asked to lie supine with the knees flexed with the nurse supporting the client's leg.

Page Ref: 593 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance 10

Standards: Nursing Process: Assessment | Learning Outcome: 14.2 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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15) The nurse is assisting the health care provider with the first prenatal exam of a client. Prior to the vaginal speculum examination, which information should the nurse give the client to improve the client's comfort during the examination?

A) "Right when the speculum is being inserted in your vagina, you should hold your breath."

B) "As the speculum is being inserted, clench your fists as tightly as possible."

C) "It will help if you begin to do isometric exercises with your hands so you won't think about the speculum being inserted in your vagina."

D) "You need to bear down as the speculum is being inserted because it will help you relax."

Answer: D Explanation: Asking the client to bear down at the time of speculum insertion helps to open the vaginal orifice and relaxes the perineal muscle.

Page Ref: 593 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 14.3 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

16) The nurse is admitting a client at full term to the labor and delivery unit. Using Leopold's maneuvers, the nurse determines that the fetus is in the left sacroanterior position (LSA) position and will obtain the fetal heart rate (FHR) at which site on the client's abdomen?

A) Midline, directly above the symphysis pubis B) To the right of the client's umbilicus C) To the left of the client's umbilicus D) To the left, below the umbilicus Answer: B Explanation: The fetus is in the LSA, which means it is in the breech position and the back of the fetus is to the right so the FHR will best be heard on the client's right side around the level of the umbilicus.

Page Ref: 601 Cognitive Level: Analyzing 12

Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 14.4 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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17) The nurse is admitting a client to the labor and delivery unit and is preparing to apply the tocodynamometer (toco). Which must the nurse do first to properly apply this equipment?

A) Apply ultrasound gel to the client's abdomen before applying the toco.

B) Determine the fetal position.

C) Locate the uterine fundus.

D) Ensure that the client's membranes have ruptured.

Answer: C Explanation: The toco should be placed over the uterine fundus because this area is the firmest during a contraction.

Page Ref: 600 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 14.5 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

18) The nurse has completed applying the ultrasound transducer to the client's abdomen and has confirmed that the rate is not the same as the client's. Which other assessment will assist the nurse in confirming that the sound that is heard is the true fetal heart rate (FHR)?

A) The rate is slightly different at each assessment time.

B) The sound of the FHR is louder than the sound of the contraction.

C) The FHR will be approximately twice the rate of the client.

D) The FHR will have a whip-like sound.

Answer: D Explanation: The FHR will have a whip-like sound, which will help confirm that the sound heard is the fetal heart rate.

Page Ref: 600 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 14.5 | QSEN Competencies: Client-Centered Care 14

AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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19) The nurse is caring for a client who is prescribed to have labor induced with oxytocin. Which assessments must be completed by the nurse before initiating the oxytocin infusion? Select all that apply.

A) Record the fetal heart rate for 15 minutes.

B) Obtain the client's pain level.

C) Explain to the client that she should expect to be nauseated.

D) Determine the client's hydration status.

E) Apply the tocodynamometer and observe for any contractions.

Answer: A, D, E Explanation: Prior to beginning the infusion, a baseline of fetal activity should be established.

It is important to establish the client's hydration status so that uterine hyperstimulation can be avoided.

A baseline of uterine activity should be established before medicating the client.

Page Ref: 605 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Assessment | Learning Outcome: 14.6 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

20) The nurse is caring for a client receiving oxytocin for induction of labor and notes that the client's contraction pattern shows a duration of 100 seconds and a frequency of 90 seconds.

Which is the nurse's next action at this time?

A) Document the contraction pattern.

B) Inform the healthcare provider that a birth is imminent.

C) Stop the oxytocin.

D) Increase the oxytocin because the contractions are not adequate.

Answer: C Explanation: The oxytocin must be stopped immediately because the uterus is hyperstimulated, which is preventing adequate oxygen from getting to the fetus.

Page Ref: 607 16

Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Intervention | Learning Outcome: 14.6 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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21) The nurse is precepting a graduate nurse who is caring for a client who received an insertion of misoprostol at 8 am. The client has not had any contractions since this was inserted. At 10 am, the graduate nurse prepares to hang the oxytocin. Which should the precepting nurse do at this time?

A) Remind the graduate nurse that a contraction pattern must be established before the oxytocin may be started.

B) Inform the graduate nurse that there must be a 4-hour window between the insertion of misoprostol and the initiation of oxytocin.

C) Assist the graduate nurse in preparing the infusion.

D) Request the graduate nurse be removed from the labor and delivery unit for incompetence.

Answer: B Explanation: The new nurse should not start the oxytocin until at least 12 pm because there must be a 4-hour window between the insertion of the misoprostol and the beginning of the oxytocin.

Page Ref: 606 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Intervention | Learning Outcome: 14.6 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

22) The nurse is caring for a client who delivered twins 2 days ago. During the morning assessment, the nurse notes that the fundus is firm and located midline and at the level of the umbilicus. Which should the nurse do in light of this information?

A) Contact the healthcare provider and request a medication to return the uterus to a normal position.

B) Ask the client to void and recheck the level of the fundus.

C) Check the previous assessments to confirm that the fundus is decreasing daily.

D) Massage the fundus until there is evidence that it has reduced in size.

Answer: C Explanation: The nurse should check the prior assessment to determine where the fundus started immediately after birth and that it has been progressively getting smaller.

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Page Ref: 620 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Intervention | Learning Outcome: 14.7 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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23) The nurse is caring for a client who had a cesarean section 4 hours ago. The client refuses to let the nurse complete the fundal assessment. Which statement is the best response to this problem?

A) "I will just gently lay my hand on your abdomen. I won't go near your incision."

B) "I will give you your pain medicine and then will come back in 30 minutes to complete the assessment."

C) "This will only take me a minute. Try and hold your breath while I do this."

D) "When do you think you will be ready? You could die if I don't check this."

Answer: B Explanation: Though the assessment may be delayed slightly, it is better to medicate the client and then return when the medication has had a chance to work.

Page Ref: 620 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 14.7 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

24) The nurse is attending the birth of a premature neonate and prepares to do the 1-minute Apgar score of this infant. Assessment data shows the infant has a heart rate of 98, is not crying, has some flexion of the extremities, has a grimace when stimulated, and is very pale. Which will the nurse record as the Apgar score?

A) 6 B) 5 C) 4 D) 3 Answer: C Explanation: The infant has a score of 4-1 for a heart rate less than 100, 0 for no cry, 1 for some flexion of the extremities, 1 for grimace, and 1 for color.

Page Ref: 621 Cognitive Level: Analyzing 12

Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 14.8 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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Clinical Nursing Skills: A Concept-Based Approach, 3e (Pearson) Chapter 15 Safety

1) The nurse is assessing an older adult client who has come to the emergency department with a possible urinary tract infection. Which would alert the nurse that this client has been abused?

A) The right knee has a large bruise.

B) The underwear smells of urine.

C) There are bilateral contusions above the elbows.

D) There are small lacerations on the forehead.

Answer: C Explanation: Bilateral bruises or contusions may indicate passive restraining, which could be a sign of abuse.

Page Ref: 637 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessment | Learning Outcome: 15.1 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

2) The nurse is completing an assessment of an older adult client whose primary caretaker is the grandson. Which would alert the nurse that this client is a possible victim of emotional abuse?

A) The client refuses to look at the grandson.

B) The client reprimands the grandson for being late to the appointment.

C) The client asks the grandson to leave the room during the pelvic examination.

D) The client tells the nurse that the grandson isn't a very good cook.

Answer: A Explanation: Signs of emotional abuse include becoming quiet when the caregiver enters the room or refusing the answer if caregiver is present.

Page Ref: 637 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control 1

Standards: Nursing Process: Assessment | Learning Outcome: 15.1 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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3) Which statement by an older adult client to the nurse would indicate that the client is being abused? Select all that apply.

A) "I am so cold all of the time because I don't have any warm clothes."

B) "I think I have a sore on my bottom. No one ever cleans me after I use the bathroom."

C) "Please don't tell that lady that brought me here that I showed you my bruises."

D) "I wish I had someone else to bring me here. That lady is a terrible driver."

E) "The lady insists on using the cheap soap to wash my clothes. I hate the smell."

Answer: A, B, C Explanation: This statement indicates that the client is being deprived of adequate clothing and is a possible sign of abuse.

This statement indicates that the client is receiving inadequate personal care and is a possible sign of abuse.

This statement indicates that the client is afraid of the caregiver and is a sign of abuse.

Page Ref: 637 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessment | Learning Outcome: 15.1 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

4) The nurse has completed an assessment of an older adult client who lives with her son and his wife. The nurse observed some bruising on the client but no other signs of abuse. Which question by the nurse to the client would be most helpful in determining if abuse is occurring?

A) "Who manages your money?"

B) "How did the bruises I noted on your wrists occur?"

C) "Are you happy with where you live?"

D) "How often do you see the doctor?"

Answer: B Explanation: The nurse should find out how the suspected abusive bruises were obtained. This would be the most helpful question in this situation.

Page Ref: 637 3

Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessment | Learning Outcome: 15.1 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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5) The nurse is caring for four clients and knows that which client is at the highest risk for falls?

A) An older adult client who is 2 days postoperative from a hip replacement, uses a walker to ambulate, and requires pain medication every 6 hours B) An older adult client who had a coronary artery stent placed three days ago C) An older adult client who is preparing for discharge and requires continued antibiotics D) An older adult client who was admitted yesterday for dehydration and is confused and sometimes combative Answer: D Explanation: This client was just admitted for dehydration and shows acute changes in cognition with signs of delirium. This client is at the highest risk for falling.

Page Ref: 638 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessment | Learning Outcome: 15.2 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

6) The nurse has just placed a bed alarm for a client who is disoriented and has explained its use to the client and his family. Which statement by a family member indicates a need for further information related to fall prevention?

A) "I know this bed alarm will help everyone know if my father tries to get out of bed without help."

B) "I wish this bed alarm would keep my father in bed."

C) "Now that this bed alarm has been installed on my dad's bed, I can go home and get a good night's sleep."

D) "It is so hard watching my father be so confused. I guess this bed alarm is better than nothing."

Answer: C Explanation: While the bed alarm lets everyone know if the client attempts to get out of bed, it doesn't negate the need for someone to be with a confused client.

Page Ref: 639

Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessment | Learning Outcome: 15.2 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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7) The nurse is caring for a client who recently began taking prescribed blood pressure medicine.

Which teaching will be most important to this client in the prevention of falls?

A) Wear slipper or non-skid socks when walking.

B) Make sure that the lighting is good when you get out of bed.

C) Use the handrails next to the toilet when getting on and off the toilet.

D) Sit on the side of the bed for at least a minute before getting out of bed.

Answer: D Explanation: Blood pressure medicine may cause postural hypotension, so the client should be taught to sit on the side of the bed for a minute or two until the possibility of dizziness is over before getting out of bed.

Page Ref: 639 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessment | Learning Outcome: 15.2 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 8) While admitting an adult client for treatment of pneumonia, the nurse discovers that the client has been diagnosed with a seizure disorder. What safety precautions will the nurse put into place for this client? Select all that apply.

A) Request that the client wear a helmet while out of bed.

B) Place suction equipment in the room.

C) Instruct the client to remain in bed at all times.

D) Place the client in a room at the end of the unit to reduce stimuli.

E) Pad the side rails and head board of the bed with blankets.

Answer: B, E Explanation: Suction equipment should be in place to prevent aspiration of secretions during a seizure.

The bed (headboard, side rails) should be padded to prevent injury in the event the client has a seizure.

Page Ref: 640 4

Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 15.3 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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9) The nurse is assisting a client to the bathroom when the client begins to have a tonic-clonic seizure. Which is the first thing that the nurse should do at this time?

A) Assist the client back to bed.

B) Take the client's vital signs.

C) Time the seizure.

D) Remove the client's clothing.

Answer: C Explanation: It is important for the nurse to time the seizure duration because it is impossible to know exactly how long the seizure lasts without timing it.

Page Ref: 641 Cognitive Level: Remembering Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 15.3 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

10) The nurse has been caring for a client who had a tonic-clonic seizure in the hallway of the nursing unit. Which is the first action the nurse should do when the seizure has finished?

A) Reassure the client that a seizure has occurred and that the nurse is providing care.

B) Assist the client to the bathroom to void.

C) Ask the client to report the last memory prior to the seizure.

D) Provide clear liquids to soothe a dry mouth.

Answer: A Explanation: After a seizure is over, the client is often confused and needs to be reassured about the present situation.

Page Ref: 641 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 15.3 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice 6

NLN Competencies: Nursing Judgment

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11) The nurse is discussing safety precautions at home with the parents of an 8-year-old child diagnosed with a seizure disorder. Which play activity would the nurse recommend to this family?

A) Sitting quietly reading a book B) Swimming at the beach C) Riding a bicycle D) Participating on a robotic team Answer: D Explanation: Joining a robotics team would allow the child to be engaged in play without needing direct supervision and the other team members could intervene if a seizure occurred while involved in this activity.

Page Ref: 642 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 15.3 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

12) The nurse is developing a safety plan for an older adult client who has just been admitted to the nursing unit. The client has limited hearing and eyesight. His medications include furosemide (Lasix) and a baby aspirin. He still lives alone in his home and is able to do small household chores but his daughter comes over every week to take him grocery shopping. Which information will have an impact on the development of the safety plan? Select all that apply.

A) The client takes furosemide.

B) The client takes aspirin.

C) The client has limited hearing and eyesight.

D) The client lives alone.

E) The client's daughter takes him grocery shopping.

Answer: A, C, D Explanation: Furosemide is a diuretic and makes the client produce more urine, which means the client would need to urinate more. This should be included in the safety plan.

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The client's limited hearing and eyesight must be a part of the safety plan because it affects the client's ability to know of an emergency.

The client's living arrangements are a large part of the emergency plan because the nurse must develop ways for the client to contact emergency assistance or to know if an emergency is taking place.

Page Ref: 644 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 15.4 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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13) The home health nurse visits an older adult client's home prior to a client's discharge from the hospital to evaluate the home for any safety issues. Which situation if seen by the nurse would constitute the largest safety issue for this client?

A) A trapeze lift has been placed above the client's bed to assist with getting out of bed.

B) The house has one bathroom with a traditional bathtub.

C) Skid-proof strips have been placed on the area rugs in the house.

D) Most of the houseplants appear to have dying foliage.

Answer: B Explanation: The client is elderly and the client will need to step into and out of a bathtub, which puts the client at high risk for falling.

Page Ref: 645 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessment | Learning Outcome: 15.4 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

14) The nurse is caring for a client who is disoriented and confused. Which is the safest and least restrictive way to assist this client?

A) Place a wrist restraint on the right arm only.

B) Dim the lights and keep the room as quiet as possible.

C) Put the call light on the client's bed but remove everything else from the client's line of vision.

D) Turn off the lights but turn on the television so the client thinks someone is in the room.

Answer: B Explanation: Confused clients often respond well to a decrease in both auditory and visual stimuli, so dimming and lights and keeping the room quiet will help keep the client safe.

Page Ref: 645 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 15.4 | QSEN Competencies: Safety 10

AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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15) The nurse is caring for a female client who has just completed taking a shower. The nurse notes that she is using her own hair dryer to dry her hair. Which is the nurse's best statement to the client concerning this possible safety issue?

A) "I noticed you are using your own hair dryer. We don't allow that."

B) "Before you start drying your hair, let me see if our maintenance department can come up and check it for safety."

C) "We usually don't allow clients to use their own electrical products from home but if I don't see you use it, then I don't know you have it."

D) "Your hair looks good just the way it is. Please put the hair dryer away for today."

Answer: B Explanation: The policy in most facilities is to have the maintenance department check home electrical appliances for safety before they are used in that facility.

Page Ref: 648 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 15.5 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 16) The nurse smells smoke and notes what appears to be a fire in the waste basket in the client's room. Which is the nurse's first action when the fire is noted?

A) Pull the fire alarm.

B) Grab the closest fire extinguisher.

C) Enter the client's room and immediately close the client's door.

D) Assist the client out of the room.

Answer: D Explanation: The nurse must first rescue and remove all clients in immediate danger.

Page Ref: 647 Cognitive Level: Remembering Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 15.6 | QSEN Competencies: 12

Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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17) The nurse notices a fire at the end of the hall of a second-floor unit and recognizes that the clients will need to be evacuated out of the hospital. The nurse will use which carrying method to evacuate clients safely out of the hospital?

A) Blanket method B) Cradle method C) Back-strap method D) Two-person swing method Answer: C Explanation: The back-strap method allows the nurse to carry the client and navigate the stairs for evacuation.

Page Ref: 647 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 15.6 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

18) The nurse is caring for a client who becomes occasionally confused. When the client has a period of confusion, he attempts to pull out his Foley catheter. When the client is oriented, he likes to do crossword puzzles. After receiving an order for restraints, which would be the best place(s) to place the restraint in this client?

A) Around the client's elbows B) Around the client's wrists C) Around the client's fingers (using a mitt restraint) D) Around the client's torso (using a vest-type restraint) Answer: A Explanation: Wrist restraints may be placed on the wrist or elbow. If placed on the elbow, it will prevent the client from grabbing the catheter during confusion but allow the client to do his crossword puzzle.

Page Ref: 654 Cognitive Level: Applying 14

Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 15.7 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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19) The nurse is caring for an older adult client who is very confused and is also very thin. The healthcare provider has prescribed wrist restraints to help prevent the client from getting out of bed. Which is the priority for the nurse in applying the wrist restraints to this client?

A) The restraints must be applied loosely to prevent the client from rubbing the skin against the restraint.

B) The nurse must pad the client's wrist bones before applying the wrist restraint.

C) The restraints should be tied to the bed rails to give the nurse easy access to allow quick removal of the restraints if necessary.

D) The nurse should use a vest restraint instead of a wrist restraint to prevent injuring the client's skin.

Answer: B Explanation: The nurse must pad the bony prominences to prevent skin breakdown from the restraints.

Page Ref: 655 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 15.7 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

20) The nurse must restrain a child and knows that a blanket restraint will be best for which child in the nurse's care?

AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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A) A 7-year-old child who has a laceration of the forearm B) A 5-year-old child who needs to have an IV started in the antecubital space C) A 3-year-old child who has a laceration of the forehead that needs stitches D) A 1-year-old child who needs a lumbar puncture to check for meningitis Answer: C Explanation: The blanket restraint would prevent the child from moving while treating the forehead laceration.

Page Ref: 650 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 15.8 | QSEN Competencies: Safety

AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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Clinical Nursing Skills: A Concept-Based Approach, 3e (Pearson) Chapter 16 Tissue Integrity

1) The nurse is preparing to change a dry dressing of a surgical wound and will use which technique to ensure that the wound stays clean during the procedure?

A) The nurse will wear a gown, cap, and shoe covers and will use sterile gloves for the procedure.

B) The nurse will wear a mask and use clean gloves to remove the outer dressing.

C) The nurse does not need to wear any personal protective equipment (PPE) during the procedure.

D) The nurse does not need to wear clean gloves to clean the wound and but should use sterile gloves to reapply the dressing.

Answer: B Explanation: A mask should be worn during the procedure to prevent contamination of the wound by droplet spray from the nurse's respiratory tract.

Page Ref: 666 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessment | Learning Outcome: 16.1 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

2) The nurse is observing a second nurse who is changing a dressing. While observing the procedure, which would cause the nurse to stop the second nurse and take over the procedure?

AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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A) The second nurse used one swab to clean the wound.

B) The second nurse cleaned the wound from near the wound and then outward.

C) The second nurse kept the forceps tip lower than the forceps handle when cleaning the wound.

D) The second nurse put on clean gloves to begin the wound cleaning process.

Answer: A Explanation: A separate swab should be used for each stroke during cleaning.

Page Ref: 666 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessment | Learning Outcome: 16.1 | QSEN Competencies: Safety

AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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3) The nurse is preparing to change the dressing and clean the wound of a client who had hip replacement surgery one day ago. The nurse plans to use which solution for the most effective cleaning of the wound?

A) Sterile water B) Hydrogen peroxide C) Providone-iodine D) Normal saline Answer: D Explanation: Normal saline is the most widely used solution for cleaning and irrigating an acute wound because it does not disrupt the physiology of the wound bed.

Page Ref: 667 Cognitive Level: Remembering Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessment | Learning Outcome: 16.1 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

4) While making rounds, the charge nurse observes a staff nurse cleaning a surgical wound and notes that the staff nurse has cleaned the wound from the top to the bottom of the wound. Which action should the charge nurse take in this situation?

A) Request the staff nurse clean the wound again using a circular motion and cleaning from outside the wound to the wound itself.

B) Make arrangements for the staff nurse to visit the education department for retraining in wound cleaning.

C) Continue with rounds with the knowledge that the staff nurse used the proper cleaning technique.

D) Inform the staff nurse that the charge nurse will be observing the client for signs of infection.

Answer: C Explanation: The staff nurse used proper wound cleaning technique so the charge nurse should continue with rounds.

Page Ref: 667 2

Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessment | Learning Outcome: 16.1 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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5) Place the steps for changing a sterile surgical dressing in the appropriate order.

A) Apply clean gloves and remove the old dressing.

B) Apply sterile gloves.

C) Create a sterile field.

D) Assess the incision area for erythema, edema, or drainage.

E) Replace sterile dressing.

F) Clean the incision using sterile saline.

Answer: C, A, D, B, F, E Explanation: A) The old dressing is removed after the sterile field is prepared.

B) Sterile gloves are put on after the old dressing is removed and the incision is assessed.

C) The sterile field is the first thing that is completed.

D) The incision is assessed after the old dressing is removed and before sterile gloves are placed for cleaning the incision.

E) The sterile dressing is replaced as the last step.

F) The incision is cleaned with sterile saline after sterile gloves are put on.

Page Ref: 666 Cognitive Level: Remembering Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessment | Learning Outcome: 16.1 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

6) The nurse is preparing to change the dressing of a client who had abdominal surgery 3 days ago. The nurse notes that the incision has purulent drainage and appears very puffy. The client states that the pain level has increased from a 3 to a 7 in the last 24 hours. Which is the nurse's next action in regard to this client's wound?

A) Clean the wound, place a new dressing, and plan to recheck the incision in 4 hours.

B) Contact the client's surgeon after obtaining the client's vital signs.

C) Recognize that this is an expected outcome for a client on the third day after surgery.

D) Culture the wound drainage and redress the wound.

Answer: B 4

Explanation: The nurse should obtain the client's vital signs to see if there are signs of systemic infection and then the surgeon should be notified with all of the information.

Page Ref: 669 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessment | Learning Outcome: 16.1 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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7) The home health nurse is making the first visit to a client who will continue to need sterile dressing changes after abdominal surgery. In assessing the home environment, which must be considered when performing the home dressing change?

A) There is dust on many of the surfaces.

B) The furniture appears worn.

C) There is a cat that is allowed on the furniture.

D) There are dirty dishes on the dining room table.

Answer: C Explanation: The nurse will need to make sure that the cat is kept out of the room where the dressing change is to be performed.

Page Ref: 681 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessment | Learning Outcome: 16.1 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

8) The healthcare provider has ordered an elastic bandage to be applied to a wound on a client's femur. The nurse will begin to apply the bandage at which point on the client's leg?

A) The groin B) The wound itself C) The knee D) The hip Answer: C Explanation: The knee is the most distal point from the femur wound, so this is where the nurse will begin wrapping the elastic bandage.

Page Ref: 677 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Intervention | Learning Outcome: 16.2 | QSEN Competencies: Client-Centered Care 6

AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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9) The nurse is caring for four clients who have had surgery and knows that which client would benefit the most from the application of a spiral elastic bandage?

A) The client who had a breast reduction.

B) The client who had a hip replacement.

C) The client who had ankle surgery.

D) The client who had a shoulder replacement.

Answer: C Explanation: A spiral elastic bandage would be appropriate for a client with ankle surgery if prescribed by the healthcare provider because it can be applied in a spiral fashion. It will also help reduce the swelling after the surgery and hold the dressing in place.

Page Ref: 676 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Assessment | Learning Outcome: 16.2 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 10) The nurse is caring for a client with a large venous injury that has just begun to show signs of healing. The nurse contacts the healthcare provider and asks for a change from the chemical method of debridement for which reason?

A) Chemical debridement may damage the tissue that has just begun to heal.

B) Chemical debridement is more painful to venous injuries that have begun to show signs of healing.

C) Chemical debridement is ineffective for venous injuries that have just begun to show signs of healing.

D) Chemical debridement is more useful with arterial injuries than venous injuries.

Answer: A Explanation: Chemical debridement causes viable tissue to be removed with necrotic tissue and may injure the new tissue in the venous injury.

Page Ref: 672 Cognitive Level: Applying 8

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Intervention | Learning Outcome: 16.3 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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11) The nurse has applied an occlusive dressing to a stage 1 pressure injury and knows that this type of dressing assists in debridement of the wound in which way?

A) It mechanically debrides the wound.

B) Enzymes are applied to the wound to remove necrotic tissue.

C) The dressing maintains a moist environment that uses the body's own enzymes.

D) The dressing dries the injury environment, which encourages sloughing of the injured tissue.

Answer: C Explanation: An occlusive dressing uses autolytic debridement by using the body's own enzymes and moisture to rehydrate, moisten, and slough tissue.

Page Ref: 672 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Intervention | Learning Outcome: 16.3 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 12) The nurse is caring for a client who sustained second-degree burns to both feet. The healthcare provider has ordered debridement of necrotic tissue by mechanical means. The nurse will use which debridement technique that would be the BEST method to complete this task?

A) Wet-to dry dressing changes B) Hydrotherapy C) Application of enzymes D) Application of an occlusive dressing Answer: B Explanation: Hydrotherapy involves placing a body part or parts, in this case feet, into a tub of water that pulses and agitates to mechanically debride a large area of tissue at one time.

Page Ref: 672 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Intervention | Learning Outcome: 16.3 | QSEN Competencies: Client-Centered Care 10

AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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13) The nurse is using wet-to-dry dressing changes to assist in debridement of an open abdominal wound and knows that which step must be performed to ensure that the newly granulated tissue in the wound will not be injured during the dressing changes?

A) Place a heat lamp over the dressing for 15 minutes after the dressing change to prevent chilling the client with the cool dressings.

B) Rewet the dressings with normal saline every 15 minutes to ensure adequate debridement.

C) Soak the dressing with normal saline prior to removal of the packed gauze to prevent damage to the granulating tissue.

D) Premedicate the client 1 hour before the dressing change to improve client cooperation during the dressing change.

Answer: C Explanation: Soaking the dressing with normal saline prior to removing the gauze prevents injury to the newly granulated tissue.

Page Ref: 676 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Intervention | Learning Outcome: 16.3 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 14) The nurse is completing a skin assessment at the beginning of the shift and will pay particular attention to which areas of the body that are most prone to skin breakdown? Select all that apply.

A) Knees B) Heels C) Shoulders D) Sacrum E) Toes Answer: B, D Explanation: The heels are an area of the body that commonly have skin breakdown because they are at the back of the foot and the weight of the foot rests against the bed.

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The sacrum is an area of the body that often sees breakdown because there is little fat between the skin and the sacrum, there is high moisture, and it takes the full weight of the body.

Page Ref: 693 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 16.4 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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15) The nurse has completed the Braden Risk Assessment Scale on a client who has been diagnosed with a pelvic fracture and has not been able to get out of bed for the last 6 days. This morning the client's score is 10, so the nurse will institute which measures that will help prevent further skin injury? Select all that apply.

A) Bathe the client every day.

B) Use tepid water when bathing the client.

C) Position the client to allow the heels to hang over the bed.

D) Elevate the client's head 45 degrees.

E) Increase the humidity in the client's room.

Answer: B, C, E Explanation: Tepid water prevents injury to the skin.

The heels should be raised off the bed by placing pillows under the legs or allow the heels to hang over the edge of the bed.

Provide humidity to prevent drying of the skin.

Page Ref: 695 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Intervention | Learning Outcome: 16.4 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 16) The nurse is caring for an older adult client who was admitted to the hospital after having a stroke. The client was in extremely critical condition on admission to the emergency department and a Braden Risk Assessment Scale was not completed. On the client's fifth day of hospitalization, the nurse notes that the client has developed a stage one pressure injury on the elbow of the side affected by the stroke. Which is the implication of this situation in relation to reimbursement for care of the pressure injury?

A) Medicare will pay for the treatment because it was noticed while the client was still hospitalized.

B) Medicare will not pay for treatment because the pressure injury was not properly documented.

C) Medicare will pay for the treatment because pressure injuries are an expected outcome in a 14

client who has had a stroke.

D) Medicare will not pay for treatment because an initial skin assessment was not completed, so it is assumed that the pressure injury was caused by improper care at the hospital.

Answer: D Explanation: Even though the client fell when the stroke occurred, which may have caused redness or even a breakdown of the client's elbow, the lack of an admission skin assessment means that Medicare will assume that the injury was caused by lack of proper skin care during the hospitalization.

Page Ref: 695 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 16.4 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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17) The nurse is caring for a client who is at high risk for pressure injury formation because of which factors? Select all that apply.

A) The client is often incontinent of urine.

B) The client uses a wheelchair occasionally.

C) The client is vegan.

D) The client has severe arthritis and has trouble being placed in a lateral position.

E) The client attempts to change position every 15 minutes when sitting in a chair.

Answer: A, C, D Explanation: Moisture of the skin from sweat or urine increases the chance for pressure injury formation.

Lack of adequate protein is associated with pressure injury formation. Being a vegan means that sources of protein may not be available to the client.

The client's arthritis limits the client's ability to move and increases the chance for pressure injury formation.

Page Ref: 696 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 16.4 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 18) The nurse is caring for 4 clients with wounds and would ask that which client be evaluated further for negative-pressure wound therapy?

A) The client with a burned right arm that requires hydrotherapy three times a day for dressing changes.

B) The client with a wound on the foot that is located near the toes.

C) The client with a wound on the forearm who is malnourished due to anorexia from chemotherapy.

D) The client with an abdominal incision that has not healed and is restricted to bed.

Answer: D Explanation: A client with an abdominal wound and who is in bed would be able to use the 16

wound vac 22 hours/day.

Page Ref: 691 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Assessment | Learning Outcome: 16.5 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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19) The wound care nurse has been asked by the healthcare provider to begin negative-pressure wound therapy on a client. Upon assessment of the wound, the nurse notes that the wound still requires a great deal of debridement. Which should the nurse do in this situation?

A) Apply the wound vac because this is the intent of the therapy.

B) Contact the healthcare provider and arrange for debridement of the wound.

C) Apply an autolytic dressing for 24 hours and then apply the wound vac.

D) Place enzymatic debridement product under the black foam and begin the negative-pressure wound therapy.

Answer: B Explanation: If debridement is required before the wound vac can be applied, the nurse should notify the appropriate person, in this case the healthcare provider who can arrange for the debridement to take place.

Page Ref: 691 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 16.5 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 20) A client is slated to begin negative-pressure wound therapy tomorrow and the nurse is reinforcing the teaching about this therapy. Which statement by the client requires further teaching by the nurse?

A) "I realize that this device will be hooked up to me almost all day and night."

B) "I believe most people have to use this therapy for about 10 days."

C) "I need to make sure that I continue to eat three balanced meals a day to help my wound heal."

D) "I realize that there will be some pain associated with this therapy but I want my wound to heal."

Answer: B Explanation: This statement needs further teaching because most clients required 4 to 6 weeks of treatment.

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Page Ref: 691 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 16.5 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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21) The nurse is caring for a client who is receiving negative-pressure wound therapy for an infected leg wound and is aware that the dressing on this wound must be changed how often?

A) Once a week B) Every 48 hours C) Every 24 hours D) Every 4 hours Answer: C Explanation: An infected wound dressing change must be performed every 12 to 24 hours.

Page Ref: 692 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 16.5 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

22) The nurse is preparing to remove staples from a woman who had a cesarean section 6 days ago and will use which forms of personal protective equipment when performing this task?

A) Sterile gloves, face shield B) Face shield, gown, clean gloves C) Gown, sterile gloves, shoe covers D) Clean gloves Answer: D Explanation: Clean gloves are all that is needed to remove staples.

Page Ref: 697 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Intervention | Learning Outcome: 16.6 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment 20

23) The nurse is preparing to remove sutures from a client who sustained a long, deep laceration after a motor vehicle accident and will use what technique to maintain wound stability?

A) The nurse will remove every other suture and reassess the wound for any gaping areas.

B) The nurse will remove all the sutures while holding the edges of the wound together.

C) The nurse will remove the top half of the sutures and return in 1 hour and remove the remaining sutures.

D) The nurse will remove all of the sutures and immediately place a tight dressing over the laceration to ensure that the wound edges stay together.

Answer: A Explanation: To prevent wound dehiscence, the nurse should remove every other suture and then reassess the wound to ensure that the remainder of the sutures can be safely removed.

Page Ref: 697 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Intervention | Learning Outcome: 16.6 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

24) The nurse has just removed sutures on a client and has completed teaching the client about care of the wound at home. Which statement by the client indicates that the client understands the instructions given?

A) "I will leave the dressing in place until I see my doctor in four weeks."

B) "I will only eat soft foods and avoid red meat until my wound is completely healed."

C) "I plan to take a shower every day but not let any soap touch my wound."

D) "I plan to use moisturizing lotion on my wound daily to soften and prevent ugly scar formation."

Answer: C Explanation: The client should shower every day but not put soap on the wound.

Page Ref: 698 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance 21

Standards: Nursing Process: Intervention | Learning Outcome: 16.6 | QSEN Competencies: Client-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Nursing Judgment

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