Test Bank for Clinical Nursing Skills 9th Edition

CHAPTER 1 1. Which tasks would be appropriate for the nurse to delegate to unlicensed assistive personnel(UAP)? Standard Text: Select all that apply.

1. Taking vital signs 2. Measuring and recording intake and output 3. Postmortem care 4. Providing telephone advice 5. Weighing the client Correct Answer: 1,2,3,5 Rationale 1: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Telephone advice involves gathering data, analysis, and planning care, which would all be beyond the scope of practice.

Vital sign measurement, recording intake and output, providing postmortem care, and weighing the client are all appropriate tasks to delegate to the UAP. Rationale 2: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Telephone advice involves gathering data, analysis, and planning care, which would all be beyond the scope of practice.

Vital sign measurement, recording intake and output, providing postmortem care, and weighing the client are all appropriate tasks to delegate to the UAP. Rationale 3: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Telephone advice involves gathering data, analysis, and planning care, which would all be beyond the scope of practice.

Vital sign measurement, recording intake and output, providing postmortem care, and weighing the client are all appropriate tasks to delegate to the UAP. Rationale 4: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Telephone advice involves gathering data, analysis, and planning care, which would all be beyond the scope of practice.

Vital sign measurement, recording intake and output, providing postmortem care, and weighing the client are all appropriate tasks to delegate to the UAP. Rationale 5: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Telephone advice involves gathering data, analysis, and planning care, which would all be beyond the scope of practice.

Vital sign measurement, recording intake and output, providing postmortem care, and weighing the client are all appropriate tasks to delegate to the UAP. Global Rationale: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Telephone advice involves gathering data, analysis, and planning care, which would all be beyond the scope of

practice. Vital sign measurement, recording intake and output, providing postmortem care, and weighing the client are all appropriate tasks to delegate to the UAP. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.B.5. Assume role of team member or leader based on the situation AACN Essential Competencies: II.1.Apply leadership concepts, skills, and decision making in the provision of high-quality nursing care, health care team coordination, and the oversight and accountability for care delivery in a variety of settings NLN Competencies: Teamwork: Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.19 Describe the steps of planning for client care.

Page Number: 19 2. Which procedure should the registered nurse delegate to unlicensed assistive personnel (UAP)?

1. Making a nursing diagnosis 2. Assisting a client to bedside commode 3. Performing assessments on client 4. Giving the client pain medication Correct Answer: 2 Rationale 1: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Formulating a nursing diagnosis is not a task that can be delegated to the UAP. Rationale 2: Assisting a client to a bedside commode is an activity that can be delegated to the UAP. Rationale 3: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Assessment is not a task that can be delegated to the UAP. Rationale 4: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Administering pain medication is not an activity that can be delegated to the UAP. Global Rationale: Assisting a client to a bedside commode is an activity that can be delegated to the UAP. Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Formulating a nursing diagnosis, performing an assessment, and administering pain medications are activities that cannot be delegated to the UAP. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care

QSEN Competencies: II.B.5.Assume role of team member or leader based on the situation AACN Essential Competencies: II.1.Apply leadership concepts, skills, and decision making in the provision of high-quality nursing care, health care team coordination, and the oversight and accountability for care delivery in a variety of settings NLN Competencies: Teamwork: Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.19 Describe the steps of planning for client care.

Page Number: 19 3. Which statement indicates that unlicensed assistive personnel (UAP) understand directions provided regarding client care?

Standard Text: Select all that apply.

1. “I will bathe the client in room 402.”

2. “I am done with the assigned tasks for Mr. Wells.”

3. “I can give the medication for you.”

4. “I will note all orders.”

5. “I understand my assignment is to take and document the vital signs.”

Correct Answer: 1,2,5 Rationale 1: Restating the task to the nurse indicates understanding and appropriate communication during delegation.

Rationale 2: Telling the nurse that the assigned tasks are done indicates understanding and appropriate communication during delegation.

Rationale 3: Medication administration cannot be delegated.

Rationale 4: The UAP cannot note orders on the medical record. This activity must be done by the nurse.

Rationale 5: Restating the task to the nurse indicates understanding and appropriate communication during delegation.

Global Rationale: Restating the task to the nurse indicates understanding and appropriate communication during delegation. Telling the nurse that the assigned tasks are done indicates understanding and appropriate communication during delegation. Medication administration cannot be delegated. The UAP cannot note orders on the medical record. This activity must be done by the nurse.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.B.5. Assume role of team member or leader based on the situation AACN Essential Competencies: II.1. Apply leadership concepts, skills and decision making in the provision of high quality nursing care, health care team coordination, and the oversight and accountability for care delivery in a variety of settings NLN Competencies: Teamwork: Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.19 Describe the steps of planning for client care.

Page Number: 19 4. The nurse observing the unlicensed assistive personnel (UAP) using alcohol-based rubs for hand hygiene would recognize that further teaching is required when the UAP performs which act?

1. Rubs palm against palm when washing hands.

2. Applies a palmful of product into cupped hands.

3. Interlaces fingers palm to palm.

4. Dries hands with clean paper towel.

Correct Answer: 4 Rationale 1: When using an alcohol-based hand rub, the hands should not be dried. Rubbing of hands palm to palm and interlacing fingers are continued until the product dries, which takes about 20–30 seconds. A palmful of product is generally required to coat all surfaces.

Rationale 2: When using an alcohol-based hand rub, the hands should not be dried. Rubbing of hands palm to palm and interlacing fingers are continued until the product dries, which takes about 20–30 seconds. A palmful of product is generally required to coat all surfaces.

Rationale 3: When using an alcohol-based hand rub, the hands should not be dried. Rubbing of hands palm to palm and interlacing fingers are continued until the product dries, which takes about 20–30 seconds. A palmful of product is generally required to coat all surfaces.

Rationale 4: When using an alcohol-based hand rub, the hNanUdR s Ss hI oNuGl dTnBo .t Cb O e dMried. Rubbing of hands palm to palm and interlacing fingers are continued until the product dries, which takes about 20–30 seconds. A palmful of product is generally required to coat all surfaces. Global Rationale: When using an alcohol-based hand rub, the hands should not be dried. Rubbing of hands palm to palm and interlacing fingers are continued until the product dries, which takes about 20–30 seconds. A palmful of product is generally required to coat all surfaces.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team NLN Competencies: Context and Environment: Apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.19 Describe the steps of planning for client care.

Page Number: 18 5. The nurse is working in a day care center where there recently has been an outbreak of viral conjunctivitis. What should the nurse instruct the staff to stop the spread of this infection?

1. Require all children with conjunctivitis to stay home until there is a reduction in drainage.

2. Require all children with an infection to be on otic antibiotics for at least 24 hours prior to returning to school.

3. Isolate all children with conjunctivitis in the same room away from those who are not infected.

4. Perform hand hygiene after providing personal care for all children.

Correct Answer: 4 Rationale 1: The best way to reduce the spread of infection is through thorough hand hygiene. There would be no need to keep children away from the day care center.

Rationale 2: The best way to reduce the spread of infection is through thorough hand hygiene. There would be no need to place a child with a viral illness on antibiotics.

Rationale 3: The best way to reduce the spread of infection is through thorough hand hygiene. There would be no need to isolate children with conjunctivitis.

Rationale 4: The best way to reduce the spread of infection is through thorough hand hygiene. Global Rationale: The best way to reduce the spread of infection is through thorough hand hygiene. There would be no need to place a child with a viral illness on antibiotics, to isolate children with conjunctivitis, or to keep children away from the day care center.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.B.1. Demonstrate effective use oNf Ut e Rc hSnIoNl oGg Ty Ba n. C dO staM ndardized practices that support safety and quality AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team NLN Competencies: Context and Environment: Apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.19 Describe the steps of planning for client care. Page Number: 18 6. For which situation should the nurse apply clean disposable gloves?

1. Providing denture care 2. Bathing a client 3. Applying antiemboli stockings 4. Assessing vital signs Correct Answer: 1

Rationale 1: The purpose of gloves is to protect the hands when the nurse is likely to handle any potentially infective material. When providing denture care, the nurse is in contact with mucous membranes and body secretions, so gloves would be required.

Rationale 2: The purpose of gloves is to protect the hands when the nurse is likely to handle any potentially infective material. In most instances, unless the client has an open wound, gloves would not be required when bathing a client.

Rationale 3: The purpose of gloves is to protect the hands when the nurse is likely to handle any potentially infective material. In most instances, unless the client has an open wound, gloves would not be required when applying stockings.

Rationale 4: The purpose of gloves is to protect the hands when the nurse is likely to handle any potentially infective material. In most instances, unless the client has an open wound, gloves would not be required when assessing vital signs.

Global Rationale: The purpose of gloves is to protect the hands when the nurse is likely to handle any potentially infective material. When providing denture care, the nurse is in contact with mucous membranes and body secretions, so gloves would be required. In most instances, unless the client has an open wound, gloves would not be required when bathing a client, applying stockings, or assessing vital signs.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team NLN Competencies: Context and Environment: Apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.19 Describe the steps of planning for client care. Page Number: 18 7. The nurse is caring for several clients during the shift. Which action demonstrates appropriate hand hygiene?

1. Putting on gloves 2. Washing hands with soap and water 3. Wiping hands off when entering room 4. Using the client’s soap on hands

Correct Answer: 2 Rationale 1: Putting on gloves does not demonstrate appropriate hand hygiene.

Rationale 2: Washing hands with soap and water demonstrates appropriate hand hygiene.

Rationale 3: Wiping hands off when entering the room does not demonstrate appropriate hand hygiene.

Rationale 4: The use of the client’s soap on the hand is not appropriate when performing hand hygiene.

Global Rationale: Washing hands with soap and water demonstrates appropriate hand hygiene. Putting on gloves and wiping hands off when entering the client’s room does not demonstrate appropriate hand hygiene. The use of the client’s soap on the hand is not appropriate when performing hand hygiene.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues, that i n v oNl vUeRi nSdI iNv iGd uTaBl s.,Cf aOmMi l i e s , groups, communities, populations, and other members of the health care team NLN Competencies: Context and Environment: Apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.19 Describe the steps of planning for client care.

Page Number: 18 8. Which behavior indicates that the nurse is practicing as a professional?

1. Documenting that a client needs pain medication 2. Visiting with family of a client on another part of the care area 3. Telling a client to ask the next nurse for help getting out of bed 4. Directing unlicensed assistive personnel (UAP) to measure urine output Correct Answer: 4 Rationale 1: A professional nurse would assess the client’s pain level and provide medication.

Documenting the need for pain medication does not demonstrate professionalism.

Rationale 2: A professional nurse would not socialize with clients or family.

Rationale 3: A professional nurse would meet the client’s needs at the time they are requested.

Rationale 4: A professional nurse appropriately delegates tasks to UAP. Global Rationale: A professional nurse appropriately delegates tasks to UAP. A professional nurse would address a client’s pain management needs, avoid socializing with clients and families, and meet the client’s needs at the time they are requested.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II. B. 4. Function competently within own scope of practice as a member of the health care team AACN Essential Competencies: VIII. 2. Assume accountability for personal and professional behaviors NLN Competencies: Context and Environment: Practice: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills Nursing/Integrated Concepts: Evaluation Learning Outcome: 1.1 Discuss what is meant by the concept “professional role of the nurse.” Page Number: 3 9. What actions should the nurse take to assist a client adapt to being hospitalized? Select all that apply.

1. Ensuring for the client’s comfort 2. Completing the admission assessment 3. Attempting to accommodate the client’s wishes 4. Communicating with the client as an individual 5. Accepting the client’s perception of the environment Correct Answer: 1, 3, 4, 5 Rationale 1: Ensuring for the client’s comfort is an action to assist a client adapt to being hospitalized.

Rationale 2: Completing the admission assessment is not an approach to assist a client adapt to being hospitalized.

Rationale 3: Attempting to accommodate the client’s wishes is an action to assist a client adapt to being hospitalized.

Rationale 4: Communicating with the client as an individual is an action to assist a client adapt to being hospitalized.

Rationale 5: Accepting the client’s perception of the environment is an action to assist a client adapt to being hospitalized.

Global Rationale: Actions to assist clients adapt to being hospitalized include ensuring for the client’s comfort, accommodating the client’s wishes if possible, communicating with the client as an individual, and accepting the client’s perception of the environment. Completing the admission assessment is not an approach to assist a client adapt to being hospitalized.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II. B. 4. Function competently within own scope of practice as a member of the health care team AACN Essential Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment: Practice: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills Nursing/Integrated Concepts: Implementation Learning Outcome: 1.7 List three ways you can assist the client to assume and adapt to the client role.

Page Number: 4 10. Which document should the nurse refer to ensure safe care is being provided to a client?

1. Core measure sets 2. Nurse practice act 3. Joint Commission standards 4. National patient safety goals (NPSGs) Correct Answer: 4 Rationale 1: Core measure sets were created as a quality improvement tool.

Rationale 2: Nurse Practice acts ensure the nurse practices in a safe and legal manner.

Rationale 3: Joint Commission standards are the basis of an objective evaluation process to help healthcare organizations measure, assess, and improve performance.

Rationale 4: NPSGs identify focus areas for client safety.

Global Rationale: NPSGs identify focus areas for client safety. Core measure sets were created as a quality improvement tool. Nurse Practice acts ensure the nurse practices in a safe and legal manner. Joint Commission standards are the basis of an objective evaluation process to help healthcare organizations measure, assess, and improve performance.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others

AACN Essential Competencies: II. 7. Promote factors that create a culture of safety and caring NLN Competencies: Quality and Safety: Ethical Comportment: Commit to a generative safety culture Nursing/Integrated Concepts: Planning Learning Outcome: 1.8 Describe Core Measures, the Joint Commission Standards, and National Patient Safety Goals and how they are developed and utilized in practice.

Page Number: 5 11. The nurse is asked to perform a task that is beyond the scope of practice. What should the nurse use as a reason when refusing to complete the task?

1. “It is not a part of the National Patient Safety Goals.”

2. “The Joint Commission does not identify it as a nursing task.”

3. “It is not identified as permitted within the Nurse Practice Act.” 4. “The task can be delegated to unlicensed assistive personnel (UAP).”

Correct Answer: 3 Rationale 1: The National Patient Safety Goals do not define nursing scope of practice. Rationale 2: The Joint Commission does not define nursing scope of practice.

Rationale 3: The Nurse Practice Act defines nursing scope of practice and should be used as a reason to refuse a task.

Rationale 4: Tasks that are beyond the nurse’s scope of practice cannot be delegated to UAP. Global Rationale: The Nurse Practice Act defines nursing scope of practice and should be used as a reason to refuse a task. The National Patient Safety Goals do not define nursing scope of practice. The Joint Commission does not define nursing scope of practice. Tasks that are beyond the nurse’s scope of practice cannot be delegated to UAP. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others AACN Essential Competencies: II. 7. Promote factors that create a culture of safety and caring NLN Competencies: Quality and Safety: Ethical Comportment: Commit to a generative safety culture Nursing/Integrated Concepts: Implementation Learning Outcome: 1.10 Discuss major sections of the Nurse Practice Act. Page Number: 5 12. For which reasons should a registered nurse contact the Board of Registered Nursing (BRN)? Select all that apply?

1. Renewing nursing license

2. Determining nursing standards 3. Identifying the date for a disciplinary hearing 4. Checking the dates for continuing education programs 5. Ascertaining when a nurse applicant became licensed Correct Answer: 1, 2, 3, 5 Rationale 1: A function of the BRN is to renew nursing licensure. Rationale 2: A function of the BRN is to determine nursing standards. Rationale 3: A function of the BRN is to investigate disciplinary actions.

Rationale 4: The BRN is not responsible for continuing education programs. Rationale 5: A function of the BRN is to register nursing licenses.

Global Rationale: Functions of the BRN include renewing nursing licensure, determining nursing standards, investigating disciplinary actions, and registering nursing licenses. The BRN is not responsible for continuing education programs.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: IV. C. 1. Appreciate that continuous quality improvement is an essential part of the daily work of all health professionals AACN Essential Competencies: V. 5. Describe state and national statues, rules and regulations that authorize and define professional nursing practice NLN Competencies: Personal and Professional Development: Knowledge: Codes of ethics and regulatory and professional standards Nursing/Integrated Concepts: Implementation Learning Outcome: 1.12 State four functions of the Board of Registered Nursing. Page Number: 6 13. The nurse manager is contacting the Board of Registered Nursing (BRN) to report a staff member.

Which action did the manager most likely observe the staff member perform?

1. Changing a client’s abdominal wound dressing 2. Instructed a client on self-administration of insulin 3. Assisting a client with ambulation to the bathroom 4. Informing a client to stop taking a prescribed medication Correct Answer: 4 Rationale 1: Changing an abdominal wound dressing is within the nurse’s scope of practice. Rationale 2: Medication teaching is within the nurse’s scope of practice.

Rationale 3: Providing direct client care is within the nurse’s scope of practice.

Rationale 4: Practicing medicine without a license is an action that is identified as misconduct.

Global Rationale: Practicing medicine without a license is an action that is identified as misconduct. Changing a dressing, providing medication teaching, and providing direct client care are all within the nurse’s scope of practice.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: V. B. 8. Use national patient safety resources for own professional development and to focus attention on safety in care settings AACN Essential Competencies: V. 5. Describe state and national statues, rules and regulations that authorize and define professional nursing practice NLN Competencies: Personal and Professional Development: Knowledge: Codes of ethics and regulatory and professional standards Nursing/Integrated Concepts: Assessment Learning Outcome: 1.13 Discuss four grounds for licensure revocation for professional misconduct.

Page Number: 7 14. What action should the nurse take to ensure the safe a dNmUi nRi sSt rI aNt iG o nToBf . pCr O e sM c r i b e d medications to a client?

Select all that apply.

1. Validating the healthcare provider’s order 2. Checking two forms of client identification 3. Leaving a client’s medications at the bedside 4. Returning a mislabeled medication to the Pharmacy 5. Deciding to report a medication error later in the shift Correct Answer: 1, 2, 4 Rationale 1: Nurses must not administer any drug without a specific healthcare provider’s order.

Rationale 2: Nurses must check two forms of client identification before administering medications.

Rationale 3: Nurses must never leave prepared medicines unattended.

Rationale 4: Nurses must send labeled bottles or packages that are unintelligible back to the pharmacist for relabeling.

Rationale 5: Nurses must always report errors immediately.

Global Rationale: Nurses must not administer any drug without a specific healthcare provider’s

order; check two forms of client identification before administering medications; and send labeled bottles or packages that are unintelligible back to the pharmacist for relabeling. Nurses must never leave prepared medicines unattended and always report errors immediately.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V. B. 8. Use national patient safety resources for own professional development and to focus attention on safety in care settings AACN Essential Competencies: V. 5. Describe state and national statues, rules and regulations that authorize and define professional nursing practice NLN Competencies: Personal and Professional Development: Knowledge: Codes of ethics and regulatory and professional standards Nursing/Integrated Concepts: Implementation Learning Outcome: 1.14 Explain the legal issues of drug administration. Page Number: 7 15. A client asks for a copy of the medical record to take home upon discharge. What action should the nurse take regarding this request?

1. Prepare the requested documentation 2. Tell the client that the record belongs to the hospital 3. Explain to the client that the record cannot be provided 4. Ask the health care provider if the medical record can be provided Correct Answer: 1 Rationale 1: Under the Health Insurance Portability and Accountability Act (HIPAA) a client can request copies of the medical record.

Rationale 2: The record may be the hospital’s property however the client can have a copy of the record according to HIPAA. Rationale 3: The record can be provided.

Rationale 4: The nurse does not need to ask the healthcare provider for permission to provide a copy of the record to the client.

Global Rationale: Under the Health Insurance Portability and Accountability Act (HIPAA) a client can request copies of the medical record. The record may be the hospital’s property however the client can have a copy of the record according to HIPAA. The record can be provided. The nurse does not need to ask the healthcare provider for permission to provide a copy of the record to the client.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care

QSEN Competencies: VI. C. 3. Protect confidentiality of protected health information in electronic health records AACN Essential Competencies: VIII. 10. Protect patient privacy and confidentiality of patient records and other privileged communications NLN Competencies: Context and Environment; Knowledge: principles of informed consent, confidentiality, patient self-determination Nursing/Integrated Concepts: Implementation Learning Outcome: 1.15 Discuss the role of HIPAA in health care. Page Number: 8 16. What should the nurse include when reviewing the Patient Care Partnership brochure with a newly admitted client?

1. Visiting hours 2. Times for meals 3. Help with billing claims 4. How to avoid paying for medications Correct Answer: 3 Rationale 1: Visiting hours is not a part of the Patient Care Partnership brochure. Rationale 2: Times for meals are not a part of the Patient Care Partnership brochure. Rationale 3: Help with biling claims is a part of the PatienNtU CaRrS e IPNa rGt nTe B r s .hCi pObM r o c h u r e.

Rationale 4: How to avoid paying for medications is not a part of the Patient Care Partnership brochure.

Global Rationale: Help with billing claims is a part of the Patient Care Partnership brochure. Visiting hours, times for meals and avoiding paying for medications are not a part of the Patient Care Partnership brochure.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: IV. C. 2. Value own and others' contributions to outcomes of care in local care settings AACN Essential Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network NLN Competencies: Context and Environment; Knowledge: principles of informed consent, confidentiality, patient self-determination Nursing/Integrated Concepts: Implementation Learning Outcome: 1.16 Describe what is meant by clients’ rights and the Patient Care Partnership brochure Page Number: 9

17. A client refuses to complete an advance directive because he is not “ready to die.” What should the nurse respond to this statement?

1. “It’s best to be safe than sorry.”

2. “You are right – it is more appropriate for someone who has a terminal illness.”

3. “That’s fine. I’ll just document that you refuse to decide your medical treatment.”

4. “It is a document that allows you to make legal decisions about how you wish to receive future medical treatment.”

Correct Answer: 4 Rationale 1: Saying that it is better to be safe than sorry does not explain the purpose of an advance directive.

Rationale 2: Advance directives are appropriate for all clients and not just those with a terminal illness.

Rationale 3: The client did not refuse to decide medical treatment.

Rationale 4: An advance medical directive is a document that allows clients to make legal decisions about how they wish to receive future medical treatment.

Global Rationale: An advance medical directive is a document that allows clients to make legal decisions about how they wish to receive future medical treatment. Saying that it is better to be safe than sorry does not explain the purpose of an adv anceNdUir R e cStiIvNe.GATdB v a.C n cOe M d irectiv es are appropriate for all clients and not just those with a terminal illness. The client did not refuse to decide medical treatment.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences, values AACN Essential Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Knowledge: principles of informed consent, confidentiality, patient self-determination Nursing/Integrated Concepts: Implementation Learning Outcome: 1.17 Explain what is meant by advance directives Page Number: 10

CHAPTER 2 1. The nurse is planning care for a newly admitted client. Which behavior indicates that the nurse is using critical thinking?

1. Recalls a similar client situation 2. Asks the healthcare provider for suggestions 3. Looks at a care plan written for another client 4. Expects the oncoming nurse to complete the care plan Correct Answer: 1 Rationale 1: An important aspect of critical thinking is the ability to use reflection and language properly.

Reflection is the action of thinking back or recalling an earlier clinical situation, remembering nursing actions that worked or didn’t work, and determining whether this information is helpful in the current situation.

Rationale 2: Asking a healthcare provider for suggestions when planning client care does not exemplify critical thinking.

Rationale 3: Looking at a care plan written for another client does not exemplify critical thinking.

Rationale 4: Expecting the oncoming nurse to complete the care plan does not exemplify critical thinking Global Rationale: An important aspect of critical thinking is the ability to use reflection and language properly. Reflection is the action of thinking back or recalling an earlier clinical situation, remembering nursing actions that worked or didn’t work, and determining whether this information is helpful in the current situation. Asking a healthcare provider for suggestions, looking at a care plan written for another client; and expecting the oncoming nurse to complete the care plan do not exemplify critical thinking.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.1 Define the term critical thinking. Page Number: 23

2. The nurse is assigned to care for a newly admitted client. Which approach should be used to address the client’s responses to the illness?

1. Best practices 2. Nursing process 3. Critical thinking 4. Evidence-based practice Correct Answer: 2 Rationale 1: Best practice is a generic or general phrase for a process of infusing nursing practice with research-based knowledge.

Rationale 2: The nursing process is used to diagnose and treat human responses to health and illness.

Rationale 3: Critical thinking involves the careful acquisition and interpretation of information and use of it to reach a well-justified conclusion.

Rationale 4: Evidence-based nursing practice is defined as the application to clinical practice of the best available empirical evidence that applies recent research findings, in order to aid clinical decision making.

Global Rationale: The nursing process is used to diagnose and treat human responses to health and illness. Best practice is a generic or gNeUnReSraINl pGhTrBa.sCeOfM or a process of infusing nursing practice with researchbased knowledge. Critical thinking involves the careful acquisition and interpretation of information and use of it to reach a well-justified conclusion. Evidence-based nursing practice is defined as the application to clinical practice of the best available empirical evidence that applies recent research findings, in order to aid clinical decision making.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.2 Define the term nursing process. Page Number: 24 3. The nurse is reviewing care provided to a client. Which behavior indicates that the nurse is using critical thinking?

1. Administers prescribed medications 2. Studies the results of diagnostic tests

3. Individually analyzes client problems 4. Documents responses to care provided Correct Answer: 3 Rationale 1: Administering prescribed medications is an action and would not be conducted when reviewing care.

Rationale 2: Studying the results of diagnostic tests would be an action completed during the assessment phase of the nursing process.

Rationale 3: The nursing process is a systematic, problem-solving approach that is considered a critical thinking competency that assists the nurse to intervene in client care.

Rationale 4: Documentation is an action that would not be completed when reviewing care provided to a client.

Global Rationale: The nursing process is a systematic, problem-solving approach that is considered a critical thinking competency that assists the nurse to intervene in client care. Administering prescribed medications is an action and would not be conducted when reviewing care. Studying the results of diagnostic tests would be an action completed during the assessment phase of the nursing process.

Documentation is an action that would not be completed when reviewing care provided to a client.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.3 Explain how critical thinking is used in each step of the nursing process. Page Number: 24 4. After receiving morning report the nurse categorizes an assigned client’s care according to priority needs. How does this behavior support the nursing process?

1. Organizes and structures care 2. Emphasizes client preferences 3. Follows Maslow’s hierarchy of needs 4. Considers time needs for each nursing action Correct Answer: 1

Rationale 1: The nursing process—assessment, analysis/nursing diagnosis, planning, implementation, and evaluation—provides an organized structure and framework for the delivery of nursing care in all settings.

Rationale 2: Client preferences may or may not coincide with care priorities.

Rationale 3: Maslow’s hierarchy of needs may or may not coincide with care priorities. Rationale 4: The time needed for nursing actions may or may not coincide with care priorities.

Global Rationale: The nursing process—assessment, analysis/nursing diagnosis, planning, implementation, and evaluation—provides an organized structure and framework for the delivery of nursing care in all settings. Client preferences, Maslow’s hierarchy of needs, and time to complete nursing actions may or may not coincide with care priorities.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.4 Describe how the nursing process relates to nursing. Page Number: 24 5. The nurse collects data slowly and methodically from a new client. Why is the nurse using this approach during this phase of the nursing process?

1. Ensures accuracy of data 2. Identifies client outcomes 3. Establishes a rapport with the client 4. Highlights the importance of the therapeutic relationship Correct Answer: 1 Rationale 1: Assessment is a critical phase because all the other steps depend on the accuracy and reliability of the information obtained.

Rationale 2: Client outcomes are not identified during the assessment phase.

Rationale 3: Client rapport does become established during the assessment phase however this is not the reason for the nurse to collect data slowly and methodically.

Rationale 4: The therapeutic relationship is important however this is not the reason for the nurse to collect data slowly and methodically.

Global Rationale: Assessment is a critical phase because all the other steps depend on the accuracy and reliability of the information obtained. Client outcomes are not identified during the assessment phase.

Client rapport and the therapeutic relationship are important however these are not reasons for the nurse to collect data slowly and methodically.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.5 Discuss the term assessment, and describe how it influences the nursing process.

Page Number: 24 6. The nurse is preparing to assess a client new to the out-patient care environment. Which actions should the nurse expect to c o mp lNetUeRdSuI NriGn Tg Bt h. CisO M p ha s e of the nursing process? Select all that apply.

1. Complete a client interview 2. Conduct a physical examination 3. Analyze test results and findings 4. Categorize data into meaningful patterns 5. Identify pertinent family health history issues Correct Answer: 1, 2, 3, 5 Rationale 1: A client interview is a part of the assessment. Rationale 2: A physical examination is a part of the assessment.

Rationale 3: Analyzing test results and findings is a part of the assessment.

Rationale 4: Categorizing data into meaningful patterns is a part of the nursing diagnosis phase of the nursing process.

Rationale 5: Identifying pertinent family health history issues is a part of the assessment.

Global Rationale: Client interview, physical examination, analysis and findings of diagnostic tests, and family health history issues are all parts of the assessment phase of the nursing process.

Categorizing data into meaningful patterns is a part of the nursing diagnosis phase of the nursing process.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.6 List the components of the assessment step. Page Number: 24 7. After completing an assessment the nurse analyzes all data collected. What is the significance of the nurse performing this analysis?

1. Confirms observations 2. Identifies client outcomes 3. Establishes a foundation for the client’s care 4. Prioritizes interventions according to client needs Correct Answer: 3 Rationale 1: Confirming observations occurs during the assessment phase. Rationale 2: Identifying client outcomes occurs during the planning phase.

Rationale 3: Analysis which occurs during the nursing diagnosis phase provides the foundation for each individual client’s therapeutic plan of care.

Rationale 4: Prioritizing interventions occurs during the implementation phase.

Global Rationale: Analysis which occurs during the nursing diagnosis phase provides the foundation for each individual client’s therapeutic plan of care. Confirming observations occurs during the assessment phase. Identifying client outcomes occurs during the planning phase.

Prioritizing interventions occurs during the implementation phase.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 2.7 Describe the primary purpose of the analysis phase of the nursing process.

Page Number: 25 8. The instructor is preparing a lecture on the nursing process. Which statement should the instructor use that best describes nursing diagnosis?

1. It is an educated judgment about a client’s potential or actual health problems 2. It refers to the priority nursing actions or interventions performed to accomplish a specified goal 3. It involves the careful acquisition and interpretation and use of information to reach a conclusion 4. It is the action of thinking back about an earlier clinical situation, recalling actions that worked or didn’t work, and determining if this information is helpful in the current situation Correct Answer: 1 Rationale 1: Nursing diagnosis is an educated judgment about potential or actual health problem or problems of a client.

Rationale 2: The implementation phase of the nursing process refers to the priority nursing actions or interventions performed to a ccNoUmRpSlIiNs hG Ta Bs.pCeOcMi fi e d goal.

Rationale 3: Critical thinking involves the careful acquisition and interpretation and use of information to reach a conclusion.

Rationale 4: Reflection is the action of thinking back about an earlier clinical situation, recalling actions that worked or didn’t work, and determining if this information is helpful in the current situation.

Global Rationale: Nursing diagnosis is an educated judgment about potential or actual health problem or problems of a client. The implementation phase of the nursing process refers to the priority nursing actions or interventions performed to accomplish a specified goal. Critical thinking involves the careful acquisition and interpretation and use of information to reach a conclusion. Reflection is the action of thinking back about an earlier clinical situation, recalling actions that worked or didn’t work, and determining if this information is helpful in the current situation.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 2.8 Define the term nursing diagnosis.

Page Number: 25 9. The nurse is completing the planning phase of the nursing process with a client. Which should the nurse perform during this phase? Select all that apply.

1. Identify short- and long-term goals 2. Strategize approaches for goal outcomes 3. List nursing measures when delivering care 4. Create outcomes that are measurable and realistic 5. Organize defining characteristics of data into meaningful patterns Correct Answer: 1, 2, 3, 4 Rationale 1: Identification of short- and long-term goals occurs during the planning phase. Rationale 2: Strategizing approaches for goal outcomes occurs during the planning phase. Rationale 3: Listing nursing measures when delivering care occurs during the planning phase.

Rationale 4: Creating outcomes that are measurable, realistic in addition to being time-specific and quantifiable occurs during the planning phase.

Rationale 5: Organizing defining characteristics of data into meaningful patterns occurs during the nursing diagnosis phase.

Global Rationale: Actions performed during the planning phase include identifying short- and long-term goals, strategizing approaches for goal outcomes, listing nursing measures when delivering care, and creating outcomes that are measureable and realistic in addition to being time-specific and quantifiable.

Organizing defining characteristics of data into meaningful patterns occurs during the nursing diagnosis phase.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 2.9 Define outcome planning and identification, and give an example of this step in the nursing process.

Page Number: 25 10. The nurse is implementing a client’s plan of care. Which action should the nurse perform at this time?

1. Record relevant information 2. Motivate and maintain optimum wellness 3. Coordinate care and community resources 4. Anticipate needs of client and family based on priorities Correct Answer: 2 Rationale 1: Recording relevant information occurs during the planning phase.

Rationale 2: Motivating and maintaining optimum wellness occurs during the implementation phase.

Rationale 3: Coordinating care and community resources occurs during the planning phase.

Rationale 4: Anticipating the needs of the client and the family based on priorities occurs during the planning phase.

O Mw elln es s occurs during the implementation phase.

Global Rationale: Motivating and m aint aNi UniRnSgI No GptTi Bm. uC m Recording relevant information occurs during the planning phase. Coordinating care and community resources occurs during the planning phase. Anticipating the needs of the client and the family based on priorities occurs during the planning phase.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.10 Define what is meant by the implementation phase of the nursing process.

Page Number: 26 11. A client is being prepared for discharge. What should the nurse perform when evaluating this client’s care? Select all that apply.

1. Reassess care plan 2. Record client responses

3. Determine effects of nursing actions 4. Communicate to client and client’s family 5. Examine appropriateness of nursing actions Correct Answer: 1, 2, 3, 5 Rationale 1: Reassessing the care plan is performed during the evaluation phase. Rationale 2: Recording client responses is performed during the evaluation phase.

Rationale 3: Determining the effectiveness of nursing actions is performed during the evaluation phase.

Rationale 4: Communicating to the client and family occurs during the implementation phase. Rationale 5: Examining appropriateness of nursing actions occurs during the evaluation phase.

Global Rationale: Actions completed during the evaluation phase include reassessing the care plan, recording client responses, determining the effectiveness of nursing actions, and examining appropriateness of nursing actions. Communicating to the client and family occurs during the implementation phase.

Cognitive Level: Applying Client Need: Safe and Effective Care EnNviUr RonS ImNeGnTt B . C O M Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.11 Explain evaluation and include your understanding of why it is an important step in the nursing process.

Page Number: 27 12. The nurse is explaining nursing diagnoses to a group of first-year nursing students. What should the nurse include in this explanation? Select all that apply.

1. Focuses on client responses 2. Focuses on injury, illness, or disease 3. Requires physician orders to address 4. Remains the same until client discharge 5. Changes according to the client’s needs Correct Answer: 1, 5

Rationale 1: Nursing diagnoses focus on client responses. Rationale 2: Medical diagnoses focus on injury, illness, or disease. Rationale 3: Medical diagnoses require physician orders to address.

Rationale 4: Medical diagnoses remain the same until client discharge.

Rationale 5: Nursing diagnoses change according to the client’s needs.

Global Rationale: Nursing diagnoses focus on client responses and change according to the client’s needs. Medical diagnoses focus on injury, illness, or disease, require physician orders to address, and remain the same until the client is discharged.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy GTuB Nursing/Integrated Concepts: Nursing PrNoUcResSsIN: N rs.iCnOgMDiagnosis Learning Outcome: 2.12 Differentiate nursing diagnosis from medical diagnosis. Page Number: 27 13. The nurse is researching nursing interventions appropriate for a particular nursing diagnosis. Which classification system should the nurse use when researching this information?

1. NIC 2. PES 3. NOC 4. NANDA Correct Answer: 1 Rationale 1: The nursing interventions classification (NIC) is a system that provides uniformity to nursing actions because each intervention has a label name and a set of activities that are identified as steps to carry it out.

Rationale 2: PES or problem, etiology, and signs and symptoms is an approach used to create a nursing diagnosis statement.

Rationale 3: The nursing outcomes classification (NOC) is a comprehensive, standardized classification of client outcomes developed to evaluate the effects of interventions provided by nurses or other healthcare professionals.

Rationale 4: The North America Nursing Diagnosis Association (NANDA) is an organization that studies and approves nursing diagnostic statements.

Global Rationale: The nursing interventions classification (NIC) is a system that provides uniformity to nursing actions because each intervention has a label name and a set of activities that are identified as steps to carry it out. PES or problem, etiology, and signs and symptoms is an approach used to create a nursing diagnosis statement. The nursing outcomes classification (NOC) is a comprehensive, standardized classification of client outcomes developed to evaluate the effects of interventions provided by nurses or other healthcare professionals. The North America Nursing Diagnosis Association (NANDA) is an organization that studies and approves nursing diagnostic statements.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning U ROSCI NaGnTdBt. hCeOi rMro l e in standardizing nursing language. Page Number: Learning Outcome: 2.13 Define NIC a n dN N 23 14. The nurse is identifying nursing diagnoses appropriate for a client’s health issues. Which information should the nurse include when creating a three-part diagnostic statement?

1. Interventions 2. Learning needs 3. Expected outcomes 4. Signs and symptoms Correct Answer: 4 Rationale 1: A three-part nursing diagnostic statement does not include interventions. Rationale 2: Learning needs is not included in a three-part nursing diagnostic statement. Rationale 3: Expected outcomes are not included in a three-part nursing diagnostic statement. Rationale 4: Signs and symptoms are included in a three-part nursing diagnostic statement.

Global Rationale: Signs and symptoms are included in a three-part nursing diagnostic statement. Interventions, learning needs, and expected outcomes are not included in a three-part nursing diagnostic statement.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 2.14 Compare and contrast the two-part and three-part Nursing Diagnosis Statement.

Page Number: 29 15. The manager is reviewing care plans created for newly admitted clients. Which nursing diagnostic statement should the manager review with the nurse as needing to be amended?

1. Risk for injury related to left sided paralysis 2. Fluid volume overload related to congestive heart failure 3. Impaired coping related to recent death of spouse and son 4. Imbalanced nutrition: Less than body requirements related to mouth and throat ulcers Correct Answer: 2 Rationale 1: This is a correctly written two-part nursing diagnostic statement. Rationale 2: A nursing diagnosis statement does not include a medical diagnosis. Rationale 3: This is a correctly written two-part nursing diagnostic statement.

Rationale 4: This is a correctly written two-part nursing diagnostic statement.

Global Rationale: A nursing diagnosis statement does not include a medical diagnosis. Risk for injury, impaired coping, and imbalanced nutrition are all correctly written nursing diagnostic statements.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis

Learning Outcome: 2.15 State two examples of nursing diagnoses. Page Number: 28 16. The nurse is explaining evidence-based practice to a group of new nursing students. Which statement should the nurse use during this explanation?

1. “Evidence-based nursing practice generates new knowledge.”

2. “Evidence-based nursing practice applies knowledge to practice.”

3. “Evidence-based nursing practice is measurable, time specific, quantifiable, and realistic.”

4. “Evidence-based nursing practice is based on the best evidence available from nursing research.”

Correct Answer: 2 Rationale 1: Research generates new knowledge.

Rationale 2: Evidence-based nursing practice applies knowledge to practice. Rationale 3: Outcomes are measurable, time specific, quantifiable and realistic.

Rationale 4: Best practices are based on the best evidence available from nursing research.

Global Rationale: Evidence-based nursing practice applies knowledge to practice. Research generates new knowledge. Outcomes are measurable, time specific, quantifiable and realistic. Best practices are based on the best e v i d Ne nUcReS aI Nv aGi Tl aBb. lCeOfMro m nursing research.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.16 Define evidence-based nursing practice. Page Number: 30 17. The nurse manager determines that a staff nurse uses critical thinking when planning the outcomes for a client’s care. What did the manager observe to come to this conclusion?

1. Prioritized client problems 2. Critically analyzed all client outcomes 3. Clustered data to determine relationships 4. Used a systematic approach to collect data

Correct Answer: 1 Rationale 1: Prioritizing client problems demonstrates critical thinking during the planning phase.

Rationale 2: Critically analyzing all client outcomes demonstrates critical thinking during the evaluation phase.

Rationale 3: Clustering data to determine relationships demonstrates critical thinking during the nursing diagnosis phase.

Rationale 4: Using a systematic approach to collect data demonstrates critical thinking during the assessment phase.

Global Rationale: Prioritizing client problems demonstrates critical thinking during the planning phase.

Critically analyzing all client outcomes demonstrates critical thinking during the evaluation phase.

Clustering data to determine relationships demonstrates critical thinking during the nursing diagnosis phase. Using a systematic approach to collect data demonstrates critical thinking during the assessment phase.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate uNnUdeRrSsItNanGdTiBn.gC Oo M f mu lt ip le dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.3 Explain how critical thinking is used in each step of the nursing process. Page Number: 26

CHAPTER 3 1. A newly admitted client says desires to have surgery to replace a knee and then return home as soon as possible to resume living. On which part of the care plan should the nurse document this information?

1. Client problems 2. Short-term goals 3. Assessment data 4. Nursing interventions Correct Answer: 2 Rationale 1: A client problem is an unmet need.

Rationale 2: Goals or expected outcomes are statements that address the client problems. For this situation, the client has stated the goal of having knee replacement surgery in order to return home and resume living.

Rationale 3: Assessment data is not a part of the care plan.

Rationale 4: Nursing interventions are actions taken to help achieve a client goal.

Global Rationale: Goals or expected outcomes are statements that address the client problems. For this situation, the client has stated t h Ne UgRoaSlINoGf Th Ba .vCi nO gM k n e e replacement surgery in order to return home and resume living. A client problem is an unmet need. Assessment data is not a part of the care plan. Nursing interventions are actions taken to help achieve a client goal.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3.1 Describe the components of the client care plan. Page Number: 36 2. After report the nurse reviews a standardized care plan for an assigned client. Where should the nurse find the current active problems identified for the client?

1. Look at the problem list area on the Kardex 2. Read the notes written about specific problems 3. Ask the charge nurse where the problems are located 4. Identify the areas with check marks placed on the care plan

Correct Answer: 4 Rationale 1: The Kardex is not used to identify current problems identified on a standardized care plan.

Rationale 2: Reading the notes written about the client’s problems would be time-consuming and potentially inaccurate.

Rationale 3: It is not the charge nurse’s responsibility to know where active problems are documented.

Rationale 4: On a standardized care plan the problems with check marks are those which are the most current and active for a client.

Global Rationale: On a standardized care plan the problems with check marks are those which are the most current and active for a client. The Kardex is not used to identify current problems identified on a standardized care plan. Reading the notes written about the client’s problems would be time-consuming and potentially inaccurate. It is not the charge nurse’s responsibility to know where active problems are documented.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.2 Explain the method for individualizing the care plan when a standard care plan is used.

Page Number: 36 3. The nurse is reviewing data collected during a client assessment. Which information should the nurse identify as a client need? Select all that apply.

1. Desires to walk without a cane 2. License to drive has been suspended 3. Attends religious services every Sunday 4. Spends time with family every winter in Florida 5. Experiences shortness of breath with ambulation Correct Answer: 1, 2, 5

Rationale 1: A client problem is identified as any unmet need. Desiring to walk without a cane is an unmet need.

Rationale 2: A client problem is identified as any unmet need. Having a suspended driver’s license will cause many needs to be unmet.

Rationale 3: A client problem is identified as any unmet need. Attending religious services is having a spiritual need met.

Rationale 4: A client problem is identified as any unmet need. Visiting with family is meeting a psychosocial need.

Rationale 5: A client problem is identified as any unmet need. Shortness of breath with ambulation is an unmet need for oxygenation.

Global Rationale: A client problem is identified as any unmet need. Desiring to walk without a cane, unable to drive, and having shortness of breath with ambulation are all unmet needs.

Attending religious services and visiting with family indicate needs that are being met.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3.3 Define the term client problem or need. Page Number: 36 4. The nurse identifies problems for a specific client. What action should the nurse perform next when planning this client’s care?

1. Identify outcomes for care 2. Determine resources needed for care 3. Translate the needs into nursing diagnoses 4. Select appropriate interventions to address the needs Correct Answer: 3 Rationale 1: Outcomes for care occurs after nursing diagnoses are identified. Rationale 2: Resource needs are identified at the time of providing care.

Rationale 3: When an individualized care plan is being generated, the nurse translates client

needs into nursing diagnoses.

Rationale 4: Interventions are selected after nursing diagnoses are identified.

Global Rationale: When an individualized care plan is being generated, the nurse translates client needs into nursing diagnoses. Outcomes and interventions are selected after nursing diagnoses are identified.

Resource needs are identified at the time of providing care.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3.4 State the most important reason for using nursing diagnoses in care planning.

Page Number: 36 5. The nurse notes that a client intervention has a deadline occurring in 3 days. What should this information indicate to the nurse?

1. The action should be observed every 3 days 2. The action should be completed every 3 days 3. The action should be documented every 3 days 4. The action will no longer be necessary in 3 days Correct Answer: 4 Rationale 1: The checkpoint indicates how often the action or intervention should be observed. Rationale 2: The checkpoint indicates how often the action or intervention should be carried out. Rationale 3: The checkpoint indicates how often the action or intervention should be charted.

Rationale 4: The deadline indicates the time when the goal should be met or the action is no longer necessary.

Global Rationale: The deadline indicates the time when the goal should be met or the action is no longer necessary. The checkpoint indicates how often the action or intervention should be checked, observed, or carried out and therefore how often it should be charted.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3.5 Define the use of deadlines and checkpoints in the client care plan. Page Number: 36 6. The nurse is meeting with physical therapist and a dietitian to review care for a client recovering from a stroke. Which tool is the nurse most likely using to coordinate this client’s care?

1. Critical pathway 2. Variance analysis 3. Standardized care plan 4. Individualized care plan Correct Answer: 1 Rationale 1: A critical path, or clinical pathway, is a standardized multidisciplinary plan of care developed for clients with common or prevalent conditions.

Rationale 2: A variance analysis is completed if a client does not achieve an expected outcome in the time specified on the critical pathway.

Rationale 3: A standardized care plan is one that can address a large portion of a client’s needs. Rationale 4: An individualized care plan is written to meet a client’s special needs.

Global Rationale: A critical path, or clinical pathway, is a standardized multidisciplinary plan of care developed for clients with common or prevalent conditions. A variance analysis is completed if a client does not achieve an expected outcome in the time specified on the critical pathway. A standardized care plan is one that can address a large portion of a client’s needs. An individualized care plan is written to meet a client’s special needs.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3.6 Compare and contrast a clinical pathway and a client care plan. Page Number: 39 7. After providing medications and changing a dressing the nurse accesses the client’s computerized medical record and enters the information about the care provided. Why is the nurse documenting at this time? Select all that apply.

1. Evaluates individual performance 2. Helps determine the staffing needs of the care area 3. Estimates the amount of time required to provide care 4. Communicates information to other members of the team 5. Provides a permanent record of the care provided to the client Correct Answer: 1, 2, 4, 5 Rationale 1: Documentation assists supervisory personnel to evaluate the staff’s performance on a day-byday basis for specific clients.

Rationale 2: Documentation helps management to establish an acuity system to maintain adequate staff levels based on client acuity.

Rationale 3: Documentation is not completed to estimate the amount of time required to provide care.

Rationale 4: Documentation communicates information to other members of the client’s healthcare team.

Rationale 5: Documentation provides a permanent record for future reference that may become a legal document in the event of litigation or prosecution.

Global Rationale: Documentation assists supervisory personnel to evaluate the staff’s performance on a day-by-day basis for specific clients, helps management to establish an acuity system to maintain adequate staff levels based on client acuity, communicates information to other members of the client’s healthcare team, and provides a permanent record for future reference that may become a legal document in the event of litigation or prosecution.

Documentation is not completed to estimate the amount of time required to provide care.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.7 Explain at least three purposes of charting. Page Number: 40 8. The nurse is preparing to make an entry into a client’s medical record after completing morning care and providing medications. What should the nurse ensure when completing this documentation? Select all that apply.

1. Time care was provided 2. Client’s response to care provided 3. Time medications were administered 4. Estimated date for goals to be achieved 5. Client’s reaction to medications provided Correct Answer: 1, 2, 3, 5 Rationale 1: To ensure accurate documentation the time that care was provided should be included.

Rationale 2: To ensure accurate documentation the client’s response to care should be included.

Rationale 3: To ensure accurate documentation the time medications were administered should be included.

Rationale 4: The estimated time for goalNs Ut oR bS IeNaGcTh Bi e. Cv Oe dMi s documented on the care plan.

Rationale 5: To ensure accurate documentation the client’s response to medications should be included.

Global Rationale: To ensure accurate documentation the time that care was provided, the client’s response to care, the time medications were administered, and the client’s response to medications should be included. The estimated time for goals to be achieved is documented on the care plan.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.8 Describe at least three major components of accurate charting. Page Number: 41

9. An organization uses the SOAP documentation format. In which area should the nurse document the appearance of a client’s abdominal wound?

1. Plan 2. Objective 3. Subjective 4. Assessment Correct Answer: 2 Rationale 1: The plan includes the next steps determined for the client’s care.

Rationale 2: Objective identifies information that can be observed or objectively measured. Rationale 3: Subjective identifies information that the client states.

Rationale 4: Assessment is the area where a conclusion is drawn from the information collected through subjective and objective findings.

Global Rationale: Objective identifies information that can be observed or objectively measured. The plan includes the next steps determined for the client’s care. Subjective identifies information that the client states. Assessment is the area where a conclusion is drawn from the information collected through subjective and objective findings.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.9 Complete a charting exercise in any of the charting systems using a simulated situation.

Page Number: 45 10. The preceptor is reviewing the content of a new graduate’s documentation of client care. What areas should the preceptor easily identify in this notation? Select all that apply.

1. Questions asked by the family 2. Changes in the client’s condition 3. Teaching and the client’s response 4. Reactions to non-routine medications 5. Assessment made at the beginning of the shift

Correct Answer: 2, 3, 4, 5 Rationale 1: Questions asked by a client’s family are not an integral part of nursing documentation.

Rationale 2: Documentation should include changes in the client’s emotional, medical, or mental condition.

Rationale 3: Client teaching and the client’s response to teaching are important to document. Rationale 4: Reactions to any unscheduled or prn medications must be documented.

Rationale 5: Documentation should include the assessment completed at the beginning of the shift.

Global Rationale: Documentation should include changes in the client’s emotional, medical, or mental condition, client teaching and the client’s response to teaching, reactions to any unscheduled or prn medications, and the assessment completed at the beginning of the shift.

Questions asked by a client’s family are not an integral part of nursing documentation.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate uNnUd eRrSsItNanGdTiBn.gC Oo fMmu lt ip le dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.10 List the four items that should be charted for every client. Page Number: 42 11. During morning care a client states that pain medication has been ineffective and wants to talk with the healthcare provider. How should the nurse categorize this information?

1. A variance 2. A complaint 3. Adverse effect 4. Subjective data Correct Answer: 4 Rationale 1: A variance is an unexpected or unachieved outcome.

Rationale 2: A complaint is something that a client states regarding dissatisfaction with care.

Rationale 3: An adverse effect is an unexpected response to a medication or treatment.

Rationale 4: Subjective data is what the client feels or says.

Global Rationale: Subjective data is what the client feels or says. A variance is an unexpected or unachieved outcome. A complaint is something that a client states regarding dissatisfaction with care. An adverse effect is an unexpected response to a medication or treatment.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.11 Define the terms subjective data and objective data in SOAP and other documentation.

Page Number: 35 12. The nurse manager notes that documentation in the medical record about a client’s fall does not match the information identified on tNh Ue RoSc IcNuGr rTeBn .cCeOrMe p o r t . What could be the potential outcome of this inconsistency?

1. A court case would not occur 2. Valuable information would be forgotten 3. Client’s hospitalization could be prolonged 4. Termination of the nurse completing the occurrence form Correct Answer: 2 Rationale 1: Eliminating information from an occurrence report would not stop a court case from occurring.

Rationale 2: When completing an unusual occurrence form with possible legal implications, it is very important to document all details of the incident. Frequently, lawsuits are not filed for months or even years after an incident, when it will not be easy to recall details of care. It is essential to document important details promptly on the form.

Rationale 3: Eliminating information from an occurrence report would not necessarily prolong the client’s hospitalization.

Rationale 4: Eliminating information from an occurrence report would not necessarily cause the nurse to be terminated.

Global Rationale: When completing an unusual occurrence form with possible legal implications, it is very important to document all details of the incident. Frequently, lawsuits are not filed for months or even years after an incident, when it will not be easy to recall details of care. It is essential to document important details promptly on the form. Eliminating information from an occurrence report would not stop a court case from occurring. Eliminating information from an occurrence report would not necessarily prolong the client’s hospitalization or cause the nurse to be terminated.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3.12 Describe the legal ramifications for completing unusual occurrence reports.

Page Number: 48 13. The nurse is preparing a consent form for a client’s signature. For which reason is this form most likely needed?

1. Chest x-ray 2. Drawing a blood sample 3. Measuring blood pressure 4. Biopsy of an abdominal mass Correct Answer: 4 Rationale 1: Routine nursing care is “consented to” when the client signs the “conditions of admissions” form. A chest x-ray would be routine care.

Rationale 2: Routine nursing care is “consented to” when the client signs the “conditions of admissions” form.

Drawing a blood sample would be routine care.

Rationale 3: Routine nursing care is “consented to” when the client signs the “conditions of admissions” form.

Measuring blood pressure would be routine care.

Rationale 4: Routine nursing care is “consented to” when the client signs the “conditions of admissions” form. A biopsy would not be routine care and would need a consent form.

Global Rationale: Routine nursing care is “consented to” when the client signs the “conditions of admissions” form. Routine care would include a chest x-ray, drawing a blood sample, and measuring blood pressure. A biopsy would not be routine care and would need a consent form.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3.13 Discuss specific client activities requiring consent forms. Page Number: 48 14. The nurse is preparing to electronically enter data in a client’s medical record. For which reason could a legal issue occur?

1. Obtains password taped under keyboard 2. Logs out of the record before leaving the terminal 3. Shreds laboratory reports after using them during report 4. Turns off the monitor when approached by a family member Correct Answer: 1 Rationale 1: Personal passwords should Nn oUtRbSeI Ns Gh aTrBe.dC Oo rMg i v e n to anyone. Taping a password under a keyboard would be sharing.

Rationale 2: Logging out of the record before leaving the terminal would not cause a legal issue.

Rationale 3: Shredding laboratory reports would ensure client confidentiality and not cause a legal issue.

Rationale 4: Protecting health information by turning off a monitor when approached by a family member would not cause a legal issue.

Global Rationale: Personal passwords should not be shared or given to anyone. Taping a password under a keyboard would be sharing. Logging out of the record before leaving the terminal, shredding laboratory reports, and turning off a monitor when approached by a family member would not cause legal issues.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality AACN Essential Competencies: IV. 8. Uphold ethical standards related to data security, regulatory requirements, confidentiality and clients’ right to privacy

NLN Competencies: Quality and Safety; Practice; Carefully maintain and use electronic and/or written health records Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.14 Discuss the legal risks of computer charting. Page Number: 47 15. After delegating an aspect of care to unlicensed assistive personnel (UAP) the nurse answers any questions and is available while the care is being provided. Which “right of delegation” is this nurse performing?

1. Person 2. Direction 3. Supervision 4. Circumstances Correct answer: 3 Rationale 1: Right Person occurs when the nurse delegates the right task to a person who can legally perform the task.

Rationale 2: Right Direction occurs when the person delegating the task has described the task clearly, including directions, special steps of the task, and the expected outcomes.

Rationale 3: Right Supervision occurs when the nurse delegating the activity answers the UAP’s questions and is available to problem s o lNv Ue ,RiSf I nNeGcTeBs s. Ca rOyM. Rationale 4: Right Circumstances occurs when the UAP understands the elements of the task and the nurse is assured that the UAP can perform the procedure safely in an appropriate setting.

Global Rationale: Right Supervision occurs when the nurse delegating the activity answers the UAP’s questions and is available to problem solve, if necessary. Right Person occurs when the nurse delegates the right task to a person who can legally perform the task. Right Direction occurs when the person delegating the task has described the task clearly, including directions, special steps of the task, and the expected outcomes. Right Circumstances occurs when the UAP understands the elements of the task and the nurse is assured that the UAP can perform the procedure safely in an appropriate setting.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: V. C. 3. Value own role in preventing errors AACN Essential Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork; Practice; manage delegation effectively Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3.15 Discuss the RN’s role in delegating client care. Page Number: 53

16. The nursing student is using a data collection tool while researching a client assignment before clinical the next day. In which category should the student document the client’s use of oxygen?

1. Medications 2. Biographical data 3. Nursing interventions 4. Physical assessment findings Correct Answer: 1 Rationale 1: To assist students with client care planning prior to and during the clinical experience, many nursing programs have developed student clinical preparation forms. Oxygen is prescribed and would be categorized as a medication.

Rationale 2: To assist students with client care planning prior to and during the clinical experience, many nursing programs have developed student clinical preparation forms.

Biographical data would be the client’s name and age.

Rationale 3: To assist students with client care planning prior to and during the clinical experience, many nursing programs have developed student clinical preparation forms. Nursing interventions would be actions that the nurse would perform while providing care.

Rationale 4: To assist students with c l i e nNt Uc Ra rSeI NpGl aTnBn. iCnOgMp r i o r to and during the clinical experience, many nursing programs have developed student clinical preparation forms. Physical assessment findings would be data collected while completing an examination.

Global Rationale: To assist students with client care planning prior to and during the clinical experience, many nursing programs have developed student clinical preparation forms. Oxygen is prescribed and would be categorized as a medication. Biographical data would be the client’s name and age. Nursing interventions would be actions that the nurse would perform while providing care. Physical assessment findings would be data collected while completing an examination.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.16 Complete a data collection tool based on a clinical situation. Page Number: 53

17. The nurse is completing a tool to help coordinate care needed for several clients. What should the nurse identify as a task that must be completed at a specific time for a client?

1. Evaluating the amount of food a client ingested after lunch 2. Providing intravenous medication before a peak blood level is drawn 3. Measuring urine in a collection bag before attending afternoon report 4. Checking the results of laboratory tests before documenting end of shift care Correct Answer: 2 Rationale 1: Evaluating the amount of food a client ingested after lunch can occur any time before the trays are removed from the bedside.

Rationale 2: Providing intravenous medication before a peak blood level is drawn would be time dependent.

Rationale 3: Measuring urine in a collection bag can occur any time before attending afternoon report.

Rationale 4: Checking the results of laboratory tests can occur any time before documenting end of shift care.

Global Rationale: Providing intravenous medication before a peak blood level is drawn would be time dependent. Evaluating the amount oNfUfRoSoIdNiGnTgBes.CteOdM , urine output, and laboratory results can occur at any time.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.17 Develop a time-management worksheet for client care. Page Number: 53

CHAPTER 4 1. The nurse is caring for a group of clients. Which nursing behaviors exemplify communication about these clients’ care? Select all that apply.

1. Making a check mark on a care tracking sheet 2. Initialing and dating an entry in the medical record 3. Volunteering to participate in an upcoming seminar 4. Reading the results of laboratory and diagnostic tests 5. Discussing a client’s response to pain medication with the care provider Correct Answer: 1, 2, 4, 5 Rationale 1: Communication is the process of sending and receiving messages by means of symbols, words, signs, gestures, or other actions. Making a check mark on a care tracking sheet is communicating care provided.

Rationale 2: Communication is the process of sending and receiving messages by means of symbols, words, signs, gestures, or other actions. Initialing and dating an entry in the medical record is communicating care provided.

Rationale 3: Communication is the process of sending and receiving messages by means of symbols, words, signs, gestures, or other actions. Volunteering to participate in an upcoming seminar is not communicating care provided to the clients.

Rationale 4: Communication is the process of sending and receiving messages by means of symbols, words, signs, gestures, or other actions. Reading the results of laboratory and diagnostic tests is receiving communication.

Rationale 5: Communication is the process of sending and receiving messages by means of symbols, words, signs, gestures, or other actions. Discussing a client’s response to pain medication with the care provider is communicating the result of care provided.

Global Rationale: Communication is the process of sending and receiving messages by means of symbols, words, signs, gestures, or other actions. Making a check mark on a care tracking sheet and initialing and dating an entry in the medical record is communicating care provided. Reading the results of laboratory and diagnostic tests is receiving communication. Discussing a client’s response to pain medication with the care provider is communicating the result of care provided. Volunteering to participate in an upcoming seminar is not communicating care provided to the clients.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 9. Discuss principles of effective communication

AACN Essential Competencies: II. 2. Demonstrate leadership and communication skills to effectively implement patient safety and quality improvement initiatives within the context of the interprofessional team NLN Competencies: Relationship Centered Care; Practice; Communicate information effectively; listen openly and cooperatively Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation Learning Outcome: 4.1 Define the term communication.

Page Number: 60 2. The nurse educator is preparing an inservice presentation about communication. What should the nurse emphasize during this training?

1. Communication is an optional task 2. Communication is a sense of self-pride 3. Communication is an essential part of nursing care 4. Communication ensures the provision of quality nursing care Correct Answer: 4 Rationale 1: Communication is a vital element in nursing. It is not an option task. Rationale 2: Self-esteem is a sense of self-pride.

Rationale 3: Communication is a vital element in nursing.

Rationale 4: Communication does not ensure the quality of nursing care provided.

Global Rationale: Communication is a vital element in nursing. It is not an option task. Self- esteem is a sense of self-pride. Communication does not ensure the quality of nursing care provided.

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 9. Discuss principles of effective communication AACN Essential Competencies: II. 2. Demonstrate leadership and communication skills to effectively implement patient safety and quality improvement initiatives within the context of the interprofessional team NLN Competencies: Relationship Centered Care; Practice; Communicate information effectively; listen openly and cooperatively Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 4.2 Explain why communication is an important concept in nursing. Page Number: 60 3. A visitor asks the nurse questions about a client’s health status. What should the nurse respond to this individual?

1. “I can tell you that the client is not doing very well.”

2. “That information cannot be shared without the client’s permission.”

3. “Please keep this to yourself. The client needs to go on hospice soon.”

4. “Since you are a visitor I can tell you that the client will be here for a few more days.” Correct Answer: 2 Rationale 1: Clients are protected by law against unauthorized release of personal clinical data such as diagnoses. The nurse is telling a stranger that the client is not doing very well which is a violation of the client’s privacy.

Rationale 2: Confidential information may be released with the consent of the client.

Rationale 3: Clients are protected by law against unauthorized release of personal clinical data such as diagnoses. The nurse is telling a visitor that the client needs to go on hospice which is a violation of the client’s privacy.

Rationale 4: Clients are protected by law against unauthorized release of personal clinical data such as diagnoses. The nurse violates the client’s privacy by telling the visitor about the length of the client’s hospitalization.

Global Rationale: Confidential information may be released with the consent of the client. Clients are protected by law against unauthorized release of personal clinical data such as diagnoses. The nurse is telling a stranger that the client is not doing very well, saying that the client needs to go on hospice, and s a y in gN tUhRatS It Nh eG Tc lBi .eCnOt M needs to remain hospitalized are all violations of the client’s privacy.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: VI.C. 3. Protect confidentiality of protected health information in electronic health records AACN Essential Competencies: VIII. 10. Protect patient privacy and confidentiality of patient records and other privileged communications NLN Competencies: Context and Environment; Knowledge; principles of informed consent, confidentiality, patient self-determination.

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.3 Describe what is meant by the term confidentiality. Page Number: 60 4. During an assessment a client answers no questions and tells the nurse to talk with the spouse who is due to arrive later in the day. What can occur with this situation?

1. Noncompliance 2. Enhanced rapport 3. Situational awareness 4. Dysfunctional communication

Correct Answer: 4 Rationale 1: Noncompliance is the failure or refusal to go along with a plan or program.

Rationale 2: Rapport is a feeling of mutual trust experienced by individuals in a satisfactory relationship.

Rationale 3: Situational awareness is the ability to gather the right information, analyze it, and make projections as it relates to client care.

Rationale 4: Dysfunctional communication results from failing to learn to communicate properly and leaving the responsibility for communicating to others.

Global Rationale: Dysfunctional communication results from failing to learn to communicate properly and leaving the responsibility for communicating to others. Noncompliance is the failure or refusal to go along with a plan or program. Rapport is a feeling of mutual trust experienced by individuals in a satisfactory relationship. Situational awareness is the ability to gather the right information, analyze it, and make projections as it relates to client care.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 9. Discuss principles of effective communication AACN Essential Competencies: II. 2. D eNmU oRnS sI Nt r GatTeBl .eCaOd M e r s h i p and communication skills to effectively implement patient safety and quality improvement initiatives within the context of the interprofessional team NLN Competencies: Relationship Centered Care; Practice; Communicate information effectively; listen openly and cooperatively Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation Learning Outcome: 4.4 Discuss four factors that affect communication.

Page Number: 61 5. The nurse is reviewing data collected during a health history. Which statement should the nurse use to clarify information?

1. “I hear what you’re saying.”

2. “When you say that, it makes me feel uncomfortable.”

3. “I don’t understand. Can you say it in a different way?”

4. “You were telling me how hard it is to talk to your spouse.” Correct Answer: 3 Rationale 1: “I hear what you’re saying” demonstrates the technique of acknowledgement.

Rationale 2: “When you say that, it makes me feel uncomfortable” demonstrates the technique of feedback.

Rationale 3: “I don’t understand. Can you say it in a different way?” demonstrates the technique of clarifying.

Rationale 4: “You were telling me how hard it is to talk to your spouse” demonstrates the technique of focus.

Global Rationale: “I don’t understand. Can you say it in a different way?” demonstrates the technique of clarifying. “I hear what you’re saying” demonstrates the technique of acknowledgement. “When you say that, it makes me feel uncomfortable” demonstrates the technique of feedback. “You were telling me how hard it is to talk to your spouse” demonstrates the technique of focus.

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 9. Discuss principles of effective communication AACN Essential Competencies: II. 2. Demonstrate leadership and communication skills to effectively implement patient safety and quality improvement initiatives within the context of the interprofessional team NLN Competencies: Relationship Centered Care; Practice; Communicate information effectively; listen openly and cooperatively Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation Learning Outcome: 4.5 List five examples of therapeutic communication.

Page Number: 63 6. The nurse manager is observing a new graduate provide client care. Which statements should the manager identify as being barriers to communication? Select all that apply.

1. “What a beautiful day! I love bright sunshine!”

2. “If it were me I would take the new medication.”

3. “You gave yourself the insulin injection very well.”

4. “You shouldn’t worry so much about your surgery.”

5. “I think it was right for you to delay having the surgery.” Correct Answer: 1, 2, 4, 5 Rationale 1: “What a beautiful day! I love bright sunshine!” demonstrates the barrier of a social response.

Rationale 2: “If it were me I would take the new medication” demonstrates the barrier of giving advice.

Rationale 3: “You gave yourself the insulin injection very well” demonstrates the communication technique of giving feedback.

Rationale 4: “You shouldn’t worry so much about your surgery” demonstrates the barrier of false reassurance.

Rationale 5: “I think it was right for you to delay having the surgery” demonstrates the barrier of value judgment.

Global Rationale: “What a beautiful day! I love bright sunshine!” demonstrates the barrier of a social response. “If it were me I would take the new medication” demonstrates the barrier of giving advice. “You shouldn’t worry so much about your surgery” demonstrates the barrier of false reassurance. “I think it was right for you to delay having the surgery” demonstrates the barrier of value judgment. “You gave yourself the insulin injection very well” demonstrates the communication technique of giving feedback.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 9. Discuss principles of effective communication AACN Essential Competencies: II. 2. Demonstrate leadership and communication skills to effectively implement patient safety and quality improvement initiatives within the context of the interprofessional team NLN Competencies: Relationship Centered Care; Practice; Communicate information effectively; listen openly and cooperatively Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation Learning Outcome: 4.6 List five examples of barriers to communication.

Page Number: 64 7. The nurse asks to attend a seminar on cultural diversity. What was the primary reason for the nurse making this request?

1. Improve ability to care for pediatric clients 2. Decide if a home care position should be accepted 3. Recognize the special needs of an aging population 4. Understand care issues of non-English speaking clients Correct Answer: 4 Rationale 1: Cultural diversity would not improve the nurse’s ability to care for pediatric clients. Rationale 2: Cultural diversity would not help the nurse decide to accept a home care position.

Rationale 3: Cultural diversity would not help the nurse recognize the special needs of an aging population.

Rationale 4: Cultural diversity implies the range of differences in values, beliefs, customs, folklore, traditions, language, and patterns of behavior for the various cultural groups. This would help with understanding care issues of non-English speaking clients.

Global Rationale: Cultural diversity implies the range of differences in values, beliefs, customs, folklore, traditions, language, and patterns of behavior for the various cultural groups. This

would help with understanding care issues of non-English speaking clients. Cultural diversity would not improve the nurse’s ability to care for pediatric clients. Cultural diversity would not help the nurse decide to accept a home care position. Cultural diversity would not help the nurse recognize the special needs of an aging population.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values AACN Essential Competencies: I. 5. Apply knowledge of social and cultural factors to the care of diverse populations NLN Competencies: Context and Environment; Practice: conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.7 Explain why multicultural health care is important and discuss the term cultural diversity.

Page Number: 65 8. The nurse is preparing to assess a client who has lived in the United States for 6 months. What should the nurse include to ensure cultural sensitivity? Select all that apply.

1. Education 2. Nutrition practices 3. Family relationships 4. Cultural background 5. Access to a computer Correct Answer: 1, 2, 3, 4 Rationale 1: When completing a total assessment on a client it is important to include the cultural component of education.

Rationale 2: When completing a total assessment on a client it is important to include the cultural component of nutrition practices.

Rationale 3: When completing a total assessment on a client it is important to include the cultural component of family relationships.

Rationale 4: When completing a total assessment on a client it is important to include the cultural component of cultural background.

Rationale 5: Access to a computer is not a component of a cultural assessment.

Global Rationale: When completing a total assessment on a client it is important to include the cultural components of education, nutritional practices, family relationships, and cultural background. Access to a computer is not a component of a cultural assessment.

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values AACN Essential Competencies: I. 5. Apply knowledge of social and cultural factors to the care of diverse populations NLN Competencies: Context and Environment; Practice: conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.8 List three components of a cultural sensitivity assessment. Page Number: 65 9. The nurse is completing a spiritual assessment as part of a health history with a newly admitted client. Which question should the nurse use to learn more about this client’s spirituality?

Select all that apply.

1. “Do you like your religion?”

2. “How often do you attend religious services?”

3. “Do you follow any particular religious practices?”

4. “Isn’t it difficult to have to go to church every Sunday?”

5. “How can I ensure that your religious practices are followed in the event of a health crisis?

Correct Answer: 3, 4 Rationale 1: Asking if the client likes their religion would not help the nurse learn more about the client’s spirituality.

Rationale 2: Asking how often the client attends religious services would not help the nurse learn more about the client’s spirituality.

Rationale 3: Asking if the client follows any particular religious practices would help the nurse learn more about the client’s spirituality.

Rationale 4: Asking if it is difficult to attend church every Sunday would not help the nurse learn more about the client’s spirituality.

Rationale 5: Asking for ways to ensure the client’s religious practices are followed in the event of a health crisis would help the nurse learn more about the client’s spirituality.

Global Rationale: Asking if the client follows any particular religious practices and asking for ways to ensure the client’s religious practices are followed in the event of a health crisis would help the nurse learn more about the client’s spirituality. Asking if the client likes their religion, how often the client attends religious services, and if it is difficult to attend church every Sunday would not help the nurse learn more about the client’s spirituality.

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values AACN Essential Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals’ spiritual beliefs and values and how those beliefs and values impact health care NLN Competencies: Context and Environment; Practice: conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.9 List two questions that would elicit information about the client’s spiritual issues.

Page Number: 66 10. The nurse is preparing to meet a newly admitted client. What should the nurse do first?

1. Ask the client for feedback 2. Introduce herself to the client 3. Ask if the client has any questions 4. Check client ID with two forms of identification Correct answer: 4 Rationale 1: Asking the client for feedback occurs at the end of the conversation. Rationale 2: Introducing self to the client occurs after identifying the client.

Rationale 3: Asking if the client has any question occurs after explaining the purpose of the communication.

Rationale 4: Checking the client ID with two forms of identification should be done first. Global Rationale: Checking the client ID with two forms of identification should be done first.

Asking the client for feedback occurs at the end of the conversation. Introducing self to the client occurs after identifying the client. Asking if the client has any question occurs after explaining the purpose of the communication.

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 9. Discuss principles of effective communication AACN Essential Competencies: II. 2. Demonstrate leadership and communication skills to effectively implement patient safety and quality improvement initiatives within the context of the interprofessional team NLN Competencies: Relationship Centered Care; Practice; Communicate information effectively; listen openly and cooperatively Nursing/Integrated Concepts: Nursing Process: Planning/Communication and Documentation

Learning Outcome: 4.10 Demonstrate the steps for beginning a client interaction. Page Number: 69 11. The nurse is caring for a client newly diagnosed with heart failure. Which nursing statement encourages the client to express thoughts and feelings?

1. “Please tell me how I can help you learn to manage this health problem.”

2. “Oftentimes heart failure can be prevented with proper diet and exercise.”

3. “Many of my clients have your same health problem and they are doing very well.”

4. “Would you mind holding any questions until I review your healthcare provider’s care orders?”

Correct Answer: 1 Rationale 1: Asking the client to say how the nurse can help the client with the health problem best encourages the client to express thoughts and feelings.

Rationale 2: There is no evidence that proper diet and exercise will prevent all episodes of heart failure. This statement also assumes that the client did not eat a proper diet or exercise.

Rationale 3: Saying that other clients with the same health problem are doing very well minimizes the impact of the health problem on this client.

Rationale 4: Asking the client to hold any questions until orders are reviewed communicates that the nurse does not have time to talk withNt UheR ScIlNieGnTt.B. C O M Global Rationale: Asking the client to say how the nurse can help the client with the health problem best encourages the client to express thoughts and feelings. There is no evidence that proper diet and exercise will prevent all episodes of heart failure. This statement also assumes that the client did not eat a proper diet or exercise. Saying that other clients with the same health problem are doing very well minimizes the impact of the health problem on this client. Asking the client to hold any questions until orders are reviewed communicates that the nurse does not have time to talk with the client.

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 9. Discuss principles of effective communication AACN Essential Competencies: II. 2. Demonstrate leadership and communication skills to effectively implement patient safety and quality improvement initiatives within the context of the interprofessional team NLN Competencies: Relationship Centered Care; Practice; Communicate information effectively; listen openly and cooperatively Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 4.11 Explain why it is therapeutic to encourage the client to express feelings and thoughts.

Page Number: 67 12. The nurse is engaged in a relationship with a client. Which action should the nurse take when in the continuation phase of this relationship?

1. Identify major problems 2. Anticipate issues once discharged 3. Teach how to self-administer insulin 4. Recognize barriers to communication Correct Answer: 3 Rationale 1: Identifying major problems occurs in the orientation phase. Rationale 2: Anticipating issues once discharged occurs in the termination phase. Rationale 3: Teaching self-care occurs during the continuation phase.

Rationale 4: Recognizing barriers to communication occurs in the orientation phase.

Global Rationale: Teaching self-care occurs during the continuation phase. Identifying major problems and recognizing barriers to communication occurs in the orientation phase.

Anticipating issues once discharged occurs in the termination phase.

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.B. 11. Recognize the boundaries of therapeutic relationships AACN Essential Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship NLN Competencies: Relationship Centered Care; Practice; Communicate information effectively; listen openly and cooperatively Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 4.12 Describe the phases of a nurse–client relationship. Page Number: 67 13. The nurse is having difficulty maintaining rapport with a client. What should the nurse do to facilitate this relationship?

1. Establish mutual goals 2. Demonstrate consistent behavior 3. Use a warm, accepting manner during interactions 4. Accept client as having value and worth as an individual Correct Answer: 4 Rationale 1: Establishing mutual goals occurs during the orientation phase of the relationship.

Rationale 2: Demonstrating consistent behavior occurs during the orientation phase of the relationship.

Rationale 3: Using a warm accepting manner during interactions occurs during the orientation phase of the relationship.

Rationale 4: Accepting the client as having value and worth as an individual is a fundamental prerequisite of a relationship and helps facilitate the nurse-client relationship.

Global Rationale: Accepting the client as having value and worth as an individual is a fundamental prerequisite of a relationship and helps facilitate the nurse-client relationship. Establishing mutual goals, demonstrating consistent behavior, and using a warm accepting manner during interactions occur during the orientation phase of the relationship.

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.B. 11. Recognize the boundaries of therapeutic relationships AACN Essential Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship NLN Competencies: Relationship Centered Care; Practice; Communicate information effectively; listen openly and cooperatively OM Nursing/Integrated Concepts: Nursing PrNoUc ResSsI :NIGmTpBl.eCm entation/Communication and Documentation Learning Outcome: 4.13 List three components for maintaining a nurse–client relationship. Page Number: 75 14. During the orientation phase of a new relationship the nurse explains the activities that need to be accomplished before the client is discharged back to home. Why should the nurse do this at this time?

1. Identifies coping mechanisms 2. Establishes trust between the nurse and client 3. Prevents the client from being placed on the defensive 4. Promotes independence and increases sense of self-esteem Correct Answer: 4 Rationale 1: Identifying coping mechanisms helps facilitate an ongoing nurse-client relationship. Rationale 2: Having consistent behavior and only making realistic promises helps establish trust. Rationale 3: Avoiding asking “why” questions helps prevent placing the client on the defensive.

Rationale 4: Working closely with the client in discharge planning and in planning the termination of the relationship from its beginning promotes the client’s independence and

increases his or her sense of self-esteem.

Global Rationale: Working closely with the client in discharge planning and in planning the termination of the relationship from its beginning promotes the client’s independence and increases his or her sense of self-esteem. Identifying coping mechanisms helps facilitate an ongoing nurse-client relationship. Having consistent behavior and only making realistic promises helps establish trust. Avoiding asking “why” questions helps prevent placing the client on the defensive.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.B. 11. Recognize the boundaries of therapeutic relationships AACN Essential Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship NLN Competencies: Relationship Centered Care; Practice; Communicate information effectively; listen openly and cooperatively Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 4.14 Describe the rationale for discussing termination at the beginning of the relationship.

Page Number: 76 G Ta yBs. CsOe eMm s to be in a hurry which causes confusion 15. A client says that the health care p r o vNiUd Re rS IaNl w with care expectations. What should the nurse recommend to this client?

1. Write questions to ask when the health care provider makes rounds 2. Suggest telephoning the healthcare provider’s office and speak to the staff 3. Volunteer to discuss the client’s concerns with the provider later in the day 4. Remind that if the healthcare provider does not mention something it probably is not an issue Correct

Answer: 1 Rationale 1: It is a good idea to recommend for clients to keep a notepad and a list of the things they want to mention when they see their provider. This way, all their concerns can be addressed.

Rationale 2: Suggesting telephoning the healthcare provider’s office and speak to the staff might be appropriate once the client is discharged.

Rationale 3: Volunteering to talk with the healthcare provider for the client enhances dependence and may make the termination phase of the nurse-client relationship more difficult.

Rationale 4: The client’s concerns may not be the same as the healthcare provider’s concerns. The client’s concerns should be addressed, regardless of what they may be.

Global Rationale: It is a good idea to recommend for clients to keep a notepad and a list of the things they want to mention when they see their provider. This way, all their concerns can be

addressed. Suggesting telephoning the healthcare provider’s office and speak to the staff might be appropriate once the client is discharged. Volunteering to talk with the healthcare provider for the client enhances dependence and may make the termination phase of the nurse-client relationship more difficult.

The client’s concerns may not be the same as the healthcare provider’s concerns. The client’s concerns should be addressed, regardless of what they may be.

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.B. 2. Communicate patient values, preferences and expressed needs to other members of health care team AACN Essential Competencies: VI. 2. Use inter-and intraprofessional communication and collaborative skills to deliver evidence-based, patient-centered care NLN Competencies: Teamwork; Knowledge; Effective strategies for communicating with different members of the health team, including nurses and other health professionals Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 4.15 Practice assisting a client to communicate with his or her healthcare provider.

Page Number: 70 16. The nurse notes that a client is having difficulty deciding to have surgery, has a heart rate of 110 beats per minute and is diaphoretic. What should the nurse consider this client is demonstrating?

1. Verbal cues of anger 2. Physical cues of anxiety 3. Physical cues of depression 4. Emotional cues of depression Correct Answer: 2 Rationale 1: Verbal cues of anger include using a loud voice, yelling, and cursing.

Rationale 2: Psychologic symptoms of anxiety include difficulty making decisions and physical symptoms include tachycardia and sweating.

Rationale 3: Physical cues of depression include loss of motivation, vegetative, frequent crying episodes, bodily complaints, psychomotor retardation, and weight loss.

Rationale 4: Emotional cues of depression include low self-esteem, preoccupation with inner thoughts, and thoughts of suicide.

Global Rationale: Psychologic symptoms of anxiety include difficulty making decisions and physical symptoms include tachycardia and sweating. Verbal cues of anger include using a loud voice, yelling, and cursing. Physical cues of depression include loss of motivation, vegetative, frequent crying episodes, bodily complaints, psychomotor retardation, and weight loss.

Emotional cues of depression include low self-esteem, preoccupation with inner thoughts, and thoughts of suicide.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care: physical comfort and emotional support AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.16 List at least three cues you would observe if a client were depressed, anxious, or angry.

Page Number: 78 17. The nurse notes that an older client is withdrawn and has lost weight over the last few weeks. What should the nurse suggest to help this client?

1. Setting firm limits 2. Maintaining a calm quiet approach 3. Talking about feelings of depression 4. Attending the bingo game in the dininNg UroRoSImNGT B. COM Correct Answer: 4 Rationale 1: Setting firm limits would be appropriate if the client were angry.

Rationale 2: Maintaining a calm quiet approach would be appropriate if the client were anxious. Rationale 3: Talking about feelings of depression will encourage more feelings of depression.

Rationale 4: For a client experiencing depression, activity lifts the mood, focuses outside the client’s feelings, and decreases depression.

Global Rationale: For a client experiencing depression, activity lifts the mood, focuses outside the client’s feelings, and decreases depression. Setting firm limits would be appropriate if the client were angry.

Maintaining a calm quiet approach would be appropriate if the client were anxious. Talking about feelings of depression will encourage more feelings of depression.

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care: physical comfort and emotional support

AACN Essential Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.17 Discuss two interventions you would make if one of your assigned clients was depressed, anxious, or angry.

Page Number: 79

CHAPTER 5 1. A client arrives to the hospital the day before orthopedic surgery. What should be completed before the client is escorted to the care area? Select all that apply.

1. Orient to the hospital room 2. Receive an identification band 3. Assign a medical record number 4. Sign consent for treatment forms 5. Document demographic information Correct Answer: 2, 3, 4, 5 Rationale 1: Orientation to the hospital room occurs on the care area.

Rationale 2: When the elective client arrives at the hospital an identification band is placed on the client’s wrist.

Rationale 3: When the elective client arrives at the hospital a medical record number is assigned.

Rationale 4: When the elective client arrives at the hospital consent for treatment forms are signed.

Rationale 5: When the elective client arrives at the hospital demographic information is documented.

Global Rationale: When the elective client arrives at the hospital an identification band, medical record number, treatment forms, and demographic information are completed by the admission clerk. Orientation to the hospital room occurs on the care area.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.1 Explain the steps of admitting a client to the hospital. Page Number: 86 2. The nurse is assessing a newly admitted client. What information should be documented about the client’s current medications? Select all that apply.

1. Allergies to drugs

2. List of nutritional supplements 3. List of all prescribed medications 4. Pharmacy used to fill prescriptions 5. List of all over-the-counter medications Correct Answer: 1, 2, 3, 5 Rationale 1: Upon admission a list of allergies to drugs is obtained. Rationale 2: Upon admission a list of supplements is obtained.

Rationale 3: Upon admission a list of all prescribed medications is obtained.

Rationale 4: The name of the pharmacy used to fill prescriptions is not obtained upon admission. Rationale 5: Upon admission a list of all over-the-counter medications is obtained.

Global Rationale: Upon admission, a comprehensive list of the client’s allergies to drugs, supplements used, and prescribed and over-the-counter medications is obtained. The pharmacy used to fill prescriptions is not a part of the admission documentation regarding medications.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.2 List client data that are included in documentation when admitting a client to the hospital, including the plan of care, goals, and outcome criteria.

Page Number: 87 3. A client wearing a diamond engagement and wedding band set does not want to send the rings home with the spouse. What should the nurse do?

1. Cover the rings with adhesive tape 2. Suggest the rings be placed in the night stand 3. Provide a “Release from Responsibility” form 4. Ask Security to explain the risk of losing the items Correct Answer: 3 Rationale 1: Covering the rings with adhesive tape will not guarantee that they will be lost or

misplaced.

Rationale 2: The night stand is not a secure area for the rings.

Rationale 3: If the client retains the expensive items a “Release from Responsibility” form should be signed.

Rationale 4: Security is not responsible for persuading a client to send the expensive items home.

Global Rationale: If the client retains the expensive items a “Release from Responsibility” form should be signed. Covering the rings with adhesive tape will not guarantee that they will be lost or misplaced. The night stand is not a secure area for the rings. Security is not responsible for persuading a client to send the expensive items home.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions O eMntation Nursing/Integrated Concepts: Nursing PrNoUcResSsI:NIGmTpBl.eCm Learning Outcome: 5.3 Describe the disposition process for safeguarding client’s valuables. Page Number: 87 4. The nurse is assessing a newly admitted client. What should the nurse include when discussing advanced directives with this client? Select all that apply.

1. It is the same for every state 2. It is sometimes called a living will 3. It includes preferences for health care 4. A copy is placed in the medical record 5. It specifies treatments desired at end of life Correct Answer: 2, 3, 4, 5 Rationale 1: Advance directives documents vary from state to state.

Rationale 2: An advance directive is sometimes called a living will.

Rationale 3: An advance directive reflects the client’s preferences for health care. Rationale 4: A copy of the advance directive is placed in the client’s chart.

Rationale 5: An advance directive specifies medical treatments the client wants at the end of life.

Global Rationale: An advance directive is sometimes called a living will. It includes preferences for health care. A copy is placed in the client’s medical record. This document specifies treatments desired at end of life.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.4 State what is meant by advance directives. Page Number: 87 5. The nurse is asking a client about lifestyle patterns and spiritual practices. For which admission document is this information needed?

1. Care plan 2. Health history 3. Demographics 4. Discharge needs Correct Answer: 2 Rationale 1: The care plan identifies client problems and appropriate interventions. Rationale 2: The health history includes lifestyle patterns and spiritual practices.

Rationale 3: Demographics would have been completed by the admission clerk.

Rationale 4: Discharge needs is a separate part of the health history.

Global Rationale: The health history includes lifestyle patterns and spiritual practices. The care plan identifies client problems and appropriate interventions. Demographics would have been completed by the admission clerk. Discharge needs are a separate part of the health history.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.5 List documents that may be included in the client’s admission record (Patient’s Care Partnership brochure, Advance Directives, etc.).

Page Number: 94 6. A newly admitted client refuses to answer any assessment questions and is seen sitting in a chair near the window crying. What should the nurse do to help this client become acclimated to the hospital environment? Select all that apply.

1. Assess emotional needs 2. Consult the case manager 3. Talk with the organization’s clergy 4. Ask the healthcare provider to prescribe a sedative 5. Suggest receiving health care in another environment Correct Answer: 1, 2, 3 Rationale 1: For the client having difficulty adapting to the hospital environment emotional needs should be assessed.

Rationale 2: The case manager should be consulted for the client having difficulty adapting to the hospital environment.

Rationale 3: The organization’s clergy should be consulted for the client having difficulty adapting to the hospital environment.

Rationale 4: The client should be assessed before suggesting medication to treat the client’s behavior.

Rationale 5: The nurse should not suggest that the client leave the organization and seek healthcare elsewhere.

Global Rationale: For the client having difficulty adapting to the hospital environment emotional needs should be assessed. The case manager and clergy should be consulted for the client having difficulty adapting to the hospital environment. The client should be assessed before suggesting medication to treat the client’s behavior.

The nurse should not suggest that the client leave the organization and seek healthcare elsewhere.

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.6 Propose two solutions for clients who are unable to adapt to the hospital environment.

Page Number: 95 7. A client is being transferred from a critical care area to the telemetry unit. What information should the nurse include when communicating this client’s care needs?

1. Last doses of medication 2. Where the spouse is employed 3. Number of children the client has 4. Family members’ opinions about the hospital Correct Answer: 1 Rationale 1: The client’s last doses of medication would be essential to provide during handoff communication.

Rationale 2: The spouse’s employer is not essential to provide during handoff communication.

Rationale 3: The number of children the client has is not essential to provide during handoff communication.

Rationale 4: The family members’ opinions about the hospital are not essential to provide during handoff communication.

Global Rationale: The client’s last doses of medication would be essential to provide during handoff communication. The spouse’s employer, the number of children the client has, and the family members’ opinions about the hospital are not essential to provide during handoff communication.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 5.7 Identify essential “handoff” information to be communicated when client care is transferred to another caregiver, setting, or home.

Page Number: 88 8. The nurse notes that a client being prepared for discharge is not to continue taking two medications at home. Where should the nurse find additional information about this change in medications?

1. Laboratory reports 2. Previous nurse’s documentation 3. Healthcare provider’s documentation 4. Summary of diagnostic testing completed Correct Answer: 3 Rationale 1: Information about medications is not documented in laboratory reports.

Rationale 2: The previous nurse would not include information about discharge medications.

Rationale 3: The healthcare provider should document reasons for discontinuing or omitting certain medications upon discharge from the hospital.

Mented in diagnostic testing summaries.

Rationale 4: Information about medicatioNnUsRiSs I nNoGtTdBo. CcuOm

Global Rationale: At discharge, the client’s list of medications received during hospitalization is reconciled by the healthcare provider and prescriptions are written or entered into the electronic system for new medications to be taken if indicated. The healthcare provider should document reasons for discontinuing or omitting certain medications upon discharge from the hospital.

Information about medications is not documented in laboratory reports or diagnostic testing summaries.

The previous nurse would not include information about discharge medications.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation Learning Outcome: 5.8 Describe the process and rationale for medication reconciliation across the continuum of care.

Page Number: 101

9. A client is being transferred from the neurologic intensive care unit to a general medical- surgical care area. What should the nurse do first when the client arrives to the new care are?

1. Update the care plan 2. Validate all nursing diagnoses 3. Complete a physical assessment 4. Check the healthcare provider’s orders Correct Answer: 3 Rationale 1: The care plan should not be updated before assessing the client. Rationale 2: Nursing diagnoses should not be validated before assessing the client.

Rationale 3: The new unit’s receiving nurse has an obligation to validate perform an independent client history and physical assessment.

Rationale 4: The client’s orders can be checked after an assessment is completed.

Global Rationale: The new unit’s receiving nurse has an obligation to validate perform an independent client history and physical assessment. The care plan should not be updated before assessing the client. Nursing diagnoses should not be validated before assessing the client. The client’s orders can be checked after an assessment is completed.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.9 Outline steps for transferring a client to another unit within the hospital or to the home.

Page Number: 88 10. A client recovering from abdominal surgery is being discharged home. What should the nurse emphasize when providing this client with discharge instructions?

1. Wound care 2. Time family should arrive 3. Where family should park 4. Antibiotics received while hospitalized Correct Answer: 1

Rationale 1: A client recovering from surgery will need information about wound care. This is a priority.

Rationale 2: The time the family should arrive to pick up the client is not an integral part of discharge instructions.

Rationale 3: The location for the family to park their vehicle is not an integral part of discharge instructions.

Rationale 4: The names of antibiotics received while hospitalized are not a part of discharge instructions. The client needs information about discharge medications.

Global Rationale: A client recovering from surgery will need information about wound care. This is a priority. The time the family should arrive to pick up the client and where they should park the vehicle are not integral parts of discharge instructions. The names of antibiotics received while hospitalized are not a part of discharge instructions. The client needs information about discharge medications.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 5.10 Discuss discharge procedures when a client leaves the hospital. Page Number: 102 11. The nurse is reviewing the status of assigned clients. Which observation should the nurse identify as appropriate for a client to be discharged?

1. Client with heart disease understands the discharge process 2. Client with multiple sclerosis wants to stay in the hospital “forever” 3. Client with asthma wants to use a previous form of inhaled medication 4. Client recovering from knee surgery is apprehensive about going home alone Correct Answer: 1 Rationale 1: An expected outcome when discharging a client is that the client understands the discharge process and is not exhibiting anxiety.

Rationale 2: A client desiring to stay in the hospital forever may be exhibiting anxiety about

going home.

Rationale 3: A client desiring to use a previous type of medication may have difficulty with medication compliance once discharged.

Rationale 4: A client who is apprehensive about going home alone may be exhibiting anxiety.

Global Rationale: An expected outcome when discharging a client is that the client understands the discharge process and is not exhibiting anxiety. A client desiring to stay in the hospital forever may be exhibiting anxiety about going home. A client desiring to use a previous type of medication may have difficulty with medication compliance once discharged. A client who is apprehensive about going home alone may be exhibiting anxiety.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Quality and Safety; Practice; Contribute to assessment of outcome achievement Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5.11 Describe e x p e c Nt eUd RoSuI Nt cGo TmBe. Cs OfoMr clients being discharged from the hospital, including meeting criteria in the initial plan of care.

Page Number: 103 12. The nurse is preparing to discharge a client with a new ileostomy. What should the nurse include when documenting discharge information about this client?

1. Last weight calculated and BMI 2. Most recent vital signs measurements 3. Findings from the physical assessment 4. Return demonstration on appliance care Correct Answer: 4 Rationale 1: Body weight and BMI are not usually included in discharge information. Rationale 2: Vital signs are not usually in discharge information.

Rationale 3: Physical assessment findings are not usually included in discharge information.

Rationale 4: Outcomes of client teaching to include return demonstration on appliance care should be included in the discharge information.

Global Rationale: Outcomes of client teaching to include return demonstration on appliance care should be included in the discharge information. Body weight and BMI, vital signs, and physical assessment findings are not usually included in discharge information Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Quality and Safety; Practice; Contribute to assessment of outcome achievement Nursing/Integrated Concepts: Nursing Process: Evaluation/Communication and Documentation Learning Outcome: 5.12 Complete discharge documentation including client’s achievement of criteria established in the initial plan of care.

Page Number: 103 13. Family members arrive to take home a client desiring to leave against medical advice. What should the nurse do?

1. Begin medication teaching 2. Refer the client to home care 3. Prepare discharge instructions 4. Notify the healthcare provider Correct Answer: 4 Rationale 1: Medication teaching should have been occurring throughout the hospitalization. Rationale 2: A healthcare provider must refer the client to home care.

Rationale 3: The nurse cannot prepare discharge instructions without a healthcare provider order to do so.

Rationale 4: The nurse needs to contact the healthcare provider if a client wants to leave the hospital against medical advice.

Global Rationale: The nurse needs to contact the healthcare provider if a client wants to leave the hospital against medical advice. Medication teaching should have been occurring throughout the hospitalization. A healthcare provider must refer the client to home care. The nurse cannot prepare discharge instructions without a healthcare provider order to do so.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation/Communication and Documentation Learning Outcome: 5.13 Describe three solutions for clients leaving the hospital against medical advice.

Page Number: 103 14. During morning rounds the nurse notes that a client is packing clothing and personal items in preparation for leaving the hospital. What should the nurse do with the signed against medical advice form?

1. Place it on the client’s medical record 2. Fax it to the healthcare provider’s office 3. Send it to the Risk Management department 4. Send a copy to the organization’s legal department Correct Answer: 1 Rationale 1: A signed “against medical advice” form should be placed on the client’s medical record.

Rationale 2: The healthcare provider does not need a copy of the signed against medical advice form.

Rationale 3: The Risk Management department does not need a copy of the signed against medical advice form.

Rationale 4: The legal department does not need a copy of the signed against medical advice form.

Global Rationale: A signed “against medical advice” form should be placed on the client’s medical record.

The healthcare provider or the Risk Management and legal departments do not need a copy of the signed against medical advice form.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.C. 1. Value seeing health care situations "through patients' eyes" AACN Essential Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 5.14 Outline discharge procedures that must be completed when a client leaves the hospital against medical advice.

Page Number: 102 15. The nurse is visiting the home of a newly discharged client. What should the nurse plan to complete at the conclusion of the physical assessment?

1. List for teaching 2. List of supplies the client will need to purchase 3. Method the client intends to pay for home care services 4. Outcome and Assessment Information Set (OASIS) forms Correct Answer: 4 Rationale 1: A list for teaching is not something that needs to be completed immediately at the conclusion of the physical assessment.

Rationale 2: A list of supplies that the client will need to purchase can be generated at any time during the first visit.

Rationale 3: The nurse does not discuss the client’s method of payment.

Rationale 4: The OASIS items were d e s iNg Un eRdS ItNo GeTn Ba .bCl Oe M systematic measurement of client home healthcare outcomes, with appropriate adjustment for client risk factors affecting those outcomes. The items have specific definitions used to measure changes in client’s health status between two or more time points.

Global Rationale: The OASIS items were designed to enable systematic measurement of client home healthcare outcomes, with appropriate adjustment for client risk factors affecting those outcomes. The items have specific definitions used to measure changes in client’s health status between two or more time points. A list for teaching is not something that needs to be completed immediately at the conclusion of the physical assessment. A list of supplies that the client will need to purchase can be generated at any time during the first visit. The nurse does not discuss the client’s method of payment.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.C. 1. Value seeing health care situations "through patients' eyes" AACN Essential Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation

Learning Outcome: 5.9 Outline steps for transferring a client to another unit within the hospital or to the home.

Page Number: 89 16. An older client on Medicare has physical limitations and telephones a local home care agency to schedule a nurse to visit. What should the nurse do first before proceeding with this client’s request?

1. Determine homebound status 2. Identify available staff to visit the client 3. Discuss the challenges the client is facing 4. Find out when the client was last hospitalized Correct Answer: 1 Rationale 1: To receive payment from Medicare for home care the client must meet the requirement of homebound status.

Rationale 2: Identifying staff can occur once it is determined that the client is homebound.

Rationale 3: The nurse needs to first identify homebound status before identifying the client’s needs.

Rationale 4: The client’s last hospitalization does not impact homebound status.

Global Rationale: To receive payment from Medicare for home care the client must meet the requirement of homebound status. Identifying staff can occur once it is determined that the client is homebound. The nurse needs to first identify homebound status before identifying the client’s needs. The client’s last hospitalization does not impact homebound status.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.C. 1. Value seeing health care situations "through patients' eyes" AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.9 Outline steps for transferring a client to another unit within the hospital or to the home.

Page Number: 105 17. The nurse is concerned that a home care client is experiencing abuse. What information did the nurse use to make this clinical determination?

1. New bruises on various body parts

2. Client states oldest daughter moved home 3. Next door neighbor brought homemade soup 4. Bank phoned because social security check will be delayed one day Correct Answer: 1 Rationale 1: Bruises could indicate physical abuse.

Rationale 2: Having a child move back home does not necessarily indicate that abuse is occurring.

Rationale 3: A neighbor bringing homemade soup does not indicate that abuse is occurring.

Rationale 4: Financial resources being delayed a day does not indicate that abuse is occurring.

Global Rationale: Bruises could indicate physical abuse. Having a child move back home does not necessarily indicate that abuse is occurring. A neighbor bringing homemade soup does not indicate that abuse is occurring. Financial resources being delayed a day does not indicate that abuse is occurring.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.C. 1. Value s e eiNn gU RhSeIaNltGhTcBa. rCeOsMit u at io n s "through patients' eyes" AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.9 Outline steps for transferring a client to another unit within the hospital or to the home.

Page Number: 107

CHAPTER 6 1. The nurse is preparing materials for client teaching. What should be the goal for this educational session?

1. Client desires to improve own health 2. Client understands follow-up appointment schedule 3. Client knows what actions to take to care for a health problem 4. Client learns to telephone the healthcare provider with questions Correct Answer: 1 Rationale 1: The goal of client education is assisting clients in learning about their health care to improve their own health.

Rationale 2: The goal of client education is more than understanding an appointment schedule.

Rationale 3: The goal of client education has changed from telling the client the best actions to take.

Rationale 4: The goal of client education is more than telephoning the healthcare provider with questions.

Global Rationale: The goal of client education is assisting clients in learning about their health care to improve their own health. The g oNa Ul oR fS IcNl iGe TntB .eCdOu M c a t i o n is more than understanding an appointment schedule or telephoning the healthcare provider with questions. The goal of client education has changed from telling the client the best actions to take.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 6.1 Describe the purpose of client and family education. Page Number: 113 2. A client who speaks English as a second language needs instruction on self-administration of injectable medications and wound care before being discharged the next day. What should the nurse identify as potential challenges when teaching this client? Select all that apply.

1. Lack of time 2. Lack of supplies

3. Various languages 4. Lack of support systems in the home 5. Lack of appropriate readable materials Correct Answer: 1, 3, 5 Rationale 1: The client needs to learn two major things before discharge – self-administration of injectable medication and wound care. There might not be enough time for teaching.

Rationale 2: There is no evidence that there is a lack of supplies for teaching.

Rationale 3: The client speaks English as a second language. There might be an issue with languages.

Rationale 4: There is no information to support the client has a lack of support systems in the home.

Rationale 5: Since the client knows English as a second language there might be issues with appropriate reading materials for the client.

Global Rationale: Challenges to providing client education include lack of time, various languages, and lack of appropriate reading materials. There is no evidence that there is a lack of supplies for teaching.

There is no information to support the client has a lack of support systems in the home.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 6.2 Describe the challenges to providing client education. Page Number: 114 3. The nurse is preparing to teach an adult client about dietary changes required in the treatment of hypertension. What adult learning principles should the nurse utilize during this teaching? Select all that apply.

1. Reinforce positive behaviors 2. Progress from simple to complex topics 3. Invite family to participate in the teaching 4. Ask the client to verbally repeat instructed material

5. Assess what the client knows about the health issue Correct Answer: 1, 2, 4, 5 Rationale 1: Adults need behavior reinforced.

Rationale 2: Teaching of adults should progress from the simpler concepts to more complex topics.

Rationale 3: Inviting family to participate in the teaching is not an adult learning principle.

Rationale 4: Asking the client to restate what has been discussed will encourage learning and provide for clarification.

Rationale 5: Teaching of adults should progress from the known to the unknown. Assess what they already know; do not reteach the things they already know.

Global Rationale: Adults need behavior reinforced. Teaching of adults should progress from the simpler concepts to more complex topics. Asking the client to restate what has been discussed will encourage learning and provide for clarification. Teaching of adults should progress from the known to the unknown.

Assess what they already know; do not reteach the things they already know. Inviting family to participate in the teaching is not an adult learning principle.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 6.3 Discuss the application of Adult Learning Principles (Knowles) to client education.

Page Number: 115 4. The nurse is caring for a client. What action should the nurse take to determine this client’s teaching needs?

1. Speak in plain language 2. Ask if the client understands 3. Select 5th grade reading material 4. Use questions beginning with “why” Correct Answer: 1

Rationale 1: When determining teaching needs the nurse should speak in plain language.

Rationale 2: Refrain from asking the client, “Do you understand?” because this conveys judgment.

Rationale 3: Using 5th grade reading material assumes the client’s literacy level.

Rationale 4: Using “why” questions places the client on the defensive.

Global Rationale: When determining teaching needs the nurse should speak in plain language. Refrain from asking the client, “Do you understand?” because this conveys judgment. Using 5th grade reading material assumes the client’s literacy level. Using “why” questions places the client on the defensive.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Ce n t e NreUdRCS IaNr eG; TPBr.aCcOt iMce ; learn cooperatively, facilitate the learning of others Nursing/Integrated Concepts: Nursing Process: Assessment/Teaching/Learning Learning Outcome: 6.4 Outline the process of collecting client data to determine learning needs. Page Number: 123 5. The nurse provides information on self-administration of injectable medication to a client in 15 minute teaching increments. If equating this teaching with the nursing process in which phase is the nurse providing care?

1. Planning 2. Evaluation 3. Assessment 4. Implementation Correct Answer: 4 Rationale 1: Planning would be when the nurse identifies the content appropriate to instruct the client.

Rationale 2: Evaluation is determining if the outcomes of instruction have been achieved. Rationale 3: Assessment is determining what teaching the client needs.

Rationale 4: Implementation is following the teaching plan and providing instruction.

Global Rationale: Implementation is following the teaching plan and providing instruction. Planning would be when the nurse identifies the content appropriate to instruct the client. Evaluation is determining if the outcomes of instruction have been achieved. Assessment is determining what teaching the client needs.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 6.5 Explain the application of the nursing process to client education. Page Number: 115 6. The nurse learns that a client will be discharged in 2 days. On what should the nurse focus when planning for this client’s discharge? Select all that apply.

1. Needs 2. Goals of care 3. Measureable outcomes 4. Implementation strategies 5. Compliance with medical treatment Correct Answer: 1, 2, 4 Rationale 1: Discharge planning - a systematic process of planning for client care following discharge includes client needs.

Rationale 2: Discharge planning - a systematic process of planning for client care following discharge includes goals of care.

Rationale 3: Measurable outcomes are not identified as being a part of discharge planning.

Rationale 4: Discharge planning - a systematic process of planning for client care following discharge includes strategies for implementation Rationale 5: Compliance with medical treatment is not identified as being a part of discharge planning.

Global Rationale: Discharge planning - a systematic process of planning for client care following discharge includes client needs, goals of care, and strategies for implementation. Measurable outcomes are not identified as being a part of discharge planning. Compliance with medical treatment is not identified as being a part of discharge planning.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 6.6 Discuss the meaning of the term discharge planning. Page Number: 113 7. The nurse is determining approaches to teach a client how to perform wound care. What should the nurse consider when determining appropriate strategies? Select all that apply.

1. Date of discharge 2. Available resources 3. Client reading level 4. Client attention span 5. Best time for teaching Correct Answer: 2, 3, 4, 5 Rationale 1: The date of discharge is not a factor to consider when determining appropriate teaching strategies.

Rationale 2: Factors to consider when determining appropriate teaching strategies include available resources.

Rationale 3: Factors to consider when determining appropriate teaching strategies include client reading level.

Rationale 4: Factors to consider when determining appropriate teaching strategies include client attention span.

Rationale 5: Factors to consider when determining appropriate teaching strategies include the best time for teaching.

Global Rationale: Factors to consider when determining appropriate teaching strategies include available resources, client reading level, client attention span, and the best time for teaching. The date of discharge is not a factor to consider when determining appropriate teaching strategies.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 6.7 List two factors to consider when determining an appropriate teaching strategy.

Page Number: 126 8. A client needs to learn how to care for a new colostomy. Which teaching strategy should the nurse select for this instruction?

1. Role playing 2. Group process 3. Lecture-discussion 4. Demonstration–return demonstration Correct Answer: 4 Rationale 1: Role playing assigns roles to various participants or learners for the purpose of clarifying various aspects of a situation.

Rationale 2: Group process use principles from group dynamics, mental health, or other related fields to enhance learning or behavior change in a small group setting.

Rationale 3: Lecture–discussion is the presentation of content in a didactic fashion with opportunity for questions and interaction during or at the conclusion of the presentation.

Rationale 4: Demonstration–return demonstration provides the learner an opportunity to demonstrate mastery of the skill.

Global Rationale: Demonstration–return demonstration provides the learner an opportunity to demonstrate mastery of the skill. Role playing assigns roles to various participants or learners for the purpose of clarifying various aspects of a situation. Group process use principles from group dynamics, mental health, or other related fields to enhance learning or behavior change in a small group setting. Lecture–discussion is the presentation of content in a didactic fashion with opportunity for questions and interaction during or at the conclusion of the presentation.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 6.8 List and describe specific teaching strategies appropriate for clients and families.

Page Number: 127 9. A client from a non-English speaking country is admitted to a care area. Which nursing behavior exemplifies cultural competence?

1. Asks the family to wait in the visitor’s lounge during the assessment 2. Realizes that teaching cannot be completed because of a language barrier 3. Contacts an interpreter to assist with data collection and goal identification 4. Documents “no response” when the client does not answer assessment questions Correct Answer: 3 Rationale 1: Asking the family to wait in the lounge is not taking the client’s core cultural values into consideration.

Rationale 2: Dismissing the need for teaching could be the nurse’s bias or prejudice. Rationale 3: Whenever possible, the nurse should use a translator to convey information.

Rationale 4: Documenting “no response” when the client does not answer questions is not taking the client’s communication needs into consideration.

Global Rationale: Cultural competence is a set of congruent behaviors, attitudes, and policies that enables nurses and other healthcare workers to work effectively in a cross-cultural situation. Whenever possible, the nurse should use a translator to convey information. Asking the family to wait in the lounge is not taking the client’s core cultural values into consideration. Dismissing the need for teaching could be the nurse’s bias or prejudice. Documenting “no response” when the client does not answer questions is not taking the client’s communication needs into consideration.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub:

QSEN Competencies: I.C. 5. Recognize personally held attitudes about working with patients from different ethnic, cultural and social backgrounds AACN Essential Competencies: VII. 7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion and disease and injury prevention interventions NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation/Culture and Spirituality Learning Outcome: 6.9 Define cultural competence.

Page Number: 120 10. The nurse determines that a teaching session scheduled with a client should be postponed for a few hours. What information caused the nurse to make this decision?

1. Family members visiting 2. Laboratory tests scheduled 3. Pain level 8 on a scale from 0 to 10 4. Healthcare provider making rounds Correct Answer: 3 Rationale 1: Family members could participate in the teaching session.

Rationale 2: Laboratory tests could be rescheduled.

Rationale 3: The degree of physical readiness is affected by pain level.

Rationale 4: The healthcare provider can observe the teaching or return afterwards.

Global Rationale: The degree of physical readiness is affected by pain level. Family members could participate in the teaching session. Laboratory tests could be rescheduled. The healthcare provider can observe the teaching or return afterwards.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others Nursing/Integrated Concepts: Nursing Process: Assessment/Teaching/Learning Learning Outcome: 6.10 Identify assessments to determine readiness to learn. Page Number: 124

11. The nurse is unsure if a teaching pamphlet would be appropriate for a client with an 8th grade reading level. What should the nurse do before providing the client with the pamphlet?

1. Use a readability formula 2. Read the material for comprehension 3. Contact the manufacturer and ask what the readability level is 4. Ask another staff member to read the material for comprehension Correct Answer: 1 Rationale 1: The nurse should use a readability formula to determine most appropriate written information for the client.

Rationale 2: The nurse’s reading level could be hirer than the client.

Rationale 3: The manufacturers may not know the readability level of the material. Rationale 4: Another staff member may have a different reading level that the client.

Global Rationale: The nurse should use a readability formula to determine most appropriate written information for the client. The nurse’s reading level could be hirer than the client. The manufacturers may not know the readability level of the material. Another staff member may have a different reading level that the client.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others Nursing/Integrated Concepts: Nursing Process: Assessment/Teaching/Learning Learning Outcome: 6.11 Identify one strategy to determine readability level of written material. Page Number: 126 12. During a home visit the nurse wants to evaluate the success of discharge teaching provided. What tool should the nurse use to evaluate the client’s ability to measure pulse before taking medications?

1. Measure the client’s heart rate 2. Provide a paper and pencil test 3. Ask the client to complete a questionnaire 4. Observe the client count the pulse for 1 minute Correct Answer: 4

Rationale 1: A physiologic measurement would not be required to evaluate effectiveness of this teaching.

Rationale 2: A paper and pencil test would not adequately evaluate the effectiveness of this teaching.

Rationale 3: A questionnaire would not adequately evaluate the effectiveness of this teaching.

Rationale 4: Direct observation would be the best approach to evaluate the effectiveness of this teaching.

Global Rationale: Direct observation would be the best approach to evaluate the effectiveness of this teaching. A physiologic measurement would not be required to evaluate effectiveness of this teaching. A paper and pencil test would not adequately evaluate the effectiveness of this teaching. A questionnaire would not adequately evaluate the effectiveness of this teaching.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, sp irituNaUliRt yS,I Np aGtTieBn. Ct O prMeferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 6.12 Describe how to develop an evaluation tool.

Page Number: 130 13. A client is being prepared to go home. For which reason should the nurse identify the client as being high-risk for discharge?

1. Adjustments made to medications 2. Recovering from open heart surgery 3. Removal of a cast for a fractured limb 4. Treatment provided to correct electrolyte imbalances Correct Answer: 2 Rationale 1: Medication adjustment is not a high-risk indicator for discharge planning.

Rationale 2: A major surgical procedure such as open heart surgery is a high-risk indicator for discharge planning.

Rationale 3: Removal of a cast for a fractured limb is not a high-risk indicator for discharge planning.

Rationale 4: Treatment to correct an electrolyte imbalance is not a high-risk indicator for discharge planning.

Global Rationale: A major surgical procedure such as open heart surgery is a high-risk indicator for discharge planning. Medication adjustment is not a high-risk indicator for discharge planning. Removal of a cast for a fractured limb is not a high-risk indicator for discharge planning.

Treatment to correct an electrolyte imbalance is not a high-risk indicator for discharge planning.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 10. Facilitate patient-centered transitions of care, including discharge planning and ensuring the caregiver’s knowledge of care requirements to promote safe care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 6.13 List three risk factors that require discharge planning. Page Number: 117 14. The nurse reviews a client’s teaching plan, activity level, and referral agencies contacted. What is the nurse most likely preparing?

1. Care plan 2. Critical pathway 3. Discharge summary 4. Admission assessment Correct Answer: 3 Rationale 1: Referral agencies would not be a part of the care plan. Rationale 2: Referral agencies would not be a part of a critical pathway.

Rationale 3: Teaching plan, activity level, and referral agencies are included in a discharge summary.

Rationale 4: Teaching plan and referral agencies are not a part of an admission assessment.

Global Rationale: Teaching plan, activity level, and referral agencies are included in a discharge summary.

Referral agencies would not be a part of the care plan or critical pathway. Teaching plan and referral agencies are not a part of an admission assessment.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 10. Facilitate patient-centered transitions of care, including discharge planning and ensuring the caregiver’s knowledge of care requirements to promote safe care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 6.14 Identify the steps necessary to complete a discharge summary. Page Number: 134 15. Family has arrived to take a client home. What should the nurse provide to the client before leaving the healthcare organization?

1. Written instructions 2. Results of diagnostic testing 3. Names of health plan approved pharmacists 4. Telephone number of the healthcare provider Correct Answer: 1 Rationale 1: The nurse should provide the client with written instructions that include diet, medications, treatments, physical activity limitations, signs and symptoms to report, follow-up medical care, equipment, and appropriate community resources.

Rationale 2: Results of diagnostic testing would not be provided to the client prior to discharge. Rationale 3: The client most likely knows the pharmacies that are approved by the health plan. Rationale 4: The client most likely already knows the healthcare provider’s telephone number.

Global Rationale: The nurse should provide the client with written instructions that include diet, medications, treatments, physical activity limitations, signs and symptoms to report, follow-up medical care, equipment, and appropriate community resources. Results of diagnostic testing would not be provided to the client prior to discharge. The client most likely knows the pharmacies that are approved by the health plan. The client most likely already knows the healthcare provider’s telephone number.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 10. Facilitate patient-centered transitions of care, including discharge planning and ensuring the caregiver’s knowledge of care requirements to promote safe care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 6.15 Describe documents required to accompany client to home. Page Number: 134 16. The charge nurse is reviewing a list of clients scheduled for discharge. Which client should have a referral for home care?

1. Client scheduled for outpatient radiation treatments 2. Client recovering from total knee replacement surgery 3. Client treated in the emergency department for a bee sting 4. Client admitted for 12 hours for fluids to treat dehydration Correct Answer: 2 Rationale 1: A client scheduled for outpatient radiation treatments would not be homebound.

Rationale 2: The client recovering from tNoUt aRl SkI Nn eGeT rBe. pC lOa M c e m e n t surgery would need home care for physical therapy and nursing assessment of the surgical wound.

Rationale 3: A client recovering from a bee sting would not be homebound. Rationale 4: A client with dehydration most likely would not be homebound.

Global Rationale: The client recovering from total knee replacement surgery would need home care for physical therapy and nursing assessment of the surgical wound. The clients having outpatient radiation treatments, recovering from a bee sting, and treated for dehydration most likely would not be homebound and not eligible for home care.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 10. Facilitate patient-centered transitions of care, including discharge planning and ensuring the caregiver’s knowledge of care requirements to promote safe care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning/Communication and Documentation

Learning Outcome: 6.16 Identify appropriate referral for Home Health Team. Page Number: 119 17. A client is instructed on the proper way to apply nitroglycerin ointment. What should the nurse use to evaluate the effectiveness of teaching provided?

1. Questionnaire 2. Verbal response 3. Teach back method 4. Paper and pencil test Correct Answer: 3 Rationale 1: A questionnaire would not be appropriate to evaluate the effectiveness of medication teaching.

Rationale 2: Verbal response would not be appropriate to evaluate the effectiveness of medication teaching.

Rationale 3: Teach-back is a way to confirm that the client was instructed in a way that the client understands.

Rationale 4: Paper and pencil test would not be appropriate to evaluate the effectiveness of medication teaching.

Global Rationale: Teach-back is a way to confirm that the client was instructed in a way that the client understands. A questionnaire, verbal response, or paper and pencil test would not be appropriate to evaluate the effectiveness of medication teaching.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 6.12 Describe how to develop an evaluation tool.

Page Number: 128

CHAPTER 7 1. The nurse administers an antianxiety (anxiolytic) medication to a client diagnosed with dementia who has been harming himself. When documenting the use of this medication as a restraint, which term is the most appropriate for the nurse to use?

1. Chemical restraint 2. Physical restraint 3. Medication restraint 4. Psychological restraint Correct Answer: 1 Rationale 1: Administering a medication for the purpose of controlling socially disruptive behavior is a form of chemical restraint.

Rationale 2: Physical restraints are visible appliances applied to the client's body to control behavior.

Rationale 3: Although medications can be used as a form of a restraint, the term medication restraint is not appropriate.

Rationale 4: Psychological restraint is not a form of restraint used in client care.

Global Rationale: Administering a medication for the purpose of controlling socially disruptive behavior is a form of chemical restraint. Physical restraints are visible appliances applied to the client's body to control behavior. Although medications can be used as a form of a restraint, the term medication restraint is not appropriate. Psychological restraint is not a form of restraint used in client care.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.15 List the components that should be included when charting for application of restraints.

Page Number: p. 154 2. The nurse is caring for a client who consistently pulls at the IV and urinary catheter. Restraints are applied that prevent the client from being able to grasp the tubing. Which term will the nurse use when documenting the restraints used for this client?

1. Jacket restraint 2. Limb restraint 3. Mitt restraint 4. Waist restraint Correct Answer: 3 Rationale 1: A jacket restraint is applied to the client's chest, and ties to the bed to keep the client from sitting up or getting out of bed.

Rationale 2: Limb restraints tie the arm to the bed and limit arm movement.

Rationale 3: The mitt restraint is like a mitten that goes over the hand and limits the ability of the fingers to grasp while not limiting arNmUm RSoIvNeGmTeBn. tC.OM Rationale 4: Waist restraints tie around the client's waist and then to the bed to limit movement.

Global Rationale: The mitt restraint is like a mitten that goes over the hand and limits the ability of the fingers to grasp while not limiting arm movement. Limb restraints tie the arm to the bed and limit arm movement. A jacket restraint is applied to the client's chest, and ties to the bed to keep the client from sitting up or getting out of bed. Waist restraints tie around the client's waist and then to the bed to limit movement.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.13 Demonstrate the application of wrist restraints. Page Number: p.

169

3. Which action performed by the nurse will be the least effective to reduce the risk of client falls?

1. Orienting clients to the unit and explaining how the call bell system works 2. Encouraging clients to use call bells for assistance and ensuring that the call bell is within easy reach 3. Placing overbed and bedside tables out of the way 4. Using nonskid mats in the tub or shower Correct Answer: 3 Rationale 1: Orienting clients to the unit and explaining how the call bell system works is a strategy to reduce the risk of falls.

Rationale 2: Encouraging clients to use call bells for assistance and ensuring that the call bell is within easy reach is a strategy to reduce the risk of falls.

Rationale 3: Tables should be placed within the reach of the client to avoid having her reach for something and fall out of bed.

Rationale 4: Using nonskid mats in the tub or shower is a strategy to reduce the risk of falls.

Global Rationale: Tables should be placed within the reach of the client to avoid having her reach for something and fall out of bed. Strategies to reduce the risk of falls include orienting clients to the unit and explaining how the call bell system works, encouraging clients to use call bells for assistance and ensuring that the call bell is within easy reach, and using nonskid mats in the tub or shower.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.C. 1. Value the contributions of standardization/reliability to safety AACN Essential Competencies: II. 6. Apply concepts of quality and safety using structure, process and outcome measures to identify clinical questions and describe the process of changing current practice NLN Competencies: Knowledge and Science: Ethical Comportment: Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.8 Identify clients who are at high risk for falls. Page Number: p.

175 4. The nurse is preparing to ambulate a client in the hall. Which action by the nurse is a strategy to reduce the client's risk of falls?

1. Encouraging client to wear nonskid footwear 2. Cautioning the client about cords or clutter on the floor 3. Encouraging the client to continue walking after complaints of feeling tired 4. Acting as the client's means of support instead of using a walker to provide additional support Correct Answer: 1 Rationale 1: The client should be encouraged to wear nonskid footwear to prevent slipping on the floor.

Rationale 2: Instead of cautioning clients about cords and clutter, they should be removed to reduce risk.

Rationale 3: When a client states fatigue and can't walk farther, encouraging the client to continue could result in a fall.

Rationale 4: It is safer to allow clients to use familiar ambulation assistants when needed instead of the nurse acting to support the client.

Global Rationale: The client should be encouraged to wear nonskid footwear to prevent slipping on the floor. Instead of cautioninNgU RclSi IeNnGtsTaBb. CouOtMcords and clutter, they should be removed to reduce risk. When a client states fatigue and can't walk farther, encouraging the client to continue could result in a fall. It is safer to allow clients to use familiar ambulation assistants when needed instead of the nurse acting to support the client.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.C. 1. Value the contributions of standardization/reliability to safety AACN Essential Competencies: II. 6. Apply concepts of quality and safety using structure, process and outcome measures to identify clinical questions and describe the process of changing current practice NLN Competencies: Knowledge and Science: Ethical Comportment: Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation 7.8 Identify clients who are at high risk for falls.

Page Number: p. 159 5. A client with paranoid schizophrenia is threatening the staff and believes the staff is trying to harm him.

When the nurse enters the client's room, the client is agitated, and attempts to slap the nurse. The nurse gets assistance from other staff members and restrains the client. Which nursing action is the priority at this time?

1. Requesting a psychiatric referral 2. Notifying the health care provider of the need to see the client 3. Padding the side rails 4. Obtaining consent from the client for use of restraints Correct Answer: 2 Rationale 1: A psychiatric referral might be required, but it is not the priority action.

Rationale 2: After applying restraints, the client must be seen by the health care provider within a timeframe specified by the organization and an order should be obtained.

Rationale 3: There is no need to pad the side rails.

Rationale 4: Consent from the client is not required if the restraints are applied to prevent harm to the client or others.

Global Rationale: After applying restraints, the client must be seen by the health care provider within a timeframe specified by the organization and an order should be obtained. A psychiatric referral might be required, but it is not the priority action. There is no need to pad the side rails.

Consent from the client is not required i fNtUh Re Sr IeNs tGr aT iBn. tCs OaMr e applied to prevent harm to the client or others.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.B. 3. Base individualized care plan on patient values, clinical expertise and evidence AACN Essential Competencies: III.2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.15 List the components that should be included when charting for application of restraints.

Page Number: p. 154 6. The nurse is caring for a pediatric client who is focused on pulling out the IV line in the right arm. Which type of restraint is the most appropriate for this client?

1. Elbow restraint to the right arm 2. Elbow restraint to the left arm

3. Mitt restraint to the right hand 4. Wrist restraint to the left arm Correct Answer: 2 Rationale 1: Restraining the right arm or hand with the IV line would not limit the left hand from pulling the IV. Rationale 2: The nurse would apply an elbow restraint to the arm that does not have the IV, because the client would reach with the left arm.

Rationale 3: A mitt restraint to the right hand would not limit the left hand from pulling out the IV. Rationale 4: Wrist restraints would limit all movement of the arm, whereas elbow restraints would only limit bending of the elbow, so this is the less restrictive and best choice.

Global Rationale: The nurse would apply an elbow restraint to the arm that does not have the IV, because the client would reach with the left arm. Restraining the right arm or hand with the IV line would not limit the left hand from pulling the IV. A mitt restraint to the right hand would not limit the left hand from pulling out the IV. Wrist restraints would limit all movement of the arm, whereas elbow restraints would only limit bending of the elbow, so this is the less restrictive and best choice.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.13 Demonstrate the application of wrist restraints. Page Number: p.

170 7. The nurse completes yearly training regarding the use of restraints. Which situation should the nurse categorize as a restraint?

1. A safety belt applied across the client's waist when sitting in a geri chair with a quick release button demonstrated to the client 2. The use of the top side rail to provide something for the client to hold on to when getting out of bed

3. A safety belt around the infant when placing the child in a swing 4. The use of all four side rails on the bed after administering preoperative sedation Correct Answer: 4 Rationale 1: The safety belt applied to the adult is not a restraint, because the client is shown how to open the belt if she wishes to remove it.

Rationale 2: Raising one side rail for support is not restraining the client because she can still get out of bed.

Rationale 3: A safety belt applied to an infant seat is not a restraint; it does not limit the child's movement, because the infant could not voluntarily get out of the chair without injury.

Rationale 4: When the nurse pulls all four side rails up on the client's bed, he is restraining the client unless he obtains the client's permission prior to administering the preoperative sedation.

Global Rationale: When the nurse pulls all four side rails up on the client's bed, he is restraining the client unless he obtains the client's permission prior to administering the preoperative sedation. Raising one side rail for support is not restraining the client because she can still get out of bed. The safety belt applied to the adult is not a restraint, because the client is shown how to open the belt if she wishes to remove it. A safety belt applied to an infant seat is not a restraint; it does not limit the child's movement, b e c Na uUsRe StIhNeGiTnBf a. Cn Ot cMould not voluntarily get out of the chair without injury.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.12 List and briefly describe at least four guidelines for using restraints to prevent mechanical injuries.

Page Number: p. 145 8. Which action is required by the nurse prior to putting the bed or chair exit safety-monitoring device in place?

1. Obtaining a health care provider’s order 2. Documenting the use of the alarm system

3. Testing the alarm 4. Applying the leg band or sensor pad Correct Answer: 3 Rationale 1: There is no need for a health care provider’s order, as this is an independent nursing action.

Rationale 2: Documentation would occur after application of the system.

Rationale 3: Before applying the system, the nurse should test the alarm to ensure that it works and is set high enough to be heard. It is also wise to allow the client to hear the alarm so it does not frighten her when it goes off.

Rationale 4: After testing the alarm, the nurse would apply the leg band or sensor pad.

Global Rationale: Before applying the system, the nurse should test the alarm to ensure that it works and is set high enough to be heard. It is also wise to allow the client to hear the alarm so it does not frighten her when it goes off. . There is no need for a health care provider’s order, as this is an independent nursing action. Documentation would occur after application of the system. After testing the alarm, the nurse would apply the leg band or sensor pad Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.8 Identify clients who are at high risk for falls. Page Number: p.

158 9. The nurse is providing care to a client who has an order for a jacket restraint. Which action by the nurse is appropriate when applying this restraint to the client?

1. Placing the vest with the opening on the side 2. Pulling the tie on the end of the vest flap across the chest and placing it through the slit on the same side of the chest 3. Using a slipknot to secure the tie around the solid leg of the bed frame 4. Using a half-bow knot to secure the tie around the movable bed frame

Correct Answer: 4 Rationale 1: The vest is placed with the opening in the front or the back depending on the type of restraint used.

Rationale 2: The tie on the end of the vest is pulled across the chest and placed in the slit at the opposite side of the chest.

Rationale 3: The nurse should tie the restraint to the movable part of the bed frame to avoid injuring the client if the head of the bed is raised or lowered.

Rationale 4: The nurse should tie the restraint to the movable part of the bed frame to avoid injuring the client if the head of the bed is raised or lowered. Use a half-bow knot, which is easy and quick to open.

Global Rationale: The nurse should tie the restraint to the movable part of the bed frame to avoid injuring the client if the head of the bed is raised or lowered. Use a half-bow knot, which is easy and quick to open.

The vest is placed with the opening in the front or the back depending on the type of restraint used. The tie on the end of the vest is pulled across the chest and placed in the slit at the opposite side of the chest.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection CNoUnRtrSoINl GTB.COM QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.14 Demonstrate the application of a torso/belt restraint.

Page Number: p. 171 10. The nurse is caring for a client who has seizure precautions. Which actions by the nurse are appropriate for these precautions?

Standard Text: Select all that apply.

1. Padding the bed around the head, foot, and side rails 2. Placing functional oral suction equipment in the room 3. Placing extremity restraints in the room for use if the client has a seizure 4. Keeping pillows handy to protect the client's head

5. Taping a bite block to the wall to protect the client from biting his or her tongue Correct Answer: 1, 2, 4 Rationale 1: Padding the bed will protect the client from injury if tonic–clonic movement of the extremities occurs during a seizure.

Rationale 2: Suctioning equipment will allow the nurse to clear the airway after the seizure.

Rationale 3: The client's extremities should never be restrained during a seizure.

Rationale 4: Pillows are useful in helping the client protect the head from banging on the floor if he is not in bed when a seizure occurs.

Rationale 5: Nothing should be inserted into the client's mouth during a seizure, so bite blocks are not necessary.

Global Rationale: Padding the bed will protect the client from injury if clonic tonic movement of the extremities occurs during a seizure. Suctioning equipment will allow the nurse to clear the airway after the seizure. Pillows are useful in helping the client protect the head from banging on the floor if he is not in bed when a seizure occurs. The client's extremities should never be restrained during a seizure. Nothing should be inserted into the client's mouth during a seizure, so bite blocks are not necessary.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.11 Describe nursing actions for clients with seizure activity.

Page Number: p. 162 11. The nurse is providing care to a client requiring restraints. How often should the nurse assess the client and document the assessment?

1. Once per shift 2. Once a day 3. Once every 4–6 hours 4. Once every 1–2 hours

Correct Answer: 4 Rationale 1: Once per shift is very dangerous, and would not meet the recommendations of close observation of restrained clients.

Rationale 2: Once per day is very dangerous, and would not meet the recommendations of close observation of restrained clients.

Rationale 3: Assessing the client every 4–6 hours is not safe, and could result in client injury.

Rationale 4: Although each facility will set its own rules for frequency of assessing and documenting the use of restraints, clients generally will need to be assessed at least once every 1–2 hours.

Global Rationale: Although each facility will set its own rules for frequency of assessing and documenting the use of restraints, clients generally will need to be assessed at least once every 1–2 hours. Once per day or per shift is very dangerous, and would not meet the recommendations of close observation of restrained clients. Assessing the client every 4–6 hours is not safe, and could result in client injury.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: VI.B.4. D o c u m enN tUaRnSdI NpGl aTnB c. Cl iOenMt care in an electronic health record AACN Essential Competencies: IV.5. Use standardized terminology in a care environment that reflects nursing’s unique contribution to client outcomes NLN Competencies: Quality and Safety: Practice; Carefully maintain and use electronic and/or written health records Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.15 List the components that should be included when charting for application of restraints.

Page Number: p. 154 12. The nurse is instructing unlicensed assistive personnel (UAP) on fall prevention for the clients.

Which statement made by the UAP warrants further instruction?

1. "I will ensure that the call light is within reach of the client."

2. "I will make sure to have at least one side rail up at all times."

3. "I don't have to worry about the clients who are bedridden, as they are moved by the staff."

4. "I will make sure that the bed is in the lowest position prior to leaving the room."

Correct Answer: 3

Rationale 1: Ensuring that the call light is within reach of the client indicates appropriate understanding by the UAP on fall prevention strategies for the client.

Rationale 2: Leaving one side rail up at all times indicates an appropriate understanding by the UAP on fall prevention strategies for the client.

Rationale 3: The statement indicating not having to worry about clients who are bedridden because they are moved by staff is not correct as clients who are bedridden are more prone to falls due to the loss of independence.

Rationale 4: Ensuring that the bed is in the lowest position possible prior to leaving the room indicates an appropriate understanding by the UAP on fall prevention strategies for the client.

Global Rationale: The statement indicating not having to worry about clients who are bedridden because they are moved by staff is not correct as clients who are bedridden are more prone to falls due to the loss of independence. All the other statements indicate an appropriate understanding by the UAP on fall prevention strategies for the client.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members S IoNnGsTt rBa.tCe OcM AACN Essential Competencies: IX. 14.NDU eRm linical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Practice; Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.8 Identify clients who are at high risk for falls.

Page Number: p. 152 13. Which items are appropriate for the nurse to include when assessing a client for falls?

Standard Text: Select all that apply.

1. Reviewing for a history of falls before admission 2. Talking with family about concerns 3. Assessing the overall physical condition 4. Assessing medication lists 5. Assessing mental status Correct Answer: 1, 3, 4, 5

Rationale 1: It is appropriate for the nurse to review the client’s medical record for any history of falls as this serves as a baseline for how to proceed when planning care for this client.

Rationale 2: Talking to the family is important, but unless the family is staying with the client it is not warranted at this time.

Rationale 3: Assessing the client’s overall condition is necessary as the client may need ambulatory devices.

Rationale 4: Assessing medications is important as many medications can alter balance and therefore lead to increased falls.

Rationale 5: Assessing mental status is important and is critical to determining fall risks.

Global Rationale: It is important for the nurse to review the client’s medical record for any history of falls along with assessing the client’s overall condition, medications, and mental status. All are important to determine the client’s risk for falls. Talking to the family is important, but unless the family is staying with the client it is not warranted at this time.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.C.1. Value the contributions of standardization/reliability to safety AACN Essential Competencies: II.6. ANpUpRlySIcNoGnTceBp.CtsOoMf quality and safety using structure, process, and outcome measures to identify clinical questions and describe the process of changing current practice NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.8 Identify clients who are at high risk for falls. Page Number: p.

152 14. The nurse is delegating supportive care to unlicensed assistive personnel (UAP) for several clients on a medical–surgical unit. Which statement made by the UAP warrants the need for more information?

1. "I can untie the restraint when giving the client a bath."

2. "I will make sure to tie the restraint in a slip-knot."

3. "I will inform you of any changes to the skin."

4. "I will assist the client with hygiene."

Correct Answer: 1

Rationale 1: The UAP should only untie the restraint while giving a bath if the client is no longer in danger of pulling out lines or becoming combative with staff. This statement indicates the need for the nurse to ask more questions to the UAP. Rationale 2: The UAP should tie the restraint in a slip-knot.

Rationale 3: The UAP should inform the nurse of any changes to the skin.

Rationale 4: The UAP should assist the client with hygiene.

Global Rationale: The UAP should only untie the restraint while giving a bath if the client is no longer in danger of pulling out lines or becoming combative with staff. This statement indicates the need for the nurse to ask more questions to the UAP. All the other statements indicate an appropriate understanding by the UAP. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Practice; Manage delegation effectively.

Nursing/Integrated Concepts: NursingNPUrRoScIeNssG: TIBm.CpOleM mentation Learning Outcome: 7.13 Demonstrate the application of wrist restraints.

Page Number: p. 168 15. When putting a client in restraints, the nurse will need to assess the client per policy. Which items will the nurse include when assessing this client?

Standard Text: Select all that apply.

1. The client’s range of motion 2. That the client’s restraint is tied in a knot 3. The client’s vital signs 4. The client’s circulation 5. The client’s hydration Correct Answer: 1, 3, 4, 5 Rationale 1: When the nurse is providing care to a client who is in restraints, appropriate items to assess include range of motion

Rationale 2: The restraint knot should also be assessed but the restraint should be a slip knot, not a regular knot.

Rationale 3: When the nurse is providing care to a client who is in restraints, appropriate items to assess include vital signs.

Rationale 4: When the nurse is providing care to a client who is in restraints, appropriate items to assess include circulation.

Rationale 5: When the nurse is providing care to a client who is in restraints, appropriate items to assess include hydration.

Global Rationale: When the nurse is providing care to a client who is in restraints, appropriate items to assess include range of motion, vital signs, circulation, and hydration. The restraint knot should also be assessed but the restraint should be a slip knot, not a regular knot.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice NGTB.COM AACN Essential Competencies: IX.8. NImUpRlSeIm ent evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.12 List and briefly describe at least four guidelines for using restraints to prevent mechanical injuries.

Page Number: p. 174 16. The nurse is completing a home safety assessment during the first care visit. What should be the focus when assessing the client’s bedroom? Select all that apply.

1. Adequate space 2. Night light availability 3. Flooring in good repair 4. Handrails fastened to wall 5. Ease in getting into and out of bed Correct answer: 1, 2, 3, 5 Rationale 1: When assessing the home environment the bedroom should be assessed for adequate space.

Rationale 2: When assessing the home environment the bedroom should be assessed for the presence of a night light.

Rationale 3: When assessing the home environment the bedroom should be assessed for flooring in good repair.

Rationale 4: Handrails fastened to the wall would be appropriate when assessing the stairs.

Rationale 5: When assessing the home environment the bedroom should be assessed for ease in getting into and out of the bed.

Global Rationale: When assessing the home environment the bedroom should be assessed for adequate space, the presence of a night light, flooring in good repair, and ease in getting into and out of the bed.

Handrails fastened to the wall would be appropriate when assessing the stairs.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.C. 1. Value the contributions of standardization/reliability to safety AACN Essential Competencies: II. 6. Apply concepts of quality and safety using structure, process and outcome measures to identify clinical questions and describe the process of changing current practice NLN Competencies: Knowledge and Science: Ethical Comportment: Value evidence-based approaches to yield best practices for nurNsUinRgS I N G T B. C O M Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.16 Describe the Home Assessment Checklist. Page Number: p.

163 17. While emptying the urinal of a client with radioactive bladder implants several drops of urine splash on the nurse’s upper arm. What should the nurse do first?

1. Pour the urine in the commode 2. Complete an occurrence report 3. Notify the radiation safety officer 4. Wash the arm with soap and water Correct answer: 4 Rationale 1: The urine should be placed in the appropriate radioactive container.

Rationale 2: An occurrence report can be completed later.

Rationale 3: The radiation officer can be notified later of the occurrence.

Rationale 4: If spillage of excreta from a client with systemic radioactive therapy occurs wash with soap and water if skin is contaminated.

Global Rationale: If spillage of excreta from a client with systemic radioactive therapy occurs wash with soap and water if skin is contaminated. The urine should be placed in the appropriate radioactive container.

An occurrence report can be completed later. The radiation officer can be notified later of the occurrence.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.C. 1. Value the contributions of standardization/reliability to safety AACN Essential Competencies: II. 6. Apply concepts of quality and safety using structure, process and outcome measures to identify clinical questions and describe the process of changing current practice NLN Competencies: Knowledge and Science: Ethical Comportment: Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.10 List the guidelines for providing safety when clients are receiving radioactive materials.

Page Number: p. 164

CHAPTER 8 1. The nurse who is planning the day will perform morning care at which point?

1. When the client first awakens 2. Before breakfast 3. Before retiring for the night 4. Whenever the client requests it Correct Answer: 2 Rationale 1: Early-morning care is provided when the client first awakens. Rationale 2: The nurse generally provides morning care before breakfast. Rationale 3: Hour of sleep (HS) care is provided before going to bed.

Rationale 4: PRN care is provided as required by the client.

Global Rationale: The nurse generally provides morning care before breakfast. Early-morning care is provided when the client first awakens. Hpo(uHr So)f csaler e is provided before going to bed. PRN care is provided as required by the client.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B.3. Provide client-centered care with sensitivity and respect for the diversity of human experience AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 8.8 Outline the steps in providing morning care..

Page Number: p. 194 2. The nurse is preparing a client for a morning bath. What should be assessed prior to providing personal hygienic care?

Standard Text: Select all that apply.

1. Allergies 2. Culture 3. Ability to provide self-care 4. Social history 5. Diagnosis Correct Answer: 2, 3, 5 Rationale 1: Allergies are not identified as being assessed prior to hygienic care.

Rationale 2: The client's culture will impact how daily hygiene needs are met.

Rationale 3: The client should be encouraged to perform as much of hygiene care as possible, so the nurse must assess the ability to provide self-care.

Rationale 4: The client’s social history is assessed during an admission assessment and not prior to providing personal hygienic care each day.

Rationale 5: The client's diagnosis will impact how much care can be tolerated at one time and the ability to move about in bed.

Global Rationale: The client's culture will impact how daily hygiene needs are met. The client should be encouraged to perform as much of hygiene care as possible, so the nurse must assess the ability to provide self-care. The client's diagnosis will impact how much care can be tolerated at one time and the ability to move about in bed. Allergies are not identified as being assessed prior to hygienic care. The client’s social history is assessed during an admission assessment and not prior to providing personal hygienic care each day.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B.3. Provide client-centered care with sensitivity and respect for the diversity of human experience AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.8 Outline the steps in providing morning care. Page Number: p.

193

3. The nurse is preparing a commercial cleansing system to bathe a client. Which action is the priority for the nurse?

1. Wetting the disposable washcloths 2. Drying the client after using a washcloth 3. Using one washcloth for the lower extremities 4. Warming the washcloth in the microwave Correct Answer: 4 Rationale 1: The package contains presoaked disposable washcloths.

Rationale 2: Drying is not necessary because the solution on the washcloths is no-rinse cleanser that will dry quickly.

Rationale 3: The nurse uses one washcloth on each area of the body (one for each arm, one for each leg).

Rationale 4: The washcloths must be warmed in the microwave.

Global Rationale: The washcloths must be warmed in the microwave. The package contains presoaked disposable washcloths. Drying is not necessary because the solution on the washcloths is no-rinse cleanser that will dry quickly. The nurse uses one washcloth on each area of the body (one for each arm, one for each leg).

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.B.3. Base individualized care plan on client values, clinical expertise, and evidence AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.6 State the advantages of using a commercial bathing system.

Page Number: p. 198

4. The nurse is caring for a healthy young adult client who was involved in a motor vehicle crash resulting in a fractured femur. The femur was pinned, and the client was placed in traction. Which type of bath should the nurse provide for this client?

1. Complete bath 2. Therapeutic bath 3. Partial bath 4. Commercial product bath Correct Answer: 3 Rationale 1: A complete bath is when the nurse bathes all areas of the body, which would not be necessary with a healthy young adult.

Rationale 2: A therapeutic bath is used as part of a treatment regimen for specific conditions, such as skin disorders, burns, high body temperature, and muscular injuries.

Rationale 3: In a partial bath, the face, axilla, hands, back, and genital area are bathed; or the areas the client cannot reach.

Rationale 4: A commercial product bath is a bath using no-rinse solution, which would not be necessary for this client because there is available water and bathing products.

Global Rationale: In a partial bath, the face, axilla, hands, back, and genital area are bathed; or the areas the client cannot reach. A complete bath is when the nurse bathes all areas of the body, which would not be necessary with a healthy young adult. A therapeutic bath is used as part of a treatment regimen for specific conditions, such as skin disorders, burns, high body temperature, and muscular injuries. A commercial product bath is a bath using no-rinse solution, which would not be necessary for this client because there is available water and bathing products.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.B.3. Provide client-centered care with sensitivity and respect for the diversity of human experience AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8.4 Differentiate between bathing a bedridden client and a critically ill client.

Page Number: p. 183 5. The nurse prepares to delegate bathing a client to unlicensed assistive personnel (UAP). Which actions are appropriate prior to delegating this task to the UAP? Standard Text: Select all that apply.

1. Informing the UAP what type of bath is appropriate 2. Describing precautions specific to the needs of the client 3. Telling the UAP who to notify if there are any concerns 4. Informing the UAP to encourage the client to perform as much self-care as appropriate 5. Having the UAP document the bathing experience for the nurse to read later Correct Answer: 1, 2, 4 Rationale 1: The nurse would inform the UAP what type of bath is appropriate for the client.

Rationale 2: The nurse would inform the UAP what precautions are appropriate for that specific client's needs.

Rationale 3: The nurse does not need to tell the UAP to whom to report concerns, because they should be reported to the nurse.

Rationale 4: Although it is often faster to perform the entire bath without encouraging client participation, the UAP should take the time needed and encourage the client to perform as much self-care as possible to promote the client's autonomy.

Rationale 5: The nurse should instruct the UAP to report about the bathing experience as soon as it is completed, and the nurse would not wait to read the UAP's documentation.

Global Rationale: The nurse would inform the UAP what type of bath and what precautions are appropriate for that specific client's needs. Although it is often faster to perform the entire bath without encouraging client participation, the UAP should take the time needed and encourage the client to perform as much self-care as possible to promote the client's autonomy. The nurse does not need to tell the UAP to whom to report concerns, because they should be reported to the nurse. The nurse should instruct the UAP to report about the bathing experience as soon as it is completed, and the nurse would not wait to read the UAP's documentation.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Practice; Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 8.3 Outline the steps in bathing a bedridden adult client.

Page Number: p. 215 6. The nurse is caring for a client who is on bed rest with bathroom privileges. While the client is in the bathroom, the nurse changes the client's bed and should make the bed in what way?

1. Unoccupied open bed 2. Occupied open bed 3. Unoccupied closed bed 4. Surgical bed Correct Answer: 1 Rationale 1: The bed is unoccupied, and the nurse would make an open bed, with the top sheets folded back, so the bed is ready for the client to return to.

Rationale 2: An occupied bed would be used if the client were unable to get out of bed.

Rationale 3: A closed bed is made with the top covers over the entire bed to keep the bed clean when not in use.

Rationale 4: A surgical bed would be made using extra materials in preparation for the returning postoperative client.

Global Rationale: The bed is unoccupied, and the nurse would make an open bed, with the top sheets folded back, so the bed is ready for the client to return to. An occupied bed would be used if the client were unable to get out of bed. A closed bed is made with the top covers over the entire bed to keep the bed clean when not in use. A surgical bed would be made using extra materials in preparation for the returning postoperative client.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: II.B.3. Base individualized care plan on client values, clinical expertise, and evidence AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice,

and research NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.1 Compare and contrast the steps in making an occupied and unoccupied bed.

Page Number: p. 186 7. When delegating bed-making to unlicensed assistive personnel (UAP), on which items should the nurse instruct the UAP? Standard Text: Select all that apply.

1. Proper disposal of linens that contain drainage 2. What tubes or dressings the client might have 3. How to make hospital corners 4. Whom to inform if they notice anything unusual 5. Placing the call bell in a specific location for a client with mobility concerns Correct Answer: 1, 2, 5 Rationale 1: The nurse should instruct the UAP on how to dispose of linens that contain drainage.

Rationale 2: The nurse should inform the UAP of any tubes or dressings the client may have in place.

Rationale 3: The nurse should not have to teach the UAP how to make a bed, because the UAP should be familiar with the procedure.

Rationale 4: There is no need to inform the UAP whom to notify because the UAP should inform the nurse if anything unusual occurs.

Rationale 5: The nurse should instruct the UAP on the importance of placing the call bell in a specific location for a client with mobility concerns.

Global Rationale: The nurse should instruct the UAP on how to dispose of linens that contain drainage, and should inform the UAP of any tubes or dressings the client may have in place and the importance of placing the call bell in a specific location for a client with mobility concerns. The nurse should not have to teach the UAP how to make a bed, because the UAP should be familiar with the procedure. There is no need to inform the UAP whom to notify because the UAP should inform the nurse if anything unusual occurs.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members ACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Practice; Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.1 Compare and contrast the steps in making an occupied and unoccupied bed.

Page Number: p. 187 8. The nurse is making beds on the medical–surgical unit. What should the nurse do differently when making a surgical bed versus an open unoccupied bed?

Standard Text: Select all that apply.

1. Strip the bed.

2. Do not tuck, miter, or toe-pleat the top covers. e TbBe.dC.OM 3. Fold top sheets into a triangle at the s i Nd Ue RoSf ItNhG 4. Place pillows on the chair beside the bed.

5. Raise the bed to a comfortable working height.

Correct Answer: 2, 3, 4 Rationale 1: The old linen should be stripped prior to making the fresh bed.

Rationale 2: When making a surgical bed, the top covers would not be tucked, mitered, or pleated.

Rationale 3: When making a surgical bed, the top covers should be folded to the side of the bed, forming a triangle so the bed is prepared for the client to slide from the stretcher to the bed.

Rationale 4: Pillows are removed from the bed and placed in the chair at the side of the bed because they will be in the way when the client is transferred from the stretcher.

Rationale 5: The bed should always be raised to a comfortable working height to avoid back strain for the nurse when making a bed.

Global Rationale: When making a surgical bed, the top covers would not be tucked, mitered, or pleated, but rather folded to the side of the bed, forming a triangle, so the bed is prepared for the

client to slide from the stretcher to the bed. Pillows are removed from the bed and placed in the chair at the side of the bed because they will be in the way when the client is transferred from the stretcher. The bed should always be raised to a comfortable working height to avoid back strain for the nurse when making a bed, and the old linen should be stripped prior to making the fresh bed.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge: Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.1 Compare and contrast the steps in making an occupied and unoccupied bed.

Page Number: p. 186 9. Which explanation is the most accurate when describing PM care to a client?

1. Providing for elimination needs, washing face and hands, giving oral care, and possibly a back massage.

2. Providing care when the client awakens to include providing urinal or bedpan, washing of face and hands, and giving oral care 3. Providing care that includes elimination needs, a bath or shower, perineal care, and oral, nail, and hair care.

4. Providing care required by the client such as changing of linen and clothes when they become soiled.

Correct Answer: 1 Rationale 1: Providing for elimination needs, washing face and hands, giving oral care, and possibly a back massage occur during PM care.

Rationale 2: Providing care when the client awakens to include providing urinal or bedpan, washing of face and hands, and giving oral care describes early morning care.

Rationale 3: Providing care that includes elimination needs, a bath or shower, perineal care, and oral, nail, and hair care describes morning care.

Rationale 4: Providing care required by the client such as changing of linen and clothes when they become soiled describes as-needed (prn) care.

Global Rationale: Providing for elimination needs, washing face and hands, giving oral care, and possibly a back massage occur during PM care. Providing care when the client awakens to include providing urinal or bedpan, washing of face and hands, and giving oral care describes early morning care.

Providing care that includes elimination needs, a bath or shower, perineal care, and oral, nail, and hair care describes morning care. Providing care required by the client such as changing of linen and clothes when they become soiled describes as-needed (pm) care.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B.3. Provide client-centered care with sensitivity and respect for the diversity of human experience AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 8.8 Outline the steps in providing morning care.

Page Number: p. 194 10. Routine hygienic care has been provided to 1 client, with no abnormal findings assessed. What should the nurse document in the medical record?

1. Foot care 2. Hair care 3. Removal or insertion of a hearing aid 4. Type of bath provided and client's ability to provide self-care Correct Answer: 4 Rationale 1: Foot care usually is not documented unless there are unexpected assessment findings.

Rationale 2: Hair care is not documented unless there are unexpected assessment findings.

Rationale 3: Removal or insertion of a hearing aid usually is not documented unless there are unexpected assessment findings.

Rationale 4: The nurse would document what type of bath was provided to the client and the client's ability to assist or provide self-care.

Global Rationale: The nurse would document what type of bath was provided to the client and the client's ability to assist or provide self-care. Foot care, hair care, and removal or insertion of a hearing aid usually is not documented unless there are unexpected assessment findings.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: VI.B.4. Document and plan client care in an electronic health record AACN Essential Competencies: IV.5. Use standardized terminology in a care environment that reflects nursing’s unique contribution to client outcomes NLN Competencies: Quality and Safety: Practice; Carefully maintain and use electronic and/or written health records Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.14 Complete client charting for morning and evening care on nurses’ notes.

Page Number: p. 202 11. The nurse delegates the making of an occupied bed to unlicensed assistive personnel (UAP). Which statement made by the UAP indicates the need for further instruction prior to this assignment?

1. "I will be sure to inform you of any wound drainage."

2. "I will inform you if any of the client’s tubes are loose."

3. "I will assess the client’s IV tubing."

4. "I will inform you of any problems."

Correct Answer: 3 Rationale 1: Although the UAP cannot assess the client, it is appropriate for the UAP to inform the nurse if there is any wound drainage.

Rationale 2: It is appropriate for the UAP to inform the nurse if the client has any loose tubes.

Rationale 3: The UAP cannot assess the client’s IV tubing. This is outside the scope of practice for the UAP. Rationale 4: It is expected that the UAP will inform the nurse of any problems that occur during the task that is delegated.

Global Rationale: The UAP cannot assess the client’s IV tubing. This is outside the scope of practice for the UAP. Although the UAP cannot assess the client, it is appropriate for the UAP to inform the nurse if there is any wound drainage or if any tubes are loose. It is expected that the UAP will inform the nurse of any problems that occur during the task that is delegated.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members ACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Practice; Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.1 Compare and contrast the steps in making an occupied and unoccupied bed.

Page Number: p. 185 12. The nurse is preparing to bathe clients assigned for the shift. Which client should the nurse wear gloves to bathe?

1. The client diagnosed with HIV/AIDS 2. The newborn just admitted from the delivery room 3. The client with psoriasis 4. The postoperative client Correct Answer: 2 Rationale 1: The client with HIV/AIDS would not require the nurse to wear gloves unless there was bleeding or drainage from open wounds.

Rationale 2: The nurse should wear gloves when bathing the newborn just admitted from the delivery room because of the high likelihood of blood and body fluids found on the baby.

Rationale 3: The client with psoriasis would not require the nurse to wear gloves unless there was bleeding or drainage from open wounds.

Rationale 4: The nurse would not need to wear gloves to bathe a postoperative client unless there was bleeding or drainage from open wounds.

Global Rationale: The nurse should wear gloves when bathing the newborn just admitted from the delivery room because of the high likelihood of blood and body fluids found on the baby.

The client with HIV/AIDS or psoriasis, or the postoperative client, would not require the nurse to wear gloves unless there was bleeding or drainage from open wounds.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.5 Compare and contrast the differences in bathing an infant, a child, and an adult client.

Page Number: p. 200 13. The nurse is reviewing bed making with newly hired unlicensed assistive personnel (UAP). What should the nurse explain as the reason for mitering the corners of the bed linen?

1. Keeps the bed linens tight 2. Helps the client stay in bed 3. Makes raising the side rails easier 4. Prevents the mattress from moving Correct answer: 1 Rationale 1: Mitered corners keep bed linens tight and wrinkle-free.

Rationale 2: Mitered corners are not used to help keep the client in bed.

SI NG T B .C O M Rationale 3: Mitered corners are not u s e dN Ut oR m a k e r a i s i n g the side rails easier. Rationale 4:

Mitered corners do not prevent the mattress from moving.

Global Rationale: Mitered corners keep bed linens tight and wrinkle-free. Mitered corners are not used to help keep the clients in bed, make raising the side rails easier, or prevent the mattress from moving.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members ACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Practice; Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.2 Demonstrate the skill of folding a mitered corner. Page Number: p.

186 14. The nurse notes that a client has extremely dry skin. How should the nurse document this finding?

1. Pallor

2. Cyanosis 3. Xeroderma 4. Poor skin turgor Correct answer: 3 Rationale 1: Skin that is pale in color would be documented as pallor. Rationale 2: Skin that is bluish in color would be documented as cyanosis. Rationale 3: Xeroderma is extremely dry skin.

Rationale 4: Skin that does not return to the original position when pinched is described as poor skin turgor.

Global Rationale: Xeroderma is extremely dry skin. Skin that is pale in color would be documented as pallor. Skin that is bluish in color would be documented as cyanosis. Skin that does not return to the original position when pinched is described as poor skin turgor.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: IV.B. 4. Document and plan patient care in an electronic health record AACN Essential Competencies: IX. 1. NCUoRnSdIuNcGt Tc Bo .mC pO rMe h e n s i v e and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Knowledge; Functionality of clinical and financial systems (data entry, documentation, data retrieval); interoperability of systems Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.9 Describe the skin assessment steps that must be completed on a daily basis.

Page Number: p. 204 15. A critically ill client needs to be repositioned in bed. Which action will help prevent tearing this client’s skin?

1. Sliding with a lift sheet 2. Raising the foot of the bed 3. Pulling to one side of the bed 4. Pulling up from the head of the bed Correct Answer: 1 Rationale 1: Using a lift sheet when moving clients at risk for developing skin tears helps prevent tears resulting from friction or shearing.

Rationale 2: Raising the foot of the bed could cause shearing when moving up in bed.

Rationale 3: Pulling the client to one side of the bed could cause skin tears. Rationale 4: Pulling the client up from the head of the bed could cause skin tears.

Global Rationale: Using a lift sheet when moving clients at risk for developing skin tears helps prevent tears resulting from friction or shearing. Raising the foot of the bed could cause shearing when moving up in bed. Pulling the client to one side of the bed could cause skin tears. Pulling the client up from the head of the bed could cause skin tears.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.11 Describe the changes in skin that occur with aging and appropriate nursing N U RSINGT B.COM interventions to prevent a skin tear.

Page Number: p. 208 16. The nurse is completing evening care for a client. What should the nurse do before documenting that this care has been completed?

1. Straighten top linens 2. Raise upper side rails 3. Remove any unnecessary equipment 4. Fluff pillow and turn cool side next to client Correct Answer: 2 Rationale 1: The top linens should be straightened after assisting the client with bathing.

Rationale 2: The upper side rails should be raised before documenting the care has been provided.

Rationale 3: Unnecessary equipment should be removed after bathing the client.

Rationale 4: The pillow should be fluffed and turned with the cool side to the client after bathing.

Global Rationale: The upper side rails should be raised before documenting the care has been provided. The top linens should be straightened after assisting the client with bathing.

Unnecessary equipment should be removed after bathing the client. The pillow should be fluffed and turned with the cool side to the client after bathing.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.12 Describe briefly the components of evening care. Page Number: p. 212 17. The nurse decides to use tapotement when providing a client with an evening back rub. What should the nurse keep in mind when using this massage stroke?

1. Avoid the kidney area 2. Use a continuous motion 3. Maintain constant skin contact 4. Focus on the shoulders and along back Correct Answer: 1 Rationale 1: The tapotement stroke stimulates the skin as the hands move up and down the back. The kidney area should be avoided.

Rationale 2: A continuous motion is used with the effleurage stroke.

Rationale 3: Constant skin contact occurs when moving hands in figure-eight motion from shoulder to buttocks and back.

Rationale 4: The petrissage, or kneading stroke, is issued over the shoulders and along back.

Global Rationale: The tapotement stroke stimulates the skin as the hands move up and down the back.

The kidney area should be avoided. A continuous motion is used with the effleurage stroke. Constant skin contact occurs when moving hands in figure-eight motion from shoulder to buttocks and back. The petrissage, or kneading stroke, is issued over the shoulders and along back.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.13 Define the three back care strokes and their use in back care. Page Number: p. 213

CHAPTER 9 1. The nurse is preparing to brush a client’s teeth. Which technique should the nurse use?

1. Gum line 2. Xerostomia 3. Gingivitis 4. Pyorrhea Correct Answer: 1 Rationale 1: The gum line technique aims the toothbrush at an angle toward the gums, and is recommended as the best means of brushing the client's teeth.

Rationale 2: Xerostomia is the term for dry mouth, and there is no technique associated with it.

Rationale 3: Gingivitis is a form of periodontal disease causing red swollen gingiva.

Rationale 4: Pyorrhea is loose teeth and pus that is evident when the gums are pressed.

Global Rationale: The gum line technique aimsatthaentaonogt hleb tr ou w s ha r d the gums, and is recommended as the best means of brushing the client's teeth. Xerostomia is the term for dry mouth, and there is no technique associated with it. Gingivitis is a form of periodontal disease causing red swollen gingiva. Pyorrhea is loose teeth and pus that is evident when the gums are pressed.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: II.B.3. Base individualized care plan on client values, clinical expertise, and evidence AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.1 Discuss oral hygiene needs of clients.

Page Number: p. 223 2. The nurse is caring for a client who feels like something is crawling through the hair. The client also has small, white dandruff-like particles along the hairline. Which term should the nurse use when documenting this client’s health problem?

1. Alopecia 2. Hirsutism 3. Pediculosis 4. Scabies Correct Answer: 3 Rationale 1: Alopecia is hair loss.

Rationale 2: Hirsutism is abnormal hair growth.

Rationale 3: Pediculosis is commonly known as lice.

Rationale 4: Scabies is a contagious skin infection caused by mites.

Global Rationale: Pediculosis is commonly known as lice. Alopecia is hair loss. Hirsutism is abnormal hair growth. Scabies is a contagious skin infection caused by mites.

Cognitive Level: Applying Client Need: Physiological Integrity N U RSINGTB.COM Client Need Sub: Basic Care and C o m fo r t QSEN Competencies: II.B.3. Base individualized care plan on client values, clinical expertise, and evidence AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.7 Describe procedure for removing lice and nits from hair and other body areas.

Page Number: p. 233 3. The nurse is caring for a female client. In which order should the nurse complete perineal- genital care?

Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list.

Response 1. Apply gloves.

Response 2. Wipe from the pubis to the rectum.

Response 3. Place a towel under the client's hips.

Response 4. Clean the labia minora.

Response 5. Position and drape the client.

Correct Answer: 5, 3, 1, 4, 2 Rationale 1: The female client should be positioned in a back-lying position with the knees flexed and spread well apart. Cover the body and legs with the bath blanket to minimize exposure. A towel is then placed under the client's hip to protect the bed. Apply gloves and clean the labia majora, then open the labia to clean the labia minora using separate quarters of the washcloth for each stroke. After cleaning the genitalia, wipe from the pubis to the rectum in order to avoid bringing bacteria from the rectum toward the urethra, which could result in a urinary tract infection.

Rationale 2: The female client should be positioned in a back-lying position with the knees flexed and spread well apart. Cover the body and legs with the bath blanket to minimize exposure. A towel is then placed under the client's hip to protect the bed. Apply gloves and clean the labia majora, then open the labia to clean the labia minora using separate quarters of the washcloth for each stroke. After cleaning the genitalia, wipe from the pubis to the rectum in order to avoid bringing bacteria from the rectum toward the urethra, which could result in a urinary tract infection.

Rationale 3: The female client should be positioned in a back-lying position with the knees flexed and spread well apart. Cover the bNoUdRySaINndGTleBg.Cs OwMi t h the bath blanket to minimize exposure. A towel is then placed under the client's hip to protect the bed. Apply gloves and clean the labia majora, then open the labia to clean the labia minora using separate quarters of the washcloth for each stroke. After cleaning the genitalia, wipe from the pubis to the rectum in order to avoid bringing bacteria from the rectum toward the urethra, which could result in a urinary tract infection.

Rationale 4: The female client should be positioned in a back-lying position with the knees flexed and spread well apart. Cover the body and legs with the bath blanket to minimize exposure. A towel is then placed under the client's hip to protect the bed. Apply gloves and clean the labia majora, then open the labia to clean the labia minora using separate quarters of the washcloth for each stroke. After cleaning the genitalia, wipe from the pubis to the rectum in order to avoid bringing bacteria from the rectum toward the urethra, which could result in a urinary tract infection.

Rationale 5: The female client should be positioned in a back-lying position with the knees flexed and spread well apart. Cover the body and legs with the bath blanket to minimize exposure. A towel is then placed under the client's hip to protect the bed. Apply gloves and clean the labia majora, then open the labia to clean the labia minora using separate quarters of the washcloth for each stroke. After cleaning the genitalia, wipe from the pubis to the rectum in order to avoid bringing bacteria from the rectum toward the urethra, which could result in a urinary tract infection.

Global Rationale: The female client should be positioned in a back-lying position with the knees flexed and spread well apart. Cover the body and legs with the bath blanket to minimize exposure. A towel is then placed under the client's hip to protect the bed. Apply gloves and clean the labia majora, then open the labia to clean the labia minora using separate quarters of the washcloth for each stroke. After cleaning the genitalia, wipe from the pubis to the rectum in order to avoid bringing bacteria from the rectum toward the urethra, which could result in a urinary tract infection.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.11 Describe the steps in providing perineal care for male and female clients.

Page Number: p. 242 4. The nurse is using a disposable system to wash a client’s hair. What should the nurse do before using the system?

1. Heat the package in the microwave 2. Apply gloves 3. Place cap on the client’s head 4. Rinse the hair with water Correct Answer: 1 Rationale 1: Heat shampoo package in microwave for no more than 30 seconds.

Rationale 2: Gloves are applied after the package is heated in the microwave.

Rationale 3: The cap is placed on the client’s head after being microwaved. Rationale 4: With a disposable system wetting the hair with water is not done.

Global Rationale: Heat shampoo package in microwave for no more than 30 seconds. Gloves are applied after the package is heated in the microwave. The cap is placed on the client’s head after being microwaved. With a disposable system wetting the hair with water is not done.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.5 Identify the appropriate method of hair care according to client’s condition.

Page Number: p. 231 5. What would the nurse document after providing hair care to the client?

1. Number of times the hair was combed or brushed throughout the shift 2. Type of brush used to provide hair care 3. Abnormal assessment findings 4. Routine nursing interventions Correct Answer: 3 Rationale 1: Generally, daily combing and brushing of the hair are not recorded.

Rationale 2: The type of brushed used to provide hair care is not documented.

Rationale 3: The nurse should document any abnormal or unusual findings during assessment.

Rationale 4: Routine nursing interventions do not need to be recorded.

Global Rationale: The nurse should document any abnormal or unusual findings during assessment.

Generally, daily combing and brushing of the hair are not recorded. The type of brushed used to provide hair care is not documented. Routine nursing interventions do not need to be recorded.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: VI.B.4. Document and plan client care in an electronic health record AACN Essential Competencies: IV.5. Use standardized terminology in a care environment that reflects nursing’s unique contribution to client outcomes NLN Competencies: Quality and Safety: Practice; Carefully maintain and use electronic and/or written health records

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.5 Identify the appropriate method of hair care according to client’s condition.

Page Number: p. 229 6. The nurse is caring for a client who is unconscious. In which order should the nurse provide oral care to this client?

Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list.

Response 1. Prepare the client by positioning in a side-lying position with the head of the bed lowered.

Response 2. Clean the teeth and rinse the mouth. Brush the teeth gently to prevent irritating the gums.

Response 3. Ensure client comfort and document procedure per policy.

Response 4. Perform hand hygiene and observe other appropriate infection control procedures.

Response 5. Place a towel under the client's chin. Place the curved basin against the client's chin and lower cheek to collect fluid.

Correct Answer: 4, 1, 5, 2, 3 Rationale 1: The second step of providing oral care for an unconscious client is to position the client in a side-lying position with the head of the bed lowered.

Rationale 2: The fourth step in providing oral care for an unconscious client is to clean the teeth and rinse the mouth. The nurse will gently brush the teeth to prevent irritating the gums.

Rationale 3: Ensuring client comfort and documenting the procedure, per policy, is the final step.

Rationale 4: The first step is to perform hand hygiene and observe other appropriate infection control procedures.

Rationale 5: The third step is to place a towel and the curved basin under the client’s chin and lower cheek to collect fluid.

Global Rationale: The first step is to perform hand hygiene and observe other appropriate infection control procedures. The second step of providing oral care for an unconscious client is to position the client in a side-lying position with the head of the bed lowered. The third step is to place a towel and the curved basin under the client’s chin and lower cheek to collect fluid. The fourth step in providing oral care for an unconscious client is to clean the teeth and rinse the

mouth. The nurse will gently brush the teeth to prevent irritating the gums. Ensuring client comfort and documenting the procedure, per policy, is the final step.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.4 Demonstrate safety awareness when providing oral care for unconscious clients.

Page Number: p. 226 7. The nurse is caring for a client with a hearing aid. In which order should the nurse care for this hearing device?

Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list.

Response 1. Perform hand hygiene and w eaRrSaINppGrToBp.rCiOatM e personal protective equipment.

NU Response 2. Wipe the casing with dry cloth.

Response 3. Check the batteries.

Response 4. Cleanse the outer ear gently with a cotton-tipped applicator.

Response 5. Determine ability of client to perform all or part of cleaning procedure.

Response 6. Insert ear mold and turn the switch to ON. Correct Answer: 5, 1, 2, 3, 4, 6 Rationale 1: Performing hand hygiene and wearing appropriate personal protective equipment is the second step.

Rationale 2: Wiping the casing with a dry cloth is the third step.

Rationale 3: Checking the batteries is the fourth step.

Rationale 4: Cleansing the outer ear with a cotton-tipped applicator is the fifth step.

Rationale 5: Determine ability of client to perform all or part of cleaning procedure is the first step.

Rationale 6: Inserting the ear mold and turning the switch to ON is the final step.

Global Rationale: Determine ability of client to perform all or part of cleaning procedure is the first step.

Performing hand hygiene and wearing appropriate personal protective equipment is the second step.

Wiping the casing with a dry cloth is the third step. Checking the batteries is the fourth step. Cleansing the outer ear with a cotton-tipped applicator is the fifth step. Inserting the ear mold and turning the switch to ON is the final step.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.13 State two suggested solutions when hearing is not improved after cleaning a hearing aid.

Page Number: p. 248 8. A client asks for help with combing the hair. In which order should the nurse assist this client?

Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list.

Response 1. Brush or comb client’s hair from scalp to hair ends, using gentle, even strokes.

Response 2. Place all hair care items within reach.

Response 3. Place towel over client’s shoulders.

Response 4. Replace hair care items in appropriate place and clean items as needed.

Response 5. Style hair in a manner suitable to client.

Correct Answer: 2, 3, 1, 5, 4 Rationale 1: Brush or comb client’s hair from scalp to hair ends, using gentle, even strokes is the third step.

Rationale 2: Placing all hair care items within reach is the first step.

Rationale 3: Placing towel over client’s shoulders is the second step.

Rationale 4: Replace hair care items in appropriate place and clean items as needed is the final step.

Rationale 5: Styling the hair in a manner suitable to client is the fourth step.

Global Rationale: Placing all hair care items within reach is the first step. Placing towel over client’s shoulders is the second step. Brushing or comb client’s hair from scalp to hair ends, using gentle, even strokes is the third step. Styling the hair in a manner suitable to client is the fourth step. Replace hair care items in appropriate place and clean items as needed is the final step.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.5 Identify the appropriate method of hair care according to client’s condition.

Page Number: p. 230 9. The nurse is helping a client with teeth flossing. What should the nurse instruct the client to do with the dental floss?

1. Wrap the length of dental floss around the wrist 2. Make a knot at the end of a length of dental floss 3. Weave the dental floss between the upper row of teeth 4. Wrap one length of floss loosely around index fingers of both hands Correct Answer: 4 Rationale 1: The dental floss is not wrapped around the wrist. Rationale 2: Knots are not tied in the dental floss.

Rationale 3: The dental floss is not woven between the teeth.

Rationale 4: The dental floss should be wrapped loosely around the index fingers of both hands.

Global Rationale: The dental floss should be wrapped loosely around the index fingers of both hands. The dental floss is not wrapped around the wrist. Knots are not tied in the dental floss. The dental floss is not woven between the teeth.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 9.2 Outline the procedure for flossing teeth.

Page Number: p. 225 10. The nurse is preparing to cleanse a client’s denture. Which action should the nurse take to prevent damaging the dentures?

1. Using hot water 2. Placing a towel in the sink 3. Cleansing them at the bedside 4. Rinsing them with mouthwash Correct Answer: 2 Rationale 1: Hot water can damage the denture mold.

Rationale 2: Placing a towel or washcloth on the bottom of the sink cushions the surface in case a denture is accidentally dropped.

Rationale 3: Cleansing the dentures at the bedside will not prevent them from being accidentally damaged.

Rationale 4: Dentures should be rinsed with cool water.

Global Rationale: Placing a towel or washcloth on the bottom of the sink cushions the surface in case a denture is accidentally dropped. Hot water can damage the denture mold. Cleansing the dentures at the bedside will not prevent them from being accidentally damaged. Dentures should be rinsed with cool water.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9.3 Compare and contrast oral hygiene for clients with natural teeth and dentures.

Page Number: p. 225 11. A male client asks if someone can help him shave. What should the nurse do first before preparing to help this client?

1. Wash hands 2. Obtain a shaving kit 3. Apply a gown and gloves 4. Check prescribed medications Correct Answer: Rationale 1: Hands should be washed before beginning the procedure.

Rationale 2: A shaving kit may or may not be able to be used.

Rationale 3: The nurse does not need a gown to shave the client. Gloves should be worn.

Rationale 4: The nurse should check to see if the client is taking anticoagulants or large doses of aspirin because if client is accidentally cut, it could lead to some loss of blood.

Global Rationale: The nurse should check to see if the client is taking anticoagulants or large doses of aspirin because if client is a cc i dNe Un tRaSl lI yN Gc uTtB, .iCt OcoMuld lead to some loss of blood. Hands should be washed before beginning the procedure. A shaving kit may or may not be able to be used. The nurse does not need a gown to shave the client. Gloves should be worn.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9.6 Outline the steps for shaving a male client. Page Number: p.

231 12. While applying a treatment for head lice the client complains that the scalp is stinging. What should the nurse do first?

1. Comb the hair 2. Wrap the head with a towel 3. Stop applying the medication 4. Contact the Poison Control Center

Correct Answer: 3 Rationale 1: Combing the hair could make the scalp irritation worse.

Rationale 2: Wrapping the head with a towel could make the scalp irritation worse. Rationale 3: The treatment should be stopped if the client complains of scalp irritation.

Rationale 4: The Poison Control Center should be contacted however the treatment should be stopped first.

Global Rationale: The treatment should be stopped if the client complains of scalp irritation. Combing the hair could make the scalp irritation worse. Wrapping the head with a towel could make the scalp irritation worse. The Poison Control Center should be contacted however the treatment should be stopped first.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and SafetyN: UKRnSoI NwGleTdBg. eC;OCMurren t best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.8 State some of the cautions that apply when using solutions that treat pediculosis.

Page Number: p. 235 13. A client treated for head lice a week ago continues to complain of scalp itching. There is evidence of nits along the shafts of the hair. What should the nurse do first?

1. Wash the client’s comb and brush 2. Obtain an order for medicated shampoo 3. Vigorously brush the client’s hair over a sink 4. Washing the client’s hair and apply conditioner Correct Answer: 2 Rationale 1: The client’s comb and brush can be washed at any time.

Rationale 2: The treatment cannot be repeated unless specifically ordered by the physician. Rationale 3: Brushing the hair will not remove the nits.

Rationale 4: Conditioner should not be applied to hair that may be treated with medicated shampoo to treat lice.

Global Rationale: The treatment cannot be repeated unless specifically ordered by the physician. The client’s comb and brush can be washed at any time. Brushing the hair will not remove the nits. Conditioner should not be applied to hair that may be treated with medicated shampoo to treat lice.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.8 State some of the cautions that apply when using solutions that treat pediculosis.

Page Number: p. 236 14. A client who has difficulty raising the hips needs to urinate. What should the nurse do?

1. Use a fracture pan 2. Raise the head of the bed 3. Ambulate to the bathroom 4. Call for a bedside commode Correct Answer: 1 Rationale 1: If a client has difficulty raising the hips, use a fracture pan.

Rationale 2: Raising the head of the bed will not help place a bedpan under this client.

Rationale 3: A client who has difficulty raising the hips may not be able to safely ambulate to the bathroom.

Rationale 4: The client might not be able to wait for a bedside commode to arrive.

Global Rationale: If a client has difficulty raising the hips, use a fracture pan. Raising the head of the bed will not help place a bedpan under this client. A client who has difficulty raising the hips may not be able to safely ambulate to the bathroom. The client might not be able to wait for a bedside commode to arrive.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as

appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.10 Demonstrate the skill of placing a bedpan for a bedridden client.

Page Number: p. 240 15. The nurse is providing perineal care to a male client. Which action ensures that crosscontamination does not occur?

1. Wring washcloth out 2. Use a clean washcloth for each motion 3. Cleanse from the shaft to the tip of the penis 4. Begin cleansing from the scrotum to the shaft Correct Answer: 2 Rationale 1: Wringing the washcloth out prevents the protective pad from getting too wet.

Rationale 2: Not washing over an area without using a new washcloth or disposable cloth prevents crosscontamination.

Rationale 3: Cleansing should start at the tip of the penis and work towards the shaft. Rationale 4: The scrotum is cleansed afteNrUt RheSIpNeGnTisB.iCs Oc M leans ed.

Global Rationale: Not washing over an area without using a new washcloth or disposable cloth prevents cross-contamination. Not washing over an area without using a new washcloth or disposable cloth prevents cross-contamination. Cleansing should start at the tip of the penis and work towards the shaft.

The scrotum is cleansed after the penis is cleansed.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.11 Describe the steps in providing perineal care for male and female clients.

Page Number: p. 243 16. The family of a client who is comatose asks why there are eye patches over the client’s eyes. What should the nurse respond to the family?

1. “They prevent the eyes from drying out.”

2. “They reduce the glare caused by the room lights.”

3. “They reduce the amount of stimulation the client receives.”

4. “They are used to keep eye medication in contact with the eyes.”

Correct Answer: 1 Rationale 1: Corneal abrasions can occur in a client who has lost the blink reflex. Eye patches will prevent the eyes from drying out causing corneal abrasions.

Rationale 2: Eye patches are not used to reduce glare from room lighting. Rationale 3: Eye patches are not used to reduce stimulation through the eyes.

Rationale 4: Eye patches are not used to keep eye medication in contact with the eyes.

Global Rationale: Corneal abrasions can occur in a client who has lost the blink reflex. Eye patches will prevent the eyes from drying out causing corneal abrasions. Eye patches are not used to reduce glare from room lighting, reduce stimulation through the eyes, or to keep eye medication in contact with the eyes.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.5. Explain tNhUeRrSoIlNe GoTf Be .vCi Od eMn c e in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 9.12 Describe nursing actions necessary to care for clients with contact lenses.

Page Number: p. 247 17. A client who wears soft contact lenses is experiencing eye pain and excessive tearing. What should the nurse suspect is occurring with this client?

1. Corneal ulcers 3. Dry contact lenses 4. Corneal abrasions 2. Lacrimal duct infection Correct Answer: Rationale 1: Corneal ulcers are infection-caused eruptions on the cornea that can lead to blindness.

Symptoms include visual changes, eye redness, eye discomfort or pain, and excessive tearing.

Rationale 2: Dry contact lenses can cause corneal ulcers.

Rationale 3: Corneal abrasions are likely to occur when the blink reflex is lost.

Rationale 4: There is no information to suggest that the client has an infection of the lacrimal ducts.

Global Rationale: Corneal ulcers are infection-caused eruptions on the cornea that can lead to blindness.

Symptoms include visual changes, eye redness, eye discomfort or pain, and excessive tearing. Dry contact lenses can cause corneal ulcers. Corneal abrasions are likely to occur when the blink reflex is lost. There is no information to suggest that the client has an infection of the lacrimal ducts.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.12 Describe nursing actions necessary to care for clients with contact lenses.

Page Number: p. 248

CHAPTER 10 1. A client has an elevated temperature. Which statement is the most clinically appropriate for the nurse to use when documenting this finding in the medical record?

1. The client is fever.

2. The client is febrile.

3. The client is hyperpyrexia.

4. The client is hyperthermia.

Correct Answer: 2 Rationale 1: The client has a fever.

Rationale 2: The client is febrile.

Rationale 3: The client has hyperpyrexia.

Rationale 4: The client has hyperthermia.

Global Rationale: The client is febrile. The client has a fever, hyperpyrexia, and hyperthermia.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: II.B.3. Base individualized care plan on client values, clinical expertise, and evidence AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.1 Identify the cardinal signs that reflect the body’s physiologic status.

Page Number: p. 258 2. A client in respiratory distress and has see-saw respirations with the chest and abdomen alternately rising, blue discoloration of the fingertips, and noisy difficult respirations. How should the nurse describe the client's condition when calling the health care provider?

1. Client is tachypneic with costal breathing and cyanosis.

2. Client is bradycardic with diaphragmatic breathing and cyanosis.

3. Client is demonstrating diaphragmatic breathing, and is dyspneic and cyanotic.

4. Client is demonstrating diaphragmatic breathing with audible Korotkoff's sounds.

Correct Answer: 3 Rationale 1: The client's respiratory rate is unknown, so it cannot be described as tachypneic.

Rationale 2: Bradycardia is a slow heart rate, and the client's pulse is unknown.

Rationale 3: The use of the abdominal muscles for respiration indicates diaphragmatic breathing. The difficult respirations would be described as dyspnea, and the blue discoloration of the fingertips is cyanosis.

Rationale 4: Korotkoff’s sounds are heard when measuring blood pressure.

Global Rationale: The use of the abdominal muscles for respiration indicates diaphragmatic breathing.

The difficult respirations would be described as dyspnea, and the blue discoloration of the fingertips is cyanosis. The client's respiratory rate is unknown, so it cannot be described as tachypneic. Bradycardia is a slow heart rate, and the client's pulse is unknown. Korotkoff’s sounds are heard when measuring blood pressure.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: II.B.3. Base individualized care plan on client values, clinical expertise, and evidence AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.1 Identify the cardinal signs that reflect the body’s physiologic status.

Page Number: p. 261 3. The nurse is informed during shift report that a client has a wide pulse pressure, is hypertensive, and has a pulse deficit. When the nurse enters the client's room, which assessments should the nurse perform in order to confirm this report?

1. Blood pressure and apical pulse assessments 2. Blood pressure and radial pulse assessment 3. Blood pressure and respiratory rate assessment

4. Blood pressure and radial-apical pulse assessment Correct Answer: 4 Rationale 1: In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulse rate, the nurse must perform an apical–radial pulse assessment. Wide pulse pressure and hypertension would be assessed by measuring blood pressure.

Rationale 2: In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulse rate, the nurse must perform an apical–radial pulse assessment. Wide pulse pressure and hypertension would be assessed by measuring blood pressure.

Rationale 3: In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulse rate, the nurse must perform an apical–radial pulse assessment. Wide pulse pressure and hypertension would be assessed by measuring blood pressure.

Rationale 4: In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulse rate, the nurse must perform an apical–radial pulse assessment. Wide pulse pressure and hypertension would be assessed by measuring blood pressure.

Global Rationale: In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulse rate, the nurse must perform an apical–radial pulse assessment. Wide pulse pressure and hypertension would be assessed by measuring blood pressure.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: II.B.3. Base individualized care plan on client values, clinical expertise, and evidence AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.8 Discuss the pulse, and indicate how it is an index of heart rate and rhythm.

Page Number: pp. 259, 261 4. When the nurse delegates measurement of vital signs to unlicensed assistive personnel (UAP), which are the nurse's responsibilities?

Standard Text: Select all that apply.

1. Assessment of vital sign readings obtained by UAP 2. Assessment of the UAP’s skills in measuring vital signs

3. Determination that the vital signs were obtained correctly 4. Follow up on vital sign measurements that are abnormal or unexpected 5. Observe the UAP as vital signs are being measured Correct Answer: 1, 2, 3, 4 Rationale 1: The nurse should review and assess all vital sign readings.

Rationale 2: The nurse should determine that the UAP is competent to perform any task delegated.

Rationale 3: The nurse should assess the UAP's competence while performing the task.

Rationale 4: If the UAP reports an unusual reading, the nurse should recheck the vital sign to determine that it is accurate before treating or responding to the reading.

Rationale 5: The nurse does not need to follow the UAP around once judged to be competent.

Global Rationale: Although the nurse can delegate the performance of tasks, the responsibility for those tasks is not delegated, and rests with the nurse. The nurse should review and assess all vital signs. The nurse should determine that the UAP is competent to perform any task delegated and should assess the UAP's U R SI N G T B .COM competen ceNw h i l e p e r fo rm ing the task. If the UAP reports an unusual reading, the nurse should recheck the vital sign to determine that it is accurate before treating or responding to the reading. The nurse does not need to follow the UAP around once judged to be competent.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Practice; Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10.15 Discuss conditions when vital signs may be delegated and when they would not be delegated.

Page Number: p. 293 5. The nurse delegates the measurement of vital signs on three clients to unlicensed assistive personnel (UAP). The nurse evaluates the UAP's performance and notes that blood pressure is measured on a client by having the client hold the arm hanging over the side of the bed. Which is the priority action by the nurse?

1. Commend the UAP for following the proper procedure.

2. Inform the charge nurse that the UAP does not know how to measure blood pressures.

3. Yell at the UAP and tell her she is incompetent.

4. Instruct the UAP that blood pressure should be measured with the artery at or above the level of the heart, and demonstrate correct technique.

Correct Answer: 4 Rationale 1: The nurse would not commend the UAP for proper technique, because blood pressure measurement performed with the artery lower than the heart will give a false reading.

Rationale 2: Telling the charge nurse transfers the responsibility held by the nurse delegating the procedure to another team member, and would not be the best choice.

Rationale 3: Yelling at a team member is never correct, and would be highly unprofessional.

Rationale 4: The nurse is responsible for teaching the UAP how to measure vital signs properly in a professional manner. Demonstrating proper technique is far more effective than just discussing it.

Global Rationale: The nurse is res po n s iNbUleRfSoI rN tGeTa Bch. CinOgMt h e UAP how to measure vital signs properly in a professional manner. Demonstrating proper technique is far more effective than just discussing it. The nurse would not commend the UAP for proper technique, because blood pressure measurement performed with the artery lower than the heart will give a false reading.

Telling the charge nurse transfers the responsibility held by the nurse delegating the procedure to another team member, and would not be the best choice. Yelling at a team member is never correct, and would be highly unprofessional.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.15 Discuss conditions when vital signs may be delegated and when they would not be delegated.

Page Number: p. 286 6. The nurse is preparing to measure a client’s temperature. Which factors could influence this measurement?

Standard Text: Select all that apply.

1. Smoking 2. Eating or drinking 3. Exercise 4. Perfusion 5. Time of day Correct Answer: 1, 2, 3, 5 Rationale 1: If the client has smoked a cigarette, the nurse should wait 15–30 minutes before measuring temperature because of the heat created in the oral cavity by the inhaled smoke.

Rationale 2: Eating or drinking will alter temperature readings, and the nurse should postpone temperature assessment 15–30 minutes after intake.

Rationale 3: The client who is exercising will have a slight elevation in temperature due to the heat produced by the muscles.

NG T B . CO M Rationale 4: Perfusion does not impact oNrUalR tSeI m p e ra t u re re adi n g s , because the sublingual area is a very vascular area that is not greatly impacted by reduced peripheral perfusion.

Rationale 5: Temperature readings have been shown to be lower in the morning than in the evening.

Global Rationale: If the client has smoked a cigarette, the nurse should wait 15–30 minutes before measuring temperature because of the heat created in the oral cavity by the inhaled smoke. Eating or drinking will alter temperature readings, and the nurse should postpone temperature assessment 15–30 minutes after intake. The client who is exercising will have a slight elevation in temperature due to the heat produced by the muscles. Perfusion does not impact oral temperature readings, because the sublingual area is a very vascular area that is not greatly impacted by reduced peripheral perfusion.

Temperature readings have been shown to be lower in the morning than in the evening.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment: Practice; Conduct population-based

transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10.5 Differentiate between the oral, rectal, axillary, and tympanic methods of taking temperature.

Page Number: pp. 266, 271 7. The nurse is caring for a client with a fever of 101.8°F oral. Which other vital signs should the nurse anticipate would be affected?

Standard Text: Select all that apply.

1. Pulse rate 2. Respiratory rate 3. Diastolic blood pressure 4. Systolic blood pressure 5. Oxygen saturation Correct Answer: 1, 2 Rationale 1: Pulse rate will increase with fever.

Rationale 2: Respiratory rate will increase with fever.

Rationale 3: Blood pressure is usually not significantly impacted by fever.

Rationale 4: Blood pressure is usually not significantly impacted by fever.

Rationale 5: The client's oxygen saturation might remain normal with a fever unless his respiratory status is compromised, and then the increased demand for oxygen could cause a drop in oxygen saturation.

Global Rationale: Pulse and respiratory rate will increase with fever. Blood pressure is usually not significantly impacted by fever. The client's oxygen saturation might remain normal with a fever unless his respiratory status is compromised, and then the increased demand for oxygen could cause a drop in oxygen saturation.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health

and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment: Practice; Conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.18 Discuss conditions when respiratory rate would be elevated or decreased.

Page Number: p. 258 8. A client's blood pressure us144/82 which is higher than the usual baseline which has been normal.

For what factors should the nurse assess the client based on the current blood pressure reading?

Standard Text: Select all that apply.

1. Diet 2. Medication history 3. Activity 4. History of recent symptoms of hypertension 5. Recent stress factors the client has expNeUriReSnIcNeGdTB.COM Correct Answer: 1, 2, 3, 5 Rationale 1: The client's diet should be assessed because foods high in sodium could elevate the systolic pressure mildly.

Rationale 2: The nurse should assess the client's medication history as this can impact blood pressure.

Rationale 3: The nurse should assess the client's activity as this can impact blood pressure.

Rationale 4: There is not likely to be a history of symptoms of hypertension, because borderline hypertension usually does not cause symptoms.

Rationale 5: The client's exposure to stress such as financial pressures and family issues can cause an elevation in systolic pressure.

Global Rationale: The client's diet should be assessed because foods high in sodium could elevate the systolic pressure mildly. The nurse should also assess the client's medication history and activity, as these can impact blood pressure. There is not likely to be a history of symptoms of hypertension, because borderline hypertension usually does not cause symptoms. The client's exposure to stress such as financial pressures and family issues can cause an elevation in systolic pressure.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment: Practice; Conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.13 Identify four of the seven factors that affect blood pressure.

Page Number: p. 2921 9. The nurse is reviewing a client's vital signs from birth to age 10. Which changes should the nurse expect to find?

1. Reduction in temperature, increase in heart rate, decrease in respiratory rate, and increase in blood pressure 2. Reduction in oxygen saturation, decreased heart and respiratory rate, and decreased blood pressure 3. Reduced heart and respiratory rate andNiUnRcSreINasGeTdBb.CloOoMd pressure 4. Decreased temperature, reduced heart and respiratory rate, and increased blood pressure Correct Answer: 3 Rationale 1: Temperature will not normally change throughout childhood. Heart rate should decrease.

Rationale 2: Blood pressure should increase through childhood. Oxygen saturation will not normally change throughout childhood.

Rationale 3: The nurse would expect to see a reduced heart and respiratory rate, and an increase in blood pressure from birth through childhood.

Rationale 4: Temperature will not normally change throughout childhood. Heart rate and respiratory rate will decrease.

Global Rationale: The nurse would expect to see a reduced heart and respiratory rate, and an increase in blood pressure from birth through childhood. Temperature will not normally change throughout childhood.

Heart rate should decrease. Blood pressure should increase through childhood. Oxygen saturation will not normally change throughout childhood. Temperature will not normally change throughout childhood. Heart rate and respiratory rate will decrease.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.B.3. Provide client-centered care with sensitivity and respect for the diversity of human experience AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment: Practice; Conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.9 Compare normal heart rate range for adults and children.

Page Number: p. 260 10. A client who plays professional football reports having no symptoms and has the following vital signs: 98.6°F; 48; 10; 88/54. Which action by the nurse is the priority?

1. Notify the health care provider.

2. Encourage fluids.

3. Document the client's vital signs and continue the history.

4. Place client in the Trendelenburg position.

Correct Answer: 3 Rationale 1: There would be no need to intervene for this client.

Rationale 2: This client is not dehydrated.

Rationale 3: Clients in excellent physical condition will often run a lower heart rate and respiratory rate because the cardiac muscle is strong and requires fewer contractions to maintain an adequate cardiac output.

Rationale 4: The Trendelenburg position is not indicated for this client.

Global Rationale: Clients in excellent physical condition will often run a lower heart rate and respiratory rate because the cardiac muscle is strong and requires fewer contractions to maintain an adequate cardiac output. There would be no need to intervene for this client. This client is not dehydrated. The Trendelenburg position is not indicated for this client.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance

Client Need Sub: QSEN Competencies: I.B.3. Provide client-centered care with sensitivity and respect for the diversity of human experience AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment: Practice; Conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.18 Discuss conditions when respiratory rate would be elevated or decreased.

Page Number: p. 278 11. The nurse is assessing a client's peripheral pulses. For what should the nurse assess for?

Standard Text: Select all that apply.

1. Bilaterality 2. Regularity 3. Strength 4. Rate 5. Arrhythmia Correct Answer: 1, 2, 3, 4 Rationale 1: When assessing peripheral pulses, the nurse assesses for bilaterality.

Rationale 2: When assessing peripheral pulses, the nurse assesses for regularity.

Rationale 3: When assessing peripheral pulses, the nurse assesses for strength.

Rationale 4: When assessing peripheral pulses, the nurse assesses for rate.

Rationale 5: The nurse could not determine if there is an arrhythmia without the use of an ECG. Global Rationale: When assessing peripheral pulses, the nurse assesses for bilaterality, regularity, strength, and rate. The nurse could not determine if there is an arrhythmia without the use of an ECG. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub:

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.16 Demonstrate the proper techniques for obtaining peripheral pulses.

Page Number: p. 276 12. The nurse is unable to palpate a client’s pedal pulse even though the foot is pink and warm. Which action by the nurse is the most appropriate?

1. Apply a warm soak to the foot.

2. Notify the health care provider that the client has lost circulation to the foot.

3. Elevate the foot.

4. Auscultate the pulse using an ultrasound Doppler.

Correct Answer: 4 Rationale 1: The nurse would not a p p ly NaUwR aSrI m e ca u s e there is the potential for reduced sensation if N GsToBa .kC, ObM pulses are not palpable, which could result in a burn.

Rationale 2: There is no need to notify the health care provider.

Rationale 3: Elevating the foot would reduce blood flow, making the pulse more difficult to palpate.

Rationale 4: If the pulse is not palpable, the nurse would attempt to auscultate using a Doppler.

Global Rationale: If the pulse is not palpable, the nurse would attempt to auscultate using a Doppler.

The nurse would not apply a warm soak, because there is the potential for reduced sensation if pulses are not palpable, which could result in a burn. There is no need to notify the health care provider, and elevating the foot would reduce blood flow, making the pulse more difficult to palpate.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Quality and Safety: Knowledge; Current best practices

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.16 Demonstrate the proper techniques for obtaining peripheral pulses.

Page Number: p. 277 13. A newborn is admitted to the nursery after delivery. Which site should the nurse use to measure this infant’s temperature?

1. Axillae 2. Temporal artery 3. Tympanic membrane 4. Oral cavity Correct Answer: 1 Rationale 1: It is appropriate to monitor an infant’s temperature using the axillae.

Rationale 2: The temporal artery is not an appropriate site to assess an infant’s temperature. Rationale 3: The tympanic membrane is not an appropriate site to assess an infant’s temperature. Rationale 4: The oral cavity is not an appropriate site to assess an infant’s temperature.

Global Rationale: It is appropriate to monitor an infant’s temperature using the axillae. It is not appropriate to use the temporal artery, the tympanic membrane, or the oral cavity to assess an infant’s temperature.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.5 Differentiate between the oral, rectal, axillary, and tympanic methods of taking temperature.

Page Number: p. 268 14. The nurse demonstrating proper placement of the stethoscope when assessing the apical pulse.

Where should the diaphragm be placed?

1. The brachial site 2. The apex of the heart 3. The carotid site 4. The radial site Correct Answer: 2 Rationale 1: An apical pulse cannot be assessed at the brachial site.

Rationale 2: An apical pulse is assessed at the apex of the heart.

Rationale 3: An apical pulse cannot be assessed at the carotid site.

Rationale 4: An apical pulse cannot be assessed at the radial site.

Global Rationale: An apical pulse is assessed at the apex of the heart. An apical pulse cannot be assessed at the brachial, carotid, or radial sites.

Cognitive Level: Applying Client Need: Health Promotion and MaiNnte U RnSaInNcGeTB.CO M Client Need Sub: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.8 Discuss the pulse, and indicate how it is an index of heart rate and rhythm.

Page Number: p. 274 15. Which respiratory finding would indicate the need for further assessment by the nurse?

1. Regular 2. Quiet 3. Deep 4. Rate of 12–20 per minute Correct Answer: 3

Rationale 1: Normal respirations are regular.

Rationale 2: Normal respirations are quiet.

Rationale 3: Depth of respirations is described as normal, deep, or shallow, and would usually be normal in depth with occasional signs of deeper breaths. Continuous deep breathing would indicate the need for further assessment.

Rationale 4: Normal respirations have a rate of 12–20.

Global Rationale: Depth of respirations is described as normal, deep, or shallow, and would usually be normal in depth with occasional signs of deeper breaths. Continuous deep breathing would indicate the need for further assessment. Normal respirations are regular and quiet at a rate of 12–20.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: NursingNPUrRoSceINssG: TABs.CseOsM sment Learning Outcome: 10.18 Discuss conditions when respiratory rate would be elevated or decreased.

Page Number: p. 281 16. The nurse is palpating a client’s systolic blood pressure. What should the nurse identify as being the systolic reading?

1. The last palpated beat 2. The first palpated beat 3. The pressure when the arterial pulse is obliterated 4. The pressure where the client says the fingers are numb Correct Answer: 2 Rationale 1: The first palpated beat is the systolic pressure. Rationale 2: There should not be a last palpated beat.

Rationale 3: The reading is not made while inflating the blood pressure cuff.

Rationale 4: The blood pressure cuff is too tight if the client experiences numb fingers.

Global Rationale: The first palpated beat is the systolic pressure. There should not be a last palpated beat.

The reading is not made while inflating the blood pressure cuff. The blood pressure cuff is too tight if the client experiences numb fingers.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.14 Demonstrate the method of palpating systolic arterial blood pressure.

Page Number: p. 288 17. The nurse notes that a client’s blood pressure reading was unusually elevated. For what should the nurse assess to determine the reason for this reading?

1. Presence of pain 2. Cuff inflation was too slow 3. Blood pressure cuff too wide 4. Arm placed above the heart level Correct Answer: 1 Rationale 1: Pain can cause the blood pressure to increase.

Rationale 2: Slow cuff inflation could cause the blood pressure to be too low. Rationale 3: A cuff that is too wide could cause the blood pressure to be too low.

Rationale 4: Placing the arm above the level of the heart could cause the blood pressure to be too low.

Global Rationale: Pain can cause the blood pressure to increase. 2: Slow cuff inflation, a cuff that is too wide, and placing the arm above the level of the heart could cause the blood pressure to be too low.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Quality and Safety: Knowledge; Current best practices

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.13 Identify four of the seven factors that affect blood pressure.

Page Number: p. 291

CHAPTER 11 1. The nurse is completing a health history with a client. Which information is least likely to be the focus of this assessment?

1. Health promotion 2. Biographic data 3. Chief complaint 4. Family history Correct Answer: 1 Rationale 1: After gathering this history, the nurse is able to determine what health promotion teaching is required by the client, but it is not part of the health history.

Rationale 2: The components of a health history include biographic data.

Rationale 3: The components of a health history include chief complaint.

Rationale 4: The components of a h ealthN UhiRsStoI NryG iTnBc.lCuOd M e family history.

Global Rationale: The components of a health history include biographic data, chief complaint, and family history. After gathering this history, the nurse is able to determine what health promotion teaching is required by the client, but it is not part of the health history.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: II.B.3. Base individualized care plan on client values, clinical expertise, and evidence AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.1 Outline the essential elements obtained from a health history.

Page Number: p. 297 2. During a health history a client relates a history of drug abuse. Where should the nurse document this information?

1. Health History

2. Biographic information 3. Psychosocial Factors 4. Lifestyle Correct Answer: 1 Rationale 1: Health history information includes general habits such as smoking, alcohol consumption, or recreational drug use.

Rationale 2: Biographic information includes age, gender, ethnicity, educational level, marital status, living arrangements.

Rationale 3: Psychosocial factors include cultural beliefs that influence health management; religious or spiritual beliefs.

Rationale 4: Lifestyle factors include cultural beliefs that influence health management; religious or spiritual beliefs.

Global Rationale: Health history information includes general habits such as smoking, alcohol consumption, or recreational drug use. Biographic information includes age, gender, ethnicity, educational level, marital status, living arrangements. Psychosocial factors and lifestyle include cultural beliefs that influence SI N G T B .C OM health m a nNaUg eRm e n t ; r e l i g i o u s or spiritual beliefs.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: II.B.3. Base individualized care plan on client values, clinical expertise, and evidence AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.1 Outline the essential elements obtained from a health history.

Page Number: p. 297 3. The nurse is helping a student understand the techniques used when completing a physical assessment. Which definitions should the nurse use to define these techniques?

1. Palpation is visualizing, inspection is feeling or touching, percussion is hearing, and auscultation is tapping and listening.

2. Palpation is touching, inspection is feeling, percussion is tapping and listening, and auscultation is listening.

3. Palpation is touching, inspection is looking, percussion is tapping, and auscultation is listening.

4. Palpation is tapping and listening, inspection is listening, percussion is touching, and auscultation is smelling.

Correct Answer: 3 Rationale 1: Palpation is touching, feeling, or pressing on an area. Inspection involves visualizing.

Percussion requires gentle tapping to listen for the returned sound. Auscultation is listening with or without an instrument such as a stethoscope.

Rationale 2: Palpation is touching, feeling, or pressing on an area. Inspection involves visualizing.

Percussion requires gentle tapping to listen for the returned sound. Auscultation is listening with or without an instrument such as a stethoscope.

Rationale 3: Palpation is touching, feeling, or pressing on an area. Inspection involves visualizing.

Percussion requires gentle tapping to listen for the returned sound. Auscultation is listening with or without an instrument such as a stethoscope.

Rationale 4: Palpation is touching, feeling, or pressing on an area. Inspection involves visualizing.

Percussion requires gentle tapping to listen for the returned sound. Auscultation is listening with or without an instrument such as a stethoscope.

Global Rationale: Palpation is touching, feeling, or pressing on an area. Inspection involves visualizing.

Percussion requires gentle tapping to listen for the returned sound. Auscultation is listening with or without an instrument such as a stethoscope.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: III.A.5.Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11.2 List the four techniques of physical assessment. Page Number: p.

297 4. The nurse needs to assess a client’s abdomen. In which order should the nurse complete this assessment?

1. Inspection and auscultation 2. Inspection, auscultation, and palpation

3. Inspection, auscultation, palpation, and percussion 4. Auscultation, percussion, and inspection Correct Answer: 3 Rationale 1: To use fewer than all four of these techniques would return less-than-complete data.

Rationale 2: To use fewer than all four of these techniques would return less-than-complete data.

Rationale 3: The nurse inspects the abdomen for appearance, auscultates for bowel sounds, palpates to determine organ location, and percusses. To use fewer than all four of these techniques would return less-than-complete data.

Rationale 4: To use fewer than all four of these techniques would return less-than-complete data.

Global Rationale: The nurse inspects the abdomen for appearance, auscultates for bowel sounds, palpates to determine organ location, and percusses. To use fewer than all four of these techniques would return less-than-complete data.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.9 Describe the assessment techniques used in an abdominal assessment in sequential order.

Page Number: p. 297 5. The nurse is assigned to accept a new admission expected from the emergency department. As the client is wheeled off the elevator, which action by the nurse is the most appropriate?

1. Waiting for the client to be placed in bed, then orienting the client to the unit 2. Accompanying the client and making introductions while assessing the client's mental status and appearance 3. Entering the client's room as soon as possible to obtain data for admission history

4. Asking the unlicensed assistive personnel to assist the client into bed Correct Answer: 2 Rationale 1: Waiting for the client to be assisted into bed delays the initial assessment required to determine the client's acuity and orientation, which could impact room placement, equipment needed, and the client's overall outcome if needed care is delayed.

Rationale 2: The initial assessment can begin as the nurse accompanies and assists the client to his room.

Rationale 3: After the client is placed in bed, the nurse would begin by assessing the client, obtaining data for the admission history during the examination.

Rationale 4: Asking the unlicensed assistive personnel to help the client delays the initial assessment required to determine the client's acuity and orientation, which could impact room placement, equipment needed, and the client's overall outcome if needed care is delayed.

Global Rationale: The initial assessment can begin as the nurse accompanies and assists the client to his room. Waiting for the client to be assisted into bed or asking the unlicensed assistive personnel to help the client delays the initial assessment required to determine the client's acuity and orientation, which could impact room placement, equipment needed, and the client's overall outcome if needed care is delayed.

After the client is placed in bed, the nurse would begin by assessing the client, obtaining data for t hNe UaRd SmI Ni sGs iToBn. ChOi sMt o r y during the examination.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance.

Client Need Sub: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.1 Outline the essential elements obtained from a health history.

Page Number: p. 297 6. The nurse is performing an assessment of the skin. Which statements regarding this assessment are correct?

Standard Text: Select all that apply.

1. Assessment of the skin involves inspection, palpation, and auscultation.

2. Assessment of the skin involves using the sense of smell.

3. The nurse assesses the client for edema.

4. The nurse may assess the client's nails and hair while assessing the skin.

5. When assessing the skin, the nurse recognizes the effect of developmental stage on findings.

Correct Answer: 2, 3, 4, 5 Rationale 1: Assessment of the skin involves inspection and palpation, but auscultation is generally not required, because there is nothing to listen to during this exam.

Rationale 2: Assessment of the skin involves using the sense of smell to note any unusual odors or the presence of body odor frequently related to poor hygiene.

Rationale 3: The nurse will note any edema that makes skin look swollen, shiny, and taut.

Rationale 4: The nurse can assess the nails and hair while performing the skin assessment.

Rationale 5: The client's developmental stage will impact the findings, and must be taken into consideration when the nurse assesses the client's skin.

Global Rationale: Assessment of the skin involves using the sense of smell to note any unusual odors or the presence of body odor frequently related to poor hygiene. The nurse will note any edema that makes skin look swollen, s h i Nn yU, RaSnI dN Gt aTuBt .. CTOhMe nurse can assess the nails and hair while performing the skin assessment. The client's developmental stage will impact the findings, and must be taken into consideration when the nurse assesses the client's skin. Assessment of the skin involves inspection and palpation, but auscultation is generally not required, because there is nothing to listen to during this exam.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance.

Client Need Sub: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.7 State three assessment components of the skin.

Page Number: p. 313 7. The nurse is assessing the client's cardiorespiratory system. Which tool will the nurse require to perform these examinations?

1. Stethoscope

2. Percussion hammer 3. Nasal speculum 4. Lubricant Correct Answer: 1 Rationale 1: The nurse will require a stethoscope to auscultate the breath and heart sounds.

Rationale 2: A percussion hammer will not be required.

Rationale 3: A nasal speculum will be required to examine the client's nares.

Rationale 4: Lubrication is not required to auscultate the breath and heart sounds.

Global Rationale: The nurse will require a stethoscope to auscultate the breath and heart sounds. A percussion hammer will not be required. A nasal speculum will be required to examine the client's nares, but not for the cardiorespiratory system. Lubrication is not required to auscultate the breath and heart sounds.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance.

Client Need Sub: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.8 Describe normal and abnormal lung sounds. Page Number: p. 315 8. When examining an older adult client's sense of smell, which finding would the nurse anticipate?

1. Heightened sense of smell 2. Normal sense of smell 3. Diminished sense of smell 4. Development does not impact the sense of smell Correct Answer: 3

Rationale 1: The sense of smell markedly diminishes because of a decrease in the number of olfactory nerve fibers and atrophy of the remaining fibers, making older adult clients less able to identify and discriminate odors.

Rationale 2: The sense of smell markedly diminishes because of a decrease in the number of olfactory nerve fibers and atrophy of the remaining fibers, making older adult clients less able to identify and discriminate odors.

Rationale 3: The sense of smell markedly diminishes because of a decrease in the number of olfactory nerve fibers and atrophy of the remaining fibers, making older adult clients less able to identify and discriminate odors.

Rationale 4: The sense of smell markedly diminishes because of a decrease in the number of olfactory nerve fibers and atrophy of the remaining fibers, making older adult clients less able to identify and discriminate odors.

Global Rationale: The sense of smell markedly diminishes because of a decrease in the number of olfactory nerve fibers and atrophy of the remaining fibers, making older adult clients less able to identify and discriminate odors.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.B.3. Provide c l iNe Un tR- ScIeNnGteTrBed.CcOaM re with sensitivity and respect for the diversity of human experience AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment: Practice; Conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.4 Describe the abnormal manifestations associated with each specific body system for one client with whom you are familiar.

Page Number: p. 345 9. The nurse is performing a head-to-toe assessment. Organize the areas that need to be assessed into the order in which the nurse would examine them.

Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list.

Response 1. Ears and eyes Response 2. General appearance Response 3. Respiratory and cardiac systems

Response 4. Neurologic status Response 5. Abdomen and GI system Correct Answer: 2 ,4, 1, 3, 5 Rationale 1: The nurse would start by performing an assessment of the client's general appearance.

Neurologic status would be assessed next, followed by the ears and eyes as part of the neurologic sensory system. The nurse would move to the chest, assessing the cardiac and respiratory system, and then on to the abdomen to assess the gastrointestinal system.

Rationale 2: The nurse would start by performing an assessment of the client's general appearance.

Neurologic status would be assessed next, followed by the ears and eyes as part of the neurologic sensory system. The nurse would move to the chest, assessing the cardiac and respiratory system, and then on to the abdomen to assess the gastrointestinal system.

Rationale 3: The nurse would start by performing an assessment of the client's general appearance.

Neurologic status would be assessed next, followed by the ears and eyes as part of the neurologic sensory system. The nurse would move to the chest, assessing the cardiac and respiratory system, and then on to the abdomen to assess the gastrointestinal system.

Rationale 4: The nurse would start by performing an assessment of the client's general appearance.

Neurologic status would be assessed next, followed by the ears and eyes as part of the neurologic TB sensory system. The n u rs Ne UwRoSuIlNdGm ov.CeOtM o the chest, assessing the cardiac and respiratory system, and then on to the abdomen to assess the gastrointestinal system.

Rationale 5: The nurse would start by performing an assessment of the client's general appearance.

Neurologic status would be assessed next, followed by the ears and eyes as part of the neurologic sensory system. The nurse would move to the chest, assessing the cardiac and respiratory system, and then on to the abdomen to assess the gastrointestinal system.

Global Rationale: The nurse would start by performing an assessment of the client's general appearance. Neurologic status would be assessed next, followed by the ears and eyes as part of the neurologic sensory system. The nurse would move to the chest, assessing the cardiac and respiratory system, and then on to the abdomen to assess the gastrointestinal system.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11.4 Describe the abnormal manifestations associated with each specific body system for one client with whom you are familiar.

Page Number: p. 297 10. The nurse is explaining to the client the role of inspection during an assessment. Which client statement indicates understanding about this assessment technique?

1. "So, you are going to listen to my heart."

2. "So, you will be touching my abdomen."

3. "So, you will be looking at my skin."

4. "So, you are going tap my abdomen."

Correct Answer: 3 Rationale 1: Auscultation is the actual listening technique used in assessment.

Rationale 2: The palpation of the abdomen allows for a better assessment of those organs located in the abdomen..

Rationale 3: Looking at the client’s s k i nNiUs Ri nS sI Np eGcTt iBo. Cn .OTMh i s statement indicates that the client has understood this portion of the assessment.

Rationale 4: Tapping the abdomen describes percussion that is used to determine size of various organs.

Global Rationale: Looking at the client’s skin is inspection. This statement indicates that the client has understood this portion of the assessment. The other statements would indicate understanding of other portions of the assessment, which include auscultation, palpation, and percussion.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: III.A.5.Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 11.2 List the four techniques of physical assessment.

Page Number: p. 297

11. The nurse is explaining to the client the need to do an assessment at the beginning of the shift.

This type of assessment involves obtaining which type of information?

1. Information regarding the client’s overall assessment 2. Information of a specific medical condition 3. Information specific to the client’s current condition 4. Information regarding past medical history Correct Answer: 3 Rationale 1: Information regarding the client’s overall assessment would be a head-to-toe assessment and is a basic assessment.

Rationale 2: Information of a specific medical condition pertains to only one specific system.

Rationale 3: Information specific to the client’s current condition is a focused assessment.

Rationale 4: Information regarding past medical history is data that is gathered as part of a head- to-toe assessment.

Global Rationale: Information specific to the client’s current condition is a focused assessment.

Information regarding the client’s overall assessment would be a head-to-toe assessment and is a basic assessment. Information of a specific medical condition pertains to only one specific system. Information regarding past medical history is data that is gathered as part of a head-to- toe assessment.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.B.3. Provide client-centered care with sensitivity and respect for the diversity of human experience AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment: Practice; Conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.3 Demonstrate six steps of the focus assessment.

Page Number: p. 298 12. The nurse is going to perform light palpation. Which statement regarding light palpation is true?

1. It is a gentle downward movement of the hand in a circular fashion.

2. It is done by using two hands to apply pressure.

3. It is only done by the health care provider.

4. It should cause the client pain.

Correct Answer: 1 Rationale 1: Light palpation is a gentle downward movement of the hand in a circular fashion.

Rationale 2: Deep palpation occurs when the practitioner uses two hands to apply pressure. Rationale 3: This statement is not true. All nurses are taught how to perform light palpation. Rationale 4: Palpation should not cause pain unless there is a problem.

Global Rationale: Light palpation is a gentle downward movement of the hand in a circular fashion. Deep palpation occurs when the practitioner uses two hands to apply pressure. All nurses are taught how to perform light palpation. Palpation should not cause pain unless there is a problem.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.2 List the four techniques of physical assessment..

Page Number: p. 298 13. The nurse is observing a student nurse performing a respiratory assessment on a client. Which statement indicates that the student nurse is performing the assessment correctly?

1. The student nurse has the client in either a sitting or lying position.

2. The client is placed in a sitting position and uncovered to the waist.

3. The client is placed in a sitting position with gown and blanket.

4. The client is placed in the semi-Fowler’s position with gown removed.

Correct Answer: 2 Rationale 1: When performing a respiratory assessment, the client should be sitting or in a lying position; however, the client should be uncovered.

Rationale 2: For a complete respiratory assessment, the client should be sitting and uncovered to the waist.

Rationale 3: Having the client in a sitting position is correct; however, the client needs to be uncovered in order to adequately assess.

Rationale 4: A semi-Fowler’s position is not appropriate when assessing a client’s respiratory system.

Global Rationale: For a complete respiratory assessment, the client should be sitting and uncovered to the waist. When performing a respiratory assessment, the client should be sitting or in a lying position; however, the client should be uncovered. Having the client in a sitting position is correct; however, the client needs to be uncovered in order to adequately assess. A semi-Fowler’s position is not appropriate when assessing a client’s respiratory system.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: III.A.5. Explain tNhUeRrSoIlNe GoTf Be .vCi Od eMn c e in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Learning Outcome: 11.8 Describe normal and abnormal lung sounds.

Page Number: p. 298 14. The nurse is explaining to student nurses the different heart sounds that are assessed during the cardiac assessment. Which statement made by a student indicates understanding of the expected normal heart sounds?

1. "If I hear the S1 as lub and S2 as dub, then that is normal and means that the valves are working."

2. " If I hear a ‘lub-dub-ee’ it means the client has a ventricular gallop."

3. "If I hear ‘dee-lub-dub’ then the client may have an atrial gallop. This occurs near the very end of diastole just before S1 and creates the sound."

4. "If I hear the ‘dee-lub-dub’ sound in an older adult, then I should know that is considered normal for the older client."

Correct Answer: 1 Rationale 1: When the AV valves close the S1 occurs and is the "lub," and when the semilunar valve closes the S2 occurs as the "dub"; this indicates normal heart sounds.

Rationale 2: This is considered a ventricular gallop and occurs early in diastole right after S2; this often disappears when the client sits up.

Rationale 3: This is correct for determining an atrial gallop, which is the S4 sound.

Rationale 4: This is the definition of the dee-lub-dub that in older adults can mean heart failure and hypertension.

Global Rationale: When the AV valves close the S1 occurs and is the "lub," and when the semilunar valve closes the S2 occurs as the "dub"; this indicates normal heart sounds. Lub-dub- ee indicates a ventricular gallop. Dee-lub-dub indicates an atrial gallop. Dee-lub-dub can indicate heart failure and hypertension.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: VI.B.4. Document and plan client care in an electronic health record AACN Essential Competencies: IV.5. U seRSstIaNnGdTaBrd.CizOeM d terminology in a care environment that reflects NU nursing’s unique contribution to patient outcomes NLN Competencies: Quality and Safety: Practice; Carefully maintain and use electronic and/or written health records Nursing/Integrated Concepts: Evaluation Learning Outcome: 11.11 Identify the four areas for heart sound auscultation.

Page Number: p. 319 15. The nurse is preparing to assess a pregnant client’s abdomen. In which order should the nurse complete this assessment?

1. Locate the fetal back 2. Locate the fetal head 3. Determine engagement 4. Identify the fetal part in the fundus Correct Answer: 2, 1, 4, 3 Rationale 1: During the second Leopold maneuver the fetal back is located. Rationale 2: During the first Leopold maneuver the fetal head is located.

Rationale 3: During the last Leopold maneuver the degree of engagement is determined. Rationale 4: During the third Leopold maneuver the contents of the fundus are identified.

Global Rationale: During the first Leopold maneuver the fetal head is located. During the second Leopold maneuver the fetal back is located. During the third Leopold maneuver the contents of the fundus are identified. During the last Leopold maneuver the degree of engagement is determined.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.4. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Assessment Learning Outcome: 11.13 Compare and contrast three elements of the antepartum obstetrical assessment.

Page Number: p. 332 16. The Apgar score for a newborn is 4 and 5 minutes, 5 at 10 minutes, and 6 at 15 and 20 minutes. What should the nurse prepare when caring for this client?

1. Radiant heat 2. Intravenous fluids 3. Vitamin K injection 4. Emergency intubation equipment Correct Answer: 4 Rationale 1: Heat will not increase this infant’s Apgar scores.

Rationale 2: Intravenous fluids will not increase this infant’s Apgar scores.

Rationale 3: Vitamin K will prevent bleeding and will not increase this infant’s Apgar scores.

Rationale 4: Scores less than 7 at 5 minutes, repeat every 5 minutes for 20 minutes. Infant may be intubated unless 2 successive scores of 7 or more occur.

Global Rationale: Scores less than 7 at 5 minutes, repeat every 5 minutes for 20 minutes. Infant may be intubated unless 2 successive scores of 7 or more occur. Heat, intravenous fluids, and vitamin K, which is used to prevent bleeding, will not increase this infant’s Apgar scores.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A.4. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Planning Learning Outcome: 11.14 Relate the elements of a “9” score on the Apgar test as part of a newborn assessment.

Page Number: p. 337 17. The nurse is preparing to conduct a mental health assessment with a client. What should be included in this assessment? Select all that apply.

1. Past medical history 2. General motor activity 3. Past and present memory 4. Coherency, logic, and relevance 5. General appearance, manner, and attitude Correct Answer: 2, 3, 4, 5 Rationale 1: Past medical history is a part of the health history.

Rationale 2: General motor activity is a part of the mental health assessment. Rationale 3: Past and present memory is a part of the mental health assessment. Rationale 4: Coherency, logic, and relevance are parts of the mental health assessment.

Rationale 5: General appearance, manner, and attitude are parts of the mental health assessment.

Global Rationale: General motor activity, past and present memory, coherency, logic, and relevance, and general appearance, manner, and attitude are parts of the mental health assessment. Past medical history is a part of the health history.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.4. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Assessment Learning Outcome: 11.12 List at least five essential elements included in a mental status assessment.

Page Number: p. 328

CHAPTER 12 1. A person maintains balance as long as the line of gravity passes through which item?

1. The base of support 2. The center of gravity 3. The center of gravity and base of support 4. The moving body part Correct Answer: 3 Rationale 1: Balance is a state of equilibrium in which opposing forces counteract each other, requiring the line of gravity to pass through the center of gravity and the base of support. Balance is the result of proper body alignment.

Rationale 2: Balance is a state of equilibrium in which opposing forces counteract each other, requiring the line of gravity to pass through the center of gravity and the base of support. Balance is the result of proper body alignment.

Rationale 3: Balance is a state of equilibrium in which opposing forces counteract each other, requiring the N U R S I N G T B .CO M line of gravity to pass t h r o u g h t h e c e n t e r o f gravity and the base of support. Balance is the result of proper body alignment.

Rationale 4: Balance is a state of equilibrium in which opposing forces counteract each other, requiring the line of gravity to pass through the center of gravity and the base of support. Balance is the result of proper body alignment.

Global Rationale: Balance is a state of equilibrium in which opposing forces counteract each other, requiring the line of gravity to pass through the center of gravity and the base of support. Balance is the result of proper body alignment.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12.4 Describe a minimum of two principles of correct body mechanics.

Page Number: p. 351

2. The nurse is preparing to lift a client up in bed. What should the nurse do prior to beginning this task in order to maintain safety?

Standard Text: Select all that apply.

1. Plan the move 2. Face the head of the bed 3. Raise the bed to waist level 4. Stand close to the bed with the legs close together 5. Straighten the knees Correct Answer: 1, 2, 3 Rationale 1: Planning the move before beginning helps to foresee any potential problems and arrange for adequate assistance with moving the client.

Rationale 2: By facing the bed, the nurse will move the client in the same direction the nurse is facing to avoid twisting or straining.

Rationale 3: The bed should always be brought to waist level when the client is performing care, to avoid back strain.

Rationale 4: The nurse should stand close to the bed with legs spread to create a broad base of support in order to avoid back injury.

Rationale 5: The knees should be bent, not straight.

Global Rationale: Planning the move before beginning helps to foresee any potential problems and arrange for adequate assistance with moving the client. By facing the bed, the nurse will move the client in the same direction the nurse is facing to avoid twisting or straining. The bed should always be brought to waist level when the client is performing care, to avoid back strain. The nurse should stand close to the bed with legs spread to create a broad base of support in order to avoid back injury. The knees should be bent, not straight.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.C.1. Value the contributions of standardization/reliability to safety AACN Essential Competencies: II.6. Apply concepts of quality and safety using structure, process and outcome measures to identify clinical questions and describe the process of changing current practice

NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12.4 Describe a minimum of two principles of correct body mechanics.

Page Number: p. 369 3. Two nurses are preparing to transfer a client from the stretcher to the bed. Which is a safe and efficient action to complete this task?

1. The nurse pulling the client onto the bed enlarges the base of support by moving the feet apart laterally.

2. The nurse pushing the object moves one foot forward.

3. The nurse pushing faces the head of the bed.

4. The nurse pulling faces the foot of the bed.

Correct Answer: 2 Rationale 1: The nurse who is pushing the client from the stretcher to the bed would put one foot forward to provide leverage. This nurse faces the direction the client is to be moved and widens the base of support in the direction the clNieUnRt Si IsNt Go TbBe. CmOoMv e d .

Rationale 2: The nurse who is pushing the client from the stretcher to the bed would put one foot forward to provide leverage. This nurse faces the direction the client is to be moved and widens the base of support in the direction the client is to be moved.

Rationale 3: The nurse who is pushing the client from the stretcher to the bed would put one foot forward to provide leverage. This nurse faces the direction the client is to be moved and widens the base of support in the direction the client is to be moved.

Rationale 4: The nurse who is pushing the client from the stretcher to the bed would put one foot forward to provide leverage. This nurse faces the direction the client is to be moved and widens the base of support in the direction the client is to be moved.

Global Rationale: The nurse who is pushing the client from the stretcher to the bed would put one foot forward to provide leverage. This nurse faces the direction the client is to be moved and widens the base of support in the direction the client is to be moved.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.C.1. Value the contributions of standardization/reliability to safety AACN Essential Competencies: II.6. Apply concepts of quality and safety using structure, process, and outcome measures to identify clinical questions and describe the process of

changing current practice NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12.4 Describe a minimum of two principles of correct body mechanics.

Page Number: p. 372 4. The nurse is caring for a postoperative client, who is on strict bed rest, after having a rod placed for scoliosis. The client is currently supine. Which action by the nurse is necessary prior to logrolling this client?

1. Moving the client closer to the side of the bed that the client will be turned toward 2. Placing a pillow under the client's head 3. Placing one or two pillows between the client's legs 4. Having the client fold the arms on the chest Correct Answer: 4 Rationale 1: The client is moved away from the side of the bed that the client will be turned toward.

Rationale 2: Pillows are not placed until after the client has been positioned.

Rationale 3: Pillows are not placed until after the client has been positioned.

Rationale 4: Having the client fold the arms on the chest prevents injury to the client and makes logrolling the client smoother and easier for the nurse.

Global Rationale: Having the client fold the arms on the chest prevents injury to the client and makes logrolling the client smoother and easier for the nurse. The client is moved away from the side of the bed that the client will be turned toward, and pillows are not placed until after the client has been positioned.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12.13 Outline the steps in logrolling a client.

Page Number: p. 370 5. The nurse is caring for a client who has been on complete bed rest for the past week. As the nurse assists the client to sit in the chair, the client becomes dizzy when the legs are dangled over the side of the bed. Which action by the nurse is the priority?

1. Returning the client to bed in the Trendelenburg position 2. Calling for help 3. Measuring the client's blood pressure 4. Having the client sit on the edge of the bed for several minutes, and encourage a few deep, slow breaths Correct Answer: 4 Rationale 1: There is no need to place the client in the Trendelenburg position.

Rationale 2: There is no need to call for help.

Rationale 3: It is better that the nurse h oNl dU Ro Sn I tNoGtTh Be . Cc lOi eMn t until the symptoms resolve rather than leave the client to obtain blood pressure equipment.

Rationale 4: It is not unusual for the client who has been on bed rest to experience orthostatic hypotension when he first sits up. The nurse should stay with the client, hold onto him in case he faints, and have the client sit on the edge of the bed taking slow, deep breaths until the symptoms abate.

Global Rationale: It is not unusual for the client who has been on bed rest to experience orthostatic hypotension when he first sits up. The nurse should stay with the client, hold onto him in case he faints, and have the client sit on the edge of the bed taking slow, deep breaths until the symptoms abate. There is no need to place the client in the Trendelenburg position or to call for help. It is better that the nurse hold on to the client until the symptoms resolve rather than leave the client to obtain blood pressure equipment.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Practice; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12.12 Demonstrate the procedures for moving a client to the side of the bed and dangling a client.

Page Number: p. 374 6. The nurse is transferring the client who is able to provide minimal assistance from the bed to the wheelchair. Which nursing action will provide for the safest transfer for this client?

1. Raising the bed height to waist height 2. Placing the wheelchair on the client's strong side 3. Placing the wheelchair with the feet pointing toward the side of the bed 4. Locking the wheels of the wheelchair and lowering the footplate Correct Answer: 2 Rationale 1: The bed should be placed in the low position so the client's feet are flat on the floor to prevent injury.

Rationale 2: The wheelchair should be placed close to the bed on the client's strong side.

Rationale 3: The wheelchair should faceN tUhRe ScI lNieGnTt Bp. CarOallel M to the bed.

Rationale 4: The wheels should be locked and the footrests lifted, not lowered, so they are out of the way.

Global Rationale: The wheelchair should be placed close to the bed on the client's strong side with the wheels locked and the footrests lifted, not lowered, so they are out of the way. The wheelchair should face the client parallel to the bed. The bed should be placed in the low position so the client's feet are flat on the floor to prevent injury.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Practice; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12.12 Demonstrate the procedures for moving a client to the side of the bed and dangling a client.

Page Number: p. 374

7. The nurse positions the client on the sling, wheels the lift into position, and connects the sling to the lift.

Which are priority safety measures prior to lifting the client?

Standard Text: Select all that apply.

1. Locking the wheels of the lift 2. Opening the base to the widest position 3. Lowering the side rails 4. Checking that the hooks are correctly placed and that matching chains are of equal length 5. Facing the hooks toward the client Correct Answer: 1, 2, 3, 4 Rationale 1: The wheels should be locked to prevent movement.

Rationale 2: The base should be widened to prevent tipping.

Rationale 3: The side rails should be lowered to prevent bumping the client into the side rails when lifted.

Rationale 4: Unequal chains could result in dropping the client, and improperly placed hooks could scratch the client.

Rationale 5: Hooks should be turned away from the client.

Global Rationale: The wheels should be locked to prevent movement, the base widened to prevent tipping, and the side rails lowered to prevent bumping the client into the side rails when lifted. Unequal chains could result in dropping the client, and improperly placed hooks could scratch the client. Hooks should be turned away from the client.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Practice; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12.10 Describe the correct placement of the canvas pieces when placing a client on the floor-based client lift.

Page Number: p. 375 8. Which assistive devices would be appropriate for the nurse to use when assisting an unconscious client from the bed to the stretcher?

Standard Text: Select all that apply.

1. Transfer belt 2. Transfer board 3. Hydraulic lift 4. Low-friction sheet 5. Egg crate mattress Correct Answer: 2, 3, 4 Rationale 1: Transfer belts would not be helpful when moving the unconscious client from bed to stretcher.

Rationale 2: The transfer board can helpNsUliRdSeI NthGeTcBl.iCeOntMfrom bed to stretcher.

Rationale 3: The hydraulic lift will allow the nurse to lift the client onto the stretcher.

Rationale 4: A low-friction sheet allows the nurse to slide the client with reduced drag, requiring less energy to make the move.

Rationale 5: Egg crate mattresses increase drag, and therefore increase the amount of energy required to slide the client.

Global Rationale: The transfer board can help slide the client from bed to stretcher, whereas the hydraulic lift will allow the nurse to lift the client onto the stretcher. The lift can be particularly helpful if the client is large in size. A low-friction sheet allows the nurse to slide the client with reduced drag, requiring less energy to make the move. Transfer belts would not be helpful when moving the unconscious client from bed to stretcher. Egg crate mattresses increase drag, and therefore increase the amount of energy required to slide the client.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span

NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12.7 Discuss the objectives for moving and turning clients.

Page Number: p. 377 9. The nurse is caring for an unconscious client who has foot drop. Which items would be useful in properly aligning the client’s foot?

1. Pillows 2. Footboard 3. Trochanter roll 4. Foot boot Correct Answer: 4 Rationale 1: Pillows will not be effective in providing enough support to prevent foot drop.

Rationale 2: A foot board can be effective for preventing dorsiflexion but will not address foot drop.

Rationale 3: A trochanter roll prevents external rotation of the leg.

Rationale 4: A foot boot provides support to the feet in a natural position and keeps the weight of the covers off the toes.

Global Rationale: A foot boot provides support to the feet in a natural position and keeps the weight of the covers off the toes. Pillows will not be effective in providing enough support to prevent foot drop. A foot board can be effective for preventing dorsiflexion but will not address foot drop. A trochanter roll prevents external rotation of the leg.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: V.C.1. Value the contributions of standardization/reliability to safety AACN Essential Competencies: II.7. Promote factors that create a culture of safety and caring NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12.9 Explain how the client is positioned in a lateral and prone position.

Page Number: p. 379 10. The nurse transfers an assigned client from the wheelchair to the hospital bed. Which items will the nurse include when documenting the client’s response to the transfer?

Standard Text: Select all that apply.

1. Number of assistants needed 2. Type of equipment used 3. Pulse rate before and after the procedure 4. Blood pressure before and after the procedure 5. Safety precautions taken Correct Answer: 3, 4 Rationale 1: Although all of these items are required when documenting a client transfer, the only items that document the client’s response to the transfer are the pulse rate and blood pressure.

Rationale 2: Although all of these items are required when documenting a client transfer, the only items that document the client’s response to the transfer are the pulse rate and blood pressure.

Rationale 3: Comparing the vital signs before and after the transfer allows the nurse to assess how the client handled the transfer.

Rationale 4: Comparing the vital signs before and after the transfer allows the nurse to assess how the client handled the transfer.

Rationale 5: Although all of these items are required when documenting a client transfer, the only items that document the client’s response to the transfer are the pulse rate and blood pressure.

Global Rationale: Although all of these items are required when documenting a client transfer, the only items that document the client’s response to the transfer are the pulse rate and blood pressure. Comparing the vital signs before and after the transfer allows the nurse to assess how the client handled the transfer.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: VI.B.4. Document and plan client care in an electronic health record AACN Essential Competencies: IV.5. Use standardized terminology in a care environment that reflects nursing’s unique contribution to client outcomes NLN Competencies: Quality and Safety: Practice; Carefully maintain and use electronic and/or written health records Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12.15 List the pertinent data that should be charted when moving a client from the bed.

Page Number: p. 380 11. The nurse is performing passive range of motion on the client and notes that the client’s ankle is red, edematous, and painful to the touch. Which action by the nurse is the most appropriate?

1. Perform range of motion very gently to the ankle.

2. Perform normal range of motion to the ankle.

3. Skip range of motion in this joint and move on to the next joints.

4. Notify the health care provider before performing range of motion to this joint.

Correct Answer: 4 Rationale 1: If a joint is traumatized, it is best to avoid ROM exercises until consulting with the primary care provider.

Rationale 2: After speaking with the health care provider, if ROM is indicated, the nurse would not move the joint to the point of res i s t a nNcUeRoSrI Np Ga iTnB, .aCnOdMmight consult with a physical therapist.

Rationale 3: The traumatized joint should not just be skipped, as it should be brought to the attention of the health care provider so diagnostic tests can be performed as indicated.

Rationale 4: If a joint is traumatized, it is best to avoid ROM exercises until consulting with the primary care provider.

Global Rationale: If a joint is traumatized, it is best to avoid ROM exercises until consulting with the primary care provider. After speaking with the health care provider, if ROM is indicated, the nurse would not move the joint to the point of resistance or pain, and might consult with a physical therapist. The traumatized joint should not just be skipped, as it should be brought to the attention of the health care provider so diagnostic tests can be performed as indicated.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12.1 Discuss the primary function of the skeletal muscles, joints, and bones.

Page Number: p. 352 12. The charge nurse on a neurologic care area is assigning clients. What should be a priority when making staff assignments?

1. Limit number of allowed lifts per worker per day 2. Identify a team of staff who are responsible for all lifts 3. Ask staff to volunteer to participate when lifting clients 4. Assign the clients requiring to be lifted evenly among all staff Correct Answer: 1 Rationale 1: OSHA developed lifting guidelines for healthcare workers to prevent injury to the client and the worker. One of these guidelines is to limit number of allowed lifts per worker per day.

Rationale 2: Having a team of staff responsible for all lifts would violate the OSHA guidelines to limit number of allowed lifts per worker per day.

Rationale 3: Asking staff to volunteer to participate when lifting clients would violate the OSHA guidelines to limit number of allowed lifts per worker per day.

Rationale 4: Assigning clients requiring Nt oU bReS Il Ni fGt eTdB e. Cv Oe nMl y among all staff would violate the OSHA guidelines to limit number of allowed lifts per worker per day.

Global Rationale: OSHA developed lifting guidelines for healthcare workers to prevent injury to the client and the worker. One of these guidelines is to limit number of allowed lifts per worker per day. Having a team of staff responsible for all lifts, asking staff to volunteer to participate when lifting clients, and assigning clients requiring to be lifted evenly among all staff would violate the OSHA guidelines to limit number of allowed lifts per worker per day.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 12.3 Describe the ANA Standards that promote safe handling of clients and prevention of injury to healthcare workers.

Page Number: p. 354

13. A client is experiencing respiratory distress. In which position should the nurse place this client?

1. High Fowlers 2. Semi-Fowlers 3. Trendelenburg 4. Reverse Trendelenburg Correct Answer: 1 Rationale 1: High Fowlers is the recommended position for severe respiratory conditions.

Rationale 2: Semi-Fowlers is the recommended position for cardiac, respiratory, neurosurgical conditions.

Rationale 3: Trendelenburg is the recommended position for percussion, vibration, and drainage procedures.

Rationale 4: Reverse Trendelenburg is the recommended position for gastric conditions.

Global Rationale: High Fowlers is the recommended position for severe respiratory conditions. SemiFowlers is the recommended position for cardiac, respiratory, neurosurgical conditions. Trendelenburg is the recommended position for percussion, vibration, and drainage procedures. Reverse Trendelenburg is the recommended position for gastric conditions.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12.8 Describe the position of the head of the bed in the four Fowler’s positions.

Page Number: p. 365 14. A comatose client is being positioned supine. What should be done to maintain the functional alignment of this client’s hands?

1. Externally rotate the arms 2. Cross the arms over the chest 3. Elevate the upper arms on pillows 4. Place a rolled washcloth in each hand Correct Answer: 4

Rationale 1: Rotating the arms will not preserve hand functioning.

Rationale 2: Crossing the arms over the chest will not preserve hand functioning. Rationale 3: Elevating the upper arms on pillows will not preserve hand functioning.

Rationale 4: Hand rolls made from folded washcloths rolled into a cone shape may be used to position and maintain wrist and fingers in a functional position. The purpose is to prevent deformity and contractures.

Global Rationale: Hand rolls made from folded washcloths rolled into a cone shape may be used to position and maintain wrist and fingers in a functional position. The purpose is to prevent deformity and contractures. Rotating the arms, crossing the arms over the chest, or elevating the upper arms on pillows will not preserve hand functioning.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: NursingNPUrRoScIeNssG: TIBm.CpOleM mentation Learning Outcome: 12.9 Explain how the client is positioned in a lateral and prone position.

Page Number: p. 367 15. The nurse is preparing to lift a client from the bed to a chair using a sling. Which action should the nurse perform to ensure for the client’s safety?

1. Raise the bed to waist level 2. Unhook the sling from lift arm 3. Move the lift away from the bed 4. Keep the client’s arms inside of the sling Correct Answer: 4 Rationale 1: The bed should not be raised when using a sling.

Rationale 2: The sling is unhooked from the lift arm after the client has been moved.

Rationale 3: The lift is moved away from the bed when completing the client move.

Rationale 4: One action to ensure for the client’s safety when using a sling is to keep the client’s arms inside of the sling. The bed should not be raised when using a sling. The sling is unhooked from the lift arm after the client has been moved. The lift is moved away from the bed when completing the client move.

Global Rationale: One action to ensure for the client’s safety when using a sling is to keep the client’s arms inside of the sling.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 12.10 Describe the correct placement of the canvas pieces when placing a client on the floor-based client lift.

Page Number: p. 378 16. The manager is identifying staff who would qualify to be a member of a lift team. What information does the manager need before finalizing this decision?

1. Date of last back injury 2. Reports of spinal x-rays 3. Evidence of daily back exercises being done 4. Staff signature relinquishing organization liability Correct Answer: 2 Rationale 1: The individuals on the team must have no prior history of a musculoskeletal injury.

Rationale 2: The individuals on the team must have an x-ray of their spine. Rationale 3: There is no need to have evidence of daily exercises being done. Rationale 4: The staff is not asked to relinquish organizational liability.

Global Rationale: The individuals on the team must have an x-ray of their spine. The individuals on the team must have no prior history of a musculoskeletal injury. There is no need to have evidence of daily exercises being done. The staff is not asked to relinquish organizational liability.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span

NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 12.14 Describe requirements for lift team members.

Page Number: p. 371 17. The nurse is concerned that a client is experiencing urinary effects of immobility. What did the nurse assess to make this clinical determination?

1. Urine retention 2. Bladder distention 3. Shortness of breath 4. Urinary tract infection Correct Answer: 4 Rationale 1: Urine retention is not a urinary effect of immobility. Rationale 2: Bladder distention is not a urinary effect of immobility. Rationale 3: Shortness of breath is not a urinary effect of immobility.

Rationale 4: Urinary effects of immobility include an increased risk of infection.

Global Rationale: Urinary effects of immobility include an increased risk of infection. Urine retention, bladder distention, and shortneNsUs Ro Sf I bNrGe aT tBh. Ca Or eMn o t urinary effects of immobility.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.2 Describe nursing measures that assist in preserving joints, bones, and skeletal muscles.

Page Number: p. 353

CHAPTER 13 1. Which joint will the nurse circumduct when performing range of motion on the hospitalized client?

1. Neck 2. Shoulder 3. Foot 4. Knee Correct Answer: 2 Rationale 1: The neck cannot make a complete circle.

Rationale 2: Circumduction is movement in a circle while the proximal end remains fixed. One joint that is circumducted is the shoulder.

Rationale 3: The foot cannot make a complete circle.

Rationale 4: The knee does not rotate inNtUhaRtSm INaGnTnBe.rC. OM Global Rationale: Circumduction is movement in a circle while the proximal end remains fixed. The two joints that are circumducted are the shoulder and the hip. The foot and neck cannot make a complete circle, whereas the knee does not rotate in that manner.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.3 Identify the joints and the type of movement they accommodate..

Page Number: p. 395 2. Which joint would the nurse pronate when performing range of motion on the hospitalized client?

1. Neck

2. Knee 3. Elbow 4. Finger Correct Answer: 3 Rationale 1: By definition, pronation is moving the bones of the forearm so the palm faces downward when held in front of the body. The neck cannot pronate.

Rationale 2: By definition, pronation is moving the bones of the forearm so the palm faces downward when held in front of the body. The knee cannot pronate.

Rationale 3: By definition, pronation is moving the bones of the forearm so the palm faces downward when held in front of the body. The joint involved in pronation is the elbow.

Rationale 4: By definition, pronation is moving the bones of the forearm so the palm faces downward when held in front of the body. The finger cannot pronate.

Global Rationale: By definition, pronation is moving the bones of the forearm so the palm faces downward when held in front of the body. The joint involved in pronation is the elbow. The neck, knee, and finger cannot pronate.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.3 Identify the joints and the type of movement they accommodate.

Page Number: p. 396 3. The nurse caring for several clients could safely delegate which task to unlicensed assistive personnel (UAP)?

1. Initial application of the continuous positive motion (CPM) device to the postoperative client 2. Assessment of client's tolerance for passive range of motion 3. Documentation of joint improvement resulting from active range of motion

4. Performance of passive range of motion to client experiencing a CVA 2 weeks ago Correct Answer: 4 Rationale 1: Initial application of the CPM must be performed by the nurse.

Rationale 2: Assessing a client's tolerance for passive range of motion must be performed by the nurse.

Rationale 3: Assessing a client's progress must be performed by the nurse.

Rationale 4: The UAP can safely perform passive range of motion on a stable client if educated in the skill.

Global Rationale: The UAP can safely perform passive range of motion on a stable client if educated in the skill. Initial application of the CPM, and assessing a client's tolerance or progress, must be performed by the nurse.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members SI N G T B . C O M AACN Essential Competencies: IX . 1 4 .NDU eRm o n s t r a t e cl i n i c al judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Practice; Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13.4 Compare and contrast passive and active range-of-motion exercises.

Page Number: p. 418 4. The nurse is caring for a client who has an order for Lofstrand crutches to assist with mobility. The client asks what the crutch looks like. Which description of the crutch by the nurse is the most accurate?

1. It rests just under the axilla with a hand bar.

2. It has a cuff for the upper arm.

3. It extends to the forearm and has a metal cuff around the forearm to stabilize the wrist.

4. It has a rubber tip to prevent slippage on a floor surface.

Correct Answer: 3 Rationale 1: An axillary crutch rests just under the axilla and has a hand bar.

Rationale 2: A platform crutch has a cuff for the upper arm.

Rationale 3: A Lofstrand crutch extends to the forearm and has a metal cuff that goes around the forearm to stabilize the wrist.

Rationale 4: All crutch types have a rubber tip to prevent slippage on a floor surface.

Global Rationale: A Lofstrand crutch extends to the forearm and has a metal cuff that goes around the forearm to stabilize the wrist. An axillary crutch rests just under the axilla and has a hand bar. A platform crutch has a cuff for the upper arm. All crutch types have a rubber tip to prevent slippage on a floor surface.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.9 Demonstrate the proper method for measuring crutches.

Page Number: p. 392 5. The client is recovering from a fractured left femur, and has just had the cast removed. Which technique is the most appropriate for the nurse to use when assisting this client to ambulate?

1. Standing on the client's left side 2. Standing on the client's right side 3. Standing behind the client and holding the client's belt 4. Standing in front of the client and having the client lean on the nurse's shoulders Correct Answer: 1 Rationale 1: When assisting with ambulation, the nurse stands on the client's weak side, on the left, in order to act as a support when the client moves the strong leg forward.

Rationale 2: Standing on the strong side would not help support the client.

Rationale 3: Standing behind the client would be dangerous.

Rationale 4: Standing in front of the client would be dangerous.

Global Rationale: When assisting with ambulation, the nurse stands on the client's weak side, on the left, in order to act as a support when the client moves the strong leg forward. Standing behind or in front of the client would be dangerous, and standing on the strong side would not be as effective.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.C.1. Value the contributions of standardization/reliability to safety AACN Essential Competencies: II.6. Apply concepts of quality and safety using structure, process, and outcome measures to identify clinical questions and describe the process of changing current practice NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.6 Explain the rationale of assisted ambulation for clients.

Page Number: p. 403 6. While walking in the hall a client suddenly complains of dizziness. Which action by the nurse is the priority?

1. Escorting the client back to the room and into bed 2. Calling for help to escort the client back to the room 3. Assisting the client to sit on the nearest chair with the head between the legs and go find assistance 4. Assisting the client to a horizontal position on the floor if no chair is available Correct Answer: 4 Rationale 1: Attempting to escort the client back to the room could result in injury if the client loses consciousness.

Rationale 2: Attempting to escort the client back to the room could result in injury if the client loses consciousness.

Rationale 3: The client should be either seated in a chair, if available, but the nurse should not leave the client unattended.

Rationale 4: The client should be assisted to a horizontal position on the floor, and the nurse must stay with the client.

Global Rationale: The client should be either seated in a chair, if available, or assisted to a horizontal position on the floor, and the nurse must stay with the client. Attempting to escort the client back to the room could result in injury if the client loses consciousness.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: V.C.1. Value the contributions of standardization/reliability to safety AACN Essential Competencies: II.6. Apply concepts of quality and safety using structure, process, and outcome measures to identify clinical questions and describe the process of changing current practice NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.7 Describe the procedure the nurse will carry out when the ambulating client appears to be falling.

Page Number: p. 403 7. The nurse is planning to delegate ambulation of a client to the unlicensed assistive personnel (UAP). In order to provide proper instructions to the UAP, which action by the nurse is the most appropriate?

1. Ambulating the client first and then haNvUinRgSItNhG e TUBA. CPO aMmb ul a te the client 2. Quizzing the UAP to assure appropriate understanding of how to ambulate the client 3. Assessing the client's ability to ambulate 4. Observing the client ambulating Correct Answer: 3 Rationale 1: Ambulating the client first would tire the client, and there would be no need to delegate to the UAP. Rationale 2: Quizzing the UAP would not be productive.

Rationale 3: The nurse must first assess the client's ability to ambulate so proper instructions can be provided to the UAP. Rationale 4: Observing the client as she ambulates would not allow the nurse to provide thorough instructions to the UAP before ambulating the client.

Global Rationale: The nurse must first assess the client's ability to ambulate so proper instructions can be provided to the UAP. Ambulating the client first would tire the client, and there would be no need to delegate to the UAP. Quizzing the UAP would not be productive. If

the nurse is uncertain about the UAP's abilities, the nurse would assist in ambulating the client and would evaluate the UAP's performance. Observing the client as she ambulates would not allow the nurse to provide thorough instructions to the UAP before ambulating the client.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Practice; Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13.6 Explain the rationale of assisted ambulation for clients.

Page Number: p. 418 8. The nurse is ambulating with a client who is moderately weak. Which action by the nurse is appropriate when applying support?

1. Grasp the gait belt firmly at the back 2. Wrapping the arm closest to the client around the client's waist 3. Holding on to the client's waistband located on the robe 4. Holding the client under the axilla Correct Answer: 1 Rationale 1: The nurse should stabilize client in a standing position and grasp the gait belt firmly at client’s back when ambulating.

Rationale 2: Holding the client by the waist could injure the client, and would not supply adequate support.

Rationale 3: The waistband on the robe would not provide adequate support.

Rationale 4: Holding the client by the axilla could injure the client, and would not supply adequate support.

Global Rationale: The nurse should stabilize client in a standing position and grasp the gait belt firmly at client’s back when ambulating. Holding the client by the waist or the axilla could injure the client, and would not supply adequate support.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.6 Explain the rationale of assisted ambulation for clients.

Page Number: p. 403 9. Which method is most appropriate for the nurse to use when teaching a client to walk with a cane?

1. Holding the cane on the stronger side of the body and moving the cane forward, then moving the weak leg forward 2. Holding the cane on the weaker side and moving the weak leg forward, then following with the cane 3. Holding the cane on the stronger side, stepping forward with the weak leg, and then moving the cane forward as the stronger leg moves forward 4. Holding the cane on the weaker side, sNteUpRpSiInNgGfToBr.wCaOrM d with the weak leg, and then moving the cane forward as the stronger leg moves forward Correct Answer: 1 Rationale 1: Holding the cane on the strong side of the body provides support and body alignment when walking, and it is normal for the arm opposite the leg to move forward, so the cane will be forward when the weak leg moves forward.

Rationale 2: Holding the cane on the weaker side does not adequately support the body when walking.

Rationale 3: Stepping on the weak leg will cause the client to become unbalanced.

Rationale 4: Holding the cane on the weaker side does not adequately support the body when walking.

Global Rationale: Holding the cane on the strong side of the body provides support and body alignment when walking, and it is normal for the arm opposite the leg to move forward, so the cane will be forward when the weak leg moves forward. Holding the cane on the weaker side does not adequately support the body when walking. Stepping on the weak leg will cause the client to become unbalanced Cognitive Level: Applying

Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.14 Describe client instructions for using a cane. Page Number: p.

405 10. The nurse is teaching the client how to walk with crutches. Which gait requires considerable skill, strength, and coordination?

1. Three-point gait 2. Swing-to gait 3. Swing-through gait 4. Two-point alternate gait Correct Answer: 3 Rationale 1: The three-point gait requires the client to bear her entire body weight on the unaffected leg.

Rationale 2: The swing-to gait lifts and swings the body to the crutches.

Rationale 3: The swing-through gait moves both crutches forward together and then the body is lifted by the arms and swings through and beyond the crutches, requiring enough strength to lift the body on the arms and enough coordination to manage to balance while the body is in the air.

Rationale 4: The two-point alternate gait is faster and requires balance, because only two points support the body at one time.

Global Rationale: The swing-through gait moves both crutches forward together and then the body is lifted by the arms and swings through and beyond the crutches, requiring enough strength to lift the body on the arms and enough coordination to manage to balance while the body is in the air. The three-point gait requires the client to bear her entire body weight on the unaffected leg. The swing-to gait lifts and swings the body to the crutches. The two-point alternate gait is faster and requires more balance, because only two points support the body at one time.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.10 Compare and contrast the four crutch-walking gaits.

Page Number: p. 411 11. The nurse is teaching the client who requires maximum support secondary to generalized weakness to walk with a walker. Which technique used by the nurse is the most appropriate?

1. Move the walker ahead while moving the weak leg forward, bearing weight on the strong leg.

2. Move the walker ahead while moving the strong leg forward, bearing weight on the weak leg and the arms.

3. Move the walker ahead, then move the right foot up to the walker while body weight is borne by the left leg and both arms, then move the left foot, bearing weight on the right leg and both arms.

4. Walk forward and push the walker aheNaUdRbSeINfoGreTBta.CkO inMg the next step.

Correct Answer: 3 Rationale 1: This client doesn't have a weaker or stronger leg, but is in a generally weakened condition, so the client should be taught to move the walker forward and support the body's weight on the arms and one leg, as first one leg and then the other is moved forward.

Rationale 2: This client doesn't have a weaker or stronger leg, but is in a generally weakened condition, so the client should be taught to move the walker forward and support the body's weight on the arms and one leg, as first one leg and then the other is moved forward.

Rationale 3: This client doesn't have a weaker or stronger leg, but is in a generally weakened condition, so the client should be taught to move the walker forward and support the body's weight on the arms and one leg, as first one leg and then the other is moved forward.

Rationale 4: This client doesn't have a weaker or stronger leg, but is in a generally weakened condition, so the client should be taught to move the walker forward and support the body's weight on the arms and one leg, as first one leg and then the other is moved forward.

Global Rationale: This client doesn't have a weaker or stronger leg, but is in a generally weakened condition, so the client should be taught to move the walker forward and support the body's weight on the arms and one leg, as first one leg and then the other is moved forward.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.15 Describe client instructions for using a walker. Page Number: p.

404 12. The nurse assists the client to ambulate for the first time, and documents the distance, pace, and support required. What should the nurse include in the documentation for this client?

1. Activity tolerance 2. Client's sense of security 3. Use of a gait belt 4. Where the client walked Correct Answer: 1 Rationale 1: In addition to the information supplied, the nurse should document how the client tolerated the activity, including vital signs, complaints of pain or discomfort, and strength.

Rationale 2: Client's sense of security has already been documented.

Rationale 3: Use of a gait belt has already been documented.

Rationale 4: Where the client walked has already been documented.

Global Rationale: In addition to the information supplied, the nurse should document how the client tolerated the activity, including vital signs, complaints of pain or discomfort, and strength. Client's sense of security, use of a gait belt, and where the client walked have already been documented.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: VI.B.4. Document and plan client care in an electronic health record AACN Essential Competencies: IV.5. Use standardized terminology in a care environment that reflects nursing’s unique contribution to client outcomes

NLN Competencies: Quality and Safety: Practice; Carefully maintain and use electronic and/or written health records Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.6 Explain the rationale of assisted ambulation for clients.

Page Number: p. 406 13. At the conclusion of an interdisciplinary team meeting it was decided that a client would benefit from preservative interventions. What should the nurse add to this client’s care plan? Select all that apply.

1. Measure for a cane 2. Instruct in the use of a walker 3. Active range of motion exercises 4. Consider the use of crutch walking 5. Assist with ambulation three times a day Correct Answer: 3, 5 Rationale 1: Restorative methods such as canes are used with clients who have decreased mobility caused by such factors as debilitating illness or major surgery.

Rationale 2: Restorative methods such as walkers are used with clients who have decreased mobility caused by such factors as debilitating illness or major surgery.

Rationale 3: Preservative methods, such NaUs Re xS eI Nr cGi sT eBs. ,C iOn M c l u d e those interventions that are needed to help clients maintain their normal mobility.

Rationale 4: Restorative methods such as crutches are used with clients who have decreased mobility caused by such factors as debilitating illness or major surgery.

Rationale 5: Preservative methods, such as assisted ambulation, include those interventions that are needed to help clients maintain their normal mobility.

Global Rationale: Preservative methods, such as exercises and assisted ambulation, include those interventions that are needed to help clients maintain their normal mobility. Restorative methods such as canes, walkers, crutches are used with clients who have decreased mobility caused by such factors as debilitating illness or major surgery.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13.2 Compare and contrast preservative and restorative methods of care.

Page Number: p. 390 14. The home care nurse is reinforcing teaching provided to a postoperative client about active range-ofmotion exercises. Which client statements indicate that teaching has been effective? Select all that apply.

1. “I stop when I feel pain.”

2. “I keep going when I feel pain.”

3. “I exercise all my joints every 4 hours.”

4. “I exercise my ankles at least every 2 hours.”

5. “I exercise once in the morning and may later on.”

Correct Answer: 1, 3, 4 Rationale 1: The client should be instructed to stop the activity if pain occurs.

Rationale 2: The client should be instructed to stop the activity if pain occurs.

Rationale 3: Exercises should be done every 4 hours.

Rationale 4: Dorsiflexion and plantar f l eNx iUoRnS (I aNnGkTl eB . pCuOmMp s ) should be done more frequently while awake and in bed or sitting to prevent deep vein thrombosis in lower extremities.

Rationale 5: Exercises should be done every 4 hours.

Global Rationale: The client should be instructed to stop the activity if pain occurs. Exercises should be done every 4 hours. Dorsiflexion and plantar flexion (ankle pumps) should be done more frequently while awake and in bed or sitting to prevent deep vein thrombosis in lower extremities Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 13.4 Compare and contrast passive and active range-of-motion exercises.

Page Number: p. 398

15. A client recovering with left leg weakness needs to learn how to walk stairs. Which approach is the safest for the nurse to review with the client?

1. Lift the left leg to the step and then bring the right leg up 2. Lift the right leg to the step and then bring the left leg up 3. Step down on the right leg and then bring the left leg down 4. Turn to the side and bring the right leg down followed by the left leg Correct Answer: 2 Rationale 1: When going upstairs the unaffected extremity is raised first followed by the affected extremity.

Rationale 2: When going upstairs the unaffected extremity is raised first followed by the affected extremity.

Rationale 3: When going downstairs the affected extremity is placed first followed by the unaffected extremity.

Rationale 4: Walking the stairs with the body turned is not recommended.

Global Rationale: When going upstairs the unaffected extremity is raised first followed by the affected extremity. : When going downstairs the affected extremity is placed first followed by the unaffected extremity. Walking the st ai rs NwUitRhS It NheG Tb Bo d. CyOtM u rned is not recommended.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 13.6 Explain the rationale of assisted ambulation for clients.

Page Number: p. 412 16. A client asks why a neighbor has a cane that has one tip and the one provided by physical therapy has four tips. What should the nurse respond to this client?

1. “A cane with one tip is more expensive.”

2. “A cane with 4 tips has a better hand grip.”

3. “A cane with one tip has a better hand grip.”

4. “A cane with 4 tips provides more stability.”

Correct Answer: Rationale 1: The cost for the cane is not contingent upon the number of tips it has. Rationale 2: The number of cane tips has nothing to do with the hand grip.

Rationale 3: The number of cane tips has nothing to do with the hand grip. Rationale 4: A cane with 4 tips or a quad cane has more stability.

Global Rationale: A cane with 4 tips or a quad cane has more stability. The cost for the cane is not contingent upon the number of tips it has. The number of cane tips has nothing to do with the hand grip.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Context and E n v i r oNnUmReSnI tN: GPTr aBc. Ct i Oc eM; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.9 Demonstrate the proper method for measuring crutches. Page Number: p. 393 17. A client who has been on bedrest for several weeks is permitted to sit out of bed in a chair. What should the nurse do to reduce the client’s risk of becoming dizzy when transferring out of bed to a chair?

1. Position prone for several hours every day 2. Raise and lower the foot of the bed several times 3. Raise and lower the head of the bed several times 4. Assist to roll in bed from side to side several times Correct Answer: 3 Rationale 1: The prone position will not reduce the risk of dizziness when transferring out of bed to a chair.

Rationale 2: Raising and the lowering the foot of the bed several times will not reduce the risk of dizziness when transferring out of bed to a chair.

Rationale 3: If the client has been on prolonged bed rest or has been immobilized, the risk of orthostatic hypotension is increased. Raising and lowering HOB several times to stimulate baroreceptors will help to prevent this condition.

Rationale 4: Rolling in bed side to side will not reduce the risk of dizziness when transferring out of bed to a chair.

Global Rationale: If the client has been on prolonged bed rest or has been immobilized, the risk of orthostatic hypotension is increased. Raising and lowering HOB several times to stimulate baroreceptors will help to prevent this condition. The prone position, raising and lowering the foot of the bed, or rolling side to side in bed will not reduce the risk of dizziness when transferring out of bed to a chair.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.7 Describe the procedure the nurse will carry out when the ambulating client appears to be falling.

Page Number: p. 401

CHAPTER 14 1. The nurse is caring for a client who developed an infection after admission to the hospital. Which term should the nurse use when documenting this infection?

1. Idiopathic infection 2. Bacterial infection 3. Health care-associated infection 4. Therapeutic infection Correct Answer: 3 Rationale 1: Idiopathic is not a term used to describe an infection.

Rationale 2: Not enough information is provided to determine whether the infection is bacterial in nature.

Rationale 3: A health care-associated infection is an infection not present and without evidence of incubation at the time of admission to a healthcare setting.

Rationale 4: Therapeutic is not a type of infection.

Global Rationale: A health care-associated infection is an infection not present and without evidence of incubation at the time of admission to a healthcare setting. Idiopathic is not a term used to describe an infection. Not enough information is provided to determine whether the infection is bacterial in nature.

Therapeutic is not a type of infection.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.4 Define the term healthcare-associated (nosocomial) infection.

Page Number: p. 423

2. The nurse is caring for a client with a medical diagnosis of HIV/AIDS admitted to the hospital with Pneumocystis carinii infection. In order to reduce the spread of infection, which is the priority nursing intervention?

1. Teaching the client to provide self-care 2. Teaching respiratory/cough etiquette 3. Teaching the use of sexual barriers 4. Teaching the use of standard precautions Correct Answer: 2 Rationale 1: Teaching self-care might be indicated for this client, but it is not related to reducing the spread of infection.

Rationale 2: The client with a respiratory infection would benefit most from learning how to use respiratory hygiene/cough etiquette in order to reduce the risk of spreading infection to others.

Rationale 3: Although teaching the use of sexual barriers would reduce the risk of sexually transmitted infections, it is not the priority need at this time.

Rationale 4: Standard precautions are used by the health care provider, and are not generally taught to clients.

Global Rationale: The client with a respiratory infection would benefit most from learning how to use respiratory hygiene/cough etiquette in order to reduce the risk of spreading infection to others. Although teaching the use of sexual barriers would reduce the risk of sexually transmitted infections, it is not the priority need at this time. Teaching self-care might be indicated for this client, but it is not related to reducing the spread of infection. Standard precautions are used by the health care provider, and are not generally taught to clients.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning

Learning Outcome: 14.13 Compare and contrast infection control practices in the home and hospital.

Page Number: p. 427 3. The nurse observes the newly hired unlicensed assistive personnel (UAP) performing routine client care. Which behaviors indicate the UAP understands the use of personal protective equipment?

1. The UAP removes the gown first and then the gloves after providing care.

2. The UAP applies gloves before emptying the client's indwelling catheter bag, then removes gloves and washes hands before measuring urine output.

3. The UAP applies gloves to clean the client's dentures, then removes gloves and performs hand hygiene prior to bathing the client.

4. The UAP wears gown and gloves when performing postmortem care.

Correct Answer: 3 Rationale 1: Gloves are removed before removing the gown.

Rationale 2: UAP should not remove g l oN vUeRs SuI Nn tGi lT aBf. tCeOr m M easuring urine output and rinsing the measuring container and returning it to its storage location.

Rationale 3: Gloves are required when providing denture care, but are not required for bathing the client.

Whenever gloves are removed, the health care provider should perform hand hygiene.

Rationale 4: Gloves should be worn when performing postmortem care, but a gown is generally not required.

Global Rationale: Gloves are required when providing denture care, but are not required for bathing the client. Whenever gloves are removed, the health care provider should perform hand hygiene. Gloves are removed before removing the gown. UAP should not remove gloves until after measuring urine output and rinsing the measuring container and returning it to its storage location. Gloves should be worn when performing postmortem care, but a gown is generally not required.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1.Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and

in all healthcare settings NLN Competencies: Context and Environment: Practice; Apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 14.7 Demonstrate donning and removing personal protection equipment.

Page Number: p. 445 4. The nurse is caring for a client with a deep draining abdominal wound. Which factor would require the nurse to wear a mask and goggles when caring for this client?

1. The wound is infected.

2. The client is confused and disoriented.

3. The wound is covered by wet-to-damp dressings.

4. The client is HIV-positive.

Correct Answer: 2 Rationale 1: An infected wound would cause the nurse to don gloves and a gown, but would not lead to the use of mask and goggles.

Rationale 2: The client who is confused and disoriented might not cooperate with care, and could cause splashing of wound drainage, so the nurse should wear a mask and goggles when caring for this client.

Rationale 3: Wet to damp dressings would cause the nurse to don gloves and a gown, but would not lead to the use of mask and goggles.

Rationale 4: Caring for an HIV positive client would cause the nurse to don gloves and a gown, but would not lead to the use of mask and goggles.

Global Rationale: The client who is confused and disoriented might not cooperate with care, and could cause splashing of wound drainage, so the nurse should wear a mask and goggles when caring for this client. An infected wound, wet to damp dressings, and caring for a client with HIV would cause the nurse to don gloves and a gown, but would not lead to the use of mask and goggles.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1.Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical

management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Context and Environment: Practice; Apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14.7 Demonstrate donning and removing personal protection equipment.

Page Number: p. 445 5. Which items should the nurse use with all clients to prevent the transmission of potentially infective organisms among the nurse, client, and other individuals?

Standard Text: Select all that apply.

1. Hand hygiene 2. Standard precautions 3. Personal protective equipment 4. Isolation procedures 5. Antimicrobial soap Correct Answer: 1, 2, 3 Rationale 1: The nurse should use hand hygiene with all clients.

Rationale 2: The nurse should use standard precautions with all clients. Rationale 3: The nurse should use personal protective equipment with all clients. Rationale 4: Isolation procedures are indicated for some clients but not all.

Rationale 5: Antimicrobial soaps are indicated for some clients but not all.

Global Rationale: The nurse should use hand hygiene, standard precautions, and personal protective equipment with all clients. Isolation procedures and antimicrobial soaps are indicated for some clients but not all.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1.Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical

management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Context and Environment: Practice; Apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14.12 Describe the difference between the first and second tier of precautions.

Page Number: p. 428 6. Which transmission of organisms is least effected by the nurse performing hand hygiene?

1. Vehicle-borne transmission 2. Vector-borne transmission 3. Indirect contact transmission 4. Direct contact transmission Correct Answer: 2 Rationale 1: Vehicle-borne transmission is a form of indirect contact transmission.

Rationale 2: Vector-borne transmission of organisms pertains to an animal or insect that serves as an immediate means of transporting the infectious agent, and so could not be prevented by hand hygiene.

Rationale 3: Vehicle-borne transmission is a form of indirect contact transmission.

Rationale 4: Direct contact transmission is transmission of a microorganism through touching, kissing, or any form of direct contact, such as the nurse touching the client who is susceptible to infection.

Global Rationale: Vector-borne transmission of organisms pertains to an animal or insect that serves as an immediate means of transporting the infectious agent, and so could not be prevented by hand hygiene.

Vehicle-borne transmission pertains to any substance that transfers infectious agents to a susceptible host, such as the nurse's hands. Vehicle-borne transmission is a form of indirect contact transmission.

Direct contact transmission is transmission of a microorganism through touching, kissing, or any form of direct contact, such as the nurse touching the client who is susceptible to infection.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes

AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14.1 Describe the six steps in the chain of infection.

Page Number: p. 424 7. The nurse uses a substance to destroy microorganisms other than spores. Which term should the nurse use to describe this substance?

1. Antiseptic 2. Disinfectant 3. Sterilizer 4. Aseptic Correct Answer: 2 Rationale 1: An antiseptic destroys some microorganisms.

Rationale 2: The substance that kills microorganisms except for spores is a disinfectant.

Rationale 3: Sterilization is complete removal of all pathogens.

Rationale 4: Aseptic means free from infection or infectious material.

Global Rationale: The substance that kills microorganisms except for spores is a disinfectant. An antiseptic destroys some microorganisms. Sterilization is complete removal of all pathogens. Aseptic means free from infection or infectious material.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14.1 Describe the six steps in the chain of infection. Page Number: p.

422

8. Which intervention should the nurse use to break the chain of infection by eliminating the reservoir?

1. Ensure that all antibiotics are taken properly and only when needed, to avoid creation of antibiotic-resistant microorganisms.

2. Avoid coughing or sneezing without covering the mouth.

3. Use sterile technique for invasive procedures.

4. Change dressings and bandages when they are soiled or wet.

Correct Answer: 4 Rationale 1: Ensuring antibiotics are taken properly breaks the chain by reducing growth of new etiologic agents.

Rationale 2: Covering the mouth when coughing or sneezing reduces the portal of exit. Rationale 3: Following sterile technique for invasive procedures reduces the portal of entry. Rationale 4: Moist dressings create ideal reservoirs for the growth of microorganisms.

Global Rationale: Moist dressings create ideal reservoirs for the growth of microorganisms. Ensuring antibiotics are taken properly breaks the chain by reducing growth of new etiologic agents. Covering the mouth when coughing or sneezing reduces the portal of exit, whereas following sterile technique for invasive procedures reduces the portal of entry.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14.1 Describe the six steps in the chain of infection. Page Number: p.

424 9. When the nurse performs hand hygiene properly, which aspect in the chain of infection is the nurse breaking?

1. Portal of entry

2. Portal of exit 3. Mode of transmission 4. Etiologic agent Correct Answer: 3 Rationale 1: Portal of entry is the opening that allows pathogens to invade the body.

Rationale 2: Portal of exit is the means of expelling pathogens from the body.

Rationale 3: Hand hygiene breaks the mode of transmission by reducing the pathogens on the hands when touching clients or objects that come in contact with clients.

Rationale 4: The etiologic agent is the pathogen.

Global Rationale: Hand hygiene breaks the mode of transmission by reducing the pathogens on the hands when touching clients or objects that come in contact with clients. Portal of entry is the opening that allows pathogens to invade the body, portal of exit is the means of expelling pathogens from the body, and the etiologic agent is the pathogen.

Cognitive Level: Analyzing Client Need: Safe and Effective Care EnNvUirRoSnINmGeTntB.COM Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14.1 Describe the six steps in the chain of infection. Page Number: p.

424 10. What should the nurse recognize as the difference between standard precautions and transmission-based isolation precaution systems?

1. Standard precautions protect the nurse, whereas transmission-based precautions protect the client.

2. Standard precautions require the use of clean gloves, whereas transmission-based precautions require the use of sterile gloves.

3. Standard precautions are used in addition to transmission-based precautions when standard precautions would not completely block the chain of infection.

4. Transmission-based precautions block the chain of infection, whereas standard precautions protect the nurse but do not block the chain of infection.

Correct Answer: 3 Rationale 1: Both standard and transmission-based precautions are used to protect the nurse, the client, and all others who are on the unit.

Rationale 2: Sterile gloves are not required for either form of precaution, and would be used for invasive procedures no matter what other types of precautions are in place.

Rationale 3: Standard precautions are used in addition to, not in place of, transmission-based precautions.

Rationale 4: Both forms of precaution block the chain of infection, but some diagnoses or conditions require additional protection in the form of transmission-based precautions.

Global Rationale: Standard precautions are used in addition to, not in place of, transmission- based precautions. Both standard and transmission-based precautions are used to protect the nurse, the client, and all others who are on the unit. Sterile gloves are not required for either form of precaution, and would be used for invasive procedures no matter what other types of precautions are in place. Both forms of precaution block the chain of infection, but some diagnoses or conditions require additional protection in the form of transmission-based precautions.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14.12 Describe the difference between the first and second tier of precautions.

Page Number: pp. 427-428 11. Which aspect of hand washing is most effective when there is visible dirt on the hands?

1. Using hot water instead of warm water 2. Using plenty of lather with friction 3. Drying the hands vigorously from wrists to fingers

4. Applying lotion to the hands Correct Answer: 2 Rationale 1: Using hot water can dry out the skin and lead to infection.

Rationale 2: Lathering the hands with the cleansing agent using friction is the best method to remove dirt and transient bacteria.

Rationale 3: Drying the hands vigorously from wrists to fingers helps keep skin intact but does nothing for visible dirt.

Rationale 4: Lotion will not help in decreasing the visible dirt.

Global Rationale: Lathering the hands with the cleansing agent using friction is the best method to remove dirt and transient bacteria. Using hot water can dry out the skin and lead to infection. Although using plenty of lather with friction is important, this will not help in decreasing the visible dirt. Drying the hands vigorously from wrists to fingers helps keep skin intact but does nothing for visible dirt.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.1. D e m o n s tNr aUt Re SkI nNoGwT lBe. dCgOeMo f basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14.6 State the main purpose of hand hygiene. Page Number: p. 439 12. The nurse is assisting the health care provider insert a chest tube into a client with a hemothorax following a motor vehicle crash. Which should the nurse don in order to assist with this procedure?

Standard Text: Select all that apply.

1. Sterile gown 2. Sterile gloves 3. Mask with eye shield

4. Mask 5. Clean gown Correct Answer: 3, 5 Rationale 1: The nurse would not need to don a sterile because the role of the nurse is to monitor the client during the procedure.

Rationale 2: The nurse would not need to don sterile gloves because the role of the nurse is to monitor the client during the procedure.

Rationale 3: Due to the risk of splatter, the nurse should wear a mask with eye shield.

Rationale 4: A mask without eye shield is not sufficient.

Rationale 5: Due to the risk of splatter, the nurse should wear a gown.

Global Rationale: The nurse would not need to don sterile gown or gloves, because the role of the nurse is to monitor the client during the procedure. However, due to the risk of splatter, the nurse would wear a gown and mask with eye shield.

Cognitive Level: Applying Client Need: Safe and Effective Care EnNvUirRoSnINmGeTnBt .COM Client Need Sub: Safety and Infection Control.

QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team NLN Competencies: Context and Environment: Practice; Apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14.7 Demonstrate donning and removing personal protection equipment.

Page Number: p. 445 13. The nurse is coming out of an isolation room. Which item is removed first to prevent any exposure of infectious materials?

1. Gloves 2. Mask 3. Gown 4. Goggles

Correct Answer: 1 Rationale 1: The first item removed when coming out of an isolation room to prevent any exposure of the infectious materials is the gloves.

Rationale 2: The mask is removed after the gloves, goggles, and gown.

Rationale 3: The gown is removed after the gloves and goggles.

Rationale 4: The goggles are removed after taking off the gloves.

Global Rationale: The first item removed when coming out of an isolation room to prevent any exposure of the infectious materials is the gloves. The goggles, gown, and mask are then removed in this order.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and SafetyN: UKRnSoI NwGleTdBg. eC;OCMurren t best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14.7 Demonstrate donning and removing personal protection equipment.

Page Number: p. 447 14. Place the steps for performing hand hygiene using soap and water in the appropriate order.

Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list.

Response 1. Apply lotion to hands.

Response 2. Dry hands thoroughly and use paper towel to turn off faucet.

Response 3. Rinse hands and wrists thoroughly, keeping hands down and elbows up.

Response 4. Wet hands and wrists thoroughly under running water. Apply a small amount of soap.

Response 5. Perform hand hygiene using plenty of lather and friction for at least 10–15 seconds.

Response 6. Turn on the water and regulate flow so that temperature is warm.

Correct Answer: 6, 4, 5, 3, 2, 1

Rationale 1: Applying lotion to the hands is the last step performed in hand hygiene.

Rationale 2: Drying the hands thoroughly and using the paper towel to turn off the faucet is done after hand washing and prior to applying lotion.

Rationale 3: Rinsing the hands and wrists thoroughly while keeping the hands down and elbows up is the fourth step in hand hygiene.

Rationale 4: Wetting the hands and wrists thoroughly under running water and applying a small amount of soap is the second step in hand hygiene.

Rationale 5: Using plenty of lather and friction for at least 10–15 seconds is the third step in hand hygiene using soap and water.

Rationale 6: Turning on the water and regulating the flow so that the temperature is warm is the first step in hand hygiene using soap and water.

Global Rationale: Turning on the water and regulating the flow so that the temperature is warm is the first step in hand hygiene using soap and water. Wetting the hands and wrists thoroughly under running water and applying a small amount of soap is the second step in hand hygiene.

Using plenty of lather and friction for at least 10–15 seconds is the third step in hand hygiene with soap and water. Rinsing the hands and wrists thoroughly while keeping the hands down and elbows up is the fourth step in hand hygiene. Drying the hands thoroughly and using the paper towel to turn off the faucet is done after NhaUnRdSIwNaGsThBin.CgOaM nd prior to applying lotion. Applying lotion to the hands is the last step performed in hand hygiene.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14.6 State the main purpose of hand hygiene.

Page Number: p. 437 15. The nurse assists the health care provider with the collection of cerebrospinal fluid. Which is an important safety measure for the nurse to follow immediately after collection of the sample?

1. Maintain sterility of the procedure tray.

2. Discard all sharps in a puncture-proof container.

3. Label specimens and send to the lab.

4. Remove PPE and discard.

Correct Answer: 2 Rationale 1: Once the procedure is completed, there is no need to maintain sterility of the procedure tray.

Rationale 2: The nurse's first action would be to discard sharps in the puncture-proof container to prevent potential injury.

Rationale 3: Labeling and sending specimens to the lab occurs after discarding sharps and before removing PPE. Rationale 4: Removal of PPE occurs last.

Global Rationale: The nurse's first action would be to discard sharps in the puncture-proof container to prevent potential injury. This should be performed before removing PPE. The next step would be to label the specimens and bag them, prior to removal of PPE, due to potential contamination of the outside of the specimen tubes. Once the procedure is completed, there is no need to maintain sterility of the procedure tray.

Cognitive Level: Analyzing Client Need: Safe and Effective Care EnNvUirRoSnINmGeTnBt .COM Client Need Sub: Safety and Infection Control QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality AACN Essential Competencies: V.7. Examine the roles and responsibilities of the regulatory agencies and their effect on client care quality, workplace safety, and the scope of nursing and other health professionals’ practice NLN Competencies: Context and Environment: Practice; Apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14.9 State the isolation procedure for removing specimens and equipment from an isolation room.

Page Number: p. 431 16. During a home care visit the nurse needs to change a client’s infected wound dressing. In which order should the nurse perform actions when additional supplies are needed once the soiled dressing has been removed from the client?

1. Wash hands 2. Apply gloves 3. Remove gloves 4. Access equipment bag 5. Place items on clean surface Correct Answer: 3, 1, 4, 5, 2

Rationale 1: After removing gloves the nurse should wash the hands. Rationale 2: Gloves are then reapplied to continue with the client’s care.

Rationale 3: The nurse should remove soiled gloves before accessing the equipment bag. Rationale 4: The equipment bag can be accessed once the hands are cleansed.

Rationale 5: The items from the bag should be placed on a clean surface.

Global Rationale: The nurse should remove soiled gloves before accessing the equipment bag. After removing gloves the nurse should wash the hands. The equipment bag can be accessed once the hands are cleansed. The items from the bag should be placed on a clean surface. Gloves are then reapplied to continue with the client’s care.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1.Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management aNcrUoRssSItNheGThBea.CltOhM -illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Context and Environment: Practice; Apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14.13 Compare and contrast infection control practices in the home and hospital.

Page Number: p. 457 17. The nurse is visiting the home of a client recovering from pneumonia. Which observation indicates that teaching about infection control practices would be indicated?

1. Picks up a sandwich after petting the family dog 2. Hands are washed before and after preparing food 3. Washes hands after coughing and blowing the nose 4. Sets out a clean wash cloth and towel at the kitchen sink Correct Answer: 1 Rationale 1: The hands should be washed after touching a pet and before eating.

Rationale 2: Hands should be washed before and after preparing food.

Rationale 3: Hands should be washed after coughing and blowing the nose.

Rationale 4: Clean wash cloths and towels should be used every day.

Global Rationale: The hands should be washed after touching a pet and before eating. Hands should be washed before and after preparing food. Hands should be washed after coughing and blowing the nose.

Clean wash cloths and towels should be used every day.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1.Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Context and Environment: Practice; Apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Assessment/Teaching/Learning Learning Outcome: 14.14 Differentiate assessment modalities to determine potential for infection in home care and hospitalized clients.

Page Number: p. 459

CHAPTER 15 1. A hurricane levels several homes and businesses in a small southwestern community. At which point should the nurse expect to become involved in the care of those affected by the storm?

1. Immediately when the storm ends 2. Once a state of emergency is declared 3. It depends upon where the nurse lives 4. When victims are brought to the hospital Correct Answer: 4 Rationale 1: Local government provides “first responders.”

Rationale 2: State and federal government become involved if the incident is large enough. Rationale 3: The nurse’s home is not a variable in this situation.

Rationale 4: Hospitals are the last link in community response to a mass casualty incident (MCI). Hospitals receive the most seriously injured and ill casualties.

Global Rationale: Hospitals are the last link in community response to a mass casualty incident (MCI).

Hospitals receive the most seriously injured and ill casualties. Local government provides “first responders.”

State and federal g o v eNrUn RmSeI nNtGbTeBc.oCmO eM i n vo l v e d if the incident is large enough. The nurse’s home is not a variable in this situation.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A. 2. Describe scopes of practice and roles of health care team members AACN Essential Competencies: VII. 9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty and other emergency situations NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 15.3 State the chain of command and reporting requirements when a mass casualty incident occurs.

Page Number: p. 467 2. In preparation to serve as a member of the Disaster Medical Assistance Team (DMAT) the nurse is preparing a home emergency kit. What should the nurse include in this kit? Select all that apply.

1. Hand-cranked radio 2. Computer battery charger 3. Bottled water to last 15 days 4. Gloves for work and protection

5. High protein and calorie snack foods Correct Answer: 1, 3, 4, 5 Rationale 1: The emergency kit should include a hand-cranked radio.

Rationale 2: In the event of a disaster there might not be electricity. A computer and battery charger will not be used or needed.

Rationale 3: The emergency kit should include bottled water to last 15 days. Rationale 4: The emergency kit should include gloves for work and protection. Rationale 5: The emergency kit should include high protein and calorie snack foods.

Global Rationale: The emergency kit should include a hand-cranked radio, bottled water to last 15 days, gloves for work and protection, and high protein and calorie snack foods. In the event of a disaster there might not be electricity. A computer and battery charger will not be used or needed.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A. 2. Describe sNcoUpReSsINofGTpBra.cCtOicMe and roles of health care team members AACN Essential Competencies: VII. 9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty and other emergency situations NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 15.10 List components of a home safety plan. Page Number: p. 468 3. The nurse stops on the way home to assist in the care of victims of a multi-motor vehicle crash site. The emergency response team uses a five level triage system. In which order should the nurse triage victims?

1. Victim walking with a limp 2. Victim bleeding from a gaping leg wound 3. Victim with a pulse of 20 and apneic periods 4. Victim sitting on the side of the road staring 5. Victim with shallow respirations and chest pain Correct Answer: 5, 2, 1, 4, 3 Rationale 1: The victim walking with a limp would be classified as Green.

Rationale 2: The victim bleeding from a gaping leg wound would be classified as Yellow.

Rationale 3: The victim with a pulse of 20 and apneic periods would be classified as Black. Rationale 4: The victim sitting on the side of the road staring would be classified as Blue. Rationale 5: The victim with shallow respirations and chest pain would be classified as Red. Global Rationale: The victim with shallow respirations and chest pain would be classified as Red. The victim bleeding from a gaping leg wound would be classified as Yellow. The victim bleeding from a gaping leg wound would be classified as Yellow. The victim bleeding from a gaping leg wound would be classified as Yellow. The victim with a pulse of 20 and apneic periods would be classified as Black.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A. 2. Describe scopes of practice and roles of health care team members AACN Essential Competencies: VII. 9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty and other emergency situations NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.5 Explain the term triage and list the steps of triage. Page Number: p. 473 4. The nurse, triaging victims of a dirty bomb, notes the radiation dosimeter reading of 150R/h. How should the nurse interpret this reading?

1. 150 rad exposure will occur in 1 hour 2. In 1 hour the radiation exposure will decrease by 150 3. Radiation exposure within 150 feet will occur in 1 hour 4. The maximum permitted amount of radiation exposure in 1 hour is 150 Correct Answer: 1 Rationale 1: An instrument reading of 150R/hr means that a healthcare worker staying in the exposed area for 1 hr will receive a 150-RAD exposure.

Rationale 2: The dosimeter does not estimate the reduction of radiation in an area. Rationale 3: The dosimeter does not measure the proximity of radiation exposure. Rationale 4: The dosimeter does not estimate the permitted amount of radiation exposure.

Global Rationale: An instrument reading of 150R/hr means that a healthcare worker staying in the exposed area for 1 hr will receive a 150-RAD exposure. The dosimeter does not estimate the

reduction of radiation in an area. The dosimeter does not measure the proximity of radiation exposure.

The dosimeter does not estimate the permitted amount of radiation exposure.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.B. 1.Demonstrate effective use of technology and standardized practices that support safety and quality AACN Essential Competencies: VII. 9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty and other emergency situations NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.7 Describe how to measure external radiation levels. Page Number: p. 477 5. The nurse is participating in attempts to rescue victims of a landslide after an earthquake in Southern Chile. Several victims are experiencing extreme diarrhea. Which microorganisms should the nurse anticipate as causing the victims’ manifestations? Select all that apply.

1. Cholera 2. Norovirus 3. Leptospirosis 4. West Nile virus 5. Vibrio vulnificus Correct Answer: 1, 2 Rationale 1: The symptoms of cholera include abrupt, painless watery stool. The incubation period is 1 to 3 days and the mode of transmission is ingestion of contaminated water.

Rationale 2: Diarrhea is a manifestation of norovirus that is acutely contagious. Rationale 3: Diarrhea is not a manifestation of Leptospirosis.

Rationale 4: Diarrhea is not a manifestation of West Nile virus. Rationale 5: Diarrhea is not a manifestation of vibrio vulnificus.

Global Rationale: The symptoms of cholera include abrupt, painless watery stool. The incubation period is 1 to 3 days and the mode of transmission is ingestion of contaminated water. Diarrhea is a manifestation of norovirus that is acutely contagious. Diarrhea is not a manifestation of Leptospirosis, West Nile virus, or vibrio vulnificus.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: VII. 9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty and other emergency situations NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.12 Identify two diarrhea-related diseases. Page Number: p.

482 6. A client is admitted with suspected gastrointestinal anthrax. Which type of precautions should the nurse anticipate being prescribed for this client?

1. Droplet 2. Contact 3. Airborne 4. Standard Correct Answer: 4 Rationale 1: Droplet transmission does not occur with anthrax. Rationale 2: Contact precautions are appropriate for cutaneous anthrax. Rationale 3: Airborne transmission does NnUoRt SoIcNcGu rT Bw. iCthO Manthrax.

Rationale 4: Standard precautions are appropriate for gastrointestinal anthrax.

Global Rationale: Standard precautions are appropriate for gastrointestinal anthrax. Droplet transmission does not occur with anthrax. Contact precautions are appropriate for cutaneous anthrax. Airborne transmission does not occur with anthrax.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: VII. 9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty and other emergency situations NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 15.6 Differentiate among biological, chemical, and radiation attacks. Page Number: p. 485

7. A client seeks medical attention for the onset of lower extremity paralysis after eating food prepared during a camping trip. Which disease process should the nurse anticipate planning care for this client?

1. Plague 2. Botulism 3. Typhoidal tularemia 4. Viral hemorrhagic fever Correct Answer: 2 Rationale 1: The plague does not cause paralysis.

Rationale 2: Food-borne botulism is a muscle-paralyzing disease caused by an anaerobic gram- positive bacillus that produces a potent neurotoxin.

Rationale 3: Typhoidal tularemia does not cause paralysis.

Rationale 4: Viral hemorrhagic fever does not cause paralysis.

Global Rationale: Food-borne botulism is a muscle-paralyzing disease caused by an anaerobic grampositive bacillus that produces a potent neurotoxin. The plague, typhoidal tularemia, and viral hemorrhagic fever do not cause paralysis.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: VII. 9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty and other emergency situations NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 15.13 List signs and symptoms of various biological agents and describe how to distinguish between them.

Page Number: p. 486 8. While participating in a religious humanitarian effort in West Africa the nurse sees several children with symptoms of an acute viral infection. What additional manifestations should cause the nurse to suspect that these children are experiencing smallpox? Select all that apply.

1. Rash localized to the trunk 2. Rash contains areas of scabbing 3. Rash located along a nerve track 4. Rash contains macules and papules 5. Rash on both sides of the face and arms

Correct Answer: 2, 4, 5 Rationale 1: Chickenpox has a rash that begins in the trunk. Rationale 2: In smallpox the rash contains areas of scabbing. Rationale 3: Shingles has a rash that is located along a nerve track. Rationale 4: In smallpox the rash contains macules and papules.

Rationale 5: In smallpox the rash is on the face and extremities.

Global Rationale: In smallpox the rash contains areas of scabbing, contains macules and papules and appears on the face and extremities. Chickenpox has a rash that begins in the trunk. Shingles has a rash that is located along a nerve track.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: VII. 9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty and other emergency situations NLN Competencies: Context and E n v i r oNnUmReSnI tN; GPTr aBc. Ct i Oc eM; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.14 Discuss the clinical features of smallpox. Page Number: p.

488 9. The nurse notes that within several hours four clients arrived to the emergency department experiencing symptoms of shortness of breath, chest tightness, and burning eyes. What should the nurse suspect is occurring with these clients?

1. Chemical exposure 2. Botulism intoxication 3. West Nile virus infestation 4. Exposure to typhoidal tularemia Correct Answer: 1 Rationale 1: The nurse should suspect a chemical agent exposure if a healthcare facility is presented with several nontrauma clients with similar symptoms.

Rationale 2: These are not symptoms associated with botulism. Rationale 3: These are not symptoms associated with West Nile virus.

Rationale 4: These are not symptoms associated with typhoidal tularemia.

Global Rationale: The nurse should suspect a chemical agent exposure if a healthcare facility is presented with several nontrauma clients with similar symptoms. These are not symptoms associated with botulism, West Nile virus, or typhoidal tularemia.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: VII. 9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty and other emergency situations NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.15 Describe the major agents of a chemical attack. Page Number: p. 488 10. A victim of cyanide exposure is transported to an urban medical center. Which treatment should the nurse anticipate being prescribed for this client?

1. Valium 2. Atropine 3. Sulfur thiosulfate 4. Anti-Lewisite (BAL) Correct Answer: 3 Rationale 1: Valium might be used for prolonged convulsions.

Rationale 2: Atropine is used to block excessive neurotransmitter activity.

Rationale 3: Sulfur thiosulfate IV (50 mL; 12.5 g); sulfur converts cyanide to form a nontoxic substance.

Rationale 4: An antidote for systemic lewisite is British anti-Lewisite (BAL), a drug given IV for heavy metal poisoning.

Global Rationale: Sulfur thiosulfate IV (50 mL; 12.5 g); sulfur converts cyanide to form a nontoxic substance. Valium might be used for prolonged convulsions. Atropine is used to block excessive neurotransmitter activity. An antidote for systemic lewisite is British anti-Lewisite (BAL), a drug given IV for heavy metal poisoning.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: VII. 9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty and other emergency situations NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 15.20 Differentiate methods of decontaminating victims after a biological versus a chemical attack.

Page Number: p. 490 11. A victim of radiation exposure from a dirty bomb several weeks ago comes into the emergency department because of excessive bleeding. For which acute radiation syndrome should the nurse plan care for this client?

1. Cutaneous 2. Hematopoietic 3. Cardiovascular 4. Gastrointestinal Correct Answer: 2 Rationale 1: Cutaneous syndrome is characterized by skin damage and temporary or permanent hair loss with “radiation burns.

Rationale 2: Hematopoietic syndrome is characterized by bleeding.

Rationale 3: Cardiovascular syndrome is characterized by vomiting and diarrhea within minutes of exposure, confusion, disorientation, cerebral edema, hypotension, and hyperpyrexia.

Rationale 4: Gastrointestinal syndrome is characterized by fluid and electrolyte loss with vomiting and diarrhea.

Global Rationale: Hematopoietic syndrome is characterized by bleeding. Cutaneous syndrome is characterized by skin damage and temporary or permanent hair loss with “radiation burns.

Cutaneous syndrome is characterized by skin damage and temporary or permanent hair loss with “radiation burns. Gastrointestinal syndrome is characterized by fluid and electrolyte loss with vomiting and diarrhea.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: VII. 9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty and other emergency situations

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 15.21 Demonstrate decontamination procedures for victims of a radiological attack.

Page Number: p. 491 12. Several individuals arrive to the emergency department experiencing manifestations that cannot be immediately determined. Which action is a priority when caring for these individuals?

1. Contact the Poison Control Center 2. Institute standard, airborne, and contact precautions 3. Contact the organization’s disaster preparedness committee 4. Notify the Centers for Disease Control and Prevention (CDC) Correct Answer: 2 Rationale 1: The Poison Control Center will not be able to assist in the identification of the victims’ exposure.

Rationale 2: If features of a disease or exposure cannot be immediately determined, institute Standard Precautions plus airborne and contact precautions until specific agent is identified.

Rationale 3: The disaster preparedness committee should be aware of the victims however they can be notified later.

Rationale 4: The Centers for Disease Control and Prevention (CDC) will not be able to assist in the identification of the victims’ exposure.

Global Rationale: If features of a disease or exposure cannot be immediately determined, institute Standard Precautions plus airborne and contact precautions until specific agent is identified. The Poison Control Center or the CDC will not be able to assist in the identification of the victims’ exposure. The disaster preparedness committee should be aware of the victims however they can be notified later.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: VII. 9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty and other emergency situations NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15.20 Differentiate methods of decontaminating victims after a biological versus a chemical attack.

Page Number: p. 492 13. Emergency personnel are establishing a hot zone to decontaminate victims of a nuclear blast. What should be a priority when caring for these victims?

1. Remove the victims’ clothing 2. Rinse the victims’ bodies’ hot water 3. Wash the victims’ bodies’ with chlorine 4. Wash and rinse the bodies with cold water Correct Answer: 1 Rationale 1: For gross decontamination the victims’ clothing should be removed. This will remove 70 to 80% of contaminants.

Rationale 2: Hot water will speed the distribution of contaminants in the body.

Rationale 3: The bodies should be washed with chlorine but only after the clothing is removed and the bodies are rinsed with tepid water.

Rationale 4: Cold water can cause hypothermia and should not be done.

Global Rationale: For gross decontamination the victims’ clothing should be removed. This will remove 70 to 80% of contaminants. Hot water will speed the distribution of contaminants in the body. The bodies should be washed w i t hNcUhRl oS rI iNnGe TbBu. tC oOnMl y after the clothing is removed and the bodies are rinsed with tepid water.

Cold water can cause hypothermia and should not be done.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: VII. 9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty and other emergency situations NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15.18 List the steps of decontamination via triage. Page Number: p.

496 14. A client comes into the emergency department after exposure to a biological agent. What should the nurse do after removing the victim’s clothing?

1. Place the victim in an isolation room 2. Administer a broad spectrum antibiotic 3. Send the victim home to wash with soap and water 4. Cleanse exposed areas with sodium hypochlorite and tepid water

Correct Answer: Rationale 1: The victim does not need to be isolated. Rationale 2: A broad spectrum antibiotic is not prescribed for this exposure.

Rationale 3: The victim can be sent home but only after being bathed with sodium hypochlorite and tepid water.

Rationale 4: After removing the victim’s closing the client should be washed with sodium hypochlorite and tepid water.

Global Rationale: After removing the victim’s closing the client should be washed with sodium hypochlorite and tepid water. The victim does not need to be isolated. A broad spectrum antibiotic is not prescribed for this exposure. The victim can be sent home but only after being bathed with sodium hypochlorite and tepid water.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: VII. 9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty and other emergency situations NLN Competencies: Context and E n v i r oNnUmReSnI tN; GPTr aBc. Ct i Oc eM; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15.18 List the steps of decontamination via triage. Page Number: p.

500 15. The waste water created from the decontaminating victims of radiation exposure is being collected. What should be done with this water?

1. Rinse down the sink 2. Flush down the commode 3. Place in bins and label “radioactive” 4. Take outside and pour it on the ground Correct Answer: 3 Rationale 1: This water is radioactive and should not be rinsed down the sink. Rationale 2: This water is radioactive and should not be flushed down the commode. Rationale 3: Runoff water should be captured, stored, and labeled “radioactive.” Rationale 4: This water is radioactive and should not be poured on the ground outside.

Global Rationale: Runoff water should be captured, stored, and labeled “radioactive.” This water is radioactive and should not be rinsed down the sink, flushed down the commode, or poured on the ground outside.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: VII. 9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty and other emergency situations NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15.21 Demonstrate decontamination procedures for victims of a radiological attack.

Page Number: p. 501 16. Emergency response personnel are caring for a victim of a nuclear blast. In which order should the trauma assessment be completed?

1. Ensure breathing 2. Plan to evacuate 3. Establish an airway 4. Determine circulation status 5. Assess level of consciousness 6. Identify contaminant exposure Correct Answer: 3, 1, 4, 5, 6, 2 Rationale 1: Breathing needs to be determined next. Rationale 2: A plan to evacuate the client occurs last. Rationale 3: An airway should be established first.

Rationale 4: Circulatory status would be determined third. Rationale 5: Level of consciousness is assessed fourth.

Rationale 6: Identification of contaminant exposure is determined fifth.

Global Rationale: An airway should be established first. Breathing needs to be determined next. Circulatory status would be determined third. Level of consciousness is assessed fourth.

Identification of contaminant exposure is determined fifth. A plan to evacuate the client occurs last.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: VII. 9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty and other emergency situations NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15.23 Demonstrate the steps for treating life-threatening conditions. Page Number: p. 507 17. A victim who witnessed the deaths of several coworkers during a terrorist attack is attending therapy sessions. Currently the victim client is dealing with event by confronting it, talking about it, and working through feelings. In which phase of recovery is this client?

1. Recovery 2. Avoidance 3. Adjustment 4. Reconsideration Correct Answer: 4 Rationale 1: In recovery the client n e ed s Nt oU Rb Se I Nr eGa Ts sBu. Cr eOdMo f being safe after experiencing of the traumatic event.

Rationale 2: In avoidance the client avoids thinking about the traumatic event.

Rationale 3: In adjustment the client rehabilitates and adjusts to the environment after event and is able to view the future positively.

Rationale 4: In reconsideration the client deals with event by confronting it, talking about it, and working through feelings.

Global Rationale: In reconsideration the client deals with event by confronting it, talking about it, and working through feelings. In recovery the client needs to be reassured of being safe after experiencing of the traumatic event. In avoidance the client avoids thinking about the traumatic event. In adjustment the client rehabilitates and adjusts to the environment after event and is able to view the future positively.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essential Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 15.24 Discuss posttraumatic stress disorder. Page Number: p.

510

CHAPTER 16 1. When documenting the maximum amount of pain a client can tolerate, which term is the most appropriate for the nurse to use?

1. Pain threshold 2. Hyperalgesia 3. Pain tolerance 4. Allodynia Correct Answer: 3 Rationale 1: Pain threshold is the lowest amount of stimuli needed for a person to label a sensation as pain.

Rationale 2: Hyperalgesia, or hyperpathia, denotes a heightened response to painful stimuli.

Rationale 3: Pain tolerance is the maximum amount of pain a client can tolerate.

Rationale 4: Allodynia is pain p r o d u ce dNbUyRnSoI Nn Gp aTiBn.fCuOl M stimuli, such as the touch of wind to the area.

Global Rationale: Pain tolerance is the maximum amount of pain a client can tolerate. Pain threshold is the lowest amount of stimuli needed for a person to label a sensation as pain.

Hyperalgesia, or hyperpathia, denotes a heightened response to painful stimuli. Allodynia is pain produced by nonpainful stimuli, such as the touch of wind to the area.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiological models of pain and comfort.

AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.7 Compare how you would assess quality of pain versus intensity of pain.

Page Number: p. 517

2. The nurse is using a nonpharmacologic method to manage a client's pain, and applies a unit that applies low-voltage electrical stimulation directly over the pain area. When documenting this intervention, which term is the most appropriate for the nurse to use?

1. TENS unit 2. Nerve block 3. Functional restoration 4. Cutaneous stimulation Correct Answer: 1 Rationale 1: The unit described is a TENS unit, or transcutaneous electrical nerve stimulator, which is a form of cutaneous stimulation.

Rationale 2: Nerve block is a pharmacologic treatment injecting an analgesic or steroid into the site of pain.

Rationale 3: Functional restoration is a form of social therapy.

Rationale 4: TENS would be the s p e c i f iNc UnRa SmI Ne GoTf Bt h. Ci sOtMr eat ment, whereas cutaneous stimulation would be a more general term.

Global Rationale: The unit described is a TENS unit, or transcutaneous electrical nerve stimulator, which is a form of cutaneous stimulation. However, TENS would be the specific name of this treatment, whereas cutaneous stimulation would be a more general term. Nerve block is a pharmacologic treatment injecting an analgesic or steroid into the site of pain.

Functional restoration is a form of social therapy.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiological models of pain and comfort.

AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.8 Outline the main points of one nonpharmacologic method of relieving pain.

Page Number: p. 523

3. The nurse working on the labor and delivery unit has noticed how differently each client responds to the pain associated with labor. Which reasons should the nurse attribute to these various responses to pain?

Standard Text: Select all that apply.

1. Ethnic and cultural values 2. Developmental stage 3. Past experience with pain 4. Physiological functioning of the brain 5. Meaning of pain Correct Answer: 1, 2, 3, 5 Rationale 1: Clients with different ethnic and cultural values are socialized to respond to pain in different manners.

Rationale 2: The developmental stage determines the client's ability to cope and report the pain.

Rationale 3: Past experience, including the effectiveness of the treatment plan in the past, with pain will have an impact on how the client deals with pain.

Rationale 4: Physiological functioning affects how pain is felt but does not affect the pain experience.

Rationale 5: Pain has different meaning to different clients, with some clients believing it is a punishment from a higher power or an opportunity to show how strong they are.

Global Rationale: Clients with different ethnic and cultural values are socialized to respond to pain in different manners. The developmental stage determines the client's ability to cope and report the pain. Past experience, including the effectiveness of the treatment plan in the past, with pain will have an impact on how the client deals with pain. Physiological functioning affects how pain is felt but does not affect the pain experience. Pain has different meaning to different clients, with some clients believing it is a punishment from a higher power or an opportunity to show how strong they are.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiological models of pain and comfort.

AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice,

and research NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.1 Discuss what is meant by the experience of pain.

Page Number: p. 520 4. The nurse is caring for a client who had extensive surgery, and is now 6 days postoperative and getting out of bed for the first time later this morning. When the nurse assesses the client for pain, the client responds, "It hurts, but I don't want to take any more drugs. I don't want to end up addicted." Which response by the nurse is the most appropriate?

1. "If you don't take the pain medication on a regular schedule, you won't get addicted."

2. "People who have real pain are unlikely to become addicted to analgesics provided to treat the pain."

3. "You are wise to be concerned, and after 6 days it is probably time to stop taking narcotics if you can manage the pain in other ways."

4. "Don't worry about getting addicted. I will make sure you don't get addicted."

Correct Answer: 2 Rationale 1: Saying that taking pain medication will not cause addiction is not a true statement.

Rationale 2: Many clients worry about becoming addicted to narcotic analgesics if they are required for more than a few days. It is important for the nurse to reassure the client by providing truthful information.

Rationale 3: There is no time limit on the length of time pain medication should be used.

Rationale 4: The nurse cannot control the client’s possible addiction.

Global Rationale: Many clients worry about becoming addicted to narcotic analgesics if they are required for more than a few days. It is important for the nurse to reassure the client by providing truthful information. Saying that taking pain medication will not cause addiction is not a true statement. There is no time limit on the length of time pain medication should be used. The nurse cannot control the client’s possible addiction.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiological models of pain and comfort.

AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.5 Discuss what it means for the nurse to be the client’s advocate in relation to pain control.

Page Number: p. 531 5. The nurse working in a surgical center is caring for a client who had an abdominal nevus removed.

The client is complaining of intense pain. Which action by the nurse is the most appropriate?

1. Administer a nonnarcotic analgesic because the client had minor surgery.

2. Attempt to divert the client without administering an analgesic because the surgery was so minor.

3. Administer the stronger analgesic ordered by the primary care provider.

4. Notify the health care provider that the client's pain is excessive for the minor surgery performed.

Correct Answer: 3 Rationale 1: Clients who have minor surgery can still experience severe pain, and administering weaker analgesics when the client reports severe pain would not be responsible practice.

Rationale 2: Diverting the client most likely will not be effective alone, although diversion might be possible after administering the analgesic.

Rationale 3: Pain perception is what the client says it is, and the nurse should medicate the client based on the client's description of the pain, not what the nurse anticipates. If the client reports severe pain, the nurse should administer strong analgesics.

Rationale 4: There is no need to notify the health care provider unless the nurse's assessment indicates there is something unusual occurring.

Global Rationale: Pain perception is what the client says it is, and the nurse should medicate the client based on the client's description of the pain, not what the nurse anticipates. If the client reports severe pain, the nurse should administer strong analgesics. Clients who have minor surgery can still experience severe pain, and administering weaker analgesics when the client reports severe pain would not be responsible practice. Diverting the client most likely will not be effective alone, although diversion might be possible after administering the analgesic. There is no need to notify the health care provider unless the nurse's assessment indicates there is something unusual occurring.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiological models of pain and comfort.

AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.5 Discuss what it means for the nurse to be the client’s advocate in relation to pain control.

Page Number: p. 531 6. The nurse is working on a surgical unit, and overhears another nurse say, "That client is asking for pain medication again. He is constantly on the call bell, always reporting how severe his pain is, and I think he's just drug-seeking. I'm going to make him wait the full 4 hours before I give this medication again." Which action by the nurse is the most appropriate in this situation?

1. Ignoring the situation because the client in question is not this nurse's responsibility 2. Entering the nurses’ station, reprimanding the nurse, and completing an incident or variance report 3. Pulling the second nurse aside and providing a reminder that the sensation of pain is subjective, and that professionals have a duty to believe clients' reports of their symptoms 4. Informing the charge nurse of what was overheard Correct Answer: 3 Rationale 1: It is every nurse's responsibility to speak up and advocate for the client when situations arise that place the client at risk of incorrect treatment.

Rationale 2: The nurse should address the situation privately, and not in front of others at the nurses’ station.

Rationale 3: It is every nurse's responsibility to speak up and advocate for the client when situations arise that place the client at risk of incorrect treatment.

Rationale 4: Informing the charge nurse would only be necessary if the nurse who was overheard did not respond constructively to the nurse's correction.

Global Rationale: It is every nurse's responsibility to speak up and advocate for the client when situations arise that place the client at risk of incorrect treatment. However, the nurse would

address the situation privately, and not in front of others at the nurses’ station. Informing the charge nurse would only be necessary if the nurse who was overheard did not respond constructively to the nurse's correction.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiological models of pain and comfort.

AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.3 Describe the body’s physiologic response to pain. Page Number: p.

531 7. The nurse is working on the orthopedic unit, and is caring for a client who complains of back pain.

Which responses by the nurse would be appropriate when caring for this client?

Standard Text: Select all that apply.

1. "I'm sorry you're hurting. I want to maNkUeRySoIuNGfeTeBl .bCeOtM ter."

2. "People with back pain experience very different symptoms. Tell me more about your back."

3. "You had medication for your pain at 4 p.m., so I can't give you any more until 8 p.m., because the health care provider ordered it every 4 hours."

4. "Does anything other than your back hurt?"

5. "Why don't you try another position to make it feel better until it's time for more pain medication?"

Correct Answer: 1, 2, 4 Rationale 1: The nurse should inform the client that she will work to make the client feel better.

Rationale 2: The nurse should seek more information about the type of pain the client is experiencing.

Rationale 3: Allowing the client to remain in pain would not be prudent practice, and would be lacking in caring.

Rationale 4: The nurse should question any other discomforts the client may be experiencing.

Rationale 5: Allowing the client to remain in pain would not be prudent practice, and would be lacking in caring.

Global Rationale: The nurse should inform the client that she will work to make the client feel better, seek more information about the type of pain the client is experiencing, and question any other discomforts the client may be experiencing. Allowing the client to remain in pain would not be prudent practice, and would be lacking in caring.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiological models of pain and comfort.

AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.5 Discuss what it means for the nurse to be the client’s advocate in relation to pain control.

Page Number: p. 531 8. The hospice nurse is making a home visit to a client with terminal cancer. The client reports poor pain control and the client's spouse says, " Is' m u c hg i bv i gn gd o s e s of medication, I'm afraid she is going to overdose if I give her more." Which response by the nurse is the most appropriate?

1. "You're wise to be concerned. These are very strong medications you're administering."

2. "You want her to be comfortable but you don't want to endanger her life. Let's talk about the medication you're giving and warning signs you'll see if the dosage you're administering is toohigh."

3. "I hear what you're saying, but you're not giving enough pain medication, so she is in severe pain. You need to give more."

4. "You aren't giving adequate pain relief, and she is in severe pain as a result."

Correct Answer: 2 Rationale 1: Telling the spouse it is wise to be concerned is untrue.

Rationale 2: It is not unusual for a family caregiver to withhold medication out of fear of overdosing the cancer client. It is important for the nurse to inform the caregiver that his feelings

are not unusual, and then provide him with the information he needs to make an informed and appropriate decision that will make the client more comfortable.

Rationale 3: This can make the spouse to feel guilty.

Rationale 4: This can make the spouse to feel guilty.

Global Rationale: It is not unusual for a family caregiver to withhold medication out of fear of overdosing the cancer client. It is important for the nurse to inform the caregiver that his feelings are not unusual, and then provide him with the information he needs to make an informed and appropriate decision that will make the client more comfortable. Telling the spouse it is wise to be concerned is untrue. The nurse should not make the spouse feel guilty for not providing enough pain medication.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiological models of pain and comfort.

AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: NursingNPUrRoScIeNssG: TIBm.CpOleM mentation Learning Outcome: 16.5 Discuss what it means for the nurse to be the client’s advocate in relation to pain control.

Page Number: p. 522 9. The nurse enters the postoperative client's room and finds the client perspiring with fists clenched. As the nurse administers routine medications and provides care, the client is pleasant and cooperative.

Which action by the nurse is the most appropriate?

1. Documenting "no complaints of pain offered" and assessing that the client is comfortable 2. Asking the client if pain is being experienced 3. Informing the client that he looks uncomfortable and asking him to describe his pain 4. Instructing the client to use the call bell if he experiences pain Correct Answer: 3 Rationale 1: The client's body language indicates the likelihood of pain.

Rationale 2: Some clients might feel that admitting to pain is a sign of weakness, and might not bring it up unless the nurse specifically refers to the client's apparent discomfort and asks him to describe his pain and indicates the client's apparent discomfort.

Rationale 3: It is the nurse's responsibility to assess for pain and not wait for the client to mention it.

Rationale 4: Instructing the client to use the call bell puts the responsibility for pain assessment on the client instead of on the nurse.

Global Rationale: It is the nurse's responsibility to assess for pain and not wait for the client to mention it.

Some clients might feel that admitting to pain is a sign of weakness, and might not bring it up unless the nurse specifically refers to the client's apparent discomfort and asks him to describe his pain and indicates the client's apparent discomfort. The client's body language indicates the likelihood of pain. Instructing the client to use the call bell puts the responsibility for pain assessment on the client instead of on the nurse.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiological models of pain and comfort.

AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.11 Describe the behavioral responses to mild versus severe pain.

Page Number: p. 527 10. The nurse is caring for a client who is experiencing acute pain. Which action by the client, noted by the nurse during the assessment, is considered an associated symptom of pain?

1. Changing position 2. Crying 3. Grimacing 4. Vomiting Correct Answer: 4 Rationale 1: Changing position, crying, and grimacing are manners of expressing pain.

Rationale 2: Changing position, crying, and grimacing are manners of expressing pain.

Rationale 3: Changing position, crying, and grimacing are manners of expressing pain.

Rationale 4: Symptoms that are often associated with pain include nausea, vomiting, and dizziness.

Global Rationale: Symptoms that are often associated with pain include nausea, vomiting, and dizziness.

Changing position, crying, and grimacing are manners of expressing pain.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.7 Compare how you would assess quality of pain versus intensity of pain.

Page Number: p. 527 11. The nurse is obtaining a pain history. The client reports pain in the right ear. Which response by the nurse is the most appropriate?

1. "Is the pain minor?"

2. "Do you have anything else that hurts?"

3. "Tell me more about the pain and what you do for it when it hurts."

4. "I'll note that in the record. Is there anything else I should know?"

Correct Answer: 3 Rationale 1: When the client reports pain, the nurse should seek more information. When assessing pain, the nurse should assesss all aspects of the pain, including character, onset, location, duration, exacerbation, relief, and radiation.

Rationale 2: When the client reports pain, the nurse should seek more information. When assessing pain, the nurse should assesss all aspects of the pain, including character, onset, location, duration, exacerbation, relief, and radiation.

Rationale 3: When the client reports pain, the nurse should seek more information. When assessing pain, the nurse should assesss all aspects of the pain, including character, onset, location, duration, exacerbation, relief, and radiation.

Rationale 4: When the client reports pain, the nurse should seek more information. When assessing pain, the nurse should assesss all aspects of the pain, including character, onset, location, duration, exacerbation, relief, and radiation.

Global Rationale: When the client reports pain, the nurse should seek more information. When assessing pain, the nurse should assesss all aspects of the pain, including character, onset, location, duration, exacerbation, relief, and radiation.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.7 Compare how you would assess quality of pain versus intensity of pain.

Page Number: p. 527 12. Pain is a complex phenomenon that affects both the physical and mental areas. When teaching the client about pain, which statement made by the client would indicate appropriate understanding?

1. "Cancer pain usually only lasts a short time."

2. "Acute pain is usually rapid and can vary in intensity."

3. "Chronic pain may be acute, chronic, or intermittent."

4. "Chronic pain usually only lasts a little while."

Correct Answer: 2 Rationale 1: Pain associated with cancer can be both acute and chronic and indicates the need for further education.

Rationale 2: This is one definition of acute pain and shows that the client understands about this type of pain.

Rationale 3: This statement defines cancer pain, not chronic pain, and indicates the need for further education.

Rationale 4: This statement describes acute pain, not chronic pain, and indicates the need for further education.

Global Rationale: Acute pain can be described as rapid and can vary in intensity. This statement indicates an appropriate understanding of the teaching session. The other statements indicate that the client requires further education.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiological models of pain and comfort.

AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 16.1 Discuss what is meant by the experience of pain.

Page Number: p. 518 13. The nurse is instructing the client on how to use the client-controlled analgesia (PCA) pump. Which statement made by the client indicates an appropriate understanding of the nurse’s instructions regarding the S I pN ?G T B . C O M use of the PC AN Up uR m 1. "I will push the button continually until I am pain free."

2. "I will likely overdose on pain medication with the use of the button."

3. "I will let my family control my pain medicine by allowing them to push the button."

4. "I will push the button when the pain becomes severe."

Correct Answer: 4 Rationale 1: Pushing the button continuously will not make the client receive more pain medication. This statement indicates the need for more education.

Rationale 2: The use of a PCA pump actually decreases the likelihood of an overdose. This statement indicates the need for further education.

Rationale 3: The family should not be in control of the client’s pain medication. This statement indicates the need for further education.

Rationale 4: The client is taught to push the button when the pain becomes severe. This statement indicates an appropriate understanding of the teaching session.

Global Rationale: The client is taught to push the button when the pain becomes severe. This statement indicates an appropriate understanding of the teaching session. The other statements indicate the need for more education regarding the use of the PCA pump.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of client values, preferences, and expressed needs AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 16.14 Describe the steps of teaching PCA to a client.

Page Number: p. 533 14. When conducting a pain history, which data is least essential for the nurse to obtain regarding the client’s pain?

1. Intensity, quality, and patterns 2. Precipitating factors, alleviating factors, and associated symptoms 3. Effects on activities of daily living, coping resources, and affective responses 4. Significant other's assessment of the pain Correct Answer: 4 Rationale 1: The nurse should determine all of these factors in order to put a plan of care in place that will help the client address and treat the pain effectively.

Rationale 2: The nurse should determine all of these factors in order to put a plan of care in place that will help the client address and treat the pain effectively.

Rationale 3: The nurse should determine all of these factors in order to put a plan of care in place that will help the client address and treat the pain effectively.

Rationale 4: During a pain history, it is the client's description of the pain that is most important, not the significant other's.

Global Rationale: During a pain history, it is the client's description of the pain that is most important, not the significant other's. The nurse should determine all of the other factors in order to put a plan of care in place that will help the client address and treat the pain effectively.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.7 Compare how you would assess quality of pain versus intensity of pain.

Page Number: p. 527 15. When caring for an older adult client who does not speak English, which assessment tool is the most appropriate for the nurse to use to assess this client’s pain?

1. The FACES rating scale 2. An interpreter 3. The client's affect 4. The client's vital signs Correct Answer: 1 Rationale 1: The FACES rating scale will help the nurse to respond to the client's pain appropriately and quickly.

Rationale 2: An interpreter might not always be readily available.

Rationale 3: Affect might not be accurate indicators of the client's discomfort.

Rationale 4: Vital signs might not be accurate indicators of the client's discomfort.

Global Rationale: An interpreter might not always be readily available, so the FACES rating scale can be used because it is not necessary to use language. If an interpreter is available the nurse can ask the interpreter to discuss the pain in more detail, but the FACES rating scale will help the nurse to respond to the client's pain appropriately and quickly without waiting for an interpreter. Affect and vital signs might not be accurate indicators of the client's discomfort.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering

AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.4 Identify the most important information elicited from the client regarding pain.

Page Number: p. 531 16. An organization is updating the policy for pain management. What should be included in the updated policy that addresses the Joint Commission’s pain management standards? Select all that apply.

1. Complete a baseline pain assessment 2. Monitor the acute pain the client is experiencing 3. Follow guidelines of pharmacologic management 4. Educate client and family about pain management 5. Limit the use of nonpharmacological management Correct Answer: 1, 2, 3, 4 Rationale 1: Guidelines for acute pain management include completing a baseline pain assessment.

Rationale 2: Guidelines for acute pain management include monitoring the acute pain the client is experiencing.

Rationale 3: Guidelines for acute pain management include following guidelines of pharmacologic management.

Rationale 4: Guidelines for acute pain management include educating clients and families about pain management.

Rationale 5: Guidelines for acute pain management include implementing nonpharmacologic management.

Global Rationale: Guidelines for acute pain management include completing a baseline pain assessment, monitoring the acute pain the client is experiencing, following guidelines of pharmacologic management, educating clients and families about pain management, and implementing nonpharmacologic management.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical,

behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 16.6 Discuss the main components of The Joint Commission’s Standards for Pain Management.

Page Number: p. 522 17. A client with intractable acute pain is undecided about the use of epidural pain management. What should the nurse explain about epidural analgesia? Select all that apply.

1. “The chance of becoming addicted to pain medication is lower.”

2. “The effects of pain medication last much longer when this route is used.”

3. “The dose of medication can be lower because it isn’t metabolized in the liver.”

4. “The narcotic moves quickly into the spinal cord and blocks the reception of pain.”

5. “The risk of developing side effects from pain medication is eliminated this route.” Correct Answer: 3, 4 Rationale 1: There is no evidence to support that the chance of being addicted to pain medication is lower using this route.

Rationale 2: There is no evidence to support that the effects of pain medication last much longer when this route is used.

Rationale 3: Administered by this method, the required drug dose is considerably lower because it is not metabolized in the liver.

Rationale 4: With epidural pain control the narcotic moves directly from the epidural space into the spinal fluid and binds with opiate receptors in the spinal cord, blocking reception of pain.

Rationale 5: There is no evidence to support that the risk of developing side effects from pain medication is eliminated through this route.

Global Rationale: Administered by this method, the required drug dose is considerably lower because it is not metabolized in the liver. With epidural pain control the narcotic moves directly from the epidural space into the spinal fluid and binds with opiate receptors in the spinal cord, blocking reception of pain. There is no evidence to support that the chance of being addicted to pain medication is lower using this route, that the effects of pain medication last much longer when this route is used, or that that the risk of developing side effects from pain medication is eliminated through this route.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering

AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.15 Discuss two advantages of epidural narcotic analgesia.

Page Number: p. 524

CHAPTER 17 1. The nurse suspects that a client is experiencing stress. Which observation indicates that the client’s manifestations fit Hans Selye’s definition of this disorder? Select all that apply.

1. Weight gain 2. Loss of appetite 3. Inability to sleep 4. Planning a vacation 5. Increased blood glucose level Correct Answer: 1, 2, 3, 5 Rationale 1: According to Hans Selye, stress is a specific syndrome that consists of all nonspecifically induced changes within the biological system and manifests by measurable changes in the body. Weight gain is a measureable body change.

Rationale 2: According to Hans Selye, stress is a specific syndrome that consists of all nonspecifically induced changes within the biological system and manifests by measurable changes in the body. Loss of appetite is a measureable body change.

Rationale 3: According to Hans Selye, stress is a specific syndrome that consists of all nonspecifically induced changes within the biological system and manifests by measurable changes in the body. Inability to sleep is a measureable body change.

Rationale 4: According to Hans Selye, stress is a specific syndrome that consists of all nonspecifically induced changes within the biological system and manifests by measurable changes in the body. Planning a vacation is not a measureable body change.

Rationale 5: According to Hans Selye, stress is a specific syndrome that consists of all nonspecifically induced changes within the biological system and manifests by measurable changes in the body.

Increased blood glucose level is a measureable body change.

Global Rationale: According to Hans Selye, stress is a specific syndrome that consists of all nonspecifically induced changes within the biological system and manifests by measurable changes in the body. Weight gain, loss of appetite, inability to sleep and increased blood glucose levels are measureable body changes.

Planning a vacation is not a measureable body change.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care: physical comfort and emotional support AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Relationship Centered Care; Practice; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.1 Define the term stress according to Hans Selye. Page Number: p. 546 2. A client is observed in the clinic waiting room bouncing both legs and snapping the fingers. After a short while the client stands and begins to pace. On what should the nurse focus when assessing this client?

1. Level of pain 2. Reason for the anxiety 3. Fear of health problems 4. Frustration with waiting Correct Answer: 2 Rationale 1: The client’s behavior does not indicate pain. Rationale 2: The client’s behavior indicates anxiety.

Rationale 3: The client’s behavior may or may not be because of the fear of a health problem. Rationale 4: The client’s behavior may or may not be caused by frustration with waiting.

Global Rationale: The client’s behavior indicates anxiety. The client’s behavior does not indicate pain. The client’s behavior may or may not be because of the fear of a health problem or frustration with waiting.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care: physical comfort and emotional support AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care; Practice; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.2 Discuss the psychological effect of stress on the body. Page Number: p. 547 3. During an assessment the nurse considers that a client’s new onset of symptoms is because of an increased amount of stress. What did the nurse assess to make this clinical determination? Select all that apply.

1. Sweating

2. Warm dry skin 3. Rapid heart rate 4. Elevated blood pressure 5. Increased depth of respirations Correct Answer: 1, 3, 4, 5 Rationale 1: Stress causes an increase in metabolic rate which can cause sweating.

Rationale 2: Warm dry skin is not a manifestation of stress.

Rationale 3: Stress affects the cardiovascular system, increasing the heart rate. Rationale 4: Stress affects the cardiovascular system, increasing the blood pressure. Rationale 5: Stress affects the respiratory system, increasing the depth of respirations.

Global Rationale: Stress causes an increase in metabolic rate which can cause sweating. Stress affects the cardiovascular system, increasing the heart rate and blood pressure. Stress affects the respiratory system, increasing the depth of respirations. Warm dry skin is not a manifestation of stress.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care: physical comfort and emotional support AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care; Practice; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.3 Describe the body’s physiologic response to stress, and include at least two body systems.

Page Number: p. 546 4. The family of a client undergoing treatment for cancer is concerned about the client’s unwillingness to spend time or talk with any family members. Which category of stress is this client demonstrating?

Select all that apply.

1. Behavioral 2. Physiologic 3. Interpersonal 4. Psychological 5. Developmental

Correct Answer: 1, 3 Rationale 1: The behavioral response is characterized by the individual becoming withdraws or becoming immobilized.

Rationale 2: The physiologic response is manifested as a loss or gain in weight over time, increase in hormone levels and blood pressure or possibly somatoform (psychosomatic) symptoms appears.

Rationale 3: The interpersonal mode can reflect stress when communication effectiveness decreases, relationships deteriorate, trust in others diminishes, and the ability to form and maintain close, intimate, loving ties with another individual decreases.

Rationale 4: The psychological response manifests as depression, mania, or withdrawal from reality.

Rationale 5: Developmental is not a category of stress.

Global Rationale: The behavioral response is characterized by the individual becoming withdraws or becoming immobilized. The interpersonal mode can reflect stress when communication effectiveness decreases, relationships deteriorate, trust in others diminishes, and the ability to form and maintain close, intimate, loving ties with another individual decreases.

The physiologic response is manifested as a loss or gain in weight over time, increase in hormone levels TBa.tCoO and blood pressure or poNssUiRblSyINsGom foMrm (psychosomatic) symptoms appears. The psychological response manifests as depression, mania, or withdrawal from reality.

Developmental is not a category of stress.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care: physical comfort and emotional support AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care; Practice; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.4 List at least three different categories of stressors. Page Number: p. 547 5. After completing an assessment the nurse asks the client questions about stress. What observations caused the nurse to focus on this area of the client’s health? Select all that apply.

1. Hives 2. Neck ache 3. Blurred vision

4. Excessive thirst 5. Heart palpitations Correct Answer: 1, 2, 5 Rationale 1: Hives are a physiological sign of stress. Rationale 2: Neck pain is a physiological sign of stress.

Rationale 3: Blurred vision is not a physiological sign of stress. Rationale 4: Excessive thirst is not a physiological sign of stress. Rationale 5: Heart palpitations are a physiological sign of stress.

Global Rationale: Hives, neck pain, and palpitations are physiological signs of stress. Blurred vision and excessive thirst are not physiological signs of stress.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care: physical comfort and emotional support B . pC rOeM AACN Essential Competencies: IX. 1. CNoUnRdSuIcNt Gc oT m h e n s i v e and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care; Practice; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.5 Identify at least five danger signals of stress. Page Number: p. 548 6. While preparing a care plan the nurse adds interventions to address stress. What behavioral manifestation did the nurse assess to make this decision?

1. Acne 2. Anger 3. Confusion 4. Hair twisting Correct Answer: 4 Rationale 1: Acne is a physiologic indicator of stress. Rationale 2: Anger is a psychological indicator of stress. Rationale 3: Confusion is a psychological indicator of stress.

Rationale 4: Hair twisting is a behavioral indicator of stress.

Global Rationale: Hair twisting is a behavioral indicator of stress. Acne is a physiologic indicator of stress.

Anger and confusion are psychological indicators of stress.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care: physical comfort and emotional support AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care; Practice; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.5 Identify at least five danger signals of stress. Page Number: p. 548 7. A client says that the environment of the health clinic is soothing and relaxing. Which essential oil is the nursing staff most likely using in the diffuser in the waiting room?

1. Rose 2. Lavender 3. Peppermint 4. Lemon and thyme Correct Answer: 2 Rationale 1: Rose oil has a high frequency however is not known to cause relaxation. Rationale 2: Lavender oil is for relaxation or sleep.

Rationale 3: Peppermint oil is used to aid in digestion. Rationale 4: Lemon and thyme oil is used to kill bacteria.

Global Rationale: Lavender oil is for relaxation or sleep. Rose oil has a high frequency however is not known to cause relaxation. Peppermint oil is used to aid in digestion. Lemon and thyme oil is used to kill bacteria.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care: physical comfort and emotional support

AACN Essential Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care NLN Competencies: Relationship Centered Care; Practice; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.6 Discuss a specific alternative method used to control stress. Page Number: p. 551 8. A client scheduled for a mastectomy requests that acupuncture be used instead of anesthesia. What should the nurse respond to this client?

1. “That’s a good idea.”

2. “Let’s talk to your doctor about that.”

3. “No one here in the hospital knows how to do acupuncture.”

4. “Your surgery is considered major and acupuncture will not be effective.” Correct Answer: 2 Rationale 1: The use of acupuncture should be discussed with the client’s healthcare provider.

Rationale 2: The client should discuss the use of acupuncture instead of traditional anesthesia with the healthcare provider.

Rationale 3: A person who is qualified to perform acupuncture can be contacted.

Rationale 4: Since the 1960s in the United States, Chinese doctors, as well as some in the U.S., have performed major surgery with acupuncture as the only anesthetic.

Global Rationale: The client should discuss the use of acupuncture instead of traditional anesthesia with the healthcare provider. A person who is qualified to perform acupuncture can be contacted. Since the 1960s in the United States, Chinese doctors, as well as some in the U.S., have performed major surgery with acupuncture as the only anesthetic.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care: physical comfort and emotional support AACN Essential Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care NLN Competencies: Relationship Centered Care; Practice; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 17.6 Discuss a specific alternative method used to control stress. Page Number: p. 551

9. A client newly diagnosed with heart failure asks what herbal preparations can be taken to help reduce the symptoms of the disorder. What should the nurse consider discussing with the client?

1. Turmeric 2. Green tea 3. Hawthorne 4. Black cohosh Correct Answer: 3 Rationale 1: Turmeric is best used as an anti-inflammatory herb.

Rationale 2: Green tea can be taken as a cancer preventative or detoxification agent.

Rationale 3: A tonic made from berries, hawthorn can be used for a variety of heart disorders— lowering blood pressure, congestive heart failure, angina, and cardiomyopathy.

Rationale 4: Black cohosh helps to maintain normal hormone balance, especially during menopause.

Global Rationale: A tonic made from berries, hawthorn can be used for a variety of heart disorders— lowering blood pressure, congestive heart failure, angina, and cardiomyopathy. Turmeric is best used as an anti-inflammatory herb. Green tea can be taken as a cancer preventative or detoxification agent. Black cohosh helps to maintain normal hormone balance, especially during menopause.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care: physical comfort and emotional support AACN Essential Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care NLN Competencies: Relationship Centered Care; Practice; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 17.7 Discuss complementary and alternative medicine (CAM) and how it can be applied to nursing.

Page Number: p. 553 10. A pregnant client has a friend who used yoga to help prepare for childbirth and asks where to learn how to do this. What should the nurse respond?

1. “Yoga is too strenuous while pregnant.”

2. “Have you asked your friend to teach you?”

3. “There are teachers who can teach you how to do this.”

4. “Yoga is just glorified stretching which you can do on your own.”

Correct Answer: 3 Rationale 1: Yoga is not sport or exercise.

Rationale 2: The friend might not be qualified to teach yoga.

Rationale 3: The best way to begin yoga is to find an experienced teacher who can correct postures and guide the individual through the breathing and relaxation exercises.

Rationale 4: Yoga is more than stretching. It incorporates postures, breathing, and relaxation exercises.

Global Rationale: The best way to begin yoga is to find an experienced teacher who can correct postures and guide the individual through the breathing and relaxation exercises. Yoga is not sport or exercise.

The friend might not be qualified to teach yoga. Yoga is more than stretching. It incorporates postures, breathing, and relaxation exercises.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care: physical comfort and emotional support AACN Essential Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role NinUhReSaINlthGTcaBr.Ce OM NLN Competencies: Relationship Centered Care; Practice; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17.7 Discuss complementary and alternative medicine (CAM) and how it can be applied to nursing.

Page Number: p. 555 11. A client has been doing tai chi and performing visualization to help reduce stress however continues to feel anxious. What dietary changes should the nurse recommend to this client? Select all that apply.

1. Eliminate caffeine products 2. Avoid sugar and carbohydrates 3. Eat more raw fruits and vegetables 4. Limit the use of vitamin supplements 5. Limit protein intake to 10%–15% of consumed calories Correct Answer: 1, 2, 3, 5 Rationale 1: A low-stress diet includes eliminating caffeine products. Rationale 2: A low-stress diet includes avoiding sugar and carbohydrates

Rationale 3: A low-stress diet includes eating more raw fruits and vegetables. Rationale 4: A low-stress diet includes using vitamin supplements.

Rationale 5: A low-stress diet includes limiting protein intake to 10%–15% of consumed calories.

Global Rationale: Consuming a low-stress diet results in more energy and stamina to cope with stress. A low-stress diet includes eliminating caffeine products, avoiding sugar and carbohydrates, eating more raw fruits and vegetables and limiting protein intake to 10%–15% of consumed calories. A low-stress diet includes using vitamin supplements.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care: physical comfort and emotional support AACN Essential Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care NLN Competencies: Relationship Centered Care; Practice; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17.7 Discuss complementary and alternative medicine (CAM) and how it can be applied to nursing.

Page Number: p. 562 12. During a home visit the nurse learns that a client’s daughter is investigating naturopathy to help with the client’s health problem. What should the nurse explain about this alternative therapy approach?

1. Drugs are not used 2. Remedies are prescribed 3. A wide variety of herbs can be used 4. A special instrument is used to measure effectiveness Correct Answer: 1 Rationale 1: Drugs are not used in naturopathy. The naturopathy school of thought believes that diseases are the body’s attempt to heal itself through release of impurities. Treatments are designed to increase the client’s “vital force” by eliminating toxins, thus allowing the body to heal.

Rationale 2: Homeopathy uses remedies to help with illnesses.

Rationale 3: Herbal medicine focuses on the use of herbs to treat diseases. Rationale 4: Biofeedback uses a special instrument to measure effectiveness.

Global Rationale: Drugs are not used in naturopathy. The naturopathy school of thought believes that diseases are the body’s attempt to heal itself through release of impurities. Treatments are designed to increase the client’s “vital force” by eliminating toxins, thus allowing the body to heal. Homeopathy uses remedies to help with illnesses. Herbal medicine focuses on the use of herbs to treat diseases.

Biofeedback uses a special instrument to measure effectiveness.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care: physical comfort and emotional support AACN Essential Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care NLN Competencies: Relationship Centered Care; Practice; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17.8 Choose two alternative therapies, discuss the major components, and relate how you use them with clients.

Page Number: p. 552 13. The nurse is caring for a client with chronic back pain. Which alternative therapy should the nurse recommend to this client?

1. Prayer 2. Chiropractic 3. Herbal medicine 4. Energy medicine Correct Answer: 2 Rationale 1: Prayer is the treatment modality used the most often however it is not specific to treat chronic back pain.

Rationale 2: The focus of chiropractic treatment is general and includes correction of such disorders as headaches; allergies; pain in the back, hip, or spinal column; or gastrointestinal problems.

Rationale 3: Herbal medicine is an alternative therapy however is not specific to the treatment of chronic back pain.

Rationale 4: This contemporary aspect of health views the human body as comprised of electronic vibrations. Interventions involving the energy field will interface with environmental, spiritual, and vibrational aspects of healing however there is no evidence to support its effectiveness with chronic back pain.

Global Rationale: The focus of chiropractic treatment is general and includes correction of such disorders as headaches; allergies; pain in the back, hip, or spinal column; or gastrointestinal problems. Prayer is the treatment modality used the most often however it is not specific to treat chronic back pain. Herbal medicine is an alternative therapy however is not specific to the treatment of chronic back pain. This contemporary aspect of health views the human body as comprised of electronic vibrations. Interventions involving the energy field will interface with environmental, spiritual, and vibrational aspects of healing however there is no evidence to support its effectiveness with chronic back pain.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care: physical comfort and emotional support AACN Essential Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care NLN Competencies: Relationship Centered Care; Practice; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17.8 Choose two alternative therapies, discuss the major components, and relate how you use them with clients.

Page Number: p. 552 14. A client recovering from rape traumaN sUyRnSdI rNoGmTeB.wChOoMexperiences severe anxiety when out of doors in the evening asks about nonpharmacological approaches to reduce stress. What should the nurse include when teaching this client controlled breathing?

1. Follow a pant-blow-pant pattern 2. Breathe in air using an open mouth 3. Sit in a chair that supports the spine 4. Take a deep breath and hold it for 10 seconds Correct Answer: 3 Rationale 1: Counts of 1 through 4 and 1 through 8 are used for controlled breathing. Rationale 2: Air is breathed in through the nose when doing controlled breathing.

Rationale 3: When teaching controlled breathing instruct the client to sit in a chair so that the spine is well supported and straight but not rigid.

Rationale 4: The breath is held for the count of four in controlled breathing.

Global Rationale: When teaching controlled breathing instruct the client to sit in a chair so that the spine is well supported and straight but not rigid. Counts of 1 through 4 and 1 through 8 are used for controlled breathing. Air is breathed in through the nose when doing controlled breathing. The breath is held for the count of four in controlled breathing.

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care: physical comfort and emotional support AACN Essential Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care NLN Competencies: Relationship Centered Care; Practice; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 17.9 Practice breathing techniques and discuss how you would teach this to a client.

Page Number: p. 563 15. A client says that a neighbor buys herbal preparations over the internet because they cost less.

What should the nurse explain about the selection of herbal preparations?

1. All herbal preparations are the same 2. Herbal preparations are not regulated 3. Preparations that cost less are less effective 4. Preparations from out of the country are the best Correct Answer: 2 Rationale 1: All herbal preparations are not the same.

Rationale 2: There is no regulation, standardization, quality control, or even efficacy with herbal preparations.

Rationale 3: There is no evidence to support that preparations that cost less are less effective.

Rationale 4: There is no evidence to support that preparations from out of the country are the best.

Global Rationale: There is no regulation, standardization, quality control, or even efficacy with herbal preparations. All herbal preparations are not the same. There is no evidence to support that preparations that cost less are less effective. There is no evidence to support that preparations from out of the country are the best.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care: physical comfort and emotional support AACN Essential Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Relationship Centered Care; Practice; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17.10 Discuss why herbs could be dangerous. Page Number: p. 555 16. A client takes warfarin for atrial fibrillation. Which herbal preparation should the nurse counsel the client to avoid?

1. Feverfew 2. Echinacea 3. Kava kava 4. Black cohosh Correct Answer: 1 Rationale 1: Feverfew causes excessive thinning of blood (bleeding) when used with blood thinners.

Warfarin is an anticoagulant that should not be taken with this herb.

Rationale 2: Echinacea stimulates the immune system. Rationale 3: Kava kava can cause sedation.

Rationale 4: Black cohosh increases the effects of synthetic hormones.

Global Rationale: Feverfew causes excessive thinning of blood (bleeding) when used with blood thinners.

Warfarin is an anticoagulant that should not be taken with this herb. Echinacea stimulates the immune system. Kava kava can cause sedation. Black cohosh increases the effects of synthetic hormones.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care: physical comfort and emotional support AACN Essential Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care NLN Competencies: Relationship Centered Care; Practice; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17.11 List two herbs that could be dangerous when taken with a specific medication.

Page Number: p. 556 17. A client with gastric ulcers has been taking licorice root. Which finding should suggest to the nurse that the client should stop taking this herbal preparation?

1. Diarrhea

2. Insomnia 3. Dry mouth 4. Elevated blood pressure Correct Answer: 4 Rationale 1: Siberian ginseng causes diarrhea.

Rationale 2: Siberian ginseng causes insomnia.

Rationale 3: St. John’s wort causes a dry mouth.

Rationale 4: A side effect of licorice root is elevated blood pressure.

Global Rationale: A side effect of licorice root is elevated blood pressure. Siberian ginseng causes diarrhea and insomnia. St. John’s wort causes a dry mouth.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care: physical comfort and emotional support AACN Essential Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role NinUhReSaINlthGTcaBr.Ce OM NLN Competencies: Relationship Centered Care; Practice; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.11 List two herbs that could be dangerous when taken with a specific medication.

Page Number: p. 556

CHAPTER 18 1. The health care provider prescribes 1,500 milligrams of medication. The nurse finds tablets in the client's drawer that are 1 gram each. How many tablets should the nurse administer to the client?

Tablets Standard Text: Record the answer rounding to the nearest tenth.

Correct Answer: 1 1/2 (1.5) Rationale: 1,500 mg = 1.5 grams. This conversion is made by moving the decimal point three places to the left. When converting from a smaller measurement (milligrams) to a larger measurement (grams), the decimal point moves to the left; when converting from larger to smaller, the decimal point moves to the right.

Global Rationale: 1,500 mg = 1.5 grams. This conversion is made by moving the decimal point three places to the left. When converting from a smaller measurement (milligrams) to a larger measurement (grams), the decimal point moves to the left; when converting from larger to smaller, the decimal point moves to the right.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18.12 Demonstrate correct calculation and preparation of a complex medication order.

Page Number: p. 576 2. The health care provider prescribes 10 grains of medication. If the medication is calculated in milligrams, how many milligrams should the nurse administer to equal 10 grains? mg Standard Text: Record the answer rounding to the nearest whole number.

Correct Answer: 600

Rationale: There are 60 mg in 1 grain. To administer 10 grains, the nurse calculates 60 mg X 10 grains = 600 mg.

Global Rationale: There are 60 mg in 1 grain. To administer 10 grains, the nurse calculates 60 mg X 10 grains = 600 mg.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18.12 Demonstrate correct calculation and preparation of a complex medication order.

Page Number: p. 576 3. The health care provider prescribes Ampicillin 850 mg PO. The medication is supplied as 1,000 mg per 5 mL. How many mL of med i catiothnewnouurslde administer using the basic formula? mL Standard Text: Record the answer rounding to the nearest hundredth.

Correct Answer: 4.25 Rationale: The desired dose is 850 mg. The dose on hand is 1,000 mg, and the vehicle is 5 mL. The formula is D X V ÷ H, or 850 X 5 ÷ 1,000. 850 X 5 = 4,250 ÷ 1,000 = 4.25 Global Rationale: The desired dose is 850 mg. The dose on hand is 1,000 mg, and the vehicle is 5 mL. The formula is D X V ÷ H, or 850 X 5 ÷ 1,000. 850 X 5 = 4,250 ÷ 1,000 = 4.25 Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and

in all health care settings NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18.12 Demonstrate correct calculation and preparation of a complex medication order.

Page Number: p. 576 4. The nurse receives this order: "Administer Ativan (lorazepam) 0.1 mg IV whenever seizure occurs."

The nurse recognizes this as which type of medication order?

1. Stat order 2. Single order 3. Routine order 4. PRN order Correct Answer: 4 Rationale 1: Stat orders are orders requesting a medication be given immediately.

Rationale 2: It is not a single order because it specifies the medication is to be given "whenever" a seizure occurs, indicating it may be given multiple times.

Rationale 3: Routine orders are given on a regular basis, without condition, and usually on a specific schedule, whether twice per day, every other day, weekly, or any schedule indicated by the medication in question.

Rationale 4: PRN orders are administered only when predetermined circumstances occur, such as pain, seizures, insomnia, and so on, so this is a PRN order to be given only when a seizure occurs.

Global Rationale: PRN orders are administered only when predetermined circumstances occur, such as pain, seizures, insomnia, and so on, so this is a PRN order to be given only when a seizure occurs. Stat orders are orders requesting a medication be given immediately. It is not a single order because it specifies the medication is to be given "whenever" a seizure occurs, indicating it may be given multiple times.

Routine orders are given on a regular basis, without condition, and usually on a specific schedule, whether twice per day, every other day, weekly, or any schedule indicated by the medication in question.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and

processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 18.2 List the seven parts of a medication order. Page Number: p. 571 5. The nurse is caring for a client with dyspnea resulting from pulmonary edema secondary to congestive heart failure. The health care provider is notified, and the nurse receives a verbal order for Lasix 40 mg STAT. Which action by the nurse is the most appropriate?

1. Administer the medication immediately.

2. Clarify the route for administration.

3. Give the medication IV because the client is in distress and rapid effects are needed.

4. Hold the medication until the prescriber comes to the unit to clarify route and sign the order.

Correct Answer: 2 Rationale 1: Administering the drug via the route the nurse determines is operating outside of the scope of nursing practice.

Rationale 2: The nurse must clarify the route of administration because Lasix (furosemide) is generally ordered in different dosages depending on the route of administration.

Rationale 3: Administering the drug via the route the nurse determines is operating outside of the scope of nursing practice.

Rationale 4: Holding the medication would put the client in danger.

Global Rationale: The nurse must clarify the route of administration because Lasix (furosemide) is generally ordered in different dosages depending on the route of administration. Administering the drug via the route the nurse determines is operating outside of the scope of nursing practice. Holding the medication would put the client in danger.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: V.C.1. Value the contributions of standardization/reliability to safety AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and

in all health care settings NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18.2 List the seven parts of a medication order. Page Number: p.

572 6. The nurse identifies the client using two forms of identification. Which methods would be acceptable?

Standard Text: Select all that apply.

1. Ask the client, "Is your name Mr. xyz?"

2. Check the client's identification band.

3. Check the client's room number.

4. Ask the client for the birthdate.

5. Ask the client for the telephone number.

Correct Answer: 2, 4 Rationale 1: Never ask the client if he is "Mr. xyz," because the client might be distracted, might have difficulty speaking English, or might be anxious, leading the client to say "yes" without really listening to the question.

Rationale 2: If the client is admitted to a clinical facility and is wearing an identification band, this can be used to identify the client.

Rationale 3: The client's room number should never be used as an identifier because clients are often moved within the facility, or another client or visitor could be sitting on the client's bed.

Rationale 4: The nurse identifies the client by using some form of personal identifiers, such as birth date.

Rationale 5: The telephone number is not an approved identifier for a client.

Global Rationale: The nurse identifies the client by using some form of personal identifiers, such as the individual’s name, an assigned identification number, or birth date. Telephone number is not an approved identifier for a client. If the client is admitted to a clinical facility and is wearing an identification band, this can be used to identify the client. Never ask the client if he is "Mr. xyz," because the client might be distracted, might have difficulty speaking English, or might be anxious, leading the client to say "yes" without really listening to the question. Instead, ask the client, "What is your name?" because it is less likely to result in misinformation. The

client's room number should never be used as an identifier because clients are often moved within the facility, or another client or visitor could be sitting on the client's bed. Proper client identification is a very important strategy for reducing the risk of medication errors.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18.3 State the “six rights” for administering medications.

Page Number: p. 572 7. The nurse is preparing several medications to administer via nasogastric tube. Which action by the nurse demonstrates correct technique?

1. Administering one medication at a timNeUeRvSeIrNyG1T5Bm utes .CiOnM 2. Giving one medication at a time, flushing the tube with water, and then administering another medication 3. Mixing the medications together and giving them at one time 4. Calling the pharmacy to ask if all of the medications may be safely mixed together Correct Answer: 2 Rationale 1: Giving one medication every 15 minutes is time-consuming and unnecessary if the tubing is flushed between medications.

Rationale 2: The medications should be administered one at a time, flushing the tubing well with water between each medication and after the last medication is administered.

Rationale 3: Medications should not be mixed together because that increases the likelihood of clogging the tubing, even if the pharmacist says they may be mixed.

Rationale 4: Medications should not be mixed together because that increases the likelihood of clogging the tubing, even if the pharmacist says they may be mixed. Delivering one at a time is the safest action.

Global Rationale: The medications should be administered one at a time, flushing the tubing well with water between each medication and after the last medication is administered. Giving one medication every 15 minutes is time-consuming and unnecessary if the tubing is flushed between medications. Medications should not be mixed together because that increases the likelihood of clogging the tubing, even if the pharmacist says they may be mixed. Delivering one at a time is the safest action.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18.11 Outline steps used when preparing parenteral medications.

Page Number: p. 586 8. Which nursing action should be questioned when applying a transdermal medication patch?

1. Removing the old patch prior to placinNgUtRhSeINnew atOchM GTBp.C 2. Donning gloves prior to administering the medication 3. Applying the patch to the same area where the old patch was removed 4. Cleansing the site where the patch is to be applied with soap and water Correct Answer: 3 Rationale 1: The old patch should be removed prior to placing the new patch in order to avoid the risk of forgetting and having two patches in place with the same medication.

Rationale 2: The nurse should wear gloves when working with transdermal patches to avoid getting medication on the skin.

Rationale 3: Transdermal patches should always be applied to a different area in order to improve absorption of the medication.

Rationale 4: The site where the new patch will go should be cleaned to prevent oils from interfering with adherence of the patch.

Global Rationale: Transdermal patches should always be applied to a different area in order to improve absorption of the medication. The old patch should be removed prior to placing the new

patch in order to avoid the risk of forgetting and having two patches in place with the same medication.

The nurse should wear gloves when working with transdermal patches to avoid getting medication on her skin. The site where the new patch will go should be cleaned to prevent oils from interfering with adherence of the patch.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18.6 Outline steps for applying a transdermal medication.

Page Number: p. 590 9. The nurse receives a written order for ophthalmic medication to be administered OU to an adult client. Which action by the nurse when administering this medication is the most appropriate?

1. Pulling the pinna up and back, and d roNpUpRinSgI Nt Gh eT Bm. Ce Od iMcation into the left ear 2. Pulling the pinna down and forward, and dropping the medication into both ears 3. Exposing the lower conjunctival sac of the left eye, and dropping the medication into the sac 4. Exposing the lower conjunctival sac of both eyes, and dropping the medication into the sac Correct Answer: 4 Rationale 1: OU stands for both eyes, so the medication should be administered into the conjunctival sac of both eyes.

Rationale 2: OU stands for both eyes, so the medication should be administered into the conjunctival sac of both eyes.

Rationale 3: OU stands for both eyes, so the medication should be administered into the conjunctival sac of both eyes.

Rationale 4: OU stands for both eyes, so the medication should be administered into the conjunctival sac of both eyes.

Global Rationale: OU stands for both eyes, so the medication should be administered into the conjunctival sac of both eyes.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18.8 Describe steps for instilling eyedrops. Page Number: p.

591 10. When administering otic drops, which action by the nurse when pulling the pinna is the most appropriate?

1. Down and back for the child under 3 years of age 2. Down and back for the adult client 3. Down and back for the child under 5 years of age 4. Up and back for the child under 3 yearNsUoRfSaIgNeGTB.COM Correct Answer: 1 Rationale 1: The pinna is pulled down and back for the child under 3 years of age, and up and back for the adult or child over 3 years of age, in order to straighten the ear canal.

Rationale 2: The pinna is pulled down and back for the child under 3 years of age, and up and back for the adult or child over 3 years of age, in order to straighten the ear canal.

Rationale 3: The pinna is pulled down and back for the child under 3 years of age, and up and back for the adult or child over 3 years of age, in order to straighten the ear canal.

Rationale 4: The pinna is pulled down and back for the child under 3 years of age, and up and back for the adult or child over 3 years of age, in order to straighten the ear canal.

Global Rationale: The pinna is pulled down and back for the child under 3 years of age, and up and back for the adult or child over 3 years of age, in order to straighten the ear canal.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an

understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18.10 Contrast the procedure for instilling ear medication in adults and children.

Page Number: p. 593 11. The nurse is teaching the client to use a metered-dose inhaler. Which information should the nurse provide to the client?

1. Take a deep breath, hold it, and then gently squeeze the inhaler to dispense the medication.

2. Take several slow deep breaths in through the nose and out through the mouth, then squeeze the inhaler while taking a deep breath.

3. Exhale comfortably, squeeze the canister to discharge the medication, and inhale slowly and deeply through the mouth, then hold the breath for 10 seconds, or as long as possible.

4. Exhale deeply, squeeze the canister to discharge the medication, and inhale slowly and deeply through the mouth, then hold the breath for 10 seconds, and exhale through the nose.

Correct Answer: 3 Rationale 1: The client should be taught to breathe normally, exhale comfortably, then take a deep slow breath through the mouth while dispensing the medication. Holding the breath for 10 seconds allows the medication to reach deeper airways. The client then breathes out through the mouth with the lips pursed.

Rationale 2: The client should be taught to breathe normally, exhale comfortably, then take a deep slow breath through the mouth while dispensing the medication. Holding the breath for 10 seconds allows the medication to reach deeper airways. The client then breathes out through the mouth with the lips pursed.

Rationale 3: The client should be taught to breathe normally, exhale comfortably, then take a deep slow breath through the mouth while dispensing the medication. Holding the breath for 10 seconds allows the medication to reach deeper airways. The client then breathes out through the mouth with the lips pursed.

Rationale 4: The client should be taught to breathe normally, exhale comfortably, then take a deep slow breath through the mouth while dispensing the medication. Holding the breath for 10 seconds allows the medication to reach deeper airways. The client then breathes out through the mouth with the lips pursed.

Global Rationale: The client should be taught to breathe normally, exhale comfortably, then take a deep slow breath through the mouth while dispensing the medication. Holding the breath for 10 seconds allows the medication to reach deeper airways. The client then breathes out through the mouth with the lips pursed.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18.7 List factors to assess before applying medications to the skin or mucous membranes.

Page Number: p. 599 12. The nurse is preparing to administer an intradermal medication. Which item will form to indicate the medication was injected at the proper depth?

1. Diluent 2. Wheel 3. Wheal 4. Blister Correct Answer: 3 Rationale 1: A diluent is the solution used to mix powdered medication into an injectable form.

Rationale 2: Wheel is a round item used on a bicycle or motor vehicle.

Rationale 3: A wheal, or small raised area, forms when an intradermal medication is injected at the proper depth.

Rationale 4: The wheal resembles a blister, but this would be incorrect terminology.

Global Rationale: A wheal, or small raised area, forms when an intradermal medication is injected at the proper depth. A diluent is the solution used to mix powdered medication into an injectable form. Wheel is a round item used on a bicycle or motor vehicle. The wheal resembles a blister, but this would be incorrect terminology.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical ComportmentValue evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 18.14 List four important factors to assess when administering parenteral medications.

Page Number: p. 610 13. The nurse is attempting to withdraw 1 mL of fluid into a 3 mL syringe, and is pulling on the plunger.

The fluid is not flowing into the syringe, and the nurse has withdrawn the plunger to the 2.5 mL line. Which action should the nurse take to correct this problem?

1. Change the needle because the current needle is clogged.

2. Inject air into the vial and draw out the remaining fluid.

3. Throw the vial away and obtain a new one, because this one is defective.

4. Obtain a larger syringe to withdraw the medication.

Correct Answer: 2 Rationale 1: It is unlikely the needle is clogged.

Rationale 2: The nurse should inject air into the vial equal to the amount of medication to be withdrawn, because a vacuum might exist within the vial that will not allow fluid to flow.

Rationale 3: Throwing the vial away is unnecessary, and the nurse is likely to find the same problem when trying the next vial.

Rationale 4: A larger syringe is not the best option for correcting the problem, because the vacuum within the vial will still exist.

Global Rationale: The nurse should inject air into the vial equal to the amount of medication to be withdrawn, because a vacuum might exist within the vial that will not allow fluid to flow. If this does not correct the problem, the nurse might need a larger-gauge needle if the fluid is viscous, but it is unlikely the needle is clogged. Throwing the vial away is unnecessary, and the nurse is likely to find the same problem when trying the next vial. A larger syringe is not the best option for correcting the problem, because the vacuum within the vial will still exist.

Cognitive Level: Analyzing

Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18.14 List four important factors to assess when administering parenteral medications.

Page Number: p. 607 14. The nurse is preparing medication that is packaged in an ampule. Which are appropriate nursing actions when preparing this medication?

Standard Text: Select all that apply.

1. Using a filter needle when administering the injection to the client 2. Using gauze when opening the ampule 3. Tapping the neck of the ampule to d roNpUaRl lS m I NeGdTicBa. Ct iOonM i n t o the body of the ampule prior to opening it 4. Checking the expiration date on the ampule 5. Wiping the container with an antimicrobial prior to opening the ampule Correct Answer: 2, 3, 4, 5 Rationale 1: Although the nurse will use a filter needle when withdrawing the medication from the ampule, this will be exchanged for a needle prior to injecting the medication.

Rationale 2: Appropriate nursing actions when preparing a medication from an ampule include using gauze when opening the ampule to prevent accidental laceration of the nurse’s finger.

Rationale 3: Appropriate nursing actions when preparing a medication from an ampule include tapping the neck of the ampule in order to clear the neck of all medication to prevent losing some when the ampule is opened.

Rationale 4: Appropriate nursing actions when preparing a medication from an ampule include checking the expiration date on the ampule to be sure the medication is not expired.

Rationale 5: Appropriate nursing actions when preparing a medication from an ampule include wiping the outside of the container with an antimicrobial prior to opening in order to prevent contamination of the fluid once the ampule is opened.

Global Rationale: Appropriate nursing actions when preparing a medication from an ampule include using gauze when opening the ampule to prevent accidental laceration of the nurse’s finger; tapping the neck of the ampule in order to clear the neck of all medication to prevent losing some when the ampule is opened; checking the expiration date on the ampule to be sure the medication is not expired; and wiping the outside of the container with an antimicrobial prior to opening in order to prevent contamination of the fluid once the ampule is opened. Although the nurse will use a filter needle when withdrawing the medication from the ampule, this will be exchanged for a needle prior to injecting the medication.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18.14 List four i m pNoUr tRaSnI tNfGa Tc tBo. rCsOt M o assess when administering parenteral medications.

Page Number: p. 609 15. The nurse observes the student administer heparin subcutaneously into the client's abdomen. Which action indicates the need for further teaching?

1. The student determines the site by placing two fingers above the umbilicus and injecting the medication above the fingers.

2. The student cleans the site, wiping in a circular motion with an antimicrobial wipe.

3. The student uses a 25 gauge needle.

4. The student inserts the needle at a 90° angle.

Correct Answer: 1 Rationale 1: The proper location for injecting into the abdominal site is at least 2 inches away from the umbilicus and above the level of the ileac crests. The other actions are correct.

Rationale 2: The proper location for injecting into the abdominal site is at least 2 inches away from the umbilicus and above the level of the ileac crests. The other actions are correct.

Rationale 3: The proper location for injecting into the abdominal site is at least 2 inches away from the umbilicus and above the level of the ileac crests. The other actions are correct.

Rationale 4: The proper location for injecting into the abdominal site is at least 2 inches away from the umbilicus and above the level of the ileac crests. The other actions are correct.

Global Rationale: The proper location for injecting into the abdominal site is at least 2 inches away from the umbilicus and above the level of the ileac crests. The other actions are correct.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18.14 List four important factors to assess when administering parenteral medications.

Page Number: p. 611 16. A client is prescribed NovoLog 70/30 15 units subcutaneous injection AC every morning. At which time should the nurse provide this medication?

1. 15 minutes before breakfast 2. 15 minutes after eating breakfast 3. Immediately after morning report 4. Prior to completing the bath and linen change Correct Answer: 1 Rationale 1: NovoLog 70/30 should be administered within 15 minutes before eating. Rationale 2: AC means before eating. PC means after eating.

Rationale 3: The insulin should be administered according to the time the breakfast meal is provided.

Rationale 4: The insulin is given before breakfast. Waiting until the bath and bed are changed is too late.

Global Rationale: NovoLog 70/30 should be administered within 15 minutes before eating. AC means before eating. PC means after eating. The insulin should be administered according to the

time the breakfast meal is provided. The insulin is given before breakfast. Waiting until the bath and bed are changed is too late.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18.13 Compare insulin types, their onset, peak, and duration of action.

Page Number: p. 614 17. The nurse is preparing to provide an intramuscular injection. For which reason should the nurse use the Z-track technique?

1. Takes less time 2. Is an easier method 3. Prevents leakage into subcutaneous tissue 4. Able to use the deltoid muscle for the injection Correct Answer: 3 Rationale 1: The Z-track is not used because it takes less time.

Rationale 2: The Z-track is not used because it is an easier method.

Rationale 3: The Z-track method creates tissue displacement and forms a track that keeps medication from seeping into subcutaneous tissue.

Rationale 4: The Z-track method is recommended for administering medications into the ventrogluteal or vastus lateralis sites.

Global Rationale: The Z-track method creates tissue displacement and forms a track that keeps medication from seeping into subcutaneous tissue. The Z-track is not used because it takes less time or because it is an easier method. The Z-track method is recommended for administering medications into the ventrogluteal or vastus lateralis sites.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes

AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18.16 Describe the Z-track method of intramuscular injection.

Page Number: p. 622

CHAPTER 19 1. The nurse is caring for a client with mild dysphagia. Which diet should the nurse anticipate being prescribed for this client?

1. Clear liquids 2. Full liquids 3. Pureed diet 4. Regular diet Correct Answer: 3 Rationale 1: The client with mild dysphagia might do best on a pureed diet because it has some substance to it, allowing the client to swallow it more easily than a regular diet while not being as thin and difficult to swallow as a clear or full-liquid diet.

Rationale 2: The client with mild dysphagia might do best on a pureed diet because it has some substance to it, allowing the client to swallow it more easily than a regular diet while not being as thin and difficult to swallow as a clear or full-liquid diet.

Rationale 3: The client with mild dysphagia might do best on a pureed diet because it has some substance to it, allowing the client to swallow it more easily than a regular diet while not being as thin and difficult to swallow as a clear or full-liquid diet.

Rationale 4: The client with mild dysphagia might do best on a pureed diet because it has some substance to it, allowing the client to swallow it more easily than a regular diet while not being as thin and difficult to swallow as a clear or full-liquid diet.

Global Rationale: The client with mild dysphagia might do best on a pureed diet because it has some substance to it, allowing the client to swallow it more easily than a regular diet while not being as thin and difficult to swallow as a clear or full-liquid diet.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 19.5 Identify clients who are candidates for modified diets.

Page Number: p. 646 2. The nurse working in an oncology clinic is caring for a client diagnosed with breast cancer. The client reports anorexia and weight loss. The client's serum albumin is low, and there is visible muscle and fat wasting. Which term should the nurse use when documenting this client’s appearance?

1. Malnutrition 2. Undernutrition 3. Overnutrition 4. Protein-calorie malnutrition Correct Answer: 4 Rationale 1: Although this client has a form of malnutrition, or undernutrition, it is best described as protein-calorie malnutrition, which can result in longer hospital stays and increased complications.

Rationale 2: Although this client has a form of malnutrition, or undernutrition, it is best described as proteincalorie malnutritionN, UwRhSicINhGcTaBn .CreOsuMlt in longer hospital stays and increased complications.

Rationale 3: Although this client has a form of malnutrition, or undernutrition, it is best described as protein-calorie malnutrition, which can result in longer hospital stays and increased complications. This client does not have overnutrition.

Rationale 4: Although this client has a form of malnutrition, or undernutrition, it is best described as protein-calorie malnutrition, which can result in longer hospital stays and increased complications.

Global Rationale: Although this client has a form of malnutrition, or undernutrition, it is best described as protein-calorie malnutrition, which can result in longer hospital stays and increased complications. This client does not have overnutrition.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.3 Identify the categories important for a total nutritional assessment.

Page Number: p. 664 3. The responsibility for nutritional assessment and support in most health care facilities belongs to which individuals?

Standard Text: Select all that apply.

1. The client 2. The primary care provider 3. The nurse 4. The dietitian or nutritionist 5. The food service staff Correct Answer: 2, 3, 4 Rationale 1: The client should be involved in the nutritional plan of care, but is not responsible for assessment.

Rationale 2: The responsibility for nutritional assessment and support in most health care facilities belongs to the primary care provider.

Rationale 3: The responsibility for nutritional assessment and support in most health care facilities belongs to the nurse.

Rationale 4: The responsibility for nutritional assessment and support in most health care facilities belongs to the dietitian.

Rationale 5: Food service staff serve trays on the floor, and may assist clients to complete their menu order, but do not assess clients.

Global Rationale: The responsibility for nutritional assessment and support in most health care facilities belongs to the primary care provider, the nurse, and the dietitian. The client should be involved in the nutritional plan of care, but is not responsible for assessment. Food service staff serve trays on the floor, and may assist clients to complete their menu order, but do not assess clients.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.C.3. Value the concept of EBP as integral to determining best clinical

practice AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.3 Identify the categories important for a total nutritional assessment.

Page Number: p. 648 4. When assessing the client's nutritional status and needs, which type of assessment is the most important for the nurse to use?

1. A complete nutritional assessment 2. A nutritional screening 3. A comprehensive nutritional assessment 4. An in-depth nutritional assessment Correct Answer: 2 Rationale 1: Nurses generally perform aNnUuRtrSiItiNoGnTaBl .sCcOr eMe n i n g , whereas the other types of nutritional assessments are completed by the nutritionist.

Rationale 2: Nurses generally perform a nutritional screening, whereas the other types of nutritional assessments are completed by the nutritionist.

Rationale 3: Nurses generally perform a nutritional screening, whereas the other types of nutritional assessments are completed by the nutritionist.

Rationale 4: Nurses generally perform a nutritional screening, whereas the other types of nutritional assessments are completed by the nutritionist.

Global Rationale: Nurses generally perform a nutritional screening, whereas the other types of nutritional assessments are completed by the nutritionist.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.C.3. Value the concept of EBP as integral to determining best clinical practice AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based

approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.3 Identify the categories important for a total nutritional assessment.

Page Number: p. 636 5. Which client would benefit from a clear liquid diet?

1. The client recovering from vomiting and diarrhea 2. The client experiencing malnutrition 3. The client requiring increased protein intake 4. The client with a newly placed gastrostomy tube Correct Answer: 1 Rationale 1: The clear liquid diet is a short-term diet ideal for clients after surgeries or in acute stages of infection, particularly of the GI tract.

Rationale 2: The diet does not supply adequate protein, fat, vitamins, minerals, or calories, so it would not be appropriate for a client with malnutrition.

Rationale 3: The diet does not supply adequate protein, fat, vitamins, minerals, or calories, so it would not be appropriate for a client with reduced protein intake.

Rationale 4: If the client had a gastrostomy tube placed, it would be anticipated that feedings would be via the tube, and would not be placed on a clear liquid diet.

Global Rationale: The clear liquid diet is a short-term diet ideal for clients after surgeries or in acute stages of infection, particularly of the GI tract. The diet does not supply adequate protein, fat, vitamins, minerals, or calories, so it would not be appropriate for a client with malnutrition or reduced protein intake. If the client had a gastrostomy tube placed, it would be anticipated that feedings would be via the tube, and would not be placed on a clear liquid diet.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.C.3. Value the concept of EBP as integral to determining best clinical practice AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 19.9 Outline the steps of administering a tube feeding.

Page Number: p. 645 6. The nurse admits an older adult client, who reports following a full liquid diet over the past 3 months.

The nurse anticipates this client will have which problems?

1. Low serum iron and high serum albumin 2. Low serum iron and high serum potassium 3. Low serum iron and serum albumin, high serum cholesterol 4. Low serum cholesterol and high serum albumin Correct Answer: 3 Rationale 1: The full liquid diet is low in iron, protein, and calories, and is high in cholesterol content because of the amount of milk consumed. As a result, serum iron and serum albumin would be expected to be low, whereas serum cholesterol would be anticipated to be high.

Rationale 2: The full liquid diet is low in iron, protein, and calories, and is high in cholesterol content because of the amount of milk consumed. As a result, serum iron and serum albumin would be expected to be low, whereas serum cholesterol would be anticipated to be high.

Rationale 3: The full liquid diet is low in iron, protein, and calories, and is high in cholesterol content because of the amount of milk consumed. As a result, serum iron and serum albumin would be expected to be low, whereas serum cholesterol would be anticipated to be high.

Rationale 4: The full liquid diet is low in iron, protein, and calories, and is high in cholesterol content because of the amount of milk consumed. As a result, serum iron and serum albumin would be expected to be low, whereas serum cholesterol would be anticipated to be high.

Global Rationale: The full liquid diet is low in iron, protein, and calories, and is high in cholesterol content because of the amount of milk consumed. As a result, serum iron and serum albumin would be expected to be low, whereas serum cholesterol would be anticipated to be high.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.C.3. Value the concept of EBP as integral to determining best clinical practice AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19.6 List foods that are restricted or supplemented for clients who are receiving modified diets.

Page Number: p. 645 7. The nurse is caring for an older adult client who is weak and has not been eating due to lack of strength.

Which task could the nurse safely delegate to unlicensed assistive personnel (UAP)?

1. Completing a nutritional screening 2. Determining why the client is feeling weak 3. Using therapeutic communication with the client to determine if psychosocial factors are influencing the ability to eat 4. Assisting the client with eating meals Correct Answer: 4 Rationale 1: Nutritional screening is completed by the nurse.

Rationale 2: Assessment for cause of weakness is completed by the nurse.

Rationale 3: Therapeutic communicationN UisRaSInNuGrsi teMchnique.

TBn.gCO Rationale 4: The UAP can assist the client to eat, but should be taught to encourage the client to do as much as possible for himself.

Global Rationale: The UAP can assist the client to eat, but should be taught to encourage the client to do as much as possible for himself. Nutritional screening, assessment for cause of weakness, and therapeutic communication are roles for the nurse, not the UAP. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Practice; Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 19.4 Discuss feeding techniques and precautions used for dysphagic clients.

Page Number: p. 675 8. The nurse is assisting the client to eat. Which action by the nurse is the most appropriate?

1. Sitting on the side of the bed while feeding the client 2. Telling the client to sit back and relax while the nurse does all the work 3. Asking what the client would like to eat or drink next 4. Feeding the client quickly to decrease the feeling of being a burden Correct Answer: 3 Rationale 1: Although the nurse should sit at the bedside, it is not appropriate to sit on the bed.

Rationale 2: Each client should be encouraged to participate to the fullest extent possible to increase autonomy.

Rationale 3: The nurse should consult the client regarding which food or drink that client would like to eat next.

Rationale 4: The nurse should set an unhurried pace when feeding the client to reduce feelings of dependence.

Global Rationale: The nurse should consult the client regarding which food or drink that client would like to eat next. Although the nurse should sit at the bedside, it is not appropriate to sit on the bed. Each client should be encourag eNdUt Ro SpI NarGtiTcBip. CatOeMto the fullest extent possible to increase autonomy. The nurse should set an unhurried pace when feeding the client to reduce feelings of dependence.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19.4 Discuss feeding techniques and precautions used for dysphagic clients.

Page Number: p. 640 9. The nurse is inserting a small-bore nasogastric tube. Which action by the nurse is appropriate when completing this procedure?

1. Removing the stylet prior to inserting the tube into the client's nose

2. Measuring from the tip of the client's nose to the xiphoid process to determine length of tube to be inserted 3. Checking the nares for patency prior to passing the catheter 4. Applying sterile gloves before beginning the procedure Correct Answer: 3 Rationale 1: The stylet should remain in place when passing a small-bore tube in order to provide some rigidity to the flexible catheter.

Rationale 2: The length of tube to be inserted is measured from the tip of the nose to the pinna and then to the xiphoid process.

Rationale 3: The nurse should check the nares for patency before passing the catheter, to check for any obstructions or irregularities.

Rationale 4: Sterile gloves are not required.

Global Rationale: The nurse should check the nares for patency before passing the catheter, to check for any obstructions or irregularities. The stylet should remain in place when passing a small-bore tube in order to provide some rigidity to the flexible catheter. The length of tube to be inserted is measured from the tip of the nNoUsRe StoINtGhTeBp.iCnOnM a and then to the xiphoid process. Sterile gloves are not required.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19.7 Outline steps for inserting a nasogastric tube. Page Number: p.

669 10. When discontinuing the nasogastric tube, the nurse instructs the client to complete which action?

1. Cough 2. Take a deep breath and hold it

3. Hold very still 4. Breathe deeply in through the nose and out through the mouth Correct Answer: 2 Rationale 1: Coughing serves no useful purpose.

Rationale 2: The client should be taught to take a deep breath and hold it to avoid any stomach contents from entering the lungs as the tube is withdrawn.

Rationale 3: Holding still serves no useful purpose.

Rationale 4: Breathing deeply serves no useful purpose.

Global Rationale: The client should be taught to take a deep breath and hold it to avoid any stomach contents from entering the lungs as the tube is withdrawn. Coughing, holding still, and breathing deeply are not indicated, because they serve no useful purpose.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice NGTB.COM AACN Essential Competencies: IX.3. NImUpRlSeIm ent holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19.7 Outline steps for inserting a nasogastric tube. Page Number: p.

660 11. The nurse administering a bolus tube feeding inserts a 60 mL syringe into the tube. After pouring formula into the syringe, where should the nurse hold the syringe?

1. 1–3 inches above the ostomy opening 2. 3–6 inches above the ostomy opening 3. 12-18 inches above the ostomy opening 4. 12 inches above the ostomy opening Correct Answer: 3

Rationale 1: Administer feeding no higher than 18 in. above client’s stomach, allowing formula to flow slowly by gravity.

Rationale 2: Administer feeding no higher than 18 in. above client’s stomach, allowing formula to flow slowly by gravity.

Rationale 3: Administer feeding no higher than 18 in. above client’s stomach, allowing formula to flow slowly by gravity.

Rationale 4: Administer feeding no higher than 18 in. above client’s stomach, allowing formula to flow slowly by gravity.

Global Rationale: Administer feeding no higher than 18 in. above client’s stomach, allowing formula to flow slowly by gravity..

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and SafetyN: UKRnSoI NwGleTdBg. eC;OCMurren t best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19.9 Outline the steps of administering a tube feeding. Page Number: p.

666 12. The nurse is checking the client's nasogastric tube for placement prior to administering the client’s first tube feeding. Which is the most accurate means of assessing placement?

1. Checking the pH of stomach contents aspirated from the tube 2. Infusing air into the tube and auscultating for the sound of the air over the stomach 3. Obtaining an x-ray 4. Checking for residual Correct Answer: 3 Rationale 1: Checking pH of stomach contents is the most cost-effective means of assessing placement, and minimizes the client's exposure to radiation.

Rationale 2: Infusing air and auscultating are not an accurate means of checking placement, because a tube that is high in the esophagus will still sound as though it is properly placed.

Rationale 3: The most accurate means of assessing placement prior to the first tube feeding is obtaining an xray, because this ensures exact location of the tube.

Rationale 4: Checking for residual is also a useful means of assessing placement, but not as accurate as an x-ray.

Global Rationale: The most accurate means of assessing placement prior to the first tube feeding is obtaining an x-ray, because this ensures exact location of the tube. Checking pH of stomach contents is the most cost-effective means of assessing placement, and minimizes the client's exposure to radiation.

Infusing air and auscultating are not an accurate means of checking placement, because a tube that is high in the esophagus will still sound as though it is properly placed. Checking for residual is also a useful means of assessing placement, but not as accurate as an x-ray.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: NursingNPUrRoScIeNssG: TIBm.CpOleM mentation Learning Outcome: 19.8 Describe ways to determine placement of a nasogastric/intestinal tube.

Page Number: p. 669 13. Which clients should the nurse consider as candidates for an enteral access device?

Standard Text: Select all that apply.

1. The client who is NPO in preparation for surgery 2. The client with an absent cough and gag reflex 3. The postoperative client who returns to the unit following bowel resection who is unconscious secondary to sedation 4. The client who needs stomach contents sent for laboratory analysis 5. The client who overdosed on an oral medication Correct Answer: 3, 4, 5 Rationale 1: The client who is NPO in preparation for surgery would not require an enteral access device at this time.

Rationale 2: The client with an absent cough and gag reflex should not have a nasogastric tube inserted, because there would be no indication if it was displaced.

Rationale 3: Indications for enteral access devices include a route for feeding the client to preventing nausea, vomiting, and gastric distention following surgery.

Rationale 4: Indications for enteral access devices include removing contents for laboratory analysis.

Rationale 5: Indications for enteral access devices include lavaging the stomach following poisoning or overdose of medication.

Global Rationale: Indications for enteral access devices include a route for feeding the client to prevent nausea, vomiting, and gastric distention following surgery; removing contents for laboratory analysis; and lavaging the stomach following poisoning or overdose of medication.

The client who is NPO in preparation for surgery would not require an enteral access device at this time.

The client with an absent cough and gag reflex should not have a nasogastric tube inserted, because there would be no indication if it was displaced.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN NeGnTtBh.C Essential Competencies: IX.3. NImUpRlSeIm olOisMtic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 19.7 Outline steps for inserting a nasogastric tube.

Page Number: p. 640 14. The nurse is caring for a client who has no cough or gag reflex and is unable to take nutrients orally.

Which device would be an appropriate choice for providing nutrition to this client?

1. A nasogastric tube 2. An orogastric tube 3. A nasoenteric tube 4. A jejunostomy tube Correct Answer: 4

Rationale 1: The client with an absent cough and gag reflex should not have a nasal tube placed, because of the risk of aspiration.

Rationale 2: The client with an absent cough and gag reflex should not have an oral tube placed, because of the risk of aspiration.

Rationale 3: The client with an absent cough and gag reflex should not have a nasal tube placed, because of the risk of aspiration.

Rationale 4: A jejunostomy tube would be a safe choice, because of the reduced risk of reflux into the esophagus.

Global Rationale: The client with an absent cough and gag reflex should not have an oral or nasal tube placed, because of the risk of aspiration. However, a jejunostomy tube would be a safe choice, because of the reduced risk of reflux into the esophagus.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 19.12 Compare and contrast aspects of gastric versus intestinal tube feedings.

Page Number: p. 641 15. The nurse is preparing to administer medications via a client’s nasogastric feeding tube that was inserted 4 weeks ago. When attempting to flush the tube, the nurse realizes that the tube is clogged.

Which action by the nurse is the priority?

1. Using coke to unclog the tube 2. Giving the medication orally 3. Using ice water to irrigate the tube 4. Replacing the current tube with a new one Correct Answer: 4 Rationale 1: Using coke to unclog the tube is not recommended.

Rationale 2: Clients with nasogastric tubes are often unable to take anything by mouth, so administering the medications orally is not a realistic option.

Rationale 3: Tepid water should be used to irrigate the tube, if needed.

Rationale 4: Nasogastric tubes should be replaced every 4 weeks. The nurse should replace the tube so that the medications can be administered in a timely fashion.

Global Rationale: The nurse should replace the tube so that the medications can be administered in a timely fashion. Using coke to unclog the tube or ice water to irrigate the tube are not recommended. Tepid water should be used to irrigate the tube, if needed. Clients with nasogastric tubes are often unable to take anything by mouth, so administering the medications orally is not a realistic option.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and SafetyN: UKRnSoI NwGleTdBg. eC;OCMurren t best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19.13 Discuss problems that may occur with tube feedings.

Page Number: p. 673 16. A client with a massive sacral wound is prescribed a 2800 calorie diet. Of these calories 55% are to be carbohydrates and 25% fats. How many calories should the client ingest of protein? Calculate to the nearest whole number.

Correct Answer: 560 calories Rationale: The nurse should determine the percentage of protein by adding the carbohydrate and fat percentages or 55 + 25 = 80. Subtract this total from 100 or 100 – 80 = 20. Then multiply the total caloric intake by 20% or 2800 x 20% = 560 calories.

Global Rationale: The nurse should determine the percentage of protein by adding the carbohydrate and fat percentages or 55 + 25 = 80. Subtract this total from 100 or 100 – 80 = 20. Then multiply the total caloric intake by 20% or 2800 x 20% = 560 calories.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice

AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19.1 List the essential nutrients necessary to sustain life.

Page Number: p. 645 17. A client is prescribed to receive enteral feedings to begin at 25 mL/hr 2 4 hours, 50 mL/hr x 2 hours, 75 mL/hr x 2 hours, and 100 mL/hr x 2 hours. In order to prepare the feeding bag for the entire 8 hour shift, how many mL of tube feeding should the nurse place in the feeding bag? Calculate to the nearest whole number.

Correct answer: 500 mL Rationale: The nurse needs to calculate the feeding as follows: 25 mL x 2 = 50; 50 mL x 2 = 100; 75 mL x 2 = 150; and 100 mL x 2 = 200. The nurse should add up the 2 hour totals or 50+100+150+200 = 500 mL. The feeding bag should contain 500 mL. Global Rationale: The nurse needs to calculate the feeding as follows: 25 mL x 2 = 50; 50 mL x 2 = 100; 75 mL x 2 = 150; and 100 mL x 2 = 200. The nurse should add up the 2 hour totals or 50+100+150+200 = 500 mL. The feeding bag should contain 500 mL. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19.9 Outline the steps of administering a tube feeding. Page Number: p.

671

CHAPTER 20 1. The nurse receives an order to collect a midstream urine specimen from the client. Which is not a part of collecting this specimen?

1. Teaching the client how to clean the genitals prior to collecting the specimen 2. Labeling the specimen and sending it to the lab 3. Assuring that the specimen is collected following sterile technique 4. Documenting that the specimen has been collected and what was done with it Correct Answer: 3 Rationale 1: When a midstream urine specimen is ordered, the nurse teaches the client how to collect the specimen.

Rationale 2: When a midstream urine specimen is ordered, the nurse labels the collection bottle and sends it to the lab.

Rationale 3: Midstream urine specimens are kept as clean as possible, but the only way to collect a truly sterile specimen is by i n s eNr tUi nRgS IaNcGaTt hBe. Ct eOr Mt o collect the urine specimen.

Rationale 4: When a midstream urine specimen is ordered, the nurse documents the specimen collection.

Global Rationale: When a midstream urine specimen is ordered, the nurse teaches the client how to collect the specimen, labels the collection bottle, sends it to the lab, and documents the specimen collection. Midstream urine specimens are kept as clean as possible, but the only way to collect a truly sterile specimen is by inserting a catheter to collect the urine specimen.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care team AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.2 Describe the major instructions that ensure uncontaminated urine specimens, including midstream urine specimens.

Page Number: p. 685 2. In which is a capillary blood specimen least likely to be indicated?

1. Testing a serum glucose level 2. Measuring a client's hematocrit 3. Obtaining blood specimens on an infant 4. Measuring an arterial blood gas Correct Answer: 4 Rationale 1: Capillary blood collection is safe and effective for testing glucose.

Rationale 2: Capillary blood collection is safe and effective for testing hematocrit.

Rationale 3: Capillary blood collection is safe and effective and may be used for blood specimens on infants.

Rationale 4: Arterial blood gases require artery puncture, and cannot be performed on a capillary specimen; it is possible to perform a c agpaisll, awryh ibclho oisd l e s s effective than an arterial sample but is less invasive.

Global Rationale: Capillary blood collection is safe and effective for testing glucose and hematocrit, and may be used for blood specimens on infants. Arterial blood gases require artery puncture, and cannot be performed on a capillary specimen; it is possible to perform a capillary blood gas, which is less effective than an arterial sample but is less invasive.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 20.11 State purpose for obtaining a blood specimen for glucose testing.

Page Number: p. 700 3. The nurse performs a guaiac stool test and gets a positive result. Based on this test result, which diagnosis is least expected for this client?

1. Colon cancer 2. Hemorrhoids 3. Bleeding stomach ulcers 4. HIV/AIDS Correct Answer: 4 Rationale 1: A positive guaiac stool test is indicative of blood in the stool, which could be the result of colon cancer.

Rationale 2: A positive guaiac stool test is indicative of blood in the stool, which could be the result of hemorrhoids.

Rationale 3: A positive guaiac stool test is indicative of blood in the stool, which could be the result of bleeding stomach ulcers.

Rationale 4: A positive guaiac stool test would not indicate the presence of HIV/AIDS, although it could be the result of a complication from the disease.

Global Rationale: A positive guaiac stool test is indicative of blood in the stool, which could be the result of colon cancer, rectal irritationN,UoRrSbI NleGe Td Bin. Cg OstMo ma ch ulcers. It would not indicate the presence of HIV/AIDS, although it could be the result of a complication from the disease.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.6 Demonstrate the procedure for testing for occult blood.

Page Number: p. 691 4. The nurse suspects the client at the urgent care center might have a urinary tract infection. Based on this, which type of urine specimen should the nurse prepare to collect from the client?

1. 24-hour urine specimen 2. Midstream urine specimen

3. Routine urine specimen 4. Timed urine specimen Correct Answer: 2 Rationale 1: There would be no need for a 24-hour urine specimen, which is generally collected to measure the amount of an agent excreted in the course of the day, such as creatinine or sodium.

Rationale 2: Midstream urine specimens are collected to reduce contamination of the specimen so it can be sent for culture and sensitivity.

Rationale 3: A routine urine specimen does not try to limit bacteria or contaminants, and is often used to test for sugar, protein, and specific gravity.

Rationale 4: A timed urine specimen is used when a small amount of a substance is being measured, such as the presence of human chorionic gonadotropin (HCG), which confirms pregnancy.

Global Rationale: Midstream urine specimens are collected to reduce contamination of the specimen so it can be sent for culture and sensitivity. There would be no need for a 24-hour urine specimen, which is generally collected to measure the amount of an agent excreted in the course of the day, such as creatinine or sodium. NAU RroSuI Nti Gn eT Bu.rCinOeMs pecimen does not try to limit bacteria or contaminants, and is often used to test for sugar, protein, and specific gravity. A timed urine specimen is used when a small amount of a substance is being measured, such as the presence of human chorionic gonadotropin (HCG), which confirms pregnancy.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 20.2 Describe the major instructions that ensure uncontaminated urine specimens, including midstream urine specimens.

Page Number: p. 6874 5. The health care provider suspects the postoperative client has an infection, but is not sure of the source, and orders sputum, wound, urine, and nasal cultures. Which culture should be collected when the client wakes in the morning?

1. Urine 2. Sputum 3. Wound 4. Nasal Correct Answer: 2 Rationale 1: Urine, nasal, and wound cultures can be collected at any time because they are easily accessible to the nurse.

Rationale 2: Sputum cultures require the client to cough secretions from the lung. Coughing is often most productive in the morning.

Rationale 3: Urine, nasal, and wound cultures can be collected at any time because they are easily accessible to the nurse.

Rationale 4: Urine, nasal, and wound cultures can be collected at any time because they are easily accessible to the nurse.

Global Rationale: Urine, nasal, and wound cultures can be collected at any time because they are easily accessible to the nurse. S p u t u mN Uc Ru lSt IuNr Ge sT rBe. qC uOiMr e the client to cough secretions from the lung. Coughing is often most productive in the morning.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 20.8 Explain the objectives for collecting a sputum specimen.

Page Number: p. 704 6. Which specimens could the nurse safely delegate to the unlicensed assistive personnel (UAP) to collect?

Standard Text: Select all that apply.

1. Wound culture

2. Routine urine specimen 3. Cerebrospinal fluid 4. Stool specimen 5. Sputum specimen Correct Answer: 2, 4, 5 Rationale 1: Wound culture collection requires sterile technique, and so must be performed by the nurse.

Rationale 2: The UAP may safely collect a routine urine specimen.

Rationale 3: A lumbar puncture is performed by the primary care provider to collect cerebrospinal fluid, and the nurse should assist because sterile technique must be followed.

Rationale 4: The UAP may safely collect a stool specimen.

Rationale 5: The UAP may safely collect a sputum specimen.

Global Rationale: The UAP may safely collect a routine urine specimen, stool specimen, and sputum specimen. Wound culture collectNioUnR SreI Nq uGiTreBs. CsOt eMrile technique, and so must be performed by the nurse. A lumbar puncture is performed by the primary care provider to collect cerebrospinal fluid, and the nurse should assist because sterile technique must be followed.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Practice; Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 20.1 Discuss the nursing responsibilities for reporting abnormal laboratory values.

Page Number: p. 712 7. The nurse is caring for several clients, and has unlicensed assistive personnel (UAP) and LPN/LVN assisting. Which client should the nurse delegate to the LPN/LVN as opposed to the UAP? 1. Assisting the health care provider with performance of a lumbar puncture

2. Collecting and testing a routine urine specimen for sugar, protein, and specific gravity 3. Testing stool for the presence of occult blood 4. Collecting a sterile urine specimen by straight-catheterizing the client Correct Answer: 4 Rationale 1: The nurse should assist the health care provider with collection of cerebrospinal fluid because the client must be assessed during this procedure, and only the RN can assess the client safely.

Rationale 2: The nurse should delegate the routine urine specimen to the UAP. Rationale 3: The nurse should delegate the stool specimen to the UAP. Rationale 4: The nurse can safely delegate performance of a straight catheterization to collect a sterile urine specimen to the LPN/LVN who is educated in the use of sterile technique.

Global Rationale: The nurse can safely delegate performance of a straight catheterization to collect a sterile urine specimen to the LPN/LVN who is educated in the use of sterile technique. The nurse would delegate the routine urine specimen and stool specimen test to the UAP. The nurse should assist the health care provider with collection of cerebrospinal fluid because the client must be assessed during this p r o c eNd Uu rReS, I aNnGdT oBn. Cl yO M t h e RN can assess the client safely.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Practice; Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 20.2 Describe the major instructions that ensure uncontaminated urine specimens, including midstream urine specimens.

Page Number: p. 712 8. The nurse is collecting a capillary blood specimen. Which statement demonstrates proper technique for this procedure?

1. Clean the site with alcohol, and puncture the finger quickly, then collect the first drop of blood.

2. If the puncture site is not bleeding, squeeze the finger as firmly as possible without causing pain.

3. Clean the site with alcohol, puncture the finger, wipe the first drop of blood with gauze, and then collect the specimen.

4. Puncture the finger in the center of the pad, which is more vascular.

Correct Answer: 3 Rationale 1: The site should be cleaned with an antimicrobial or soap and water, then dried or allowed to dry before puncturing the site. The side of the finger should be punctured, because it is less innervated, and so causes less pain. The first drop of blood should not be used, due to the risk of epithelial contamination. After the first drop is wiped away, the specimen can be collected. To encourage bleeding, the finger can be milked but should not be squeezed, because that would cause hemolysis.

Rationale 2: The site should be cleaned with an antimicrobial or soap and water, then dried or allowed to dry before puncturing the site. The side of the finger should be punctured, because it is less innervated, and so causes less pain. The first drop of blood should not be used, due to the risk of epithelial contamination. After the first drop is wiped away, the specimen can be collected. To encourage bleeding, the finger can be milked but should not be squeezed, because that would cause hemolysis.

Rationale 3: The site should be cleaned with an antimicrobial or soap and water, then dried or allowed to dry before puncturing the site. The side of the finger should be punctured, because it is less innervated, and so causes less pain. The first drop of blood should not be used, due to the risk of epithelial contamination. After the first drop is wiped away, the specimen can be collected. To encourage bleeding, the finger can be milked but should not be squeezed, because that would cause hemolysis.

Rationale 4: The site should be cleaned with an antimicrobial or soap and water, then dried or allowed to dry before puncturing the site. The side of the finger should be punctured, because it is less innervated, and so causes less pain. The first drop of blood should not be used, due to the risk of epithelial contamination. After the first drop is wiped away, the specimen can be collected. To encourage bleeding, the finger can be milked but should not be squeezed, because that would cause hemolysis.

Global Rationale: The site should be cleaned with an antimicrobial or soap and water, then dried or allowed to dry before puncturing the site. The side of the finger should be punctured, because it is less innervated, and so causes less pain. The first drop of blood should not be used, due to the risk of epithelial contamination. After the first drop is wiped away, the specimen can be collected. To encourage bleeding, the finger can be milked but should not be squeezed, because that would cause hemolysis.

Cognitive Level: Analyzing

Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.11 State purpose for obtaining a blood specimen for glucose testing.

Page Number: p. 700 9. How does the procedure change when a nurse collects a midstream urine specimen from a woman versus a man?

1. Women should be taught to begin their stream before collecting the specimen.

2. Women would be provided with three antimicrobial wipes, whereas men would be provided with only one or two.

3. Men should be taught not to touch the inside of the collection container or the lid.

4. Men should be taught to fil the co n t a iNnUe rR nS IoNm h aMn one-half to one-third full.

G To Br e. Ct O Correct Answer: 2 Rationale 1: Both men and women are taught to begin their urine stream before collecting the specimen.

Rationale 2: Women require more antimicrobial wipes than men because of the many folds of the labia that must be cleaned prior to specimen collection.

Rationale 3: Both men and women are taught to use care not to touch the sterile inside of the container and lid.

Rationale 4: Both men and women are taught to fill the container no more than one-half to one- third full.

Global Rationale: Women require more antimicrobial wipes than men because of the many folds of the labia that must be cleaned prior to specimen collection. Both men and women are taught to begin their urine stream before collecting the specimen, to use care not to touch the sterile inside of the container and lid, and to fill the container no more than one-half to one-third full.

Cognitive Level: Applying Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.2 Describe the major instructions that ensure uncontaminated urine specimens, including midstream urine specimens.

Page Number: p. 685 10. The nurse is obtaining a throat culture. Which action indicates correct technique?

1. Inserting the swab into the sterile tube without touching the outside of the container 2. Inserting a tongue blade to depress the anterior two-thirds of the tongue 3. Swabbing along the side of the cheek inside the mouth 4. Swabbing the pharynx gently and quickly, avoiding the tonsils Correct Answer: 1 Rationale 1: The swab is placed into the container without touching the outside.

Rationale 2: The nurse inserts a tongue blade to depress the anterior third of the tongue, not two- thirds.

Rationale 3: The swab is inserted without touching the mouth or tongue.

Rationale 4: The swab is inserted and swabbed along the tonsils, making sure to contact any areas on the pharynx that are particularly erythematous, or contain exudate.

Global Rationale: The nurse inserts a tongue blade to depress the anterior third of the tongue, not twothirds. The swab is inserted without touching the mouth or tongue, and swabs along the tonsils, making sure to contact any areas on the pharynx that are particularly erythematous, or contain exudate. The swab is removed and placed into the container without touching the outside.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the

life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.10 Compare and contrast obtaining an aerobic and anaerobic culture.

Page Number: p. 708 11. The nurse obtains a specimen from the client's wound. Which items will the nurse include when documenting this procedure in the medical record?

Standard Text: Select all that apply.

1. Source of specimen 2. Type of culture obtained 3. Appearance of wound 4. Dispersal of the specimen 5. Microorganism causing infection Correct Answer: 1, 2, 3, 4 Rationale 1: The nurse would document the source of the specimen.

Rationale 2: The nurse would document whether aerobic or anaerobic culture was obtained.

Rationale 3: The nurse would document the appearance of wound.

Rationale 4: The nurse would document what was done with the specimen.

Rationale 5: The microorganism is unknown, or there would be no need for a culture.

Global Rationale: The nurse would document the source of the specimen, whether aerobic or anaerobic culture was obtained, appearance of wound, and what was done with the specimen. The microorganism is unknown, or there would be no need for a culture.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: VI.B.4. Document and plan client care in an electronic health record AACN Essential Competencies: IV.5. Use standardized terminology in a care environment that reflects nursing’s unique contribution to client outcomes NLN Competencies: Quality and Safety: Practice; Carefully maintain and use electronic and/or written health records

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.10 Compare and contrast obtaining an aerobic and anaerobic culture.

Page Number: p. 709 12. The nurse is preparing to collect a stool specimen. Place the steps involved in the procedure in the correct order.

Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list.

Response 1. Provide for client privacy.

Response 2. Assist the clients who need help, either with bedside commode or a bedpan.

Response 3. Perform hand hygiene and observe other appropriate infection control procedures.

Response 4. Apply gloves to prevent contamination, and clean the client as required. Inspect the skin around the anus for any irritation, especially if the client defecates frequently and has liquid stools.

Response 5. Transfer the required amount of stool to the stool specimen container. Use tongue blades to transfer some or the entire stool specimen container, taking care not to contaminate the outside of the container.

Response 6. Prior to beginning of procedure, introduce self and verify the client's identity. Explain what is going to be done, why it is necessary, and how the client can help.

Correct Answer: 6, 3, 1, 2, 4, 5 Rationale 1: Providing privacy occurs prior to starting the procedure in which to collect the stool specimen.

Rationale 2: Assisting the client to a bedside commode or a bedpan is done after hand hygiene and providing for client privacy.

Rationale 3: Performing hand hygiene and observing for other appropriate infection control measures is done immediately prior to starting the procedure of collecting a stool specimen.

Rationale 4: Applying gloves, cleaning the client, and inspecting the skin around the anus for irritation is done after performing hand hygiene but prior to obtaining the stool specimen.

Rationale 5: Transferring the correct amount of stool into the specimen container is the last step in stool specimen collection.

Rationale 6: Introducing yourself to the client, verifying the client’s identity, and explaining what will be done and how the client may assist is the first step in obtaining a stool specimen.

Global Rationale: Introducing yourself to the client, verifying the client’s identity, and explaining what will be done and how the client may assist is the first step in obtaining a stool specimen. Performing hand hygiene and observing for other appropriate infection control measures is done immediately prior to starting the procedure of collecting a stool specimen.

Providing privacy occurs prior to starting the procedure in which to collect the stool specimen. Assisting the client to a bedside commode or a bedpan is done after hand hygiene and providing for client privacy.

Applying gloves, cleaning the client, and inspecting the skin around the anus for irritation is done after performing hand hygiene but prior to obtaining the stool specimen.

Transferring the correct amount of stool into the specimen container is the last step in stool specimen collection.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.4 State two objectives for obtaining a stool specimen.

Page Number: p. 690 13. A client is prescribed intravenous antibiotics however a culture and sensitivity has been ordered.

What should the nurse do prior to starting the intravenous antibiotics?

1. Assess vital signs.

2. Collect the ordered culture and sensitivity specimen.

3. Start intravenous antibiotics.

4. Obtain culture after two doses have been given.

Correct Answer: 2 Rationale 1: Although it is important to assess the client’s vital signs, this is not the priority in this situation.

Rationale 2: The culture and sensitivity must be obtained prior to the first dose of antibiotics being administered.

Rationale 3: The antibiotic is started immediately after obtaining the culture and sensitivity.

Rationale 4: The antibiotic is started immediately after obtaining the culture and sensitivity.

Global Rationale: The culture and sensitivity must be obtained prior to the first dose of antibiotics being administered. This is the priority. Although it is important to assess the client’s vital signs, this is not the priority in this situation.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care team AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.10 Compare and contrast obtaining an aerobic and anaerobic culture.

Page Number: pp. 682, 684 14. The nurse has delegated the collection of a clean catch urine specimen to the unlicensed assistive personnel (UAP). Which statement by the UAP indicates an appropriate understanding of the procedure?

NURSINGTB.COM

1. "I will have the client urinate in the specimen container the next time he or she urinates."

2. "I will provide the client with sterile gloves for collecting the urine specimen."

3. "I will ask the client to cleanse the urethra to avoid contamination of the urine specimen."

4. "I will watch the client obtain the urine specimen to ensure correct obtainment."

Correct Answer: 3 Rationale 1: This statement is missing the need to have the client properly cleanse the area, which is the proper procedure for clean catch urine.

Rationale 2: The collection of this specimen does not require the use of sterile gloves.

Rationale 3: This statement is correct as it indicates the need for proper cleansing to ensure the specimen is not contaminated.

Rationale 4: This is incorrect as the UAP should help the client, if needed, to avoid contamination

Global Rationale: The client must be asked to cleanse the urethra to avoid contamination of the urine specimen. Sterile gloves are not needed for this collection. The UAp should help the client, if needed, to avoid contamination.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 20.2 Describe the major instructions that ensure uncontaminated urine specimens, including midstream urine specimens.

Page Number: p. 681 15. The nurse is preparing to obtain a throat culture. Which observation indicates that the nurse has performed this skill before?

1. The nurse allows the client to insert the swab in the mouth.

2. The nurse removes the swab while m aNkUi nRgS IsNu Gr eT tBo. Ct oOuMc h the sides of the tonsils.

3. The nurse has the client tilt the head back and say "ah" to relax the tongue to avoid the gagging reflex.

4. The nurse asks the client to blow the nose to clear the nasal passageway and then checks with penlight for patency.

Correct Answer: 3 Rationale 1: Allowing the client to insert the swab in the mouth is inappropriate and will result in the need to re-swab.

Rationale 2: Touching the sides of the tonsils will contaminate the swab.

Rationale 3: Having the client tilt the head back and say “ah” helps to relax the throat and prevent gagging.

Rationale 4: Asking the client to blow the nose to clear the nasal passageways and then checking with a penlight for patency is the procedure for a nasal specimen.

Global Rationale: Having the client tilt the head back and say “ah” helps to relax the throat and prevent gagging. Allowing the client to insert the swab in the mouth is inappropriate and will result in the need to reswab. Touching the sides of the tonsils will contaminate the swab. Asking

the client to blow the nose to clear the nasal passageways and then checking with a penlight for patency is the procedure for a nasal specimen.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 20.10 Compare and contrast obtaining an aerobic and anaerobic culture.

Page Number: p. 708 16. The manager interrupts a new graduate at the completion of a venipuncture. What did the manager observe that caused this interruption?

1. Removed the tube before withdrawing the needle 2. Bent the client’s elbow after withdrawing the needle 3. Released the tourniquet once blood began to flow into the tube 4. Held a gauze sponge on the puncture site after withdrawing the needle Correct Answer: 2 Rationale 1: The tube should be removed before withdrawing the needle. Rationale 2: Bending the elbow can precipitate hematoma formation.

Rationale 3: The tourniquet should be released once blood begins to flow in the tube. Rationale 4: Gauze should be held over the puncture site after withdrawing the needle.

Global Rationale: Bending the elbow can precipitate hematoma formation. The tube should be removed before withdrawing the needle. The tourniquet should be released once blood begins to flow in the tube.

Gauze should be held over the puncture site after withdrawing the needle.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 20.16 State the nursing action when a hematoma occurs at the puncture site.

Page Number: p. 696 17. The nurse is obtaining a gum swab for an HIV test. What should the nurse include when performing this procedure? Select all that apply.

1. Check window display on device 2. Swab outer gum with device included in kit 3. Insert swab into vial containing special solution 4. Have the client flush the mouth with mouthwash 5. Instruct client to confirm results with a Western blot test Correct Answer: 1, 2, 3, 5 Rationale 1: The nurse should check the window display on the device after inserting the swab. Rationale 2: The outer gum is swabbed with the device provided in the kit.

Rationale 3: The swab is inserted into the vial containing a special solution. Rationale 4: The client does not need to flush the mouth with mouthwash.

Rationale 5: The client should be instructed to confirm the results with a Western blot test.

Global Rationale: The nurse should check the window display on the device after inserting the swab. The outer gum is swabbed with the device provided in the kit. The swab is inserted into the vial containing a special solution. The client should be instructed to confirm the results with a Western blot test. The client does not need to flush the mouth with mouthwash.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.17 Describe procedure for testing for the presence of HIV antibodies.

Page Number: p. 708

CHAPTER 21 1. The health care provider performs a specimen collection by inserting a needle into the abdomen to collect fluid. Which term should the nurse use when documenting this procedure?

1. Paracentesis 2. Thoracentesis 3. Lumbar puncture 4. Venogram Correct Answer: 1 Rationale 1: A paracentesis is insertion of a needle to remove or collect fluid accumulating in the peritoneal cavity.

Rationale 2: A thoracentesis removes fluid from the thoracic cavity.

Rationale 3: A lumbar puncture is the insertion of a needle into the lumbar spine.

Rationale 4: A venogram is an imagingNteUstRSthI NatGaTllBo. CwOs Mvisualization of veins using an injected contrast media.

Global Rationale: A paracentesis is insertion of a needle to remove or collect fluid accumulating in the peritoneal cavity. A thoracentesis removes fluid from the thoracic cavity. A lumbar puncture is the insertion of a needle into the lumbar spine. A venogram is an imaging test that allows visualization of veins using an injected contrast media.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.B.3. Base individualized care plan on client values, clinical expertise, and evidence AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21.15 Describe the data that should be included in the charting for clients undergoing diagnostic procedures.

Page Number: p. 750 2. The nurse is assisting the health care provider collect cerebrospinal fluid for testing to rule out meningitis. Which are the nurse's responsibilities?

Standard Text: Select all that apply.

1. Explain the procedure and obtain signed consent.

2. Teach the client how to assist during the procedure by maintaining proper positioning.

3. Observe sterile technique when preparing the equipment for the procedure.

4. Label all specimens collected and send them to the lab.

5. Assess the client before, during, and after the procedure.

Correct Answer: 2, 3, 4, 5 Rationale 1: The nurse does not explain the procedure prior to obtaining the consent; this is the role of the health care provider. The nurse may witness the signature if the client does not have questions.

Rationale 2: The client should be taught how to maintain proper positioning during the procedure to prevent complications.

Rationale 3: The nurse observes sterile technique when setting up the sterile tray in preparation for the procedure.

Rationale 4: Once the fluid has been collected, all tubes should be properly labeled and sent to the lab.

Although the nurse may delegate this to the unlicensed assistive personnel, the nurse is responsible.

Rationale 5: The nurse's primary responsibility is to monitor the client's condition before, during, and after the procedure.

Global Rationale: The nurse does not explain the procedure prior to obtaining the consent; this is the role of the health care provider. The nurse may witness the signature if the client does not have questions.

The client should be taught how to maintain proper positioning during the procedure to prevent complications. Once the fluid has been collected, all tubes should be properly labeled and sent to the lab.

Although the nurse may delegate this to the unlicensed assistive personnel, the nurse is responsible. The nurse's primary responsibility is to monitor the client's condition before, during, and after the procedure.

The nurse also observes sterile technique when setting up the sterile tray in preparation for the procedure.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care team AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an

understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21.1 Describe the major components of client teaching for diagnostic studies.

Page Number: p. 725 3. Which is the nurse's most important role in assisting the health care provider to perform an aspiration or biopsy?

1. Administering analgesic 2. Monitoring the client's condition before, during, and after procedure 3. Preparing the sterile tray with needed equipment 4. Documenting the specimen collection Correct Answer: 2 Rationale 1: Although all of these are among the nurse's roles, the most important role of the nurse when performing a biopsy or aspiration is assessment of the client before, during, and after the procedure, and responding to problems that might arise.

Rationale 2: Although all of these are among the nurse's roles, the most important role of the nurse when performing a biopsy or aspiration is assessment of the client before, during, and after the procedure, and responding to problems that might arise.

Rationale 3: Although all of these are among the nurse's roles, the most important role of the nurse when performing a biopsy or aspiration is assessment of the client before, during, and after the procedure, and responding to problems that might arise.

Rationale 4: Although all of these are among the nurse's roles, the most important role of the nurse when performing a biopsy or aspiration is assessment of the client before, during, and after the procedure, and responding to problems that might arise.

Global Rationale: Although all of these are among the nurse's roles, the most important role of the nurse when performing a biopsy or aspiration is assessment of the client before, during, and after the procedure, and responding to problems that might arise.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential

QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care team AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.1 Describe the major components of client teaching for diagnostic studies.

Page Number: pp. 741, 752 4. The nurse is preparing a client for diagnostic studies requiring the administration of contrast media.

Which action by the nurse is the priority in this situation?

1. Obtaining informed consent 2. Obtaining results of lab tests 3. Checking for allergies 4. Checking if routine medications are to be held Correct Answer: 3 Rationale 1: The priority action for the nurse is to determine if the client has any allergies, due to the risk of reaction to the contrast media. All of the other actions are to be performed in preparation for the diagnostic test, but none is as important as establishing the client's allergies.

Rationale 2: The priority action for the nurse is to determine if the client has any allergies, due to the risk of reaction to the contrast media. All of the other actions are to be performed in preparation for the diagnostic test, but none is as important as establishing the client's allergies.

Rationale 3: The priority action for the nurse is to determine if the client has any allergies, due to the risk of reaction to the contrast media. All of the other actions are to be performed in preparation for the diagnostic test, but none is as important as establishing the client's allergies.

Rationale 4: The priority action for the nurse is to determine if the client has any allergies, due to the risk of reaction to the contrast media. All of the other actions are to be performed in preparation for the diagnostic test, but none is as important as establishing the client's allergies.

Global Rationale: The priority action for the nurse is to determine if the client has any allergies, due to the risk of reaction to the contrast media. All of the other actions are to be performed in preparation for the diagnostic test, but none is as important as establishing the client's allergies.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care team AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21.4 Explain the importance of determining allergic responses to shellfish before clients undergo contrast media studies.

Page Number: p. 718 5. The nurse is preparing the client for diagnostic testing using contrast media. The client is questioned regarding allergies. The nurse would contact the health care provider if the client reported an allergy to which item?

1. Eggs 2. Milk 3. Betadine 4. Scallops Correct Answer: 3 Rationale 1: Betadine, like contrast media, is an iodine-containing compound, so the primary care provider should be notified due to the risk of administering contrast to this client. The other allergies have no impact on the procedure, and the primary care provider would not need to be notified.

Rationale 2: Betadine, like contrast media, is an iodine-containing compound, so the primary care provider should be notified due to the risk of administering contrast to this client. The other allergies have no impact on the procedure, and the primary care provider would not need to be notified.

Rationale 3: Betadine, like contrast media, is an iodine-containing compound, so the primary care provider should be notified due to the risk of administering contrast to this client. The other allergies have no impact on the procedure, and the primary care provider would not need to be notified.

Rationale 4: Betadine, like contrast media, is an iodine-containing compound, so the primary care provider should be notified due to the risk of administering contrast to this client. The other allergies have no impact on the procedure, and the primary care provider would not need to be notified.

Global Rationale: Betadine, like contrast media, is an iodine-containing compound, so the primary care provider should be notified due to the risk of administering contrast to this client. The other allergies have no impact on the procedure, and the primary care provider would not need to be notified.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care team AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.4 Explain the importance of determining allergic responses to shellfish before clients undergo contrast media stuNdUieRsS. I NG T B. C O M Page Number: p. 718 6. The nurse is assisting with a thoracentesis. Place the steps of the procedure for assisting the client in the correct order.

Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list.

Response 1. Help position the client and cover the client as needed with a bath blanket. Response 2.

Observe the client for signs of distress, such as dyspnea, pallor, and coughing. Response 3. Support the client verbally and describe the steps as needed.

Response 4. Support the client throughout the procedure.

Response 5. Collect drainage and laboratory specimens. Then apply small sterile dressing over the site.

Correct Answer: 1, 4, 3, 2, 5 Rationale 1: Positioning and properly covering the client with a bath blanket is the first step.

Rationale 2: Observing the client for signs of distress, such as dyspnea, pallor, and coughing, is the fourth step.

Rationale 3: Supporting the client verbally and describing the steps as needed is the third step.

Rationale 4: Supporting the client throughout the procedure is the second step.

Rationale 5: Collecting the drainage and laboratory specimens and covering the site with a small, sterile dressing is the last step of the procedure.

Global Rationale: Positioning and properly covering the client with a bath blanket is the first step.

Supporting the client throughout the procedure is the second step. Supporting the client verbally and describing the steps as needed is the third step. Observing the client for signs of distress, such as dyspnea, pallor, and coughing, is the fourth step. Collecting the drainage and laboratory specimens and covering the site with a small, sterile dressing is the last step of the procedure.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care team AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and devNelUoRpSmINenGtT, Bp .aCthOoMp hy siol og y, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21.12 Compare and contrast postprocedure nursing observations for clients undergoing liver biopsy, paracentesis, and thoracentesis.

Page Number: p. 750 7. A staff nurse position has been posted for the radiology department. Which nurse is the most qualified for this position?

1. Nurse with 10 years of experience in the intensive care unit 2. Nurse with 6 months of experience in the post anesthesia care unit 3. Nurse with 7 years of experience working in the hemodialysis center 4. Nurse with 4 years of experience in the outpatient ambulatory center Correct Answer: 1 Rationale 1: The nurse working in the radiology department is a critical care RN who manages clients during interventional radiology procedures. This nurse must have experience in ICU or ER and be certified in both advanced cardiac life support (ACLS) and administration of moderate sedation.

Rationale 2: The nurse with post anesthesia care unit experience is not the most qualified. Rationale 3: The nurse with hemodialysis experience is not the most qualified.

Rationale 4: The nurse with outpatient ambulatory center experience is not the most qualified.

Global Rationale: The nurse working in the radiology department is a critical care RN who manages clients during interventional radiology procedures. This nurse must have experience in ICU or ER and be certified in both advanced cardiac life support (ACLS) and administration of moderate sedation. Nurses with post anesthesia care unit, hemodialysis, and ambulatory care experience are not the most qualified.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care team AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe NclUi eRnSt I Nc aGr Te B . C O M Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.2 Define interventional radiology (IR) and the nurse’s role in IR. Page Number: p. 720 8. A client is scheduled for a CT scan of the brain with and without contrast. What needs to be done to prepare the client for this diagnostic test? Select all that apply.

1. Explain what happens during the test 2. Review what needs to be done after the test is completed 3. Discuss what needs to be done before arriving for the test 4. Obtain information about the client’s health insurance plan 5. Ask if the client has any questions after receiving instructions Correct Answer: 1, 2, 3, 5 Rationale 1: To prepare the client for a diagnostic test, the nurse should explain what happens during the test.

Rationale 2: To prepare the client for a diagnostic test, the nurse should review what needs to be done after the test is completed.

Rationale 3: To prepare the client for a diagnostic test, the nurse should discuss what needs to be done before arriving for the test.

Rationale 4: The health insurance information is not a part of preparation for a diagnostic test.

Rationale 5: To prepare the client for a diagnostic test, the nurse should ask if the client has any questions after receiving instructions.

Global Rationale: To prepare the client for a diagnostic test, the nurse should explain what happens during the test, review what needs to be done after the test is completed, discuss what needs to be done before arriving for the test, and ask if the client has any questions after receiving instructions. The health insurance information is not a part of preparation for a diagnostic test.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care team AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning N U RSI N G TB . COM Outcome: 21.3 List at least t h r e e p r e p a r at o r y f u n c t i o n s for clients undergoing diagnostic studies.

Page Number: p. 717 9. During an intravenous pyelogram the nurse suspects that a client is experiencing an allergic reaction to the contrast medium. What did the nurse assess to make this clinical determination? Select all that apply.

1. Onset of nausea 2. Hives on the neck 3. Respiratory rate 28 4. Complaint of being thirsty 5. Blood pressure 88/50 mm Hg Correct Answer: 1, 2, 3, 5 Rationale 1: Symptoms of contrast media reactions include nausea.

Rationale 2: Symptoms of contrast media reactions include hives.

Rationale 3: Symptoms of contrast media reactions include respiratory distress.

Rationale 4: Thirst is not a symptom of a contrast media reaction.

Rationale 5: Symptoms of contrast media reactions include decreased blood pressure.

Global Rationale: Symptoms of contrast media reactions include nausea, hives, respiratory distress, and decreased blood pressure. Symptoms of contrast media reactions include nausea Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care team AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.5 List the signs and symptoms that occur when a client experiences an allergic reaction.

Page Number: p. 724 10. A client is scheduled for a diagnostic test using radioactive isotopes. What should the nurse expect to be provided to this client before the test?

1. A sedative 2. A blocking agent 3. Intravenous fluids 4. A dose of an antibiotic Correct Answer: 2 Rationale 1: A sedative is not routinely provided before a test using radioactive isotopes.

Rationale 2: Some clients are given blocking agents before the administration of the radioisotope. This prevents the radioactive material from entering organs other than those being studied.

Rationale 3: Intravenous fluids are not routinely provided before a test using radioactive isotopes.

Rationale 4: Antibiotics are not routinely provided before a test using radioactive isotopes.

Global Rationale: Some clients are given blocking agents before the administration of the radioisotope.

This prevents the radioactive material from entering organs other than those being studied. Sedatives, intravenous fluids, and antibiotics are not routinely provided before a test using radioactive isotopes.

Cognitive Level: Applying

Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care team AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 21.6 Explain the reason for giving blocking agents before administering radioisotopes to clients.

Page Number: p. 719 11. A client is recovering from a myelogram in the outpatient ambulatory surgical center. What is a priority when caring for this client?

1. Restrict fluids 2. Keep the bed flat 3. Encourage ambulation 4. Raise the head of the bed to a 60 degree angle Correct Answer: 2 Rationale 1: Fluids should be encouraged after a myelogram.

Rationale 2: After a myelogram the bed should be flat for 4 to 8 hours to prevent a spinal headache or CSF leak.

Rationale 3: Ambulation should be limited to prevent the development of a spinal headache or CSF leak.

Rationale 4: After 8 hours the head of the bed can be raised 30 to 60 degrees.

Global Rationale: After a myelogram the bed should be flat for 4 to 8 hours to prevent a spinal headache or CSF leak. Fluids should be encouraged after a myelogram. Ambulation should be limited to prevent the development of a spinal headache or CSF leak. After 8 hours the head of the bed can be raised 30 to 60 degrees.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care team AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical

management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21.7 Outline the nursing care responsibilities when a client returns from myelography.

Page Number: p. 725 12. The nurse is preparing to assess a client recovering from an arteriogram. What should be the priority for this client?

1. Monitor pulses distal to the puncture site 2. Elevate the extremity used for the puncture site 3. Place a pillow under the extremity used for the puncture sit 4. Increase intravenous fluids to ensure an adequate urine output Correct Answer: 1 Rationale 1: After an arteriogram the nurse should monitor pulses distal to the puncture site. Rationale 2: The extremity used for the puncture site should be flat.

Rationale 3: A pillow should not be placed under the extremity used for the puncture site.

Rationale 4: Intravenous fluids are not routinely increased after an arteriogram to ensure an adequate urine output but rather to ensure elimination of the contrast medium.

Global Rationale: After an arteriogram the nurse should monitor pulses distal to the puncture site. The extremity used for the puncture site should be flat. A pillow should not be placed under the extremity used for the puncture site. Intravenous fluids are not routinely increased after an arteriogram to ensure an adequate urine output but rather to ensure elimination of the contrast medium.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care team AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21.8 Discuss the nursing care responsibilities when a client returns from arteriography.

Page Number: p. 725 13. The nurse notes that a client returning from a cardiac catheterization has the extremity used for the procedure elevated on a pillow. What should the nurse do?

1. Remove the pillow 2. Position on the left side 3. Keep the pillow in place 4. Raise the head of the bed Correct Answer: 3 Rationale 1: The pillow should not be removed.

Rationale 2: The client should be supine for several hours before turning from side to side.

Rationale 3: The extremity used for the catheterization should be elevated. This position promotes blood supply back to heart and prevents thrombus formation.

Rationale 4: The bed should be flat.

Global Rationale: The extremity used for the catheterization should be elevated. This position promotes blood supply back to heart a n dNpUr Re vS IeNn Gt sTtBh.rCoOmMb u s formation. The pillow should not be removed. The client should be supine for several hours before turning from side to side. The bed should be flat.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care team AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21.9 Describe the care necessary after cardiac catheterization to prevent postprocedure complications.

Page Number: p. 726 14. A client scheduled for an outpatient endoscopy asks when he can eat since the black cup of coffee wasn’t enough. What should the nurse do?

1. Provide with dry crackers

2. Notify the radiology department 3. Document that the client had black coffee 4. Explain that a meal will be provided shortly Correct Answer: 3 Rationale 1: The client should be NPO. Rationale 2: The radiology department should be notified because the client should have been on NPO status for 6 to 12 hours before the test.

Rationale 3: The nurse needs to do more than document the client had black coffee before the test.

Rationale 4: The nurse has no way of knowing if the client will receive a meal. The test will most likely need to be rescheduled.

Global Rationale: The radiology department should be notified because the client should have been on NPO status for 6 to 12 hours before the test. The nurse needs to do more than document the client had black coffee before the test. The nurse has no way of knowing if the client will receive a meal. The test will most likely need to be rescheduled.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care team AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21.10 Explain the steps you would take if a client is given medication before a GI series.

Page Number: p. 742 15. The nurse is preparing a client for a liver biopsy. In which position should the client be placed?

1. Sims position 2. Seated in a chair 3. Leaning forward 4. Right arm raised and extended over the left shoulder Correct Answer: 4

Rationale 1: The Sims position is used for a lumbar puncture. Rationale 2: Sitting in a chair is the position for a paracentesis. Rationale 3: The leaning forward position is used for a thoracentesis.

Rationale 4: The right arm should be raised and extend it over the left shoulder behind the head to facilitate needle insertion for liver biopsy.

Global Rationale: The right arm should be raised and extend it over the left shoulder behind the head to facilitate needle insertion for liver biopsy. The Sims position is used for a lumbar puncture. Sitting in a chair is the position for a paracentesis. The leaning forward position is used for a thoracentesis.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care team AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21.11 Describe client positions for at least four diagnostic procedures commonly performed at the bedside.

Page Number: p. 749 16. A client is returning to the care area after a bronchoscopy. What should the nurse make a priority when caring for this client?

1. Keep NPO 2. Encourage clear liquids 3. Report hoarseness or a sore throat 4. Assist with deep breathing and coughing Correct Answer: Rationale 1: The nurse should instruct the client not to eat or drink until gag reflex returns, usually in 1–2 hours.

Rationale 2: The client should be NPO until the gag reflex returns. Rationale 3: Hoarseness or a sore throat would be expected after this test.

Rationale 4: The client does not need to deep breathe and cough after this test.

Global Rationale: The nurse should instruct the client not to eat or drink until gag reflex returns, usually in 1–2 hours. The client should be NPO until the gag reflex returns. Hoarseness or a sore throat would be expected after this test. The client does not need to deep breathe and cough after this test.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care team AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21.13 Explain the nurse’s role during procedures that use fiberoptic scopes.

Page Number: p. 743 17. The nurse completes a health historyNwUiRthSIaN cGlTieBn. tCOscMheduled for an MRI of the knee and immediately notifies the health care provider. What did the nurse assess to make this clinical decision?

1. Wears religious metals 2. History of heart failure 3. Metal in spine from a spinal fusion 4. Takes insulin for type 1 diabetes mellitus Correct Answer: 3 Rationale 1: Religious metals can be temporarily removed. Rationale 2: Heart failure is not a contraindication for an MRI. Rationale 3: Clients with metal implants are exempt from having an MRI. Rationale 4: Insulin is not a contraindication for an MRI. Global Rationale: Clients with metal implants are exempt from having an MRI. Religious metals can be temporarily removed. Heart failure is not a contraindication for an MRI. Insulin is not a contraindication for an MRI. Cognitive Level: Analyzing

Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care team AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.16 Describe the preparation clients must complete before an MRI. Page Number: p. 728

CHAPTER 22 1. The nurse is caring for an older adult male client who demonstrates frequent urinary incontinence.

Which option should the nurse use to reduce the risk of skin damage secondary to urinary incontinence for this client?

1. Coude catheter 2. Straight catheter 3. Condom catheter 4. Foley catheter Correct Answer: 3 Rationale 1: A Coudé catheter or 12 Fr catheter may be easier to insert if the client has an obstruction.

Rationale 2: Use of a straight catheter is an invasive procedure.

Rationale 3: The condom catheter fits ovNeUrRtShIeNpGeTnBis.CaOnM d reduces skin contact with urine by diverting the urine to a collection bag. It is not invasive, and can be applied as a nursing order.

Rationale 4: A Foley catheter is an indwelling catheter that requires a health care provider's order.

Global Rationale: The condom catheter fits over the penis and reduces skin contact with urine by diverting the urine to a collection bag. It is not invasive, and can be applied as a nursing order. A Coudé catheter or 12 Fr catheter may be easier to insert if the client has an obstruction. A Foley catheter is an indwelling catheter that requires a health care provider's order. Use of both the indwelling catheter and the straight catheter are invasive procedures.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 22.3 State two nursing diagnoses that relate to urine elimination.

Page Number: p. 771 2. Which term is not used interchangeably with urinary elimination?

1. Micturition 2. Voiding 3. Urination 4. Incontinence Correct Answer: 4 Rationale 1: Micturition, voiding, or urination all indicate the act of urinary elimination. Rationale 2: Micturition, voiding, or urination all indicate the act of urinary elimination. Rationale 3: Micturition, voiding, or urination all indicate the act of urinary elimination.

Rationale 4: Incontinence indicates lack of control of elimination, and can be applied to urinary control or bowel control.

Global Rationale: Micturition, voiding, or urination all indicate the act of urinary elimination. Incontinence indicates lack of control of elimination, and can be applied to urinary control or bowel control.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.1 Describe the process of urine production. Page Number: p.

760 3. Which task could the nurse safely delegate to the unlicensed assistive personnel (UAP)?

1. Inserting a urinary retention catheter 2. Inserting a straight catheter

3. Applying a condom catheter 4. Collecting data for a urinary elimination history Correct Answer: 3 Rationale 1: Inserting a urinary retention catheter is a sterile technique.

Rationale 2: Inserting a straight catheter is a sterile technique.

Rationale 3: The application of a condom catheter could be safely delegated to the UAP. Rationale 4: Data collection cannot be delegated to UAP. Global Rationale: The application of a condom catheter could be safely delegated to the UAP. The other options should be completed by the RN because they either require sterile technique or a thorough assessment.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members SI N G T B . C O M AACN Essential Competencies: IX . 1 4 .NDU eRm o n s t r a t e cl i n i c al judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Practice; Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 22.6 Describe the major parameters needed to preserve a sterile environment when inserting a catheter.

Page Number: p. 813 4. After emptying the urine from a urinal, which actions by the nurse are appropriate?

Standard Text: Select all that apply.

1. Rinsing the urinal 2. Recording the output on the intake and output record, if indicated 3. Returning the urinal to the bedside area, where the client can reach it, if the male client prefers 4. Placing the urinal between the client's legs and propping the penis in the opening, if the client is unable to do this independently 5. Donning clean gloves

Correct Answer: 1, 2, 3 Rationale 1: The urinal should be rinsed to remove any remaining urine.

Rationale 2: The output should be recorded if the client has monitored intake and output.

Rationale 3: The urinal should be returned to the bedside unit so it is handy when it is next required.

Rationale 4: The bottle should never be propped between the client's legs, as it can lead to tissue damage.

Rationale 5: The nurse should already be wearing gloves if the urinal was just emptied.

Global Rationale: The urinal should be rinsed to remove any remaining urine. The output should be recorded if the client has monitored intake and output. The urinal should be returned to the bedside unit so it is handy when it is next required. The bottle should never be propped between the client's legs, as it can lead to tissue damage. The nurse should already be wearing gloves if the urinal was just emptied.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain tNhUeRrSoIlNe GoTf Be .vCi Od eMn c e in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.4 Complete an intake and output bedside record. Page Number: p.

767 5. The nurse is preparing to insert a urinary catheter. Place the steps for this procedure in the proper order.

Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list.

Response 1. Cleanse the meatus.

Response 2. Apply sterile gloves.

Response 3. Test the balloon of the indwelling catheter, if recommended by manufacturer.

Response 4. Organize the supplies in the catheter kit.

Response 5. Place a sterile drape under the buttocks of the female or penis of the male without contaminating the center of the drape.

Correct Answer: 5, 2, 4, 3, 1 Rationale 1: After testing the balloon of the indwelling catheter the nurse cleans the meatus in preparation for insertion.

Rationale 2: After the drape is in place, the nurse dons sterile gloves.

Rationale 3: The nurse tests the balloon of the indwelling catheter (if recommended by the manufacturer).

Rationale 4: With sterile gloves on the nurse organizes the supplies in the catheter kit.

Rationale 5: The nurse places the sterile drape before applying gloves because the nurse would contaminate sterile gloves in the process of placing the drape.

Global Rationale: The nurse places the sterile drape before applying gloves because the nurse would contaminate sterile gloves in the process of placing the drape. After the drape is in place, the nurse dons sterile gloves and organizes the supplies in the catheter kit. The nurse tests the balloon of the indwelling catheter (if recommended by the manufacturer), and then cleans the meatus in preparation for insertion.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.5 Compare and contrast the steps for inserting a straight catheter in a male and female client.

Page Number: p. 779 6. When performing catheter care, which action is least appropriate to perform?

1. Applying sterile gloves 2. Washing the meatus and proximal catheter with soap and water 3. Drying the catheter and urinary meatus

4. Performing hand hygiene Correct Answer: 1 Rationale 1: Sterile gloves are not required when performing catheter care. Rationale 2: The meatus and proximal catheter are cleansed with soap and water. Rationale 3: The catheter and urinary meatus are dried.

Rationale 4: Hand hygiene is to be performed.

Global Rationale: Sterile gloves are not required when performing catheter care. All of the other actions are appropriate for the nurse to perform during this procedure.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and SafetyN: UKRnSoI NwGleTdBg. eC;OCMurren t best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.3 State two nursing diagnoses that relate to urine elimination.

Page Number: p. 786 7. The nurse is initiating closed continuous bladder irrigation using a three-way catheter. Prior to beginning the flow of the irrigation fluid, which action by the nurse is the most appropriate?

1. Opening the roller clamp to the desired flow rate 2. Emptying the urine collection bag 3. Documenting the procedure 4. Assessing the drainage for amount, color, and clarity Correct Answer: 2 Rationale 1: The roller clamp is opened when beginning irrigation.

Rationale 2: Prior to beginning irrigation, the nurse should empty the collection bag and record the output on the client's intake and output record.

Rationale 3: After initiating the procedure, the nurse documents the irrigation.

Rationale 4: The roller clamp is opened when beginning irrigation, and the output drainage is then assessed for amount, color, and clarity.

Global Rationale: Prior to beginning irrigation, the nurse should empty the collection bag and record the output on the client's intake and output record. The roller clamp is opened when beginning irrigation, and the output drainage is then assessed for amount, color, and clarity. After initiating the procedure, the nurse documents the irrigation.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.2 List four alterations that result in urinary elimination problems.

Page Number: p. 791 8. When is it appropriate for the nurse toNpUr RepS aI NreG aT Bn.eCwO M o s to my pouch for a client?

1. After removing the old pouch in all instances 2. Before removing the old pouch in all instances 3. Before removing the old pouch whenever possible 4. After removing the old pouch whenever possible Correct Answer: 3 Rationale 1: Whenever possible, the new pouch should be prepared before removing the old pouch, because it reduces the risk of urine leakage onto the tissues, causing skin breakdown.

Rationale 2: Whenever possible, the new pouch should be prepared before removing the old pouch, because it reduces the risk of urine leakage onto the tissues, causing skin breakdown.

Rationale 3: Whenever possible, the new pouch should be prepared before removing the old pouch, because it reduces the risk of urine leakage onto the tissues, causing skin breakdown.

Rationale 4: Whenever possible, the new pouch should be prepared before removing the old pouch, because it reduces the risk of urine leakage onto the tissues, causing skin breakdown.

Global Rationale: Whenever possible, the new pouch should be prepared before removing the old pouch, because it reduces the risk of urine leakage onto the tissues, causing skin breakdown.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.11 Outline the steps for applying a urinary diversion pouch.

Page Number: p. 800 9. The nurse is caring for an older adult client with a medical diagnosis of benign prostatic hyperplasia resulting in urinary retention. When attempting to pass the catheter, the nurse encounters an obstruction, and cannot get the catheter to pass beyond it. Which action by the nurse is the most appropriate?

1. Documenting that catheterization is noNtUpRoSsIsNibGlTe,Ba. CnOd Mnotifying the health care provider 2. Attempting to pass a Coudé catheter 3. Attempting to push the catheter past the obstruction 4. Applying ice to the base of the penis, and attempting to pass the catheter in 30 minutes Correct Answer: 2 Rationale 1: Merely documenting that the catheter cannot be passed causes the client to continue to experience the discomfort of bladder distention until the health care provider arrives.

Rationale 2: The nurse would attempt to pass a Coudé catheter, which has a curved tip that is somewhat stiffer and can be better controlled during insertion, with passage often less traumatic.

Rationale 3: Pushing the catheter past the obstruction could result in serious trauma.

Rationale 4: Applying ice would not reduce the obstruction, and would most likely be very uncomfortable for the client.

Global Rationale: The nurse would attempt to pass a Coudé catheter, which has a curved tip that is somewhat stiffer and can be better controlled during insertion, with passage often less

traumatic. Merely documenting that the catheter cannot be passed causes the client to continue to experience the discomfort of bladder distention until the health care provider arrives. Pushing the catheter past the obstruction could result in serious trauma. Applying ice would not reduce the obstruction, and would most likely be very uncomfortable for the client.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.5 Compare and contrast the steps for inserting a straight catheter in a male and female client.

Page Number: p. 778 10. A client requiring long-term catheterization is allergic to latex. Which catheter should the nurse choose to insert?

1. Silver alloy catheter 2. Antimicrobial-coated catheter 3. Silicone catheter 4. Latex catheter Correct Answer: 3 Rationale 1: Silver alloy catheters have a lower incidence of bacteriuria than with silver oxide catheter.

Rationale 2: Antimicrobial-coated catheters are used when the risk of urinary tract infection is great.

Rationale 3: Silicone catheters are preferable for long-term use because they create less encrustation at the urethral meatus.

Rationale 4: Latex would be contraindicated because the client is allergic to latex.

Global Rationale: Silicone catheters are preferable for long-term use because they create less encrustation at the urethral meatus. Silver alloy catheters have a lower incidence of bacteriuria than with silver oxide catheter. Antimicrobial-coated catheters are used when the risk of urinary tract infection is great. Latex would be contraindicated because the client is allergic to latex.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 22.2 List four alterations that result in urinary elimination problems..

Page Number: p. 776 11. The nurse is caring for a client with an indwelling catheter. When emptying the urine collection bag, the nurse notes the urine is cloudy with moderate amounts of sedimentation and a foul odor. Based on these assessment f i nNd Ui nRgSsI, NwGhTaBt . Cs hOoMu l d the nurse suspect?

1. Urethral irritation 2. Bladder atrophy 3. Urinary tract infection 4. Kidney infection Correct Answer: 3 Rationale 1: Urethral irritation would most likely present with hematuria.

Rationale 2: Bladder atrophy would be demonstrated by urinary incontinence or frequency.

Rationale 3: Cloudy, foul-smelling urine with sedimentation indicates a bladder infection. These findings should be reported to the health care provider, and an order for a urine culture would be anticipated.

Rationale 4: Further testing would be needed to suspect kidney infection, and a lower urinary tract infection would be more likely.

Global Rationale: Cloudy, foul-smelling urine with sedimentation indicates a bladder infection. These findings should be reported to the health care provider, and an order for a urine culture would be anticipated. Bladder atrophy would be demonstrated by urinary incontinence or frequency. Urethral irritation would most likely present with hematuria. Further testing would be needed to suspect kidney infection, and a lower urinary tract infection would be more likely.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.6 Describe the major parameters needed to preserve a sterile environment when inserting a catheter.

Page Number: p. 763 12. The nurse is caring for a client receiving continuous bladder irrigation following transurethral prostatectomy. When emptying the urine collection bag, the nurse notes that 500 mL of irrigant has infused with only 100 mL of d ra i n a gNe Ur RetSuI rNnGe Td.B.W i c h is the priority action by the nurse?

C Oh M 1. Irrigating the outflow port using an irrigation syringe to determine patency 2. Notifying the health care provider immediately 3. Irrigating the irrigation port to determine patency 4. Continuing to monitor output Correct Answer: 1 Rationale 1: The outflow port that drains urine and irrigation fluid from the bladder should be irrigated gently to assure patency.

Rationale 2: If the port is blocked, the nurse should not apply excessive pressure but should notify the health care provider.

Rationale 3: The fluid is continuing to flow into the bladder, so there is no indication the irrigation port is blocked, making irrigation of this port unnecessary.

Rationale 4: Continuing to monitor output, without resolving the issue, could result in trauma to the client's bladder.

Global Rationale: The outflow port that drains urine and irrigation fluid from the bladder should be irrigated gently to assure patency. If the port is blocked, the nurse should not apply excessive pressure but should notify the health care provider. The fluid is continuing to flow into the bladder, so there is no indication the irrigation port is blocked, making irrigation of this port unnecessary. Continuing to monitor output, without resolving the issue, could result in trauma to the client's bladder.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.2 List four alterations that result in urinary elimination problems.

Page Number: p. 792 13. The nurse is caring for a client with a newly created urinary diversion ostomy appliance. Which is the priority when caring for this client?

1. Increasing fluid intake 2. Limiting fluid intake 3. Administering IV fluids, because the client will be NPO 4. Teaching the client self-care and support persons’ care Correct Answer: 4 Rationale 1: In most cases, there is no need to increase limit fluid intake.

Rationale 2: In most cases, there is no need to limit fluid intake.

Rationale 3: In most cases, there is no need to maintain the client NPO. Rationale 4: It is essential that the client and support persons be taught how to care for the ostomy prior to discharge.

Global Rationale: It is essential that the client and support persons be taught how to care for the ostomy prior to discharge. In most cases, there is no need to increase or limit fluid intake or maintain the client NPO.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 22.11 Outline the steps for applying a urinary diversion pouch.

Page Number: p. 801 14. After applying a condom catheter, what should the nurse document?

Standard Text: Select all that apply.

1. Appearance of the penis, such as swelling or discoloration 2. Amount of urine flow 3. Assessment 30 minutes after application and every 8 hours thereafter 4. Any client complaints or concerns 5. Time of application Correct Answer: 1, 2, 4, 5 Rationale 1: The nurse would document the appearance of the penis if any abnormal findings were noted, such as penile swelling or discoloration.

Rationale 2: The nurse would document the amount of urine flow.

Rationale 3: The penis should be inspected 30 minutes after applying the condom catheter and every 4 hours thereafter.

Rationale 4: The nurse would document any client complaints or concerns.

Rationale 5: The nurse would document the time of application.

Global Rationale: The nurse would document the appearance of the penis if any abnormal findings were noted, such as penile swelling or discoloration; amount of urine flow; any client complaints or concerns; and time of application. The penis should be inspected 30 minutes after applying the condom catheter and every 4 hours thereafter.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: VI.B.4. Document and plan client care in an electronic health record AACN Essential Competencies: IV.5. Use standardized terminology in a care environment that reflects nursing’s unique contribution to client outcomes NLN Competencies: Quality and Safety: Practice; Carefully maintain and use electronic and/or written health records Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.3 State two nursing diagnoses that relate to urine elimination..

Page Number: p. 772 15. Prior to applying the condom catheter, which action by the nurse is the most appropriate?

1. Documenting the use of the catheter 2. Inspecting and cleansing the penis 3. Calling the health care provider to obtain an order 4. Attaching the urinary drainage system securely Correct Answer: 2 Rationale 1: Documentation would be performed after the catheter was applied.

Rationale 2: The penis should be inspected and cleaned before applying the catheter, to minimize skin irritation and excoriation.

Rationale 3: An order is not required for use of a condom catheter.

Rationale 4: The drainage system is attached after applying the condom catheter.

Global Rationale: The penis should be inspected and cleaned before applying the catheter, to minimize skin irritation and excoriation. Documentation would be performed after the catheter was applied. An order is not required for use of a condom catheter. The drainage system is attached after applying the condom catheter.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings

NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.2 List four alterations that result in urinary elimination problems.

Page Number: p. 771 16. A client with a closed urinary drainage system is demonstrating signs of a urinary tract infection.

In which order should the nurse obtain a urine specimen from this system?

1. Remove gloves 2. Clamp the tubing 3. Cleans the access port 4. Perform hand hygiene 5. Remove drainage clamp 6. Aspirate a 2 mL sample of urine 7. Transfer urine to a specimen cup 8. Engage Luer-Lok syringe to the port Correct Answer: 2, 4, 3, 8, 6, 7, 5, 1 Rationale 1: The gloves are removed prior to performing hand hygiene. Rationale 2: The tubing is clamped first.

Rationale 3: The access port is then cleansed.

Rationale 4: Hand hygiene occurs after the tubing is clamped. Rationale 5: The drainage clamp is then release.

Rationale 6: A 2 mL sample of urine is aspirated from the port.

Rationale 7: The urine in the syringe is then transferred to a specimen cup. Rationale 8: The Luer-Lock syringe is attached to the port on the tubing.

Global Rationale: The tubing is clamped first. Hand hygiene occurs after the tubing is clamped. The access port is then cleansed. The Luer-Lock syringe is attached to the port on the tubing. A 2 mL sample of urine is aspirated from the port. The urine in the syringe is then transferred to a specimen cup. The drainage clamp is then release. The gloves are removed prior to performing hand hygiene.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical

management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.10 Outline the steps necessary to obtain a urine specimen from a closed urinary drainage system.

Page Number: p. 797 17. A client with chronic renal failure is being discharged after surgery to create an arteriovenous fistula for hemodialysis. Which client statements indicate that teaching provided about the care of this fistula have been effective? Select all that apply.

1. “I will not lie on the arm with the fistula.”

2. “I will not wear clothing with tight sleeves.”

3. “I will contact the doctor if my hand feels cold.”

4. “I will tell people to use the fistula arm for blood pressures.”

5. “I will not carry anything heavy with my arm with the fistula.” Correct Answer: 1, 2, 3, 5 Rationale 1: For a fistula the client should avoid lying on the arm with the fistula. Rationale 2: For a fistula the client should avoid wearing tight clothing.

Rationale 3: For a fistula the client s h ou lNdUcRoSnItNa GctTtBh.eC Od oMct o r if the hand feels cold. This could indicate a change in blood flow to the extremity.

Rationale 4: For a fistula the client should avoid any use of the arm with the fistula for blood pressure measurements.

Rationale 5: For a fistula the client should avoid carrying anything heavy with the arm with the fistula.

Global Rationale: For a fistula the client should avoid lying on the arm with the fistula, wearing tight clothing, and carrying anything heavy with the arm with the fistula. The client should contact the doctor if the hand feels cold. This could indicate a change in blood flow to the extremity. The client should avoid any use of the arm with the fistula for blood pressure measurements.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Quality and Safety: Knowledge; Current best practices

Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 22.13 List safety precautions for caring for a client with a fistula or graft for vascular access for hemodialysis.

Page Number: p. 805

CHAPTER 23 1. The nurse is caring for a client with abdominal distention who is unable to expel flatus. Which type of enema should the nurse anticipate administering?

1. Cleansing enema 2. Carminative enema 3. Retention enema 4. Soapsuds enema Correct Answer: 2 Rationale 1: A cleansing enema is used to eliminate feces. Soapsuds enemas are a type of cleansing enema.

Rationale 2: A carminative enema is used to reduce abdominal distention by helping to expel flatus.

Rationale 3: Retention enemas introduce oil or medication into the rectum and sigmoid colon. They are retained for a relatively long peNriUoRdS. INGTB.COM Rationale 4: Soapsuds enemas are a type of cleansing enema.

Global Rationale: A carminative enema is used to reduce abdominal distention by helping to expel flatus.

A cleansing enema is used to eliminate feces. Soapsuds enemas are a type of cleansing enema.

Retention enemas introduce oil or medication into the rectum and sigmoid colon. They are retained for a relatively long period.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.6 Outline the essential steps in administering a tap water or saline enema to an adult client.

Page Number: p. 836

2. The nurse is caring for a client with a colostomy who has continuous liquid drainage with a fecal odor.

Which term should the nurse use when documenting the type of colostomy for this client?

1. Ileostomy 2. Ascending colostomy 3. Transverse colostomy 4. Descending colostomy Correct Answer: 2 Rationale 1: An ileostomy has similar drainage but, because of the lack of enzymes, generally does not have much of an odor.

Rationale 2: An ascending colostomy drains liquid that cannot be regulated but, because of the presence of enzymes, has a fecal odor.

Rationale 3: A transverse colostomy drains mushy drainage because some of the liquid has been reabsorbed.

Rationale 4: A descending colostomy produces increasingly solid fecal drainage, and can be regulated.

Global Rationale: An ascending colostomy drains liquid that cannot be regulated but, because of the presence of enzymes, has a fecal odor. An ileostomy has similar drainage but, because of the lack of enzymes, generally does not have much of an odor. A transverse colostomy drains mushy drainage because some of the liquid has been reabsorbed. A descending colostomy produces increasingly solid fecal drainage, and can be regulated.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.4 Describe the anatomic locations for an ileostomy, cecostomy, or colostomy.

Page Number: p. 823

3. The nurse is caring for a client who complains of frequent constipation. Which factor in the client’s history is least likely to be the cause of the constipation?

1. Inadequate fluid intake 2. Repeated inhibition of the urge to defecate 3. Inadequate fiber intake 4. The presence of Escherichia coli Correct Answer: 4 Rationale 1: Inadequate fluid intake could result in constipation, and correcting these generally is the first recommendation for treatment.

Rationale 2: Clients who frequently resist the urge to defecate can develop constipation because of the expansion of the rectum to accommodate accumulated feces, eventually losing sensitivity to the need to defecate.

Rationale 3: Inadequate fiber intake could result in constipation, and correcting these generally is the first recommendation for treatment.

Rationale 4: The bowel normally contains Escherichia coli, and its presence would not contribute to constipation.

Global Rationale: The bowel normally contains Escherichia coli, and its presence would not contribute to constipation. Inadequate fluid intake or fiber intake could result in constipation, and correcting these generally is the first recommendation for treatment. Clients who frequently resist the urge to defecate can develop constipation because of the expansion of the rectum to accommodate accumulated feces, eventually losing sensitivity to the need to defecate.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.2 Compare and contrast hypermotility with hypomotility.

Page Number: p. 825

4. The nurse assists the client off the bedpan after defecating. After emptying and cleaning the bedpan, the nurse finds the bedside table is full, and there is no room for storage of the pan. Which action by the nurse is the most appropriate?

1. Store the bedpan under the bed, where it is out of sight.

2. Place the bedpan on the overbed table until creating a space in the bedside table.

3. Place the bedpan on the floor of the bathroom behind or on the side of the toilet, where it is not likely to be tripped over.

4. Remove objects from the bedside stand and return the bedpan to the stand.

Correct Answer: 4 Rationale 1: Aseptic practice prohibits placing the bedpan on the floor under the bed.

Rationale 2: Aseptic practice prohibits placing the bedpan on the bedside stand.

Rationale 3: Aseptic practice prohibits placing the bedpan on the floor of the bathroom.

Rationale 4: The nurse should remove objects preventing proper storage of the bedpan and find another location for these items.

Global Rationale: Aseptic practice prohibits placing the bedpan on the floor under the bed, on the bedside stand, or on the floor of the bathroom. The nurse should remove objects preventing proper storage of the bedpan and find another location for these items.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.15 Compare and contrast nursing interventions for clients with alterations in bowel elimination in home care and hospital.

Page Number: p. 827 5. The nurse is caring for an older adult client with an ileostomy and hemiplegia secondary to a stroke experienced a few years ago. When changing the client's one-piece appliance, the nurse finds the skin under the skin barrier is ulcerated and erythematous. The client does not empty the

pouch until it is completely full because it hurts so much to remove the skin barrier. Which action by the nurse is the priority?

1. Apply a two-piece ostomy appliance.

2. Treat the damaged skin and replace the one-piece pouch.

3. Keep the skin open to air to allow time for healing, and replace the ostomy appliance in a few days.

4. Call the health care provider to report the damaged skin.

Correct Answer: 1 Rationale 1: The client who requires emptying of the pouch one or more times per day will benefit from a drainable pouch. However, when the client lacks dexterity, he will benefit from a drainable two-piece pouch, allowing the pouch to be removed to empty, instead of a drainable pouch.

Rationale 2: A one-piece pouch needing to be changed daily requires the client to remove both the pouch and the skin barrier, which could be the cause of the trauma.

Rationale 3: Because the client has an ilNeoUsRtSoIm e.aCvOinMg the appliance off is not an option, because the NyG,TlB ostomy will drain continuously.

Rationale 4: There is no need to call the health care provider, because the nurse can provide skin care without an order.

Global Rationale: The client who requires emptying of the pouch one or more times per day will benefit from a drainable pouch. However, when the client lacks dexterity, he will benefit from a drainable twopiece pouch, allowing the pouch to be removed to empty, instead of a drainable pouch. A one-piece pouch needing to be changed daily requires the client to remove both the pouch and the skin barrier, which could be the cause of the trauma. Because the client has an ileostomy, leaving the appliance off is not an option, because the ostomy will drain continuously. There is no need to call the health care provider, because the nurse can provide skin care without an order.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 23.8 Compare and contrast stoma care of an ileostomy and a colostomy.

Page Number: p. 846 6. Which actions could the nurse safely delegate to the unlicensed assistive personnel (UAP)?

Standard Text: Select all that apply.

1. Assist the client to use the bedpan for bowel elimination.

2. Change the ostomy appliance for the new ostomy.

3. Administer a cleansing enema.

4. Remove a fecal impaction.

5. Determine effectiveness of cleansing enema.

Correct Answer: 1, 3 Rationale 1: The UAP can be entrusted with assisting the client to use a bedpan.

Rationale 2: Only the nurse can change a new oasnt ocem, yb ea cpapul is e of the need to assess the drainage and the site.

Rationale 3: The UAP can administer most types of enemas.

Rationale 4: Because of the risk of vagal nerve stimulation, the nurse should remove fecal impactions.

Rationale 5: Assessing the effectiveness of any treatment should be performed by the nurse.

Global Rationale: The UAP can be entrusted with assisting the client to use a bedpan, and can administer most types of enemas. However, only the nurse can change a new ostomy appliance, because of the need to assess the drainage and the site. Because of the risk of vagal nerve stimulation, the nurse should remove fecal impactions. Assessing the effectiveness of any treatment should be performed by the nurse.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A.2.Describe scopes of practice and roles of health care team members AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Practice; Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 23.15 Compare and contrast nursing interventions for clients with alterations in bowel elimination in home care and hospital.

Page Number: p. 850 7. The nurse is caring for a client who is on complete bed rest secondary to a deep vein thrombosis in the right leg. When placing the client on the bedpan, which position is most appropriate?

1. Prone 2. Semi-Fowler's 3. Fowler's 4. Supine Correct Answer: 3 Rationale 1: The client is likely to be better able to evacuate her bowels if the normal position for toileting is obtained. Placing the client in the Fowler's position simulates this normal toileting position, and would not be contraindicat Ne dU bR yS I tNhGe TmB e. CdOicMal diagnosis. The other positions are not optimal.

Rationale 2: The client is likely to be better able to evacuate her bowels if the normal position for toileting is obtained. Placing the client in the Fowler's position simulates this normal toileting position, and would not be contraindicated by the medical diagnosis. The other positions are not optimal.

Rationale 3: The client is likely to be better able to evacuate her bowels if the normal position for toileting is obtained. Placing the client in the Fowler's position simulates this normal toileting position, and would not be contraindicated by the medical diagnosis. The other positions are not optimal.

Rationale 4: The client is likely to be better able to evacuate her bowels if the normal position for toileting is obtained. Placing the client in the Fowler's position simulates this normal toileting position, and would not be contraindicated by the medical diagnosis. The other positions are not optimal.

Global Rationale: The client is likely to be better able to evacuate her bowels if the normal position for toileting is obtained. Placing the client in the Fowler's position simulates this normal toileting position, and would not be contraindicated by the medical diagnosis. The other positions are not optimal.

Cognitive Level: Applying

Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.5 List the components of a good bowel training program.

Page Number: p. 829 8. The nurse is administering a cleansing enema. Which action would indicate the need for further instruction on the process?

1. Enema solution is warmed to 40°C (105°F).

2. The solution container is held 12 inches above the rectum.

3. The client is in the Fowler’s position.

4. The client is encouraged to retain the eNnUeRmSaINfor 5–.C1O0Mminutes.

GTB Correct Answer: 3 Rationale 1: The solution should be warmed.

Rationale 2: The container should be about 12 inches above the rectum.

Rationale 3: The client should be in the Sim’s position for the enema.

Rationale 4: The enema should be retained for 5 to 10 minutes.

Global Rationale: The client should be in the Sim’s position for the enema. The solution should be warmed. The container should be about 12 inches above the rectum. The enema should be retained for 5 to 10 minutes.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings

NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.6 Outline the essential steps in administering a tap water or saline enema to an adult client.

Page Number: p. 838 9. While the nurse is removing a fecal impaction, the client begins to perspire profusely and complains of shortness of breath. The nurse notes that the client’s pulse rate has slowed to 44 beats per minute.

Which is the priority action by the nurse?

1. Holding the fingers still until the symptoms stop, and then resuming removal of fecal impaction 2. Stopping the procedure immediately 3. Continuing the procedure, and monitoring the client carefully 4. Stopping the procedure and calling the health care provider immediately Correct Answer: 2 Rationale 1Holding the fingers still a n d Nt hUeRnS rI Ne sGuTmBi. nCgO M t h e procedure is likely to result in arrhythmias and worsening symptoms.

Rationale 2: The client is demonstrating signs of vagal nerve stimulation, so the nurse should stop the procedure immediately and monitor the client for easing of symptoms.

Rationale 3: Continuing the procedure is likely to result in arrhythmias and worsening symptoms.

Rationale 4: If symptoms do not resolve within a few minutes, the nurse might need to notify the health care provider, but discontinuation of stimulation is usually the only treatment required.

Global Rationale: The client is demonstrating signs of vagal nerve stimulation, so the nurse should stop the procedure immediately and monitor the client for easing of symptoms. If symptoms do not resolve within a few minutes, the nurse might need to notify the health care provider, but discontinuation of stimulation is usually the only treatment required. Holding the fingers still and then resuming the procedure, or continuing the procedure, is likely to result in arrhythmias and worsening symptoms.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an

understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.7 Describe the precautions necessary when performing digital stimulation to remove a fecal impaction.

Page Number: p. 827

10. The nurse is changing the ostomy appliance for a client with a new loop colostomy. Which action by the nurse is the most appropriate?

1. Remove the plastic bridge in order to create a tight fit with the ostomy appliance.

2. Cut two holes in the skin barrier for each loop.

3. Cut an opening in the skin barrier for only the afferent or proximal end of the stoma.

4. Place a piece of tissue or gauze over the stoma, and use a guide to measure the size of the stoma.

Correct Answer: 4 Rationale 1: The plastic bridge or piece of rubber tubing helps to support the loop of bowel brought to the skin, and should never be removed.

Rationale 2: Only one hole needs to be cut in the skin barrier, because both will fit through the opening.

Rationale 3: Only one hole needs to be cut in the skin barrier, because both will fit through the opening.

Rationale 4: The nurse will place a piece of tissue or gauze over the stoma to absorb seepage from the stoma while the ostomy appliance is being changed, and will measure the correct size of the stoma using a guide.

Global Rationale: The nurse will place a piece of tissue or gauze over the stoma to absorb seepage from the stoma while the ostomy appliance is being changed, and will measure the correct size of the stoma using a guide. The plastic bridge or piece of rubber tubing helps to support the loop of bowel brought to the skin, and should never be removed. Only one hole needs to be cut in the skin barrier, because both will fit through the opening.

Cognitive Level: Applying Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.8 Compare and contrast stoma care of an ileostomy and a colostomy.

Page Number: p. 824 11. The nurse is caring for a client with a newly created ostomy. After changing the ostomy appliance, which items should the nurse include when documenting the procedure?

Standard Text: Select all that apply.

1. How the drainage was disposed 2. Quantity of drainage recorded on output record 3. Any client participation in the procedure 4. Assessment of stoma and skin around the stoma 5. The odor of the drainage Correct Answer: 2, 3, 4 Rationale 1: The disposal of the drainage would not need to be documented. Rationale 2: The nurse should document how much drainage was emptied. Rationale 3: The nurse should document the client's involvement in the procedure.

Rationale 4: The nurse should document the assessment of both the stoma and the skin around the stoma.

Rationale 5: The odor would only be documented if it were unusual.

Global Rationale: The nurse should document how much drainage was emptied, the client's involvement in the procedure, and the assessment of both the stoma and the skin around the stoma. The disposal of the drainage would not need to be documented. The odor would only be documented if it were unusual.

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: VI.B.4. Document and plan client care in an electronic health record AACN Essential Competencies: IV.5. Use standardized terminology in a care environment that reflects nursing’s unique contribution to client outcomes NLN Competencies: Quality and Safety: Practice; Carefully maintain and use electronic and/or written health records Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.11 Describe at least three precautions necessary when applying a fecal ostomy pouch.

Page Number: p. 832 12. The nurse educator is conducting an in-service to a group of new nurses regarding the use of ostomy appliances. When discussing the characteristics of ostomy appliances, which statements are appropriate for the educator to include in the presentation?

Standard Text: Select all that apply.

1. The ostomy appliance comes in a three-piece set.

2. The ostomy appliance should protect the skin near the stoma.

3. The ostomy appliance should collect bNoUthRSsItoNoGlTaBn.Cd Ourine.

M 4. The ostomy appliance controls odor.

5. All ostomy appliances can only be used once.

Correct Answer: 2, 4 Rationale 1: Ostomy appliances come in one- or two-piece sets.

Rationale 2: Ostomy appliances should protect the skin near the stoma.

Rationale 3: The client would use a separate appliance for the collection of stool and the collection of urine.

Rationale 4: Ostomy appliances should control odor.

Rationale 5: Many ostomy appliances are reusable.

Global Rationale: Ostomy appliances should protect the skin near the stoma, collect stool, and control odor. Although there are ostomy appliances that collect urine, the client would use a separate appliance for the collection of stool and the collection of urine. Ostomy appliances come in one- or two-piece sets.

Many ostomy appliances are reusable.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 23.11 Describe at least three precautions necessary when applying a fecal ostomy pouch.

Page Number: p. 846 13. The nurse is working with unlicensed assistive personnel (UAP) in a long-term care facility. Which tasks can the nurse delegate to the UAP? Standard Text: Select all that apply.

1. Administering an enema to a stable client 2. Removing a fecal impaction for an unNstUabRlSeINclGieTnBt.COM 3. Assisting a client to perform ostomy care after hand surgery 4. Helping a client onto a bedpan 5. Assessing skin during an ostomy appliance change Correct Answer: 1, 3, 4 Rationale 1: The UAP can administer most enemas.

Rationale 2: The UAP cannot remove an impaction.

Rationale 3: The UAP can assist a client to perform ostomy care if the ostomy is not new.

Rationale 4: The UAP can help a client onto a bedpan.

Rationale 5: The UAP cannot assess a client’s skin during an ostomy appliance change.

Global Rationale: The UAP can administer most enemas, assist a client to perform ostomy care if the ostomy is not new, and help a client onto a bedpan. The UAP cannot remove an impaction nor can the UAP assess a client’s skin during an ostomy appliance change.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Practice; Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.15 Compare and contrast nursing interventions for clients with alterations in bowel elimination in home care and hospital.

Page Number: p. 850 14. The nurse is providing ostomy care for a client with a colostomy. Which assessment findings should the nurse report to the health care provider if noted during the procedure?

Standard Text: Select all that apply.

1. No change in stoma size 2. A stoma that appears dry and grey in color 3. The presence of skin irritation 4. The amount of drainage 5. The odor of the drainage Correct Answer: 2, 3 Rationale 1: No change in the size of the stoma is a normal finding that does not require reporting to the health care provider.

Rationale 2: Findings that are abnormal include a stoma that is dry and grey in color, as this indicates circulatory impairment.

Rationale 3: Findings that are abnormal include the presence of skin irritation.

Rationale 4: The amount of drainage is documented but not reported unless there is a problem.

Rationale 5: Odor is not reportable and is only documented if a change is noted.

Global Rationale: The nurse would report abnormal assessment findings to the health care provider if noted when providing ostomy care to the client. Findings that are abnormal include a stoma that is dry and grey in color, as this indicates circulatory impairment, and the presence of skin irritation. No change in the size of the stoma is a normal finding that does not require

reporting to the health care provider. The amount of drainage is documented but not reported unless there is a problem. Odor is not reportable and is only documented if a change is noted.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: VI.B.4. Document and plan client care in an electronic health record AACN Essential Competencies: IV.5. Use standardized terminology in a care environment that reflects nursing’s unique contribution to client outcomes NLN Competencies: Quality and Safety: Practice; Carefully maintain and use electronic and/or written health records Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.11 Describe at least three precautions necessary when applying a fecal ostomy pouch.

Page Number: p. 848 15. The nurse notes that the skin around the stoma of a client with an ileostomy is partially denuded. What should the nurse do?

1. Keep the appliance off 2. Apply skin barrier paste 3. Apply Stomahesive powder 4. Increase the size of the stoma opening on the barrier Correct Answer: 3 Rationale 1: Keeping the appliance off can increase skin irritation. Rationale 2: Skin barrier paste is applied to the opening on the pouch. Rationale 3: Stomahesive powder should be applied to denuded skin only.

Rationale 4: Increasing the size of the stoma opening will encourage leakage and cause more skin breakdown.

Global Rationale: Stomahesive powder should be applied to denuded skin only. Keeping the appliance off can increase skin irritation. Skin barrier paste is applied to the opening on the pouch. Increasing the size of the stoma opening will encourage leakage and cause more skin breakdown.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care: AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical

management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.10 Describe at least three interventions used when skin is denuded from leakage.

Page Number: p. 846 16. A client is considering the placement of a continent ileostomy. What should the nurse explain as an advantage of this type of surgery?

1. Gas may be expelled 2. An appliance is not needed 3. Additional surgery may be required 4. A drainage catheter needs to be inserted several times a day Correct Answer: 2 Rationale 1: A disadvantage is that gas may be expelled.

Rationale 2: With a continent ileostomy the stoma is flush with the skin, and no appliance is needed.

Rationale 3: A disadvantage is the potenNtiaUlRnSeI NedG TfoBr. Ca OddMitional surgery due to a slipped nipple valve or a fistula.

Rationale 4: The pouch stores liquid waste and is drained several times each day using a small catheter. The catheter is inserted through the opening on the abdomen into the pouch.

Global Rationale: With a continent ileostomy the stoma is flush with the skin, and no appliance is needed.

A disadvantage is that gas may be expelled and the potential need for additional surgery due to a slipped nipple valve or a fistula. The pouch stores liquid waste and is drained several times each day using a small catheter. The catheter is inserted through the opening on the abdomen into the pouch.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care: AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.12 Discuss the corking and intubation procedure for a client with a continent ileostomy.

Page Number: p. 822 17. A client with a rectal tube begins to experience diarrhea. What should the nurse do?

1. Clamp the tube 2. Remove the tube 3. Reposition the client 4. Attach a collection bag Correct Answer: 2 Rationale 1: A rectal tube should not be used to manager diarrhea. The tube should not be clamped.

Rationale 2: The tube should be removed because a rectal tube is to relieve flatus and not manage diarrhea.

Rationale 3: Repositioning the client will have no effect.

Rationale 4: A rectal tube should not be left in place in the event the client experiences diarrhea.

NU Global Rationale: The tube should be rem ovReSdINbGeTcBau.CsO eM a rectal tube is to relieve flatus and not manage diarrhea.

The tube should not be clamped. Repositioning the client will have no effect.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care: AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.13 Describe the precautions necessary when using a rectal tube. Page Number: p. 831

CHAPTER 24 1. The nurse applies an aquathermia heat pack to the client's right leg and removes it after no more than 45 minutes. What is the nurse trying to avoid by completing this action?

1. Vasodilation 2. Rebound phenomenon 3. Heat tolerance 4. Systemic effects Correct Answer: 2 Rationale 1: Vasodilation is the desired effect of heat.

Rationale 2: A rebound phenomenon occurs at the time the maximum therapeutic effect is achieved and the opposite effects begin, and can result in a burn.

Rationale 3: Heat tolerance begins shortly after applying the heat pack as the skin adapts to the warmth.

Rationale 4: Systemic effects will occur when heat is applied to a large localized area of the body, increasing cardiac output and pulmonary ventilation.

Global Rationale: A rebound phenomenon occurs at the time the maximum therapeutic effect is achieved and the opposite effects begin, and can result in a burn. Vasodilation is the desired effect of heat. Heat tolerance begins shortly after applying the heat pack as the skin adapts to the warmth. Systemic effects will occur when heat is applied to a large localized area of the body, increasing cardiac output and pulmonary ventilation.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24.6 Describe the physiologic effects of local heat applications (thermotherapy).

Page Number: p. 877

2. The client calls the nurse into the room and says that the heat pack the nurse applied feels cold, and asks the nurse to turn the heat up on the aquathermia unit. Which response by the nurse is the most appropriate?

1. "I'll turn it up a little at a time and you let me know when it feels warm again."

2. "The doctor wants the aquathermia pad maintained at a specific temperature, so there's no need to change it."

3. "The aquathermia pad still feels warm to me."

4. "Your body has adjusted to the warmth, and is making it feel cooler, but it's actually the same temperature as when it was first applied."

Correct Answer: 4 Rationale 1: If the nurse increases the temperature, there is a great risk the client will be burned.

Rationale 2: Telling the client the doctor ordered it this way does not explain the phenomenon that causes the pad to feel cooler or give the client a reason for why the temperature is not increased.

Rationale 3: Telling the client that the pNadURfeSeIlNsGwTaBr.m o the nurse does not explain the phenomenon that COtM causes the pad to feel cooler or give the client a reason for why the temperature is not increased.

Rationale 4: When the heat pack is applied, the body vasodilates the vessels near the warmth and the heat pack begins to feel cold, when in fact it is the same temperature it was when first applied.

Global Rationale: When the heat pack is applied, the body vasodilates the vessels near the warmth and the heat pack begins to feel cold, when in fact it is the same temperature it was when first applied. If the nurse increases the temperature, there is a great risk the client will be burned. Telling the client the doctor ordered it this way or that the pad feels warm to the nurse does not explain the phenomenon that causes the pad to feel cooler or give the client a reason for why the temperature is not increased.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.B.3. Base individualized care plan on client values, clinical expertise, and evidence AACN Essential Competencies: III.2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24.6 Describe the physiologic effects of local heat applications (thermotherapy).

Page Number: p. 855 3. The nurse receives a call from a client who reports a deep, long cut to the left hand sustained while slicing a bagel and asks the nurse what to do. Which action should the nurse direct the client to take?

1. Elevate the arm above the head and apply ice and pressure while en route to the emergency department.

2. Apply heat and pressure en route to the emergency department.

3. Apply ice and elevate the arm.

4. Apply pressure and elevate the arm.

Correct Answer: 1 Rationale 1: The nurse would advise the client to apply ice because it will cause vasoconstriction, and to elevate the arm while applying direct pressure to the wound in order to slow the bleeding process. The client s h oNuUl dR SbI eN dGiTr eBc. Ct eOdMt o the emergency department for further treatment.

Rationale 2: Heat would increase blood flow to the wound and is not recommended.

Rationale 3: Direct pressure needs to be applied and the client needs to go to the emergency department.

Rationale 4: Ice needs to be applied and the client needs to go to the emergency department.

Global Rationale: The nurse would advise the client to apply ice because it will cause vasoconstriction, and to elevate the arm while applying direct pressure to the wound in order to slow the bleeding process.

The client should be directed to the emergency department for further treatment. Heat would increase blood flow to the wound and is not recommended.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.B.3. Base individualized care plan on client values, clinical expertise, and evidence AACN Essential Competencies: III.2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based

approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24.10 Predict the type of thermal agent that would be most therapeutic for a particular client’s condition.

Page Number: p. 859 4. The nurse is caring for a client diagnosed with osteoarthritis. Which intervention should the nurse advise the client to do in order to reduce discomfort?

1. Apply ice to the painful joint.

2. Immerse the painful joint in cold water.

3. Apply heat pack once a day.

4. Apply heat to the painful joint several times a day.

Correct Answer: 4 Rationale 1: Ice will increase the client's discomfort. Rationale 2: Cold water will increase t h Ne UclRieSnINt'Gs Td Bi s. cCoOmMf o r t . Rationale 3: Heat should be applied more than once a day.

Rationale 4: Heat is more effective for chronic joint pain, and it would be best to have the client apply heat several times a day because the pain is chronic and the effects of the warm pack will subside.

Global Rationale: Heat is more effective for chronic joint pain, and it would be best to have the client apply heat several times a day because the pain is chronic and the effects of the warm pack will subside. Ice or cold water will increase the client's discomfort.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.B.3. Base individualized care plan on client values, clinical expertise, and evidence AACN Essential Competencies: III.2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24.9 Identify indications and contraindications for various heat and cold therapies.

Page Number: p. 859 5. The nurse is providing care to several clients on a medical–surgical unit. Which clients would benefit from the application of heat?

Standard Text: Select all that apply.

1. Client with muscle spasms in the lower back 2. Client with traumatic injury and bleeding 3. Client with joint contracture 4. Client in pain 5. Client with inflammation Correct Answer: 1, 3, 4, 5 Rationale 1: Heat is appropriate to treat muscle spasms.

Rationale 2: Clients with traumatic i n j u rNyUcRaSuI sNinGgT Bb.lCe OedMi n g should apply ice to vasoconstrict the vessels and reduce the blood loss.

Rationale 3: Heat is appropriate to treat joint contractures.

Rationale 4: Heat is appropriate to treat pain.

Rationale 5: Heat is appropriate to treat inflammation.

Global Rationale: Clients with traumatic injury causing bleeding should apply ice to vasoconstrict the vessels and reduce the blood loss. Heat is appropriate to treat muscle spasms, joint contractures, pain, and inflammation.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.B.3. Base individualized care plan on client values, clinical expertise, and evidence AACN Essential Competencies: III.2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 24.10 Predict the type of thermal agent that would be most therapeutic for a particular client’s condition.

Page Number: p. 859 6. Which activity can the nurse safely delegate to unlicensed assistive personnel (UAP)?

1. Sterile warm soak to client's infected postoperative wound 2. Application of warm moist soak to client's left leg 3. Determine effectiveness of cold application to reduce client's pain 4. Responsibilities for the application of a warm pack to client's IV infiltrate Correct Answer: 2 Rationale 1: Sterile procedures must be performed by the nurse.

Rationale 2: Application of warm moist soaks to the client's left leg could be safely delegated to the UAP as long as the nurse instructed the UAP on the optimal temperature of the soak for this client.

N UR S I N G T B . C O M

Rationale 3: Assessing the effectiv eness o f a c o ld pa c k i s the nurse's responsibility, and assessment should never be delegated to the UAP. Rationale 4: The nurse is responsible for applying a warm pack to treat a specific condition.

Global Rationale: Application of warm moist soaks to the client's left leg could be safely delegated to the UAP as long as the nurse instructed the UAP on the optimal temperature of the soak for this client. Sterile procedures must be performed by the nurse, who is also responsible for the application of the warm pack, even if performed by the UAP. Assessing the effectiveness of a cold pack is the nurse's responsibility, and assessment should never be delegated to the UAP. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Practice; Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 24.9 Identify indications and contraindications for various heat and cold therapies.

Page Number: p. 879

7. While applying a warm wet soak to the client's left leg, the unlicensed assistive personnel (UAP) notes a small burn on the inside of the calf. The UAP informs the RN. Which response by the nurse is the most appropriate?

1. "Please notify the health care provider."

2. "Describe the burn in detail, please."

3. "I'll go take a look at it."

4. "Make sure you document it and complete an incident form."

Correct Answer: 3 Rationale 1: The nurse should notify the health care provider.

Rationale 2: The nurse should not rely on the UAP’s description of the wound but should assess it thoroughly.

Rationale 3: Although the nurse can delegate the performance of the task, the responsibility for the task is not delegated, so the nurse s h oNuUl dR SgI oN Ga sTsBe. sCsOt M h e wound.

Rationale 4: The nurse should complete an incident report.

Global Rationale: Although the nurse can delegate the performance of the task, the responsibility for the task is not delegated, so the nurse should go assess the wound prior to notifying the health care provider and completing an incident report. The nurse should not rely on the UAP’s description of the wound but should assess it thoroughly.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Practice; Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24.9 Identify indications and contraindications for various heat and cold therapies.

Page Number: p. 879

8. The nurse is applying an aquathermia pad to a client complaining of arthritic pain in the right knee.

Which filler is appropriate for this unit?

1. Sterile water 2. Normal saline 3. Tap water 4. Distilled water Correct Answer: 4 Rationale 1: The water is contained, and does not come in contact with the client, so there is no need to use sterile water.

Rationale 2: The water is contained, and does not come in contact with the client, so there is no need to use saline.

Rationale 3: Tap water could corrode the device, making it malfunction.

Rationale 4: The unit should be filled with distilled water.

Global Rationale: The unit should be filled with distilled water because nondistilled or tap water could corrode the device, making it malfunction. The water is contained, and does not come in contact with the client, so there is no need to use sterile water or saline.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24.5 Identify various modes of heat therapy. Page Number: p. 879 9. Which is the most effective way for the nurse to apply an appliance such as a hot water bottle or disposable hot pack to a client?

1. Directly to the client’s skin

2. Directly to the client’s skin with a towel or blanket wrapped over the appliance to hold it to the leg 3. If possible, have the client lay on top of the appliance 4. Wrap the appliance in a towel and lay it on the site on the client Correct Answer: 4 Rationale 1: Laying the appliance directly on the client’s skin could result in a burn.

Rationale 2: Covering the appliance would increase the intensity of the heat, and could result in a burn.

Rationale 3: Having the client lay on top of it would increase the intensity of the heat, and could result in a burn.

Rationale 4: In order to reduce the risk of burning the client, it would be best to place a towel or cloth between the client and the device.

Global Rationale: In order to reduce the risk of burning the client, it would be best to place a towel or cloth between the client and the device. Covering the appliance or having the client lay on top of it would increase the intensity of the heat, and could result in a burn.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24.12 List four safety precautions to consider when applying heat and cold treatments.

Page Number: p. 867 10. The nurse is preparing an ice bag to apply to the client's sprained left ankle. How should the nurse fill the bag?

1. One-third full of ice, and add water to make it more pliable 2. One-half to two-thirds full of crushed ice 3. Completely full to make it last longer

4. One-third to two-thirds full of ice cubes Correct Answer: 2 Rationale 1: Adding water to the bag adds weight, which could make it uncomfortable for the client.

Rationale 2: The bag should be filled one-half to two-thirds full of crushed ice in order to make it more pliable.

Rationale 3: If the bag is filled completely full, it will be too stiff to stay in place.

Rationale 4: If the bag is filled with ice cubes it will be too stiff to stay in place.

Global Rationale: The bag should be filled one-half to two-thirds full of crushed ice in order to make it more pliable. Adding water to the bag also adds weight, which could make it uncomfortable for the client. If the bag is filled completely full, or ice cubes were used, it will be too stiff to stay in place.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice NeGnTtBe.C AACN Essential Competencies: IX.8. NImUpRlSeIm viOdM ence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24.7 Identify various modes of cold therapy (local cryotherapy and induced hypothermia).

Page Number: p. 867 11. The nurse is applying a warm moist compress to the client's right calf. Prior to putting the compress in place, which action by the nurse is the most appropriate?

1. Turn the client onto the left side.

2. Position the client appropriately.

3. Turn the client onto the right side.

4. Elevate the head of the bed.

Correct Answer: 2

Rationale 1: The client should be positioned appropriately to expose and assess area to be treated.

Rationale 2: The client should be positioned appropriately to expose and assess area to be treated.

Rationale 3: The client should be positioned appropriately to expose and assess area to be treated.

Rationale 4: The client should be positioned appropriately to expose and assess area to be treated.

Global Rationale: The client should be positioned appropriately to expose and assess area to be treated.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation N URS I N G T B.C O M Learning Outcome: 24.5 Identify v a r i o u s m o d e s o f h e at therapy. Page Number: p. 863 12. The nurse applies a warm moist compress to the client’s left wrist. Which item should the nurse exclude from the documentation of the intervention for this client?

1. Assessment of site before and after the application 2. Client's response to the compress 3. Assessment of the site every 5–10 minutes 4. Vital signs before, during, and after the treatment Correct Answer: 4 Rationale 1: The site should be assessed before and after application of heat.

Rationale 2: The client’s response should be documented.

Rationale 3: The site should be assessed every 5 to 10 minutes.

Rationale 4: Although it is never wrong to monitor vital signs, it is only required when heat is applied to a large area of the body. Heat applied to only the wrist should not impact vital signs, and would not be required unless the client showed an unexpected response.

Global Rationale: Although it is never wrong to monitor vital signs, it is only required when heat is applied to a large area of the body. Heat applied to only the wrist should not impact vital signs, and would not be required unless the client showed an unexpected response. The site should be assessed before, after, and during the treatment. The client’s response should be documented,.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: VI.B.4. Document and plan client care in an electronic health record AACN Essential Competencies: IV.5.Use standardized terminology in a care environment that reflects nursing’s unique contribution to client outcomes NLN Competencies: Quality and Safety: Practice; Carefully maintain and use electronic and/or written health records Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24.6 Describe the physiologic effects of local heat applications (thermotherapy).

Page Number: p. 865 13. Many conditions can increase the r i s Nk Uf oRrS iI nNjGu Tr yB .fCr oOm M heat applications. Which clients would be at the greatest risk for injury?

Standard Text: Select all that apply.

1. A client with a lot of body fat 2. A client being treated for anxiety 3. A client with peripheral vascular disease 4. A malnourished client 5. A client prescribed steroids Correct Answer: 3, 4, 5 Rationale 1: Body fat has nothing to do with decreased circulation issues.

Rationale 2: Clients being treated for anxiety are not necessarily prone to decreased circulation issues.

Rationale 3: Clients with decreased circulation are at risk for tissue injury.

Rationale 4: Clients with conditions that cause decreased fluid or nutrients to their systems are at risk for tissue injury.

Rationale 5: Clients taking steroids for a long time are at risk for tissue injury.

Global Rationale: Clients with decreased circulation, conditions that cause decreased fluid or nutrients to their systems, and the use of steroids for a long time are at risk for tissue injury.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.B.3. Base individualized care plan on client values, clinical expertise, and evidence AACN Essential Competencies: III.2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 24.9 Identify indications and contraindications for various heat and cold therapies.

Page Number: p. 861 14. The nurse is going to apply a cold compress to a client’s lower forearm. What nursing intervention would be indicated?

1. Decrease the length of time the cold compress would normally be applied.

2. Increase the length of time that the compress would be applied.

3. Keep the length of time the same as it would be when applying to other areas of the body.

4. Leave the cold compress in place until it is no longer cool.

Correct Answer: 1 Rationale 1: Because the area being treated has little fat or tissue around it, the amount of time spent applying the cold compress should be decreased.

Rationale 2: Because the area being treated has little fat or tissue around it, the amount of time spent applying the cold compress should be decreased.

Rationale 3: Because the area being treated has little fat or tissue around it, the amount of time spent applying the cold compress should be decreased.

Rationale 4: Because the area being treated has little fat or tissue around it, the amount of time spent applying the cold compress should be decreased.

Global Rationale: Because the area being treated has little fat or tissue around it, the amount of time spent applying the cold compress should be decreased.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24.8 Describe the physiologic effects of local cold applications (cryotherapy).

Page Number: p. 867 15. The nurse is instructing the unlicensed assistive personnel (UAP) to apply a warm compress to the client’s knee. Which statement made by the UAP indicates that further instruction should be given?

1. "I can place the heating pad directly to the client’s knee."

2. "I will maintain the proper temperature of the heating pad."

3. "I will inform you of any redness of the skin."

4. "I will report to you when the treatment is over."

Correct Answer: 1 Rationale 1: The heating pad should not be placed directly on the client’s knee. This is incorrect and the nurse should explain to the UAP the need to place a barrier between the heating pad and the client’s body part.

Rationale 2: The temperature of the heating pad should be maintained during the treatment to prevent adverse effects.

Rationale 3: The UAP must inform the nurse of any adverse effects that occur during the treatment.

Rationale 4: The UAP should report to the nurse when the treatment is over. The nurse will need to assess the client after the treatment.

Global Rationale: The heating pad should not be placed directly on the client’s knee. This is incorrect and the nurse should explain to the UAP the need to place a barrier between the heating pad and the client’s body part. The other statements indicate that the UAP has an accurate understanding of the procedure and the role of the UAP.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Practice; Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24.9 Identify indications and contraindications for various heat and cold therapies.

Page Number: p. 863 16. The nurse is caring for a client with body temperature instability. What hypothalamic reactions should the nurse consider occurring to help control the client’s temperature instability? Select all that apply.

1. Radiation 2. Convection 3. Conduction 4. Evaporation 5. Condensation Correct Answer: 1, 2, 3, 4 N URSING TB.COM

Rationale 1: The hypothalamus interprets information from both the superficial and internal (core) sources and triggers vasomotor responses to maintain a normal temperature through processes of radiation.

Rationale 2: The hypothalamus interprets information from both the superficial and internal (core) sources and triggers vasomotor responses to maintain a normal temperature through processes of convection.

Rationale 3: The hypothalamus interprets information from both the superficial and internal (core) sources and triggers vasomotor responses to maintain a normal temperature through processes of conduction.

Rationale 4: The hypothalamus interprets information from both the superficial and internal (core) sources and triggers vasomotor responses to maintain a normal temperature through processes of evaporation.

Rationale 5: Condensation is not a mechanism to control body temperature.

Global Rationale: The hypothalamus interprets information from both the superficial and internal (core) sources and triggers vasomotor responses to maintain a normal temperature through processes of conduction, convection, evaporation, and radiation. Condensation is not a mechanism to control body temperature.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.2 Discuss the role of the hypothalamus in thermoregulation.

Page Number: p. 855 17. The nurse is caring for a client with induced hypothermia for major thoracic surgery. For which potential health problems should the nurse assess this client? Select all that apply.

1. Acidosis 2. Afterdrop 3. Hypotension 4. Hypertension 5. Rebound fever Correct Answer: 1, 2, 3 Rationale 1: Acidosis may occur as accumulated tissue acids enter the central circulation.

Rationale 2: As cool blood from the periphery moves to mix with warmer blood in the core, central temperature drops 2°–5°C (3.5–9°F) causing afterdrop.

Rationale 3: Hypotension can occur when peripheral vessels dilate when the body is rewarmed. Rationale 4: Hypertension is not an effect of induced hypothermia.

Rationale 5: Rebound fever is not an effect of induced hypothermia.

Global Rationale: Hypothermia may be therapeutically induced in certain situations to protect vital organs because it provides metabolic quiescence. Acidosis may occur as accumulated tissue acids enter the central circulation. As cool blood from the periphery moves to mix with warmer blood in the core, central temperature drops 2°–5°C (3.5–9°F) causing afterdrop. Hypotension can occur when peripheral vessels dilate when the body is rewarmed. Hypertension and rebound fever are not effects of induced hypothermia.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes

AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.11 Discuss the rationale for induced hypothermia for special clients.

Page Number: p. 859

CHAPTER 25 1. The nurse notes black necrotic tissue on the client's wound. Which term should the nurse use when documenting this finding?

1. Debridement 2. Eschar 3. Alginate 4. Purulence Correct Answer: 2 Rationale 1: Debridement is the process of removing dead tissue.

Rationale 2: Eschar is black necrotic tissue.

Rationale 3: Alginate is a fluid-absorbing substance that can be placed in highly exudative wounds to absorb the drainage.

Rationale 4: Purulence is the result of wNoUunRdSIiNnGfeTcBti.ConO.M Global Rationale: Eschar is black necrotic tissue. Debridement is the process of removing dead tissue.

Alginate is a fluid-absorbing substance that can be placed in highly exudative wounds to absorb the drainage. Purulence is the result of wound infection.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.26 Complete documentation on a wound assessment and wound care.

Page Number: p. 885 2. The client experiences a burn on the arm that is confined to the skin. How should the nurse describe this burn when documenting this client’s care?

1. A clean wound 2. A dirty or infected wound 3. A partial-thickness wound 4. A full-thickness wound Correct Answer: 3 Rationale 1: There is not enough information provided to know if it is a clean wound.

Rationale 2: There is not enough information provided to know if it is a dirty wound.

Rationale 3: The burn described is a partial-thickness burn if it is confined to the skin or dermis and epidermis.

Rationale 4: TA full-thickness burn involves the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone.

Global Rationale: The burn described is a partial-thickness burn if it is confined to the skin or dermis and epidermis. A full-thickness burn involves the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone. There is not enough information provided to know if it is a clean or dirty wound.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1.Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.26 Complete documentation on a wound assessment and wound care..

Page Number: p. 993 3. For which client should the nurse consider applying a transparent film for wound care?

1. The client with a postoperative wound held together by sutures 2. A client with a stage I pressure ulcer 3. The client with a venous stasis ulcer

4. A client with a highly exudative wound Correct Answer: 2 Rationale 1: The client with a postoperative wound would not be a candidate for a transparent film, due to the risk of removing or applying pressure to the sutures or staples, and would be better suited for an impregnated nonadherent dressing.

Rationale 2: The client with a stage I pressure ulcer might benefit from a transparent film.

Rationale 3: A clear, absorbent acrylic dressing would be best for the client with a venous stasis ulcer.

Rationale 4: Polyurethane foams would be best for the wound with a large amount of exudate.

Global Rationale: The client with a stage I pressure ulcer might benefit from a transparent film. The client with a postoperative wound would not be a candidate for a transparent film, due to the risk of removing or applying pressure to the sutures or staples, and would be better suited for an impregnated nonadherent dressing. A clear, absorbent acrylic dressing would be best for the client with a venous stasis ulcer, and polyurethane foams would be best for the wound with a large amount of exudate.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 25.12 Describe dressing classification and indication for each type of dressing: gauze, transparent film, hydrogel, calcium alginate, foam, composite, hydrocolloid, and impregnated gauze.

Page Number: p. 908 4. A client is assessed as: having no sensory deficits; skin is dry and not exposed to moisture; confined to bed; is completely immobile; requires moderate assistance in moving; and nutritional status is adequate.

Which pressure ulcer risk score is the most appropriate based on the assessment data?

1. 14, indicating moderate risk 2. 15, indicating high risk 3. 12, indicating risk 4. 14, indicating high risk Correct Answer: 1 Rationale 1: The client gets 4 points for lack of sensory deficits, 4 points for dry skin, 1 point for being bedridden, 1 point for immobility, 3 points for adequate nutrition, and 1 point for shear related to needing moderate assistance to move, totaling 14. A score of 15–18 indicates some risk, 13–14 indicates moderate risk, 10–12 indicates high risk, and 9 indicates very high risk. As a result, this client, with a score of 14, is at moderate risk.

Rationale 2: The client gets 4 points for lack of sensory deficits, 4 points for dry skin, 1 point for being bedridden, 1 point for immobility, 3 points for adequate nutrition, and 1 point for shear related to needing moderate assistance to move, totaling 14. A score of 15–18 indicates some risk, 13–14 indicates moderate risk, 10–12 indicates high risk, and 9 indicates very high risk. As a result, this client, with a score of 14, is at moderate risk.

Rationale 3: The client gets 4 points for lack of sensory deficits, 4 points for dry skin, 1 point for being bedridden, 1 point for immobility,N3UpRoSiInNtsGTfoBr. CaOd eMquate nutrition, and 1 point for shear related to needing moderate assistance to move, totaling 14. A score of 15–18 indicates some risk, 13–14 indicates moderate risk, 10–12 indicates high risk, and 9 indicates very high risk. As a result, this client, with a score of 14, is at moderate risk.

Rationale 4: The client gets 4 points for lack of sensory deficits, 4 points for dry skin, 1 point for being bedridden, 1 point for immobility, 3 points for adequate nutrition, and 1 point for shear related to needing moderate assistance to move, totaling 14. A score of 15–18 indicates some risk, 13–14 indicates moderate risk, 10–12 indicates high risk, and 9 indicates very high risk. As a result, this client, with a score of 14, is at moderate risk.

Global Rationale: The client gets 4 points for lack of sensory deficits, 4 points for dry skin, 1 point for being bedridden, 1 point for immobility, 3 points for adequate nutrition, and 1 point for shear related to needing moderate assistance to move, totaling 14. A score of 15–18 indicates some risk, 13–14 indicates moderate risk, 10–12 indicates high risk, and 9 indicates very high risk. As a result, this client, with a score of 14, is at moderate risk.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice,

and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.6 Compare and contrast the four stages of pressure ulcers.

Page Number: p. 935 5. The nurse is admitting a client with a pressure ulcer to the long-term care facility. When assessing the wound, the nurse finds partial-thickness skin loss free of eschar. In which stage is this client’s ulcer?

1. Stage I 2. Stage II 3. Stage III 4. Stage IV Correct Answer: 2 Rationale 1: A stage I ulcer is c h a ra c t e riNzUe dR SbIyN Ge rTyBt h. CeOmMa that does not resolve within minutes of pressure relief.

Rationale 2: A stage II ulcer has partial-thickness skin loss free of eschar.

Rationale 3: A full-thickness loss that goes through the dermis to the subcutaneous tissue but does not extend through the underlying fascia is a stage III pressure ulcer.

Rationale 4: Stage IV pressure ulcers have full-thickness skin loss, and can involve muscle, joint, and/or bone. This client has a stage II ulcer.

Global Rationale: A stage I ulcer is characterized by erythema that does not resolve within minutes of pressure relief. A stage II ulcer has partial-thickness skin loss free of eschar. A full- thickness loss that goes through the dermis to the subcutaneous tissue but does not extend through the underlying fascia is a stage III pressure ulcer. Stage IV pressure ulcers have full- thickness skin loss, and can involve muscle, joint, and/or bone. This client has a stage II ulcer.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research

NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.6 Compare and contrast the four stages of pressure ulcers.

Page Number: p. 933 6. Which task could the nurse safely delegate to the unlicensed assistive personnel (UAP)?

1. Changing the postoperative dressing on a clean wound 2. Irrigating the client's wound 3. Apply a dry dressing 4. Performing a damp-to-damp dressing change Correct Answer: 3 Rationale 1: Due to the need for aseptic technique and assessment skills, changing a postoperative dressing cannot be delegated to the UAP. Rationale 2: Due to the need for asepticNteUcRhSnIiNqGu Te Ba.nCdO aMssessment skills, irrigating a wound cannot be delegated to the UAP. Rationale 3: UAP may apply a dry dressing.

Rationale 4: Due to the need for aseptic technique and assessment skills, performing damp-to- damp dressing changes cannot be delegated to the UAP. Global Rationale: UAP may apply a dry dressing. Due to the need for aseptic technique and assessment skills, changing a postoperative dressing, irrigating a wound, or performing damp-to- damp dressing changes cannot be delegated to the UAP. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Practice; Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 25.13 Explain appropriate use of dressings: gauze, transparent adhesive film, hydrocolloid, and hydrogel.

Page Number: p. 947

7. The nurse is changing the client's dressing on a postoperative nondraining wound. Which personal protective equipment (PPE) should the nurse apply prior to the dressing change?

1. Sterile gown, mask, and sterile gloves 2. Sterile gown, mask, and goggles 3. Sterile gloves and mask

4. Sterile gloves Correct Answer: 3 Rationale 1: Gowns are needed only if the wound is contaminated and there is a risk of spray.

Rationale 2: Goggles and gowns are needed only if the wound is contaminated and there is a risk of spray.

Rationale 3: Applying a face mask will reduce the risk of contamination of the wound by droplet spray from the nurse's respiratory tract. Sterile gloves are worn to prevent contamination of the dressing.

Rationale 4: The nurse needs to wear more than sterile gloves.

Global Rationale: Applying a face mask will reduce the risk of contamination of the wound by droplet spray from the nurse's respiratory tract. Sterile gloves are worn to prevent contamination of the dressing.

Goggles and gowns are needed only if the wound is contaminated and there is a risk of spray.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.11 Compare and contrast clean and sterile technique.

Page Number: p. 900

8. The nurse changes the client's IV dressing and removes the existing transparent wound barrier. Prior to applying the new barrier, which action by the nurse is the most appropriate?

1. Applying benzoin to make the dressing stick firmly 2. Placing a sterile piece of gauze over the insertion site before placing a new transparent barrier over the wound 3. Cleansing the site with normal saline or a mild cleansing agent 4. Applying sterile gloves Correct Answer: 3 Rationale 1: Benzoin is not needed, but the dressing can be window-paned with tape if needed.

Rationale 2: Placing a piece of gauze over the insertion site defeats the purpose of the transparent dressing and makes it impossible to see the site to monitor for changes, so it is contraindicated.

Rationale 3: The nurse should clean the site with normal saline or a mild cleansing agent to reduce pathogen exposure into the wound.

Rationale 4: It is not necessary to wear sterile gloves, because the nurse should not touch the insertion site directly, and does not touch the sterile dressing. Clean gloves should be worn to protect the nurse.

Global Rationale: The nurse should clean the site with normal saline or a mild cleansing agent to reduce pathogen exposure into the wound. It is not necessary to wear sterile gloves, because the nurse should not touch the insertion site directly, and does not touch the sterile dressing.

Clean gloves should be worn to protect the nurse. Benzoin is not needed, but the dressing can be windowpaned with tape if needed. Placing a piece of gauze over the insertion site defeats the purpose of the transparent dressing and makes it impossible to see the site to monitor for changes, so it is contraindicated.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25.12 Describe dressing classification and indication for each type of dressing: gauze, transparent film, hydrogel, calcium alginate, foam, composite, hydrocolloid, and impregnated gauze.

Page Number: p. 900 9. The nurse is applying a hydrocolloid dressing to a client's wound, which measures 2 inches by 3 inches.

The nurse should cut the dressing to which dimensions?

1. 3.25 inches by 4.55 inches 2. 2 inches by 3 inches 3. 1 1/2 inches by 2 1/2 inches 4. 1 inch by 1 1/2 inches Correct Answer: 1 Rationale 1: The nurse should cut the hydrocolloid dressing approximately 1 1/4 inches larger than the wound, so the dressing would be 3.25 inches by 4.25 inches.

Rationale 2: The nurse should cut the h yNdUroR cS oI Nl lGo iTdB d. Cr Oe sMs i n g approximately 1 1/4 inches larger than the wound, so the dressing would be 3.25 inches by 4.25 inches.

Rationale 3: The nurse should cut the hydrocolloid dressing approximately 1 1/4 inches larger than the wound, so the dressing would be 3.25 inches by 4.25 inches.

Rationale 4: The nurse should cut the hydrocolloid dressing approximately 1 1/4 inches larger than the wound, so the dressing would be 3.25 inches by 4.25 inches.

Global Rationale: The nurse should cut the hydrocolloid dressing approximately 1 1/4 inches larger than the wound, so the dressing would be 3.25 inches by 4.25 inches.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.13 Explain appropriate use of dressings: gauze, transparent adhesive film, hydrocolloid, and hydrogel.

Page Number: p. 926 10. The nurse is irrigating a wound with tracts and crevices. Which piece of equipment should be applied to the syringe in order to irrigate these areas?

1. A 22 gauge needle 2. A small gauge Robinson catheter 3. An IV catheter with the needle removed 4. An IV catheter with the needle in place Correct Answer: 3 Rationale 1: A needle would be painful and inappropriate. A Robinson catheter would not be small enough.

Rationale 2: A Robinson catheter would not be small enough.

Rationale 3: The safest means of irrigating the wound without causing further tissue trauma would be with the use of an IV c at h e t er, NwUhRicShI NcGa Tn Br.eCaOc hM into tracts without causing further tissue damage.

Rationale 4: A needle would be painful and inappropriate.

Global Rationale: The safest means of irrigating the wound without causing further tissue trauma would be with the use of an IV catheter, which can reach into tracts without causing further tissue damage. A needle would be painful and inappropriate. A Robinson catheter would not be small enough.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.15 Outline the steps in irrigating a wound. Page Number: p.

919

11. The nurse is performing a damp-to-damp dressing change, and is removing the old dressing. Part of the dressing is adhered to the tissue. Which action by the nurse is the most appropriate?

1. Removing that part of the dressing quickly, to reduce the pain 2. Wetting the dressing with alcohol to release the section adhered to the wound 3. Wetting the dressing with tap water to release the section adhered to the wound 4. Wetting the dressing with sterile saline to release the section adhered to the wound Correct Answer: 4 Rationale 1: Removing the dressing quickly would debride the new, healthy tissue forming inside the wound and would retard wound healing.

Rationale 2: Alcohol would be excruciatingly painful and would slow tissue healing.

Rationale 3: Tap water would not be sterile and could introduce pathogens into the wound.

Rationale 4: The dressing would be removed using sterile saline, which will allow the dressing to peel away from the wound without removing the new tissue forming to heal the wound.

Removing the dressing quickly would deNbUriRdSeINthGeTnBe.CwO, healthy tissue forming inside the wound and would M retard wound healing. Alcohol would be excruciatingly painful and would slow tissue healing. Tap water would not be sterile and could introduce pathogens into the wound.

Global Rationale: The dressing would be removed using sterile saline, which will allow the dressing to peel away from the wound without removing the new tissue forming to heal the wound. Removing the dressing quickly would debride the new, healthy tissue forming inside the wound and would retard wound healing. Alcohol would be excruciatingly painful and would slow tissue healing. Tap water would not be sterile and could introduce pathogens into the wound.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.24 Outline the procedure for changing a wet-to-moist dressing.

Page Number: p. 924

12. When the nurse documents a client's wound, which is the best means of describing the wound?

1. Measuring the wound and documenting size 2. Comparing the wound to a universally understood object, such as a quarter or cashew 3. Using terms such as small, medium, or large 4. Taking a picture and inserting it into the record Correct Answer: 1 Rationale 1: The wound should be described in as objective a manner as possible to allow for continuity of care. An objective description allows successive care providers to evaluate changes. The most objective means of describing a wound is using measurements.

Rationale 2: If measurement is not possible, comparing the wound to a universally understood object would be the next best means of describing the wound.

Rationale 3: Terms such as small, medium, or large have no universal meaning, and are very subjective.

Rationale 4: Taking a picture would require the client’s signed consent. This is not usually done.

Global Rationale: The wound should be described in as objective a manner as possible to allow for continuity of care. An objective description allows successive care providers to evaluate changes. The most objective means of describing a wound is using measurements. If measurement is not possible, comparing the wound to a universally understood object would be the next best means of describing the wound. Terms such as small, medium, or large have no universal meaning, and are very subjective. Taking a picture would require the client’s signed consent. This is not usually done.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: VI.B.4. Document and plan client care in an electronic health record AACN Essential Competencies: IV.5. Use standardized terminology in a care environment that reflects nursing’s unique contribution to client outcomes NLN Competencies: Quality and Safety: Practice; Carefully maintain and use electronic and/or written health records Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.26 Complete documentation on a wound assessment and wound care.

Page Number: p. 903

13. The nurse is preparing to assess a wound on a new admission on a medical–surgical unit. Which items should the nurse review in the medical record prior to assessing the client’s wound?

Standard Text: Select all that apply.

1. The cause of the wound 2. The length of time the wound has been present 3. The previous treatments and client responses 4. The equipment used by other nurses 5. The current medication list Correct Answer: 1, 2, 3 Rationale 1: Prior to assessing a wound for any client, the nurse would review the medical record for the cause of the wound.

Rationale 2: Prior to assessing a wound for any client, the nurse would review the medical record for the length of time the wound has been present.

NUR S ING TB . C O M

Rationale 3: Prior to assessing a wo un d fo r a n y c li e n t, th e nurse would review the medical record for the previous treatments and client responses.

Rationale 4: The nurse would not review the medical record for the equipment used by other nurses. and the current medication list prior to assessing the client’s wound.

Rationale 5: The nurse would not review the medical record for the current medication list prior to assessing the client’s wound.

Global Rationale: Prior to assessing a wound for any client, the nurse would review the medical record for the cause of the wound, the length of time the wound has been present, and the previous treatments and client responses. The nurse would not review the medical record for the equipment used by other nurses and the current medication list prior to assessing the client’s wound.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based

approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.5 State criteria used to assess a wound.

Page Number: p. 899 14. Prior to beginning a client’s intravenous antibiotics the nurse needs to culture the wound. In which order should the nurse perform the steps to obtain this culture?

2. Use non–cotton-tipped swab 6. Place swab in culture medium 3. Rotate swab while obtaining specimen 1. Rinse wound thoroughly with sterile saline 5. Do not take specimen from exudate or eschar 4. Swab edges starting at top, crisscross wound to bottom Correct Answer: 4, 1, 3, 6, 5, 2 Rationale 1: Non-cotton tipped swabs are to be used. Rationale 2: The swab should be placed in culture medium. Rationale 3: The swab should be rotated.

Rationale 4: The wound is to be rinsed first with sterile saline.

Rationale 5: Areas with exudate or eschar are to be avoided.

Rationale 6: The wound edges should be swabbed starting at the top, moving crisscross across the wound to the bottom.

Global Rationale: When obtaining a wound culture the nurse should: rinse wound thoroughly with sterile saline; use non–cotton-tipped swab; rotate swab while obtaining specimen; swab edges starting at top, crisscross wound to bottom; do not take specimen from exudate or eschar; and place the swab in culture medium and take to laboratory immediately.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.16 Describe the steps to obtain a wound specimen for culture.

Page Number: p. 909 15. The nurse is preparing to assist with the debridement of a client’s wounds. In which order should the nurse complete surgical hand antisepsis?

1. Remove all jewelry 2. Wet hands with warm water.

3. Turn on water using foot pedal 4. Completely dry hands and forearms 5. Rub hands together for at least 20 sec 6. Apply 3–5 mL of antimicrobial soap to hands 7. Scrub hands and forearms up to 3 in. above elbows 8. Rinse hands and arms from finger tips to elbows Correct answer: 1, 3, 2, 6, 5, 7, 8, 4 Rationale 1: All jewelry is to be removed. Rationale 2: The hands are wet with warm water. Rationale 3: The water is turned on.

Rationale 4: The arms and hands are dried.

Rationale 5: The hands are scrubbed togeNtUheRrS IfNorG 2T 0B . sCeOcM onds. Rationale 6: Antimicrobial soap is placed in the hands.

Rationale 7: The forearms are scrubbed up to 3 inches above the elbows. Rationale 8: The hands and arms are rinsed from fingers to elbows.

Global Rationale: When performing surgical hand antisepsis the nurse should first remove all jewelry, turn on the water using a foot pedal, wet the hands, apply soap, rub the hands together for 20 seconds, cleanse up to 3 inches above the elbows, rinse the hands and arm, and then dry the hands and arms.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based

approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.17 Perform the steps of a surgical hand scrub. Page Number: p. 893 16. The nurse is preparing a care plan for a client with a stage IV pressure ulcer. What should be the goals of care for this client? Select all that apply.

1. Speed healing 2. Absorb drainage 3. Prevent infection 4. Prevent from injury 5. Remove necrotic tissue Correct Answer: 2, 3, 4, 5 Rationale 1: Speed healing is not a goal of wound care. Rationale 2: Absorb draining is a goal of wound care. Rationale 3: Prevent infection is a goal of wound care.

Rationale 4: Prevent from injury is a goal of wound care. Rationale 5: Remove necrotic tissue is a NgUoaRlS oI Nf GwToBu. nC dO M ca re.

Global Rationale: Goals of wound care include absorbing drainage, preventing infection, preventing injury, and removing necrotic tissue. Speeding healing is not a goal of wound care.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 25.8 State three goals of wound care. Page Number: pp. 887-888 17. A client has a deep wound with areas of exudate and eschar. Which would be the fastest way to debride this wound?

1. Surgical 2. Chemical

3. Autolytic 4. Mechanical Correct answer: 1 Rationale 1: Infected tissue is best removed by surgical debridement. Surgical debridement uses sterile instruments and requires local anesthesia. Only a qualified clinician can use this technique.

Rationale 2: Chemical debridement is slower than surgical debridement and uses proteolytic enzymes.

Rationale 3: Mechanical debridement is accomplished through whirlpool treatments Rationale 4: Autolytic debridement uses moisture-retentive or moisture-donating dressings to facilitate digestion of tissue by the client’s own enzymes and phagocytes.

Global Rationale: Infected tissue is best removed by surgical debridement. Surgical debridement uses sterile instruments and requires local anesthesia. Only a qualified clinician can use this technique.

Chemical debridement is slower than surgical debridement and uses proteolytic enzymes. Mechanical debridement is accomplished through whirlpool treatments. Autolytic debridement uses moisture-retentive or moisture-donating dressings to facilitate digestion of tissue by the client’s own enzymes and phagocytes.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 25.27 State five debridement methods. Page Number: p. 913

CHAPTER 26 1. A client is scheduled for surgery the new day. Which type of teaching should the nurse provide?

1. Postoperative 2. Preoperative 3. Perioperative 4. Intraoperative Correct Answer: 2 Rationale 1: The postoperative phase begins with the admission of the client to the postanesthesia care unit, and ends when healing is complete.

Rationale 2: The nurse would perform preoperative teaching. The preoperative phase begins when surgery is planned, and ends when the client is transferred to the operating table.

Rationale 3: The perioperative period covers all three time periods, from planning surgery until healing is complete.

Rationale 4: The intraoperative phase begins when the client is transferred to the operating table, and ends when the client is admitted to the recovery room.

Global Rationale: The nurse would perform preoperative teaching. The preoperative phase begins when surgery is planned, and ends when the client is transferred to the operating table. The intraoperative phase begins when the client is transferred to the operating table, and ends when the client is admitted to the recovery room. The postoperative phase begins with the admission of the client to the postanesthesia care unit, and ends when healing is complete. The perioperative period covers all three time periods, from planning surgery until healing is complete.

Cognitive Level: Planning Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning

Learning Outcome: 26.7 Discuss how preoperative teaching can reduce the surgical client’s stress.

Page Number: p. 954 2. A client arrives at the surgeon's office 1 week after surgery to have the sutures removed. Which classification should the nurse use when documenting care for this client?

1. Preoperative 2. Postoperative 3. Perioperative 4. Intraoperative Correct Answer: 2 Rationale 1: The preoperative phase begins when surgery is planned, and ends when the client is transferred to the operating table.

Rationale 2: The client is in the postoperative phase. The postoperative phase begins with the admission of the client to the postanesthesia care unit, and ends when healing is complete.

Rationale 3: The perioperative period c oNvUe Rr sS IaNl lGtTh Br e. Ce Ot iMm e periods, from planning surgery until healing is complete.

Rationale 4: The intraoperative phase begins when the client is transferred to the operating table, and ends when the client is admitted to the recovery room.

Global Rationale: The client is in the postoperative phase. The preoperative phase begins when surgery is planned, and ends when the client is transferred to the operating table. The intraoperative phase begins when the client is transferred to the operating table, and ends when the client is admitted to the recovery room. The postoperative phase begins with the admission of the client to the postanesthesia care unit, and ends when healing is complete. The perioperative period covers all three time periods, from planning surgery until healing is complete.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26.2 Discuss the nursing care focus in each of the three stages of the perioperative period.

Page Number: p. 957 3. The nurse administers the preoperative medication to the client 1 hour before elective surgery, and then discovers the preoperative consent is not signed. Which action by the nurse is the most appropriate?

1. Have the client sign the consent quickly, before the medication begins taking effect.

2. Have a family member or medical power of attorney sign the consent.

3. Send the client to the holding area without a signed consent.

4. Notify the health care provider that surgery will need to be canceled.

Correct Answer: 4 Rationale 1: The nurse cannot have the client sign the consent once the preoperative medication has been administered, because it affects the client's ability to reason.

Rationale 2: Emergency surgery, in some facilities, may be performed if a family member or medical power of attorney signs the consent when the client is unable to do so, but elective surgery requires the client's signature if sNhUeRiSs IcNaGpTaBbl.Ce OoM f making a reasoned decision.

Rationale 3: The client has not consented to surgery and should not be sent to the holding area.

Rationale 4: The nurse will notify the health care provider, who will need to cancel surgery until the preoperative medication is excreted and no longer affecting the client's ability to make informed decisions, at which time the consent can be signed.

Global Rationale: The nurse will notify the health care provider, who will need to cancel surgery until the preoperative medication is excreted and no longer affecting the client's ability to make informed decisions, at which time the consent can be signed. The nurse cannot have the client sign the consent once the preoperative medication has been administered, because it affects the client's ability to reason. The client has not consented to surgery and should not be sent to the holding area. Emergency surgery, in some facilities, may be performed if a family member or medical power of attorney signs the consent when the client is unable to do so, but elective surgery requires the client's signature if she is capable of making a reasoned decision.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical

management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.8 Describe the information contained in the surgical permit.

Page Number: p. 979 4. When providing preoperative teaching for the client who is scheduled for coronary artery bypass surgery in the morning, the nurse should include which dimensions?

Standard Text: Select all that apply.

1. Information 2. Psychosocial support 3. The role of the client and support people 4. Skills training 5. Coughing and deep breathing Correct Answer: 1, 2, 3, 4 Rationale 1: The nurse will provide information, including what will happen to the client, when and what the client will experience, and expected sensations and discomfort.

Rationale 2: Psychosocial support is provided to reduce anxiety.

Rationale 3: The roles of the client and support people in preoperative preparation, the surgical procedure, and during the postoperative phase will be explained by the nurse.

Rationale 4: Skills training will include moving, deep breathing, coughing, splinting incisions, and use of an incentive spirometer.

Rationale 5: Coughing and deep breathing are a component of skills training, but are not a dimension of teaching.

Global Rationale: The nurse will provide information, including what will happen to the client, when and what the client will experience, and expected sensations and discomfort. Psychosocial support is provided to reduce anxiety. The roles of the client and support people in preoperative preparation, the surgical procedure, and during the postoperative phase will be explained by the nurse. Skills training will include moving, deep breathing, coughing, splinting incisions, and use of an incentive spirometer. Coughing and deep breathing are a component of skills training, but are not a dimension of teaching.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.B.3. Provide client-centered care with sensitivity and respect for the diversity of human experience AACN Essential Competencies: IX.7. Provide appropriate client teaching that reflects developmental stage, age, culture, spirituality, client preferences, and health literacy considerations to foster client engagement in their care NLN Competencies: Relationship Centered Care: Practice; Learn cooperatively, facilitate the learning of others.

Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 26.7 Discuss how preoperative teaching can reduce the surgical client’s stress.

Page Number: pp. 956, 966 5. Upon receiving the client from the postanesthesia care unit, which nursing action is the priority?

1. Apply clean linens to the bed.

2. Assemble required equipment, such as suction, IV pole, or oxygen equipment.

3. Assess the client.

4. Notify the family of the client's return to the room.

Correct Answer: 3 Rationale 1: Clean linens should be applied to the bed as soon as the client leaves for surgery or upon notification that the client will be coming to the unit.

Rationale 2: Equipment should be gathered in advance and set up to be ready when the client returns.

Rationale 3: The priority action for the nurse is to perform a thorough assessment of the client's condition.

Rationale 4: Only after assessing the client would the nurse notify family members.

Global Rationale: The priority action for the nurse is to perform a thorough assessment of the client's condition. Clean linens should be applied to the bed as soon as the client leaves for surgery or upon notification that the client will be coming to the unit. Equipment should be gathered in advance and set up to be ready when the client returns. Only after assessing the client would the nurse notify family members.

Cognitive Level: Analyzing

Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.13 Outline the essential postoperative nursing interventions completed in the surgical unit.

Page Number: p. 990 6. In the ongoing postoperative period, the nurse independently determines, within the protocols of the hospital, the need for which provision of care?

1. Type of diet 2. Activity level 3. Assessment intervals 4. Intravenous solutions Correct Answer: 3 Rationale 1: Type of diet is ordered by the health care provider.

Rationale 2: Activity level is ordered by the health care provider.

Rationale 3: The nurse will determine the frequency of client assessments required, within the protocols established by the facility. The minimum frequency is determined by the facility, but more frequent assessment may be determined by the client's condition, and is the decision of the nurse.

Rationale 4: Intravenous solutions are ordered by the health care provider.

Global Rationale: The nurse will determine the frequency of client assessments required, within the protocols established by the facility. The minimum frequency is determined by the facility, but more frequent assessment may be determined by the client's condition, and is the decision of the nurse. Activity level, intravenous solutions, and type of diet are ordered by the health care provider.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 26.13 Outline the essential postoperative nursing interventions completed in the surgical unit.

Page Number: p. 990 7. A postoperative client displays sudden chest pain, shortness of breath, cyanosis, tachycardia, and low blood pressure. Which complication should the nurse suspect is occurring?

1. Pneumonia 2. Atelectasis 3. Hypovolemia 4. Pulmonary embolism Correct Answer: 4 Rationale 1: The client with pneumonia is likely to have a fever, but usually will not display sharp chest pain.

Rationale 2: Atelectasis can cause respiratory distress, but will not cause chest pain.

Rationale 3: Hypovolemia does not produce chest pain either, and will usually be displayed by tachycardia, decreased urine output, and drop in blood pressure.

Rationale 4: The client is displaying signs of pulmonary emboli, which will cause sudden chest pain and difficulty breathing.

Global Rationale: The client is displaying signs of pulmonary emboli, which will cause sudden chest pain and difficulty breathing. The client with pneumonia is likely to have a fever, but usually will not display sharp chest pain. Atelectasis can cause respiratory distress, but will not cause chest pain. Hypovolemia does not produce chest pain either, and will usually be displayed by tachycardia, decreased urine output, and drop in blood pressure.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice

AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.15 Discuss at least three major postoperative complications and the nursing interventions to prevent and treat the complications.

Page Number: p. 998 8. The nurse performs preoperative teaching for a client requiring a surgical intervention. Which actions by the client indicate appropriate understanding of the information provided?

Standard Text: Select all that apply.

1. Demonstrating proper coughing and deep breathing 2. Asking questions about and voicing understanding of information provided 3. Having no anxiety about the impending surgery 4. Demonstrating proper performance of leg exercises 5. Demonstrating how to turn and get out of bed Correct Answer: 1, 2, 4, 5 Rationale 1: The nurse evaluates the client's understanding through the questions asked and the return demonstration of skills performed.

Rationale 2: The nurse evaluates the client's understanding through the questions asked and the return demonstration of skills performed.

Rationale 3: Although preoperative teaching can help to reduce anxiety, it is unlikely to completely eliminate fear.

Rationale 4: The nurse evaluates the client's understanding through the questions asked and the return demonstration of skills performed.

Rationale 5: The nurse evaluates the client's understanding through the questions asked and the return demonstration of skills performed.

Global Rationale: The nurse evaluates the client's understanding through the questions asked and the return demonstration of skills performed. Although preoperative teaching can help to reduce anxiety, it is unlikely to completely eliminate fear.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 26.7 Discuss how preoperative teaching can reduce the surgical client’s stress.

Page Number: p. 973 9. The nurse is completing the preoperative checklist on the night shift in preparation for the client's surgery, scheduled for 0800. Which tasks could the nurse complete at this time?

1. Documenting the time of last voiding 2. Checking the medical record for the history, physical, and signed informed consent 3. Administering preoperative medication 4. Removing the prosthesis Correct Answer: 2 Rationale 1: The nurse on day shift preparing to send the client to surgery would document time of last voiding.

Rationale 2: The nurse on night shift could check the medical record to ensure that a history and physical have been completed, and that the consent for surgery is signed.

Rationale 3: The nurse on day shift preparing to send the client to surgery would administer preoperative medication.

Rationale 4: Many clients prefer to wait until just before going to surgery before removing dentures, contact lenses, and other prostheses.

Global Rationale: The nurse on night shift could check the medical record to ensure that a history and physical have been completed, and that the consent for surgery is signed. The nurse on day shift preparing to send the client to surgery would document time of last voiding and administration of preoperative medication. Many clients prefer to wait until just before going to surgery before removing dentures, contact lenses, and other prostheses.

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: VI.B.4. Document and plan client care in an electronic health record AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Quality and Safety: Practice; Carefully maintain and use electronic and/or written health records Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.2 Discuss the nursing care focus in each of the three stages of the perioperative period.

Page Number: p. 978 10. The nurse is caring for a client scheduled for surgery the next day. On what should the nurse focus to determine this client’s level of stress? Select all that apply.

1. The surgical procedure 2. The client’s religious beliefs 3. If the surgery is going to alter the client’s life 4. Client’s perception of the surgical experience 5. Number of stress-producing events in the client’s recent past Correct Answer: 2, 3, 4, 5 Rationale 1: The degree of anxiety and stress does not depend on the surgical procedure.

Rationale 2: The degree of anxiety and stress depends on the client’s belief system and religious conviction.

Rationale 3: The degree of anxiety and stress depends on the significance of the surgery to the client and how life will be altered.

Rationale 4: The degree of anxiety and stress depends on the client’s perceptions of the hospitalization and surgical experience.

Rationale 5: The degree of anxiety and stress depends on the number of stress-producing events that have occurred recently in the client’s life or within the client’s family.

Global Rationale: The degree of anxiety and stress depends on the client’s belief system and religious conviction, the significance of the surgery to the client and how life will be altered, the client’s perceptions of the hospitalization and surgical experience, and the number of stress- producing events that have occurred recently in the client’s life or within the client’s family. The degree of anxiety and stress does not depend on the surgical procedure.

Cognitive Level: Applying Client Need: Psychosocial Integrity

Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.3 Identify at least three factors that influence the surgical client’s degree of stress.

Page Number: pp. 954-955 11. A client scheduled for surgery is demonstrating mild levels of stress. How should this stress level affect the client’s recovery? Select all that apply.

1. Increased alertness 2. Increased wound healing 3. Increased ability to learn 4. Increased ability to adjust to stressors 5. Increased adjustment to the environment Correct Answer: Rationale 1: Mild anxiety increases a le rtNn eUsRs S. INGTB.COM Rationale 2: Anxiety level does not affect wound healing. Rationale 3: Mild anxiety increases the ability to learn.

Rationale 4: Mild anxiety increases the ability to adjust to several simultaneous stressors.

Rationale 5: Mild anxiety increases the ability to assess and to adjust to the environment.

Global Rationale: Mild anxiety increases alertness, increases the ability to learn, and increases the ability to assess and to adjust to the environment. Mild anxiety also increases the ability to adjust to several simultaneous stressors. Anxiety level does not affect wound healing.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.4 Explain why postoperative complications are reduced by decreasing the stress level.

Page Number: p. 955 12. A client is highly anxious about an upcoming surgical procedure. What action should the nurse take to reduce this client’s anxiety?

1. Answer the client’s questions 2. Provide written teaching material 3. Instruct on range of motion exercises 4. Assign to review videotapes prior to teaching Correct Answer: 1 Rationale 1: Fear and anxiety are greatly reduced when explanations are complete and time is allowed during the teaching session to answer questions by both the client and family.

Rationale 2: Written teaching material is not identified as an approach to reduce preoperative stress.

Rationale 2: Although relaxation exercises can help reduce anxiety range of motion exercises will not.

Rationale 4: Watching videotapes prior to teaching is not identified as an approach to reduce preoperative stress.

Global Rationale: Fear and anxiety are greatly reduced when explanations are complete and time is allowed during the teaching session to answer questions by both the client and family.

Although relaxation exercises can help reduce anxiety range of motion exercises will not. Written teaching material and videotapes are not identified as approaches to reduce preoperative stress.

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning

Learning Outcome: 26.5 Describe at least one potential problem and the suggested solution for clients demonstrating high stress levels in the preoperative period.

Page Number: p. 956 13. The nurse is caring for a client who had surgery a day ago. Which observation indicates that the client was physically prepared for the procedure?

1. Does leg exercises 3 times a day 2. Rates pain as 5 on a scale from 0 to 10 3. Permits staff to reposition in bed every 2 to 4 hours 4. Deep breathes and coughs every 2 hours while awake Correct Answer: 4 Rationale 1: Leg exercises should be done every hour while awake.

Rationale 2: Pain level does not determine if the client was prepared physically for the surgery. Rationale 3: The client should assist with moving in bed.

Rationale 4: Deep breathing exercises should be done three to four times, at least every 2 hr when awake.

Global Rationale: Deep breathing exercises should be done three to four times, at least every 2 hr when awake. Leg exercises should be d oNn Ue ReSvIeNryG ThBo.uCrOwMh i l e awake. Pain level does not determine if the client was prepared physically for the surgery. The client should assist with moving in bed.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 26.9 Outline the essential steps in physically preparing a client for surgery.

Page Number: p. 971 14. Before beginning a surgical procedure the safety checklist is reviewed. Which information is necessary prior to starting this client’s case?

1. Date of birth 2. Known allergies 3. Last urine output 4. Family members’ names

Correct Answer: 2 Rationale 1: It is not essential to know the client’s date of birth before starting the surgery. Rationale 2: The client’s known allergies should be documented in the medical record.

Rationale 3: It is not essential to know the client’s last urine output before starting the surgery. Rationale 4: It is not essential to know the family members’ names before starting the surgery.

Global Rationale: The client’s known allergies should be documented in the medical record. It is not essential to know the client’s date of birth, last urine output, or family members’ names before starting the surgery.

Cognitive Level: Analyzing Client Need: Management of Care Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches R SeInNt :G PT Br a. cCtOi cMe ; conduct population-based transcultural health NLN Competencies: Context and E n v i rNo nU m assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.10 Describe information contained in the surgical safety checklist.

Page Number: p. 958 15. The nurse is preparing preoperative medications for a client. Which medication will reduce the amount of respiratory secretions?

1. Opiate 2. Antibiotic 3. Antianxiolytic 4. Anticholinergic Correct Answer: 4 Rationale 1: Opiates allow smooth anesthetic induction. Rationale 2: Antibiotics are not routine preoperative medications. Rationale 3: Antianxiolytics decrease anxiety.

Rationale 4: Anticholinergics decrease secretions.

Global Rationale: Anticholinergics decrease secretions. Opiates allow smooth anesthetic induction.

Antibiotics are not routine preoperative medications. Antianxiolytics decrease anxiety.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.11 Explain the purpose for administering the three classifications of drugs used for preoperative medications.

Page Number: p. 981 16. The nurse notes that a client is scheduled to receive conscious sedation for a surgical procedure.

What should the nurse review prior to preparing the client for this type of anesthesia?

1. Adverse effects 2. Reversal agents 3. State nurse practice act 4. Assignment of a student nurse Correct Answer: 3 Rationale 1: Adverse effects of the sedation would be addressed by the anesthesiologist. Rationale 2: Reversal agents would be appropriate once the sedation has been provided.

Rationale 3: Nurses who administer conscious sedation must function within the standard of practice and be allowed to administer conscious sedation according to the Nurse Practice Act in the state in which they are practicing.

Rationale 4: At no time are student nurses allowed to administer conscious sedation.

Global Rationale: Nurses who administer conscious sedation must function within the standard of practice and be allowed to administer conscious sedation according to the Nurse Practice Act in the state in which they are practicing. Adverse effects of the sedation would be addressed by the anesthesiologist. Reversal agents would be appropriate once the sedation has been provided. At no time are student nurses allowed to administer conscious sedation.

Cognitive Level: Applying Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: V. 3. Value own role in preventing errors AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal or unethical care practices NLN Competencies: Knowledge and Science; Knowledge; Relationships between knowledge/science and quality and safe patient care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.12 Describe the nurses’ role in caring for a client with moderate sedation (conscious sedation).

Page Number: p. 985 17. A client receiving an opiate for postoperative pain management is experiencing nausea and vomiting. What action would be the most beneficial for the client?

1. Provide an emesis basin 2. Maintain on NPO status 3. Keep Narcan at the bedside 4. Administer an antiemetic as prescribed Correct Answer: 4 Rationale 1: An emesis basin would be helpful, however is not the most beneficial action for the client.

N UsRu SrgI Ne rGyT aBn. Cd OmMo s t likely will be NPO for a while.

Rationale 2: The client is recovering f ro m

Rationale 3: The client is not demonstrating adverse effects from the opiate pain medication. Narcan is not indicated.

Rationale 4: An antiemetic would be appropriate for the client experiencing nausea and vomiting after surgery.

Global Rationale: An antiemetic would be appropriate for the client experiencing nausea and vomiting after surgery. An emesis basin would be helpful, however is not the most beneficial action for the client. The client is recovering from surgery and most likely will be NPO for a while. The client is not demonstrating adverse effects from the opiate pain medication. Narcan is not indicated.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.14 Summarize the major categories of postoperative pain medications and describe the general side effects of each category.

Page Number: p. 997

CHAPTER 27 1. The nurse is caring for a client with a fracture of cervical vertebrae 4. Which piece of equipment connects the client to traction for this type of injury?

1. Pearson attachment 2. Buck's extension 3. Thomas splint 4. Crutchfield tongs Correct Answer: 4 Rationale 1: Pearson attachment connects to a Thomas splint for leg traction.

Rationale 2: Buck's traction is used to stabilize the hip.

Rationale 3: Pearson attachment connects to a Thomas splint for leg traction.

Rationale 4: Crutchfield tongs connect to the skull and help to maintain stability of the fractured cervical vertebrae.

Global Rationale: Crutchfield tongs connect to the skull and help to maintain stability of the fractured cervical vertebrae. Pearson attachment connects to a Thomas splint for leg traction. Buck's traction is used to stabilize the hip.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.9 Identify types of skin and skeletal traction. Page Number: p.

1031 2. The nurse observes the health care provider apply a cast made of strips of open-weave cotton saturated with powdered calcium sulfate crystals. When documenting this procedure, which term should the nurse use for this type of cast?

1. Plaster cast 2. Synthetic cast 3. Fiberglass cast 4. Thermoplastic cast Correct Answer: 1 Rationale 1: The cast described is a plaster cast. Rationale 2: The cast described is a plaster cast. Rationale 3: The cast described is a plaster cast. Rationale 4: The cast described is a plaster cast. Global Rationale: The cast described is a plaster cast.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.1. Demons trate k n ob w a sliecdsgcei eonf t i f i c methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.7 Describe differences between plaster of Paris and synthetic casts.

Page Number: p. 1023 3. For which client should the nurse anticipate a plaster cast would be used?

1. The client with a diagnosis of amyotrophic lateral sclerosis (ALS) 2. The client who had a compound fracture and multiple lacerations 3. The older adult client with muscle wasting secondary to cancer 4. The client with a fractured femur who plans to return to construction work before cast removal Correct Answer: 2 Rationale 1: The client with ALS would benefit from the lighter weight of the synthetic casts.

Rationale 2: Plaster casts are used when a window must be cut in the cast to monitor wound healing, such as with the client with the compound fracture and multiple lacerations.

Rationale 3: The client with muscle wasting would benefit from the lighter weight of the synthetic casts.

Rationale 4: The construction worker who plans to return to work would benefit from the synthetic cast's ability to tolerate moisture.

Global Rationale: Plaster casts are used when a window must be cut in the cast to monitor wound healing, such as with the client with the compound fracture and multiple lacerations. The client with ALS or muscle wasting would benefit from the lighter weight of the synthetic casts, and the construction worker who plans to return to work would benefit from the synthetic cast's ability to tolerate moisture.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 27.7 Describe differences between plaster of Paris and synthetic casts.

Page Number: p. 1011 4. The nurse working in the emergency department (ED) is providing discharge teaching for a client with a newly applied cast to the left arm. Which statement by the client indicates additional teaching is required?

1. "When I take a shower, I will put a plastic bag over my cast and keep it dry."

2. "When my fingers feel cold, I will cover them with a blanket."

3. "I will go home today and put ice on the cast over the fracture and prop it on pillows."

4. "If I lose sensation in my fingers, I will call my doctor."

Correct Answer: 2 Rationale 1: This statement reflects understanding of home care.

Rationale 2: The client needs to understand the importance of performing neurovascular checks, and of the signs of compromise, including cold, pale fingers. The nurse would instruct the client that if the fingers of the casted arm feel colder than the other hand, the health care provider should be notified.

Rationale 3: This statement reflects understanding of home care.

Rationale 4: This statement reflects understanding of home care.

Global Rationale: The client needs to understand the importance of performing neurovascular checks, and of the signs of compromise, including cold, pale fingers. The nurse would instruct the client that if the fingers of the casted arm feel colder than the other hand, the health care provider should be notified. All of the other statements would reflect understanding of home care.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care.

NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: NursingNPUrRoSceINssG: TEBv.CalOuM ation Learning Outcome: 27.10 Develop a teaching plan for the client with a cast.

Page Number: p. 1012 5. A client with a new case is complaining of itching under the cast. Which should the nurse instruct this client?

1. Use a back scratcher to scratch under the cast.

2. Use a wooden spoon to scratch inside the cast.

3. Blow air from a hair dryer set to cool under the cast, or apply ice.

4. Take an antihistamine to reduce itching.

Correct Answer: 3 Rationale 1: Nothing should be inserted into the cast, even if it is not sharp, because it can scratch the skin or bunch the padding.

Rationale 2: Nothing should be inserted into the cast, even if it is not sharp, because it can scratch the skin or bunch the padding.

Rationale 3: Strategies for dealing with itching include a hair dryer set on cool, applying ice, or blowing air from a vacuum set on reverse.

Rationale 4: An antihistamine will not resolve the itching if it is not related to an allergy.

Global Rationale: Strategies for dealing with itching include a hair dryer set on cool, applying ice, or blowing air from a vacuum set on reverse. Nothing should be inserted into the cast, even if it is not sharp, because it can scratch the skin or bunch the padding. An antihistamine will not resolve the itching if it is not related to an allergy.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.10 Develop a teaching plan for the client with a cast.

Page Number: p. 1025 6. An adolescent client newly placed in traction says, "Lying in this bed all the time is going to turn my body into mush. Is there any w a Ny UI RcSoIuNl Gd TeBx .eCr Oc iMs e while I'm in traction?" Which response by the nurse is the most appropriate?

1. "Many people worry about muscle weakness when they are confined to bed. You could perform range of motion, isometric, and specific exercises."

2. "Don't worry about your muscles, because you can get them back after you get out of traction."

3. "You're young and in great shape. Your muscles won't weaken with a few weeks in bed."

4. "I'll put a referral in for physical therapy to come and work with you."

Correct Answer: 1 Rationale 1: The nurse should first recognize the client's feelings and then make recommendations for how the client could exercise to maintain muscle integrity.

Rationale 2: Telling him not to worry minimizes the client's concern and negatively impacts the nurse–client relationship.

Rationale 3: Reassuring the client his muscles will improve later minimizes the client's concern and negatively impacts the nurse–client relationship.

Rationale 4: Physical therapy referrals are not required or indicated at this time.

Global Rationale: The nurse should first recognize the client's feelings and then make recommendations for how the client could exercise to maintain muscle integrity. Reassuring the client his muscles will improve later or telling him not to worry minimizes the client's concern and negatively impacts the nurse– client relationship. Physical therapy referrals are not required or indicated at this time.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.11 Outline the nursing care needs of the client in traction.

Page Number: p. 1031 7. Which task could be safely delegated by the nurse to the unlicensed assistive personnel (UAP)?

1. Caring of the client with the newly placed cast 2. Explaining to the client how to respond to itching under the cast 3. Caring of the insertion site for Crutchfield tongs 4. Caring of the client with a stable cast Correct Answer: 4 Rationale 1: The newly casted client requires frequent neurovascular assessments, which can be performed only by the nurse.

Rationale 2: Teaching is the responsibility of the nurse.

Rationale 3: Wound care is the responsibility of the nurse.

Rationale 4: The UAP could safely provide routine care for the client with a stable cast.

Global Rationale: The UAP could safely provide routine care for the client with a stable cast. The newly casted client requires frequent neurovascular assessments, which can be performed only by the nurse.

Teaching and sterile wound care is the responsibility of the nurse.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Practice; Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 27.10 Develop a teaching plan for the client with a cast.

Page Number: p. 1047 8. The nurse admits a client from the emergency department (ED) with a newly placed leg cast. Which actions should the nurse perform to prevent neurovascular impairment?

Standard Text: Select all that apply.

1. Assess the toes for nerve and circulatory impairment every hour for 8 hours.

2. Place the leg on pillows.

3. Apply ice to the site.

4. Elevate the foot of the bed.

5. Report excessive swelling or indications of neurovascular impairment.

Correct Answer: 2, 3, 4, 5 Rationale 1: The toes should be assessed every 30 minutes for 4 hours and then every 3 hours for the first 24–48 hours, when edema is likely to subside somewhat.

Rationale 2: The limb should be elevated. Rationale 3: Ice should be applied to the site. Rationale 4: The foot of the bed should be elevated.

Rationale 5: Excessive swelling or neurovascular impairment should be reported.

Global Rationale: The toes should be assessed every 30 minutes for 4 hours and then every 3 hours for the first 24–48 hours, when edema is likely to subside somewhat. The limb should be

elevated. Ice should be applied to the site. The foot of the bed should be elevated. Excessive swelling or neurovascular impairment should be reported.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.5 Recognize indicators of circulatory compromise in an injured or immobilized extremity.

Page Number: p. 1024 9. The nurse working in the emergency department (ED) is assisting the health care provider with cast application. Which nursing action is the most appropriate after the health care provider completes application of the cast?

1. Holding the casted arm from the top of the cast to place it in a splint 2. Holding the casted arm from the top oNf Ut hReS cI Na sGt Tt Bo . CplOaMce it on pilows 3. Using the palm of the hand to place the casted arm into a splint 4. Using the palm of the hand to place the casted arm on pillows Correct Answer: 4 Rationale 1: Only after the cast has dried can a splint be applied, if necessary.

Rationale 2: The cast should not be held from the top.

Rationale 3: Only after the cast has dried can a splint be applied, if necessary.

Rationale 4: Placing the cast on pillows applies equal pressure that will avoid flattening of the cast on the bottom.

Global Rationale: The newly placed cast should be held only in the palm of the hand to avoid pushing finger ridges into the easily malformed cast. Placing the cast on pillows applies equal pressure that will avoid flattening of the cast on the bottom. Only after the cast has dried can a splint be applied, if necessary.

Cognitive Level: Applying

Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: 27.10 Develop a teaching plan for the client with a cast. Page Number: p. 1023 10. The nurse caring for a client with a plaster cast applied several days ago notes crumbs of plaster on the skin just under the edge of the cast. Which action by the nurse is the most appropriate?

1. Leaving the crumbs there to avoid injuring the skin 2. Using a surgical scrub brush to remove the crumbs 3. Using a dry cloth to remove the crumbs to avoid wetting the cast 4. Pull inner stockinette out and over the edge and secure with tape Correct Answer: 4 Rationale 1: Leaving the crumbs there could cause skin injury or could get under the cast and cause irritation.

Rationale 2: A surgical brush could scratch the client.

Rationale 3: Use of a dry cloth would not be effective.

Rationale 4: If cast edges are rough or crumbly, pull inner stockinette out and over the edge and secure with tape.

Global Rationale: If cast edges are rough or crumbly, pull inner stockinette out and over the edge and secure with tape. Leaving the crumbs there could cause skin injury or could get under the cast and cause irritation. A surgical brush could scratch the client. Use of a dry cloth would not be effective.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an

understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.7 Describe differences between plaster of Paris and synthetic casts.

Page Number: p. 1023 11. The nurse caring for a client in traction inspects the apparatus and determines all is well when noting which finding?

1. The weight is sitting on the floor.

2. The rope is on the side of the pulley.

3. The knots are positioned 5 inches from the pulley.

4. All ropes are intact and connected with slipknots, and short ends are taped.

Correct Answer: 4 Rationale 1: Weights should not touch the floor, because they cannot apply traction unless they are hanging freely.

Rationale 2: The rope should sit in the groove of the pulley to move freely.

Rationale 3: Knots should be no closer than 12 inches from the nearest pulley.

Rationale 4: The ropes should be intact and securely attached with slipknots, and the short ends of the rope should be attached with tape.

Global Rationale: The ropes should be intact and securely attached with slipknots, and the short ends of the rope should be attached with tape. Weights should not touch the floor, because they cannot apply traction unless they are hanging freely. The rope should sit in the groove of the pulley to move freely. Knots should be no closer than 12 inches from the nearest pulley.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 27.9 Identify types of skin and skeletal traction.

Page Number: p. 1030 12. The nurse is providing care to a client who has a short arm cast. Which nerve areas should the nurse assess to determine if irritation is occurring?

Standard Text: Select all that apply.

1. Radial 2. Ulnar 3. Median 4. Peroneal 5. Tibial Correct Answer: 1, 2, 3 Rationale 1: For an arm cast the radial nerve should be assessed.

Rationale 2: For an arm cast the ulnar nerve should be assessed.

Rationale 3: For an arm cast the median nerve should be assessed.

Rationale 4: For a leg cast the peroneal nerve should be assessed.

Rationale 5: For a leg cast the tibial nerve should be assessed.

Global Rationale: For an arm cast the radial, ulnar, and median nerves should be assessed. For a leg cast the peroneal and tibial nerves should be assessed.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.4 Assess circulation, motion, and sensation in an injured limb.

Page Number: p. 1013

13. The nurse is caring for a client who is in skin traction. Which nursing actions are appropriate for this client?

Standard Text: Select all that apply.

1. Assess neurovascular status every 4 hours, once stable.

2. Place sheep skin under pressure areas.

3. Massage the skin with lotion or alcohol every 4 hours if redness is noted.

4. Remove the weight first when removing nonadhesive traction.

5. Use a fracture bedpan to minimize movement during elimination.

Correct Answer: 1, 2, 4, 5 Rationale 1: Appropriate nursing actions for a client who is in skin traction include assessing neurovascular status every 4 hours, once the client is stable.

Rationale 2: Appropriate nursing actions for a client who is in skin traction include placing sheep skin under the pressure areas.

Rationale 3: Although alcohol or lo t io n NruUbRsS aI NndG TmBa. Cs sOaMg e s are appropriate, they should be completed every 2 hours if redness is noted, not every 4 hours.

Rationale 4: Appropriate nursing actions for a client who is in skin traction include removing the weight first when removing nonadhesive traction.

Rationale 5: Appropriate nursing actions for a client who is in skin traction include using a fracture bedpan to minimize movement during elimination.

Global Rationale: Appropriate nursing actions for a client who is in skin traction include assessing neurovascular status every 4 hours, once the client is stable; placing sheep skin under the pressure areas; removing the weight first when removing nonadhesive traction; and using a fracture bedpan to minimize movement during elimination. Although alcohol or lotion rubs and massages are appropriate, they should be completed every 2 hours if redness is noted, not every 4 hours.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and

in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.11 Outline the nursing care needs of the client in traction.

Page Number: p. 1029 14. A client comes into the emergency department with a soft tissue ankle sprain. In which order should the nurse instruct the client to treat this injury at home?

1. Apply ice 2. Rest the ankle 3. Elevate the foot 4. Apply an ace bandage Correct Answer: 2, 1, 4, 3 Rationale 1: The usual initial treatment is “RICE.” “R” stands for resting the injured part, “I” refers to application of ice, “C” stands for compression, such as with a bandage, and “E” stands for elevating the affected part 15 cm (6 in.) above the heart.

Rationale 2: The usual initial treatment is “RICE.” “R” stands for resting the injured part, “I” refers to application of ice, “C” stands for compression, such as with a bandage, and “E” stands for elevating the affected part 15 cm (6 in.) above the heart.

Rationale 3: The usual initial treatment i Ns U“ RR SICI NEG. ”T B“ .RC ”O M s t a n d s for resting the injured part, “I” refers to application of ice, “C” stands for compression, such as with a bandage, and “E” stands for elevating the affected part 15 cm (6 in.) above the heart.

Rationale 4: The usual initial treatment is “RICE.” “R” stands for resting the injured part, “I” refers to application of ice, “C” stands for compression, such as with a bandage, and “E” stands for elevating the affected part 15 cm (6 in.) above the heart.

Global Rationale: Sprains and strains are common musculoskeletal injuries. The usual initial treatment is “RICE.” “R” stands for resting the injured part, “I” refers to application of ice, “C” stands for compression, such as with a bandage, and “E” stands for elevating the affected part 15 cm (6 in.) above the heart.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.2 Outline emergency measures for an injured extremity.

Page Number: p. 1010 15. A client’s x-ray report shows a fractured leg where one part of fractured bone is driven into another.

How should the nurse document this client’s fracture?

1. Impacted 2. Greenstick 3. Comminuted 4. Compression Correct Answer: 1 Rationale 1: In an impacted fracture one part of fractured bone driven into another. Rationale 2: In a greenstick fracture only one side of the periosteum is cracked.

Rationale 3: In a comminuted fracture the bone is broken into several fragments. Rationale 4: In a compression fracture fractured bone compresses other bones.

Global Rationale: In an impacted fracture one part of fractured bone driven into another. In a greenstick fracture only one side of the periosteum is cracked. In a comminuted fracture the bone is broken into several N Up Rr eSsI sNi oGnT Bf r. aCcOt uMr e fractured bone compresses other bones. fragments. In a c o m Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.3 Describe different ways to classify fractures Page Number: p. 1011 16. The nurse is assisting a client recovering from spinal fusion surgery with the application of a back brace. What action should be done prior to placing the brace on the client?

1. Apply lotion to the skin 2. Assist the client to put on a T-shirt 3. Measure the client’s abdominal girth 4. Dust the skin with baby or corn powder

Correct Answer: 2 Rationale 1: Lotion will make the brace stick to the skin.

Rationale 2: Putting on a T-shirt protects the skin from the brace rubbing on bare skin. Rationale 3: There is no reason for abdominal girth to be measured.

Rationale 4: Baby or corn powder should not be applied to the skin.

Global Rationale: Putting on a T-shirt protects the skin from the brace rubbing on bare skin. Lotion will make the brace stick to the skin. There is no reason for abdominal girth to be measured. Baby or corn powder should not be applied to the skin.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Context and E n v i r oNnUmReSnI tN; GPTr aBc. Ct i Oc eM; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.6 Apply a variety of immobilizing devices (sling, bandage, splint, brace). Page Number: p. 1020 17. A client is recovering from hip arthroplasty using the anterolateral approach. What should the nurse ensure to maintain the integrity of the joint?

1. Place needed items on operative side 2. Keep needed items on the non-operative side 3. Instruct to avoid bending at the waist to put on shoes 4. Instruct to avoid crossing the operative leg past the body’s midline Correct Answer: 1 Rationale 1: With the anterolateral hip arthroplasty approach needed items should be placed on the operative side.

Rationale 2: With the posterolateral hip arthroplasty approach needed items should be on the nonoperative side.

Rationale 3: With the posterolateral hip arthroplasty approach the client should not bend at the waist to put on shoes.

Rationale 4: With the posterolateral hip arthroplasty approach the client should not cross the operative leg past the body’s midline.

Global Rationale: With the anterolateral hip arthroplasty approach needed items should be placed on the operative side. With the posterolateral hip arthroplasty approach needed items should be on the nonoperative side, avoid bending at the waist to put on shoes, and avoid crossing the operative leg past the body’s midline.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.13 Develop a teaching plan for a client undergoing joint replacement (arthroplasty).

Page Number: p. 1038

CHAPTER 28 1. The nurse is initiating IV therapy for an adult client who requires IV fluid infusion for 2–3 days and might require blood administration. What should the nurse choose as the best option for IV catheterization?

1. Butterfly 2. Huber needle 3. Angiocatheter 4. Implantable venous access device Correct Answer: 3 Rationale 1: A butterfly can be used, if necessary, for IV catheterization, but is best when used for shortterm IV infusion, as the needle remains in place within the vein, and is more likely to infiltrate sooner than is an angiocatheter.

Rationale 2: A Huber needle is used to access an implantable venous access device, and would not be used for short-term use of a few days.

Rationale 3: An angiocatheter would be the b e s ct acuhsoei c e t bh e needle is removed and only the catheter remains in place, so it is more likely to last for 2 days without infiltrating.

Rationale 4: Implantable venous access devices are used when IV fluid needs are anticipated for several months.

Global Rationale: An angiocatheter would be the best choice because the needle is removed and only the catheter remains in place, so it is more likely to last for 2 days without infiltrating. A butterfly can be used, if necessary, for IV catheterization, but is best when used for short-term IV infusion, as the needle remains in place within the vein, and is more likely to infiltrate sooner than is an angiocatheter. A Huber needle is used to access an implantable venous access device, and would not be used for short-term use of a few days.

Implantable venous access devices are used when IV fluid needs are anticipated for several months.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 28.8 Describe the steps for performing vein cannulation. .

Page Number: p. 1064 2. A client receiving an infusion of Dextrose 5% and water complains of a burning pain along the course of the vein. The site is red, warm, and is mildly edematous. Which term should the nurse use when documenting these findings?

1. Phlebitis at the IV insertion site 2. IV infiltrate 3. Extravasated vesicant drug 4. Extravasation Correct Answer: 1 Rationale 1: Redness, warmth, edema, and pain that runs along the course of the vein characterize phlebitis.

Rationale 2: An infiltrate is defined as flu heM tissues, resulting in swelling, coolness, pallor, and NUidRSen INte GrTin Bg.CtO discomfort at the site. This client's site is red and warm, not cool and pale, so it is not an infiltrate.

Rationale 3: Dextrose and water are not vesicants, and do not require immediate intervention.

Rationale 4: Extravasation includes a vesicant drug (one that causes blistering when in the tissues but not in the vascular system), so this is not an extravasation.

Global Rationale: Redness, warmth, edema, and pain that runs along the course of the vein characterize phlebitis. Dextrose and water are not vesicants, and do not require immediate intervention. An infiltrate is defined as fluid entering the tissues, resulting in swelling, coolness, pallor, and discomfort at the site. This client's site is red and warm, not cool and pale, so it is not an infiltrate. Extravasation includes a vesicant drug (one that causes blistering when in the tissues but not in the vascular system), so this is not an extravasation.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based

approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.7 State at least two potential problems that can occur with venipuncture and one suggested solution for each problem.

Page Number: p. 1071 3. The nurse is caring for a client with a medical diagnosis of increased intracranial pressure. Which IV fluid order should the nurse accept without questioning?

1. Normal saline at 125 mL/hour.

2. Dextrose 5% and water at 80 mL/hour.

3. Dextrose 5% and 0.45% NaCl at 75 mL/hour.

4. Normal saline 0.45% at 200 mL/hour.

Correct Answer: 3 Rationale 1: Isotonic and hypotonic fluids should not be administered to clients with increased intracranial pressure, because they increase the risk of cerebral edema. Normal saline is an isotonic solution and would need to be questioned.

Rationale 2: Isotonic and hypotonic fluids should not be administered to clients with increased intracranial pressure, because they increase the risk of cerebral edema. D5W is an isotonic solution and would need to be questioned.

Rationale 3: Isotonic and hypotonic fluids should not be administered to clients with increased intracranial pressure, because they increase the risk of cerebral edema. D5 in one-half normal saline is hypertonic, and would be an acceptable IV solution for this client.

Rationale 4: Isotonic and hypotonic fluids should not be administered to clients with increased intracranial pressure, because they increase the risk of cerebral edema. Half-normal saline is hypotonic and would not be advisable for this client.

Global Rationale: Isotonic and hypotonic fluids should not be administered to clients with increased intracranial pressure, because they increase the risk of cerebral edema. D5 in one-half normal saline is hypertonic, and would be an acceptable IV solution for this client. Normal saline and D5W are isotonic solutions, and so would need to be questioned. Half-normal saline is hypotonic, and so would not be advisable for this client.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes

AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 28.9 Outline the steps in preparing the IV bag for fluid administration.

Page Number: p.1085 4. The nurse working in the emergency department is caring for a client who experienced deep- thickness burns over 40% of the body and is in shock. Which order should the nurse anticipate for this client?

1. Electrolyte solutions 2. Volume expanders 3. Nutrient solutions 4. Total parenteral nutrition Correct Answer: 2 N U R SIN G T B . C O M

Rationale 1: Once vital signs are stabilized , the p r i m a r y ca r e provider may order electrolyte solutions.

Rationale 2: Initially, the client who is in shock will require volume expanders.

Rationale 3: Nutritional solutions would not be a priority concern this early in the client's course of treatment.

Rationale 4: Long term, this client might require total parenteral nutrition if he is unable to maintain adequate calorie intake orally.

Global Rationale: Initially, the client who is in shock will require volume expanders. Once vital signs are stabilized, the primary care provider may order electrolyte solutions. Long term, this client might require total parenteral nutrition if he is unable to maintain adequate calorie intake orally, but nutritional solutions would not be a priority concern this early in the client's course of treatment.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an

understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 28.4 Identify the assessment data to determine a client’s fluid status.

Page Number: p. 1053

5. Which aspect of intravenous therapy could the nurse safely delegate to the unlicensed assistive personnel (UAP)?

1. Watching the IV insertion site of the client who complained of pain at the site 2. Changing the IV site dressing on the client's left hand 3. Reporting client's complaints of pain or leakage from the IV site when bathing the client 4. Replacing client's IV solution when bag runs dry if it is only D5W, without medications added Correct Answer: 3 N U R S I N G T B. C O M

Rationale 1: The UAP is not responsible f o r a ss essin g the site.

Rationale 2: The IV dressing should be changed using sterile technique, and should not be delegated to the UAP. Rationale 3: The UAP can safely be taught to report complaints of pain or leakage from an IV site if it is noted during routine care.

Rationale 4: UAP. Whether medications are added to the IV fluid or not, only the nurse can change the bag, because sterile technique is required, and even a plain solution is considered a medication.

Global Rationale: The UAP can safely be taught to report complaints of pain or leakage from an IV site if it is noted during routine care, but the UAP is not responsible for assessing the site, because the nurse is responsible for all assessments. The IV dressing should be changed using sterile technique, and should not be delegated to the UAP. Whether medications are added to the IV fluid or not, only the nurse can change the bag, because sterile technique is required, and even a plain solution is considered a medication.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team

members AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Practice; Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 28.4 Identify the assessment data to determine a client’s fluid status.

Page Number: p. 1105 6. The nurse is performing venipuncture to initiate IV therapy. The venipuncture site is chosen based on which indicators?

Standard Text: Select all that apply.

1. Using the client's dominant arm, whenever possible 2. Choosing a relatively straight vein 3. Avoiding sclerotic veins 4. Looking for a site sufficiently distal to joints 5. Choosing a vein that is visible in addition to palpable Correct Answer: 2, 3, 4 Rationale 1: It is best, when possible, to use the client's nondominant arm, because movement might be somewhat limited, so the client should be allowed to use the dominant arm.

Rationale 2: The nurse should choose a vein that is straight. Straight veins provide space for the catheter to be inserted easily.

Rationale 3: The nurse should choose a vein that is not sclerotic. Sclerotic veins make it difficult to obtain and maintain IV therapy.

Rationale 4: The site should be sufficiently distal to the wrist or elbow joint to avoid bending or kinking of the IV catheter.

Rationale 5: Some clients, especially dark-skinned people, might not have easily visible veins, so the veins should be palpable even if not visible.

Global Rationale: The nurse should choose a vein that is straight and not sclerotic. Sclerotic veins make it difficult to obtain and maintain IV therapy. Straight veins provide space for the catheter to be inserted easily. The site should be sufficiently distal to the wrist or elbow joint to avoid bending or kinking of the IV catheter. It is best, when possible, to use the client's nondominant arm, because movement might be somewhat limited, so the client should be

allowed to use the dominant arm. Some clients, especially dark-skinned people, might not have easily visible veins, so the veins should be palpable even if not visible.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: 28.6 Describe the steps for performing venipuncture using a winged needle or over-the-needle catheter.

Page Number: p. 1060 7. The nurse initiating IV therapy is preparing a solution to which potassium chloride has been added.

After adding the medication, which action by the nurse regarding the IV label is appropriate?

1. Writing the time the IV solution needs to be changed 2. Placing it upside-down on the container 3. Putting it around the IV tubing 4. Documenting the size of the angiocatheter inserted to obtain IV access Correct Answer: 2 Rationale 1: The time the solution needs to be changed would be indicated with a time label to indicate when the solution was hung.

Rationale 2: The label should be applied upside-down so it can be read when the IV bag is hung upsidedown from the IV pole.

Rationale 3: A label indicating when the IV tubing needs to be changed would be applied around the tubing, not the medication label.

Rationale 4: The size of the angiocatheter should be documented, but it would not be written on the medication label.

Global Rationale: The label should be applied upside-down so it can be read when the IV bag is hung upside-down from the IV pole. The time the solution needs to be changed would be indicated with a time label to indicate when the solution was hung. A label indicating when the IV tubing needs to be changed would be applied around the tubing, not the medication label. The

size of the angiocatheter should be documented, but it would not be written on the medication label.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28.9 Outline the steps in preparing the IV bag for fluid administration.

Page Number: p. 1089 8. The nurse is setting up an IV infusion on an electronic infusion pump. After leaving the room, the pump alarms and reads high pressure. Which is the priority action by the nurse?

1. Resetting the pump to resume infusion 2. Discontinuing the client's IV access and restarting in a different area 3. Assessing the client's IV site and the tubing for kinks or closed roller clamps 4. Asking the client if the pump has been tampered with in any way Correct Answer: 3 Rationale 1: Resetting the pump without performing a thorough assessment could increase the tissue damage if the site is infiltrated.

Rationale 2: The IV site should not be discontinued if it is intact, so it should be assessed before considering moving the site.

Rationale 3: The nurse should assess the IV site because an infiltrated IV, or a site that is proximal to a joint, can impede infusion. If the IV site appears to be within normal limits, the tubing should be checked for any kinks, closed roller clamps, or any other impediment to infusion.

Rationale 4: Accusing the client of tampering with the pump would not be justified.

Global Rationale: The nurse should assess the IV site because an infiltrated IV, or a site that is proximal to a joint, can impede infusion. If the IV site appears to be within normal limits, the tubing should be checked for any kinks, closed roller clamps, or any other impediment to

infusion. Resetting the pump without performing a thorough assessment could increase the tissue damage if the site is infiltrated. The IV site should not be discontinued if it is intact, so it should be assessed before considering moving the site. Accusing the client of tampering with the pump would not be justified.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.13 Discuss client safety and the use of infusion control pumps.

Page Number: p. 1070 9. The nurse discontinues the client's IV prior to discharge. After removing the catheter, which actions by the nurse are appropriate?

Standard Text: Select all that apply.

1. Applying pressure to the insertion siteNuUnRtiSlIbNlGeTedBi.nCgOM stops 2. Examining the removed catheter to ensure that it is intact 3. Teaching the client to inform the nurse if the site begins to bleed at any time 4. Holding the client's extremity below the level of the heart if bleeding persists 5. Covering the venipuncture site with a sterile dressing Correct Answer: 1, 2, 3, 5 Rationale 1: The nurse should apply pressure to the insertion site until bleeding stops.

Rationale 2: The nurse should examine the removed catheter to ensure that it is intact.

Rationale 3: The nurse should teach the client to inform the nurse if the site begins to bleed at any time.

Rationale 4: The client's extremity should be held above the level of the heart if bleeding persists.

Rationale 5: The nurse should cover the venipuncture site with a sterile dressing.

Global Rationale: The nurse should apply pressure to the insertion site until bleeding stops; examine the removed catheter to ensure that it is intact; teach the client to inform the nurse if the site begins to bleed at any time; and cover the venipuncture site with a sterile dressing. The client's extremity should be held above the level of the heart if bleeding persists.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28.7 State at least two potential problems that can occur with venipuncture and one suggested solution for each problem.

Page Number: p. 1079 10. A client receiving a blood transfusion for 15 minutes complains of suddenly feeling cold and is shivering. Blood pressure has decreased since the last assessment. Which is the nurse's priority action?

1. Notify the health care provider.

2. Monitor the client's blood pressure every 5 minutes.

3. Stop the blood infusion, and run the normal saline on the other side of the Y tubing.

4. Stop the blood infusion, and remove the tubing from the IV catheter, replacing it with normal saline.

Correct Answer: 4 Rationale 1: Only after the blood infusion is discontinued would the nurse notify the health care provider.

Rationale 2: Only after the blood infusion is discontinued would the nurse monitor the client's condition.

Rationale 3: Stopping the blood infusion and running saline through the blood tubing will administer the blood found in the tubing, and could make the transfusion reaction worse.

Rationale 4: The nurse should completely discontinue the blood infusion, disconnecting the tubing from the IV catheter and placing normal saline or the ordered solution infusing prior to beginning the blood infusion with new tubing.

Global Rationale: The nurse should completely discontinue the blood infusion, disconnecting the tubing from the IV catheter and placing normal saline or the ordered solution infusing prior to beginning the blood infusion with new tubing. Stopping the blood infusion and running saline through the blood tubing will administer the blood found in the tubing, and could make the transfusion reaction worse. Only after the blood infusion is discontinued would the nurse notify the health care provider and monitor the client's condition.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28.17 Differentiate signs and symptoms of hemolytic and allergic blood transfusion reaction Page Number: p. 1102 11. The nurse receives an order to administer 3 liters of IV fluid over the next 24 hours. The infusion device would be set to administer how many mL per hour? mL/hour Standard Text: Record the answer rounding to the nearest whole number.

Correct Answer: 125 Rationale: The correct answer is obtained by dividing 3,000 mL (total amount of fluid to be administered over the next 24 hours is 3 liters = 3,000 mL) by the number of hours it is to be infused (24). 3,000 divided by 24 = 125 mL/hr.

Global Rationale: The correct answer is obtained by dividing 3,000 mL (total amount of fluid to be administered over the next 24 hours is 3 liters = 3,000 mL) by the number of hours it is to be infused (24).

3,000 divided by 24 = 125 mL/hr.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings

NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28.11 Calculate an IV flow rate using a standard formula.

Page Number: p. 1069 12. A client has a urine output of 350 mL of urine over the last 24 hours. Which health problem should the nurse consider as causing this low output? Select all that apply.

1. Pain 2. Trauma 3. Surgery 4. Hemorrhage 5. Elevated sodium Correct Answer: 1, 2, 3, 4 Rationale 1: Conditions that can stimulate the secretion of ADH and lead to increased water retention by the kidneys includes pain.

Rationale 2: Conditions that can stimulate the secretion of ADH and lead to increased water retention by the kidneys includes trauma.

Rationale 3: Conditions that can stimulate the secretion of ADH and lead to increased water retention by the kidneys includes surgeryN.URSINGTB.COM Rationale 4: Conditions that can stimulate the secretion of ADH and lead to increased water retention by the kidneys includes hemorrhage.

Rationale 5: Aldosterone affects urine output however would not be excreted when the sodium level is elevated.

Global Rationale: Conditions that can stimulate the secretion of ADH and lead to increased water retention by the kidneys include pain, trauma, surgery, and hemorrhage. Aldosterone affects urine output however would not be excreted when the sodium level is elevated.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.2 Discuss the two hormonal regulatory systems that influence urinary excretion by the kidneys.

Page Number: p. 1053 13. A client is admitted with severe vomiting and diarrhea. On what should the nurse focus when planning this client’s care?

1. Fluid deficit 2. Infection risk 3. Skin integrity 4. Altered tissue perfusion Correct Answer: 1 Rationale 1: A fluid deficit is associated with losses from vomiting and diarrhea.

Rationale 2: A risk for infection occurs with chronic diseases, invasive procedures, immunodeficiency, tissue destruction, and increased environmental exposure.

Rationale 3: Skin integrity is impacted by skin turgor, edema, tissue damage, IV infiltration, infection, and immobilization.

Rationale 4: Altered tissue perfusion would be caused by hemorrhage or losses related to hemodialysis.

Global Rationale: A fluid deficit is associated with losses from vomiting and diarrhea. A risk for infection occurs with chronic diseases, invasive procedures, immunodeficiency, tissue destruction, and increased environmental exposure, Skin integrity is impacted by skin turgor, edema, tissue damage, IV infiltration, infection, and immobilization. Altered tissue perfusion would be caused by hemorrhage or losses related to hemodialysis.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.5 Compare and contrast the client assessment data associated with fluid volume excess or deficit.

Page Number: p. 1055

14. The nurse is hanging a secondary bag with an antibiotic for a client. Which action should the nurse take when performing this skill?

1. Lower the secondary bag 2. Clamp the primary bag tubing 3. Regulate the flow with the primary bag 4. Regulate the flow with the secondary bag Correct Answer: 3 Rationale 1: The primary bag should be lowered. The primary solution ceases to flow because of increased hydrostatic pressure in the higher secondary bag.

Rationale 2: If the primary bag tubing is clamped, nothing will infuse. Rationale 3: The primary bag controls the flow of the secondary bag. Rationale 4: The clamp on the secondary bag should be wide open.

Global Rationale: The primary bag controls the flow of the secondary bag. The primary bag should be lowered. The primary solution ceases to flow because of increased hydrostatic pressure in the higher secondary bag. If the primary bag tubing is clamped, nothing will infuse. The clamp on the secondary bag should be wide open.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28.10 Describe the steps for hanging a secondary IV bag.

Page Number: pp. 1089-1090 15. A client is prescribed a medication to be administered IV push that is incompatible with the primary intravenous solution. What should the nurse do to safely administer this medication?

1. Insert a new angiocatheter 2. Change the route to an oral dose 3. Flush the angiocatheter with normal saline 4. Discontinue the primary infusion for several hours Correct Answer: 3

Rationale 1: A new angiocatheter is not required.

Rationale 2: The order was written for intravenous administration. Changing the route to oral is beyond the nurse’s scope of practice.

Rationale 3: Flushing the primary infusion tubing will be necessary both before and after administering the drug if incompatibility exists. Normal saline is used to flush the line.

Rationale 4: Discontinuing the primary infusion for several hours can be harmful to the client and does not ensure that the medication will not react with the remaining fluid in the angiocatheter.

Global Rationale: Flushing the primary infusion tubing will be necessary both before and after administering the drug if incompatibility exists. Normal saline is used to flush the line. A new angiocatheter is not required. The order was written for intravenous administration. Changing the route to oral is beyond the nurse’s scope of practice. Discontinuing the primary infusion for several hours can be harmful to the client and does not ensure that the medication will not react with the remaining fluid in the angiocatheter.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: III.A.1. D e m o n s tNr aUt Re SkI nNoGwT lBe. dCgOeMo f basic scientific methods and processes AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28.12 Describe the procedure for administering an intravenous push medication.

Page Number: p. 1094 16. A client is prescribed intravenous fluids to treat dehydration. Which solution should the nurse use to disinfect the skin prior to catheter placement for these fluids?

1. Betadine 2. Soap and water 3. Chlorhexidine gluconate 4. Alcohol-based hand sanitizer Correct Answer: 3

Rationale 1: Use of chlorhexidine gluconate has demonstrated superiority to povidone–iodine in decreasing infections at the site of IV catheter insertion.

Rationale 2: Soap and water can be used for hand hygiene before catheter placement however is not recommended to cleanse the skin prior to IV catheter insertion.

Rationale 3: The CDC Guidelines for Prevention of Catheter-Related Infections state that skin should be disinfected before catheter placement and that chlorhexidine gluconate is preferred.

Rationale 4: Alcohol-based hand sanitizer can be used for hand hygiene before catheter placement however is not recommended to cleanse the skin prior to IV catheter insertion.

Global Rationale: The CDC Guidelines for Prevention of Catheter-Related Infections state that skin should be disinfected before catheter placement and that chlorhexidine gluconate is preferred. Use of chlorhexidine gluconate has demonstrated superiority to povidone–iodine in decreasing infections at the site of IV catheter insertion. Soap and water or alcohol-based hand sanitizer can be used for hand hygiene before catheter placement however is not recommended to cleanse the skin prior to IV catheter insertion.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28.14 Describe the proper use of chlorhexidine gluconate or alcohol as a skin preparation for intravenous access.

Page Number: p. 1054 17. A client is prescribed to receive a unit of packed red blood cells. What should be checked prior to administering the blood to this client? Select all that apply.

1. Client name 2. Unit number 3. Blood group 4. Client birthday 5. Expiration date Correct Answer: 1, 2, 3, 5

Rationale 1: Prior to administering the blood the client’s name should be checked with another nurse.

Rationale 2: Prior to administering the blood the unit number should be checked with another nurse.

Rationale 3: Prior to administering the blood the client’s blood group should be checked with another nurse.

Rationale 4: The client’s birthday is not checked prior to administering blood.

Rationale 5: Prior to administering the blood the expiration date should be checked with another nurse.

Global Rationale: Prior to administering the blood the client’s name, unit number, blood group, and expiration date should be checked with another nurse. The client’s birthday is not checked prior to administering blood.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes UR AACN Essential Competencies: IX. 3. NIm pSleINmGeTnBt .hCoOl iMs t i c , patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 28.16 Describe safety checks utilized to ensure proper blood administration.

Page Number: p. 1098

CHAPTER 29 1. Which clients may benefit from central venous IV access?

Standard Text: Select all that apply.

1. The client requiring long-term IV therapy 2. The client receiving caustic IV therapy 3. The client requiring numerous IV infusions that are not compatible and cannot be infused together 4. The unstable client requiring reliable IV access for administration of medications required immediately 5. The client who is afraid of needles and does not want a catheter in the peripheral extremity Correct Answer: 1, 2, 3, 4 Rationale 1: Central venous access can be very useful for clients requiring long-term IV therapy because the catheter can remain in place for extended periods, and IV sites do not have to be changed every few days.

Rationale 2: Caustic medications are less likely to cause phlebitis when administered into the large central veins as opposed to the smaller peripheral veins.

Rationale 3: In the critical care areas where clients may receive numerous continuous IV medication drips that might not all be compatible infusing through the same site, a multiple-port central venous access device can provide the best option.

Rationale 4: Clients who are unstable and require rapid administration of medications require reliable IV access that might not be available with peripheral IV lines, and central venous access may be the best option.

Rationale 5: Because of the potential complications from central venous access, it would not be an option considered because of client preference if short-term IV therapy is required.

Global Rationale: Central venous access can be very useful for clients requiring long-term IV therapy because the catheter can remain in place for extended periods, and IV sites do not have to be changed every few days. Caustic medications are less likely to cause phlebitis when administered into the large central veins as opposed to the smaller peripheral veins. In the critical care areas where clients may receive numerous continuous IV medication drips that might not all be compatible infusing through the same site, a multiple-port central venous access device can provide the best option. Clients who are unstable and require rapid administration of medications require reliable IV access that might not be available with peripheral IV lines, and central venous

access may be the best option. Because of the potential complications from central venous access, it would not be an option considered because of client preference if short-term IV therapy is required.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 29.2 Discuss the rationale for using central vascular catheters for long-term IV therapy.

Page Number: p. 1112 2. The nurse is caring for a client with a central venous catheter used for intermittent medication administration. When flushing the catheter prior to administering the next dose of medication, which initial action by the nurse is the mNost prGoTpBri.aCtOeM ?

U RaSpIN 1. Aspirating the catheter for blood 2. Obtaining a 3 mL syringe and filling it with normal saline for flushing the line 3. Flushing the catheter, using as much force as required in order to clear the line 4. Positioning the client in reverse Trendelenburg position Correct Answer: 1 Rationale 1: The catheter should be aspirated for blood prior to flushing the tubing.

Rationale 2: The tubing would be flushed with a 10 mL syringe or larger because small syringes exert too much pressure, which can damage the catheter.

Rationale 3: Excessive pressure should not be used when flushing the catheter, because it can dislodge a clot or cause the catheter to rupture.

Rationale 4: There would be no need to place the client in reverse Trendelenburg position, although a left Trendelenburg position may be used if an air embolism is suspected.

Global Rationale: The catheter should be aspirated for blood prior to flushing the tubing. The tubing would be flushed with a 10 mL syringe or larger because small syringes exert too much pressure, which can damage the catheter. Excessive pressure should not be used when flushing the catheter, because it can dislodge a clot or cause the catheter to rupture. There would be no need to place the client in reverse Trendelenburg position, although a left Trendelenburg position may be used if an air embolism is suspected.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.6 Compare and contrast features of various central vascular access devices.

Page Number: p. 1120 3. When removing an old central line dressing, which action by the nurse is the priority?

1. Pulling the tape off in the direction of the catheter 2. Inspecting the insertion site for signs of infection 3. Pressing the catheter into the client's skin while removing the tape 4. Applying sterile gloves Correct Answer: 1 Rationale 1: The tape should be removed in the direction of the catheter to avoid displacing the catheter.

Rationale 2: The site is inspected after the old dressing is removed, not while removing the dressing.

Rationale 3: The catheter should be held in the nurse's hand while the tape is removed, not pressed into the client's skin.

Rationale 4: Sterile gloves are not used when removing the old dressing.

Global Rationale: The tape should be removed in the direction of the catheter to avoid displacing the catheter. The site is inspected after the old dressing is removed, not while

removing the dressing. The catheter should be held in the nurse's hand while the tape is removed, not pressed into the client's skin. Sterile gloves are not used when removing the old dressing.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.9 Outline steps for dressing and protecting the CVAD insertion site.

Page Number: p. 1120 4. The nurse is caring for a client who is to have a peripherally inserted central catheter (PICC) line inserted tomorrow afternoon. The client's peripheral access line is infiltrated, and needs to be restarted.

Which site would the nurse avoid using?

1. Median cubital vein 2. Cephalic vein 3. Radial vein 4. Dorsal metacarpal veins Correct Answer: 1 Rationale 1: The median cubital vein is often used for PICC lines, so the nurse should attempt to avoid this site in order to maintain it for the central line.

Rationale 2: The cephalic vein is an acceptable choice.

Rationale 3: The radial vein is an acceptable choice.

Rationale 4: The dorsal metacarpal vein is an acceptable choice.

Global Rationale: The median cubital vein is often used for PICC lines, so the nurse should attempt to avoid this site in order to maintain it for the central line. The cephalic, radial, and dorsal metacarpal veins are acceptable choices.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies

QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 29.6 Compare and contrast features of various central vascular access devices.

Page Number: p. 1112 5. The nurse caring for a client receiving parenteral nutrition via a central venous catheter determines that the client's temperature is elevated, white blood cell count is elevated, and the client is lethargic.

The nurse suspects the client is septic. Which actions by the nurse are appropriate in this situation?

Standard Text: Select all that apply.

1. Replacing the parenteral nutrition with a normal saline solution 2. Changing the IV tubing 3. Saving the remaining TPN 4. Recording the lot number of the TPN 5. Notifying the health care provider.

Correct Answer: 2, 3, 4, 5 Rationale 1: The fluid should be replaced with a 5% or 10% dextrose solution, not normal saline, because the client has adjusted to a high sugar intake via the TPN, and eliminating all sugar infused could result in hypoglycemia.

Rationale 2: Changing the IV tubing is a correct action.

Rationale 3: Saving the remaining TPN is a correct action. Rationale 4: Recording the lot number of the TPN is a correct action. Rationale 5: Notifying the health care provider is a correct action.

Global Rationale: The fluid should be replaced with a 5% or 10% dextrose solution, not normal saline, because the client has adjusted to a high sugar intake via the TPN, and eliminating all

sugar infused could result in hypoglycemia. Changing the tubing, saving the remaining TPN, recording the TPN lot number, and notifying the health care provider are correct actions.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacologic and Parenteral Therapies QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.3 Discuss the special needs of clients with central vascular catheters (prevention of infection, air embolism).

Page Number: p. 1132 6. The nurse caring for a client with a central line accidentally infuses an air embolism. Which is the highest-priority action of the nurse?

1. Notifying the health care provider 2. Notifying the charge nurse 3. Assessing the client 4. Positioning the client in left Trendelenburg and applying oxygen Correct Answer: 4 Rationale 1: Notifying the health care provider can be done later.

Rationale 2: Notifying the charge nurse can be done later.

Rationale 3: The client can be assessed after intervening actions are completed.

Rationale 4: Lowering the head of the bed increases intrathoracic pressure, decreasing the flow of air into the vein during inhalation. A left side-lying position helps prevent air from moving into the pulmonary artery. Oxygen helps to hyperoxygenate the tissues if the air embolism reduces blood flow to the tissues.

Global Rationale: Lowering the head of the bed increases intrathoracic pressure, decreasing the flow of air into the vein during inhalation. A left side-lying position helps prevent air from moving into the pulmonary artery. Oxygen helps to hyperoxygenate the tissues if the air embolism reduces blood flow to the tissues.

Once interventions are applied the client can be assessed. Then the charge nurse and health care provider can be notified.

Cognitive Level: Analyzing Client Need: Physiologic Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.3 Discuss the special needs of clients with central vascular catheters (prevention of infection, air embolism).

Page Number: p. 1132 7. After changing the client's central line dressing, what should the nurse include when documenting this procedure?

Standard Text: Select all that apply.

1. Fluid infusing into the catheter 2. Assessment of the central line insertion site 3. Type of dressing applied 4. Aseptic technique under which the dressing was changed 5. Client complaints or concerns Correct Answer: 2, 3, 4, 5 Rationale 1: The fluid infusing is documented on the IV infusion record, but not in the note regarding dressing change.

Rationale 2: The nurse should document the appearance of the central line insertion site.

Rationale 3: The nurse should document the type of dressing applied.

Rationale 4: The nurse should document the aseptic technique used, such as "sterile technique used to apply Tegaderm dressing."

Rationale 5: If the client voices any concerns or complaints, the nurse would record them, along with actions taken to care for the client.

Global Rationale: The nurse should document the appearance of the central line insertion site, the type of dressing applied, and the aseptic technique used, such as "sterile technique used to

apply Tegaderm dressing." If the client voices any concerns or complaints, the nurse would record them, along with actions taken to care for the client. The fluid infusing is documented on the IV infusion record, but not in the note regarding dressing change.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: VI.B.4. Document and plan client care in an electronic health record AACN Essential Competencies: IV.5. Use standardized terminology in a care environment that reflects nursing’s unique contribution to client outcomes NLN Competencies: Quality and Safety: Practice; Carefully maintain and use electronic and/or written health records Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.9 Outline steps for dressing and protecting the CVAD insertion site.therapy.

Page Number: p. 1120 8. The nurse receives a bag of total parenteral nutrition (TPN) for the client. Prior to hanging the solution, which nursing actions are priorities?

Standard Text: Select all that apply.

1. Checking the expiration date 2. Creating a sterile field 3. Checking the nutrients in the bag against the order written by the primary care provider with another licensed nurse 4. Adding additional medications to the fluid 5. Check rate of infusion on physician’s orders Correct Answer: 1, 3, 5 Rationale 1: The nurse should check the expiration date because the solution is high in sugar, providing an ideal location for pathogen growth. Outdated solutions should never be administered.

Rationale 2: There is no need to create a sterile field until the fluid is checked for accuracy and the bag prepared.

Rationale 3: The primary care provider's order should be checked against the contents of the solution with another nurse to ensure the proper mixture is prepared and administered.

Rationale 4: Nurses do not add medications or anything to the prepared TPN, because it must be mixed under sterile technique with a laminar air flow device to prevent introduction of pathogens.

Rationale 5: The nurse should check the rate of infusion on physician’s orders.

Global Rationale: The nurse should check the expiration date because the solution is high in sugar, providing an ideal location for pathogen growth. Outdated solutions should never be administered. The primary care provider's order should be checked against the contents of the solution with another nurse to ensure the proper mixture is prepared and administered. The nurse should check the rate of infusion on physician’s orders. There is no need to create a sterile field until the fluid is checked for accuracy and the bag prepared. Nurses do not add medications or anything to the prepared TPN, because it must be mixed under sterile technique with a laminar air flow device to prevent introduction of pathogens.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and SafetyN: UKRnSoI NwGleTdBg. eC;OCMurren t best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.2 Discuss the rationale for using central vascular catheters for long-term IV therapy.

Page Number: p. 1130 9. When deciding if parenteral nutrition should be given peripherally or centrally, the nurse recognizes which statement is true?

1. Lipids must be given centrally.

2. The maximum percentage of dextrose that can be given peripherally is up to 10%.

3. Clients requiring long-term parenteral nutrition generally receive it peripherally.

4. Providing parenteral nutrition peripherally cannot meet calorie needs.

Correct Answer: 2 Rationale 1: Lipids may be given peripherally as well as centrally.

Rationale 2: Dextrose concentrations greater than 10% must be given centrally because of the risk of phlebitis at higher concentrations.

Rationale 3: Clients requiring long-term parenteral nutrition generally receive it centrally.

Rationale 4: Parenteral nutrition can meet caloric needs, but should be started gradually and increased slowly to prevent hyperglycemia.

Global Rationale: Dextrose concentrations greater than 10% must be given centrally because of the risk of phlebitis at higher concentrations. Lipids may be given peripherally as well as centrally. Clients requiring long-term parenteral nutrition generally receive it centrally.

Parenteral nutrition can meet caloric needs, but should be started gradually and increased slowly to prevent hyperglycemia.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.2 Discuss the rationale for using central vascular catheters for long-term IV therapy.

Page Number: p. 1114 10. The charge nurse is observing a new graduate care for a client with a Groshong catheter. For which observation should the charge nurse interrupt this client’s care?

1. Preparing fluids for infusion 2. Clamp applied to the catheter 3. Catheter not flushed with heparin 4. Client response to medication assessed Correct Answer: 2 Rationale 1: The Groshong catheter is used when low flow rates will be infused.

Rationale 2: Groshong catheters are never clamped, because of the design feature that prevents backflow. Pressure from clamping the catheter or extension tubing can force the slit valve to open, allowing a blood leak back into the lumen.

Rationale 3: Heparin flushing is not routinely done with a Groshong catheter because of the design of the catheter tip.

Rationale 4: The client’s response to medication should be assessed.

Global Rationale: Groshong catheters are never clamped, because of the design feature that prevents backflow. Pressure from clamping the catheter or extension tubing can force the slit valve to open, allowing a blood leak back into the lumen. The Groshong catheter is used when low flow rates will be infused.

Heparin flushing is not routinely done with a Groshong catheter because of the design of the catheter tip.

The client’s response to medication should be assessed.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.1 Identify the common types of central vascular access devices (CVADs).

Page Number: p. 1112 11. A client is having a central venous catheter inserted. After positioning and preparing the client what should the nurse do?

1. Perform hand hygiene 2. Apply a mask and gloves 3. Open antimicrobial prep pads 4. Open glove packet and sterile drape pack Correct Answer: Rationale 1: Hand hygiene should be been performed prior to beginning to prepare the client. Rationale 2: The nurse should apply a mask and gloves to assist with central catheter insertion. Rationale 3: The antimicrobial prep pads are opened before a mask and gloves are applied.

Rationale 4: The glove packet and sterile drape pack should be opened before a mask and gloves are applied.

Global Rationale: The nurse should apply a mask and gloves to assist with central catheter insertion. The nurse should apply a mask and gloves to assist with central catheter insertion. The antimicrobial prep pads, glove packet, and sterile drape pack are opened before a mask and gloves are applied.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 29.4 Describe the role of the nurse in the insertion of CVADs. Page Number: p. 1117 12. The healthcare provider is preparing to insert a percutaneous central vascular device. What should the nurse instruct the client to do while the catheter is being inserted?

1. Hum 2. Cough 3. Count to 10 4. Take a deep breath Correct Answer: 1 Rationale 1: As a licensed provider inserts the catheter, the client is instructed to perform Valsalva maneuver to prevent air embolism. If the client is unable to exhale against a closed glottis the client should be instructed to hum since this will decrease the chance of an air embolism.

Rationale 2: Coughing could cause an air embolism. Rationale 3: Talking could cause an air embolism.

Rationale 4: Taking a deep breath could cause an air embolism Global Rationale: As a licensed provider inserts the catheter, the client is instructed to perform Valsalva maneuver to prevent air embolism. If the client is unable to exhale against a closed glottis the client should be instructed to hum since this will decrease the chance of an air embolism. Coughing, talking, and taking a deep breath could cause an air embolism.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 29.5 Explain the nurse’s responsibility for assisting the physician with a percutaneous central vascular catheter insertion.

Page Number: p. 1117 13. The nurse is preparing to administer a liter of fluid through a client’s central line. What should the nurse do after attaching the syringe to the designated port?

1. Ask the client to cough 2. Aspirate for a blood return 3. Withdraw 20 mL of blood 4. Inject 10 mL of saline flush Correct Answer: 2 Rationale 1: The client should not cough while the access port is being used.

Rationale 2: After attaching the syringe, aspirate for blood return, using very little force, to check for lumen patency and placement.

Rationale 3: The nurse is not drawing a blood sample.

Rationale 4: Saline flush occurs after the blood return is assessed.

Global Rationale: After attaching the syringe, aspirate for blood return, using very little force, to check for lumen patency and pl acem e nt.NAUfRt eSrI NatGtaTcBh. CinOgMth e syringe, aspirate for blood return, using very little force, to check for lumen patency and placement. : The nurse is not drawing a blood sample. Saline flush occurs after the blood return is assessed.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.7 Describe initiation and discontinuation of infusions via CVADs. Page Number: p. 1120 14. An implanted subcutaneous port is occluded. What should the nurse do first?

1. Aspirate the clot 2. Change the needle 3. Instill a fibrinolytic agent 4. Forcefully flush the catheter

Correct Answer: 2 Rationale 1: Aspirating the clot can be attempted after the needle is changed. Rationale 2: The first thing to do is change the needle.

Rationale 3: A healthcare provider has to prescribe a fibrinolytic agent.

Rationale 4: Catheters should never be forcefully flushed. The catheter could rupture or the clot could be pushed into the general circulation.

Global Rationale: The first thing to do is change the needle. Aspirating the clot can be attempted after the needle is changed. A healthcare provider has to prescribe a fibrinolytic agent. Catheters should never be forcefully flushed. The catheter could rupture or the clot could be pushed into the general circulation.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.8 Differentiate protocols for maintaining patency of intermittently used CVADs. Page Number: p. 1153 15. A client asks why a BIOPATCH is being used as part of a central line dressing. What should the nurse respond to this client?

1. “It ensures no air gets into the line.”

2. “It reduces the risk of an infection.”

3. “It keeps the catheter from moving.”

4. “It stops germs for a minimum of 3 days.”

Correct Answer: 2 Rationale 1: The BIOPATCH has nothing to do with reducing air getting into the line.

Rationale 2: The BIOPATCH is made of a hydrophilic polyurethane absorptive foam with chlorhexidine gluconate (CHG). The CHG inhibits bacterial growth under dressing.

Rationale 3: The BIOPATCH is not used to stabilize the catheter.

Rationale 4: The BIOPATCH is changed a minimum of every 7 days.

Global Rationale: The BIOPATCH is made of a hydrophilic polyurethane absorptive foam with chlorhexidine gluconate (CHG). The CHG inhibits bacterial growth under dressing. The BIOPATCH has nothing to do with reducing air getting into the line. The BIOPATCH is not used to stabilize the catheter.

The BIOPATCH is changed a minimum of every 7 days.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.10 Discuss the advantage of using a BIOPATCH at the catheter insertion site.

Page Number: p. 1124 16. The nurse is caring for a client with a central line. What criteria should be used to determine if the access cap needs to be changed?

1. Fluid being administered 2. Cap was changed 3 days ago 3. The line is used for blood samples 4. Length of time the catheter will be in place Correct Answer: 3 Rationale 1: The type of fluid does not impact the frequency of changing the cap. Rationale 2: Caps should be changed every 7 days.

Rationale 3: The cap should be changed after blood draws.

Rationale 4: The length of time the catheter will be in place does not impact the frequency of changing the cap.

Global Rationale: The cap should be changed after blood draws. The type of fluid does not impact the frequency of changing the cap. Caps should be changed every 7 days. The length of time the catheter will be in place does not impact the frequency of changing the cap.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 29.11 Outline the steps in changing an access cap.

Page Number: p. 1126 17. A client asks why a central line is being placed in the right arm. What should the nurse respond to this client?

1. “It is more stable.”

2. “It costs less than another site for a central line.”

3. “It doesn’t get infected as often as other central lines.

4. “It is the best approach for the medicine that you need to receive.”

Correct Answer: 4 Rationale 1: PICC lines are not more stable because of their location.

Rationale 2: There is no information to support that PICC lines are more cost-effective. Rationale 3: PICC lines have a high rate NoUf RinSfI eNcGt iToBn..C O M Rationale 4: A PICC line is the most appropriate method for infusing vesicants, hyperosmolar solutions, or blood products and antibiotics that are potentially irritating drugs.

Global Rationale: A PICC line is the most appropriate method for infusing vesicants, hyperosmolar solutions, or blood products and antibiotics which are potentially irritating drugs. PICC lines are not more stable because of their location. There is no information to support that PICC lines are more cost-effective.

PICC lines have a high rate of infection.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.12 Discuss the data included in client education for the care and maintenance of vascular access devices.

Page Number: p. 1113

CHAPTER 30 1. The nurse observes a client while using the prescribed incentive spirometer. Which items will the nurse include when documenting this observation in the nursing notes?

Standard Text: Select all that apply.

1. Type of spirometer 2. Number of breaths taken 3. Education provided 4. Medications administered 5. Code status Correct Answer: 1, 2, 3 Rationale 1: When documenting the observation of a client using the prescribed incentive spirometer, the nurse will include the type of spirometer used.

Rationale 2: When documenting the observation of a client using the prescribed incentive spirometer, the nurse will include the number ofkberne.aths ta Rationale 3: When documenting the observation of a client using the prescribed incentive spirometer, the nurse will include any education that was provided to the client and family.

Rationale 4: Medication administration is not documented in the nursing notes, but in the medication administration record.

Rationale 5: The client’s code status is not relevant to this situation.

Global Rationale: When documenting the observation of a client using the prescribed incentive spirometer, the nurse will include the type of spirometer used, the number of breaths taken, and any education that was provided to the client and family. Medication administration is not documented in the nursing notes, but in the medication administration record. The client’s code status is not relevant to this situation.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: VI.B.4. Document and plan client care in an electronic health record AACN Essential Competencies: IV.5. Use standardized terminology in a care environment that reflects nursing’s unique contribution to client outcomes

NLN Competencies: Quality and Safety: Practice; Carefully maintain and use electronic and/or written health records Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30.4 Discuss the purpose of using an incentive spirometer.

Page Number: p. 1173 2. The nurse is caring for a client who had major abdominal surgery yesterday. Which assessment finding would indicate inadequate airway clearance that might be cleared with coughing and deep breathing?

1. Tachypnea with rales heard in the upper lobes and over the trachea 2. Bradypnea with wheezing heard throughout all lung fields 3. Tachypnea with wheezing heard throughout all lung fields 4. Tachypnea with rhonchi heard in the lower lobes Correct Answer: 1 Rationale 1: The client with inadequate airway clearance would most likely be found tachypneic, with rales in the upper lobes and over the trachea indicating secretions are high enough in the airway to clear with coughNinUgR. SINGT B.COM Rationale 2: Wheezing is heard with airway narrowing. It is unlikely that the client will have slow respirations.

Rationale 3: Wheezing is heard with airway narrowing.

Rationale 4: Rhonchi would be heard if the airway was narrowed from secretion collection in the smaller airways.

Global Rationale: The client with inadequate airway clearance would most likely be found tachypneic, with rales in the upper lobes and over the trachea indicating secretions are high enough in the airway to clear with coughing. Wheezing is heard with airway narrowing, whereas rhonchi would be heard if the airway was narrowed from secretion collection in the smaller airways. It is unlikely that the client will have slow respirations.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based

approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30.3 Describe the steps for teaching a client deep breathing and coughing exercises.

Page Number: p. 1172 3. Which teaching point is least likely to be included when instructing a client to perform breathing exercises?

1. Breathing in deeply through the nose with the mouth closed 2. Avoiding arching the back 3. Holding the breath for 30–40 seconds 4. Breathing out slowly Correct Answer: 3 Rationale 1: The client should be taught to breathe in through the nose.

Rationale 2: The client should be taught to avoid arching the back.

Rationale 3: The client should be taught to hold the breath for 3–5 seconds to help maintain open alveoli.

Rationale 4: The client should be taught to breathe out slowly through the mouth.

Global Rationale: The client should be taught to hold the breath for 3–5 seconds to help maintain open alveoli. The client should be taught to breathe in through the nose, avoid arching the back, and to breathe out slowly through the nose.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 30.3 Describe the steps for teaching a client deep breathing and coughing exercises.

Page Number: p. 1173

4. The nurse needs to deliver the highest concentration of oxygen (95% to 100%). Which type of oxygen delivery device should the nurse choose?

1. Face mask 2. Nasal cannula 3. Partial rebreather mask 4. Nonrebreather mask Correct Answer: 4 Rationale 1: Face masks deliver 40% to 60%.

Rationale 2: The nasal cannula delivers low oxygen concentrations (24% to 44%)., whereas face masks deliver 40% to 60%. The partial nonrebreather can deliver 40% to 60% oxygen.

Rationale 3: The partial nonrebreather can deliver 40% to 60% oxygen.

Rationale 4: The nonrebreather mask is used when high concentrations of oxygen are required (greater than 90%).

Global Rationale: The nonrebreather mask is used when high concentrations of oxygen are required (greater than 90%). The nasal cannula delivers low oxygen concentrations (24% to 44%), whereas face masks deliver 40% to 60%. The partial nonrebreather can deliver 40% to 60% oxygen.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 30.7 Differentiate modes of oxygen delivery and describe nursing care relevant to each mode.

Page Number: p. 1189 5. The nurse is caring for a 31-week premature infant requiring oxygen therapy after delivery. Which would be the most effective means of delivering oxygen?

1. Partial rebreather mask 2. Nonrebreather mask 3. Face mask 4. Oxygen hood Correct Answer: 4 Rationale 1: The infant will not usually allow placement of a mask of any type, and this is not an effective means of delivering oxygen to young children.

Rationale 2: The infant will not usually allow placement of a mask of any type, and this is not an effective means of delivering oxygen to young children.

Rationale 3: The infant will not usually allow placement of a mask of any type, and this is not an effective means of delivering oxygen to young children.

Rationale 4: Oxygen hoods allow placement over the child's face allowing uninterrupted delivery of oxygen.

Global Rationale: The infant will not usually allow placement of a mask of any type, and this is not an effective means of delivering o x y Ng eUnR tSoI NyGo Tu Bn .gC cOhMi l d r en . Infants might tolerate nasal cannulas if the tubing is secured using tape, but the older infant or toddler will usually attempt to pull it off. Oxygen hoods allow placement over the child's face allowing uninterrupted delivery of oxygen.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30.7 Differentiate modes of oxygen delivery and describe nursing care relevant to each mode.

Page Number: p. 1190 6. The client is started on 90% oxygen by nonrebreather mask at 0800. The nurse working the night shift assesses the client, who complains of substernal pain and dyspnea and has rales audible in the lower lung field bilaterally. Based on these assessment findings, what should the nurse suspect?

1. Myocardial hypoxia 2. Pulmonary emboli 3. Oxygen toxicity 4. Congestive heart failure Correct Answer: 3 Rationale 1: It is unlikely that the client is experiencing myocardial hypoxia.

Rationale 2: It is unlikely that the client is experiencing pulmonary emboli.

Rationale 3: Oxygen toxicity can develop as early as 12 hours after breathing high concentrations of oxygen, and is indicated by substernal pain, cough, sore throat, dyspnea, and pulmonary edema. Oxygen toxicity should be ruled out before assessing for other causes.

Rationale 4: It is unlikely that the client is experiencing congestive heart failure.

Global Rationale: Oxygen toxicity can develop as early as 12 hours after breathing high concentrations of oxygen, and is indicated by substernal pain, cough, sore throat, dyspnea, and pulmonary edema. Oxygen toxicity should be ruled out before assessing for myocardial hypoxia, pulmonary emboli, or congestive heart faNiUluRr Se.I N G T B . C O M Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30.7 Differentiate modes of oxygen delivery and describe nursing care relevant to each mode.

Page Number: p. 1183 7. The nurse is using a curved hard plastic tube to suction the client's oral cavity. Which term should the nurse use when referring to this piece of equipment?

1. Whistle-tipped catheter

2. Yankauer suction tube 3. Open-tipped catheter 4. Closed suctioning system Correct Answer: 2 Rationale 1: Whistle-tipped is a soft, pliable catheter.

Rationale 2: The Yankauer suction tube is a hard plastic device used for suctioning the client's oral cavity.

Rationale 3: An open-tipped catheter is soft and pliable.

Rationale 4: A closed suctioning system is an inline catheter covered by a plastic sheath.

Global Rationale: The Yankauer suction tube is a hard plastic device used for suctioning the client's oral cavity. Whistle-tipped and open-tipped catheters are soft, pliable catheters, and a closed suctioning system is an inline catheter covered by a plastic sheath.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and C o m foN rUt RSINGTB.COM QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30.12 Describe safety measures used when suctioning clients.

Page Number: p. 1198 8. The nurse is caring for a client who had oromaxillary surgery a few hours ago. The client is arousable, but is still sedated following anesthesia, and sleeps deeply when not disturbed. The client's respiratory effort is adequate, but the nurse notes the client is having issues maintaining an open airway when asleep. Which airway should the nurse choose for this client?

1. Oropharyngeal airway 2. Nasopharyngeal airway 3. Endotracheal tube 4. Tracheostomy

Correct Answer: 2 Rationale 1: Because this client had oromaxillary surgery, an oral airway would not be appropriate.

Rationale 2: Because this client had oromaxillary surgery, a nasopharyngeal airway would be the best choice.

Rationale 3: The client's respiratory effort is adequate, so there would be no need for the very invasive insertion of an endotracheal tube.

Rationale 4: The client's respiratory effort is adequate, so there would be no need for the very invasive insertion of a tracheostomy.

Global Rationale: Because this client had oromaxillary surgery, an oral airway would not be appropriate, so the best choice would be a nasopharyngeal airway. The client's respiratory effort is adequate, so there would be no need for the very invasive insertion of an endotracheal tube or tracheostomy.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 30.8 Differentiate various modes of airway maintenance.

Page Number: p. 1195 9. Which client would be in particular need of a closed airway suctioning system?

1. The client post-bone marrow transplant 2. The postoperative client 3. The client with a long-term tracheostomy on 25% oxygen via mask 4. The client with excessive oral secretions Correct Answer: 1

Rationale 1: The client who is post-bone marrow transplant has a reduced immune response, and would be at greatest risk if pathogens were introduced into the airway, so the closed system would be of particular importance with this client.

Rationale 2: The postoperative client does not have an immune system that is as depressed as the bone marrow client.

Rationale 3: Closed airway suctioning systems are usually used only with clients requiring mechanical ventilation, so they would not be appropriate for the client receiving oxygen via mask.

Rationale 4: Closed airway suctioning systems are usually used only with clients requiring mechanical ventilation, so they would not be appropriate for the client with excessive oral secretions.

Global Rationale: The client who is post-bone marrow transplant has a reduced immune response, and would be at greatest risk if pathogens were introduced into the airway, so the closed system would be of particular importance with this client. The postoperative client does not have an immune system that is as depressed as the bone marrow client. Closed airway suctioning systems are usually used only with clients requiring mechanical ventilation, so they would not be appropriate for the client receiving oxygen via mask or the client with excessive oral secretions.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 30.12 Describe safety measures used when suctioning clients.

Page Number: p. 1203 10. The nurse is caring for a client being weaned from the ventilator, and wants to improve the client's ability to communicate. Which item should the nurse request an order for from the health care provider?

1. Cuffed tracheostomy tube 2. Uncuffed tracheostomy tube 3. Fenestrated tracheostomy tube

4. Obturator Correct Answer: 3 Rationale 1: The cuffed tracheostomy would need to be deflated in order for the fenestrated tube to function.

Rationale 2: An uncuffed tube does not improve communication.

Rationale 3: The fenestrated tracheostomy tube allows clients to speak, and could be safely used on the client who is being weaned from the ventilator.

Rationale 4: An obturator is used to make the tracheostomy tube more rigid during insertion, and must be removed as soon as the tube is in place, because it occludes the airway.

Global Rationale: The fenestrated tracheostomy tube allows clients to speak, and could be safely used on the client who is being weaned from the ventilator. The cuffed tracheostomy would need to be deflated in order for the fenestrated tube to function. An uncuffed tube does not improve communication. An obturator is used to make the tracheostomy tube more rigid during insertion, and must be removed as soon as the tube is in place, because it occludes the airway.

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 30.10 Describe the nursing actions included in tracheostomy care.

Page Number: p. 1212 11. The nurse is performing tracheostomy care. Which portion of the trach should the nurse use when tying the new trach ties?

1. Inner cannula 2. Outer cannula 3. Obturator 4. Flange

Correct Answer: 4 Rationale 1: The trach ties do not attach to the inner cannula.

Rationale 2: The trach ties do not attach to the outer cannula.

Rationale 3: The trach ties do not attach to the obturator.

Rationale 4: The trach ties attach to the flange.

Global Rationale: The trach ties attach to the flange. The trach ties do not attach to the inner cannula, inner cannula, or the obturator.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30.10 Describe the nursing actions included in tracheostomy care.

Page Number: p. 1211 12. The nurse is caring for a client with a longstanding permanent tracheostomy that has been in place for several years in order to provide mechanical ventilation. Which type of tracheostomy should the nurse anticipate this client may have based on the health history?

1. Uncuffed tracheostomy 2. Cuffed tracheostomy 3. Fenestrated tracheostomy 4. Uncuffed or fenestrated tracheostomy Correct Answer: 2 Rationale 1: The client with a long-term tracheostomy who does not require mechanical ventilation would be likely to have an uncuffed tube.

Rationale 2: Cuffed tracheostomy tubes are essential when the client requires mechanical ventilation because they provide a seal so that air does not leak when the ventilator provides a breath.

Rationale 3: It is unlikely that a fenestrated tracheostomy tube will be used.

Rationale 4: Both uncuffed and fenestrated tracheostomies would not be indicated for this client.

Global Rationale: Cuffed tracheostomy tubes are essential when the client requires mechanical ventilation because they provide a seal so that air does not leak when the ventilator provides a breath. The client with a long-term tracheostomy who does not require mechanical ventilation would be likely to have an uncuffed or fenestrated tube.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and int eNrvUeRnStiI oNnGsT B . C O M Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30.8 Differentiate various modes of airway maintenance.

Page Number: p. 1198 13. The nurse is caring for a client who has a small pneumothorax and is capable of being ambulatory. Which prescription should the nurse anticipate when caring for this client?

1. Chest tube placed in the upper chest on the side of the pneumothorax 2. Chest tube placed in the lower chest on the side of the pneumothorax 3. Heimlich chest drain valve in the upper chest on the side of the pneumothorax 4. Heimlich chest drain valve in the lower chest on the side of the pneumothorax Correct Answer: 3 Rationale 1: Placement of the chest tube would be lower in the chest because blood falls to the lowest point secondary to gravity.

Rationale 2: Because air rises, the chest drain would be placed in the upper chest.

Rationale 3: Because air rises, the chest drain would be placed in the upper chest. Because the client is ambulatory and the pneumothorax is small, a Heimlich chest drain valve could be used to allow the client to move about more easily.

Rationale 4: Because air rises, the chest drain would be placed in the upper chest.

Global Rationale: Because air rises, the chest drain would be placed in the upper chest. Because the client is ambulatory and the pneumothorax is small, a Heimlich chest drain valve could be used to allow the client to move about more easily. The valve would not be used if the client had a hemothorax, and placement of the chest tube would be lower in the chest because blood falls to the lowest point secondary to gravity.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: NursingNPUrRoSceINssG: TPBl.aCnOnM ing Learning Outcome: 30.13 List measures to promote safe, effective care for clients with chest tubes.

Page Number: p. 1218 14. When caring for a client with a chest tube in place, the nurse maintains safety by keeping which items at the client's bedside at all times?

1. Bag and mask with oxygen supply 2. Two rubber-tipped clamps, gauze, and petroleum gauze 3. Emergency phone numbers 4. An extra chest tube of the same size inserted into the client Correct Answer: 2 Rationale 1: A bag and mask should be kept at the bedside of any client with respiratory disorders.

Rationale 2: Two rubber-tipped clamps should be kept at the bedside in case the tube requires rapid clamping to prevent air from entering the pleural space. Gauze and petroleum gauze are kept close by to create an airtight seal should the chest tube accidentally be dislodged.

Rationale 3: Emergency phone numbers should be written on all facility phones.

Rationale 4: There would be no need to keep an extra chest tube at the bedside, because there would be time to obtain this while waiting for the health care provider to arrive.

Global Rationale: Two rubber-tipped clamps should be kept at the bedside in case the tube requires rapid clamping to prevent air from entering the pleural space. Gauze and petroleum gauze are kept close by to create an airtight seal should the chest tube accidentally be dislodged. A bag and mask should be kept at the bedside of any client with respiratory disorders.

Emergency phone numbers should be written on all facility phones. There would be no need to keep an extra chest tube at the bedside, because there would be time to obtain this while waiting for the health care provider to arrive.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management aNcUroRsSsINthGeThBe.aClOthM-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 30.13 List measures to promote safe, effective care for clients with chest tubes.

Page Number: pp. 1217, 1219 15. When assisting the health care provider with removal of the chest tube, which instruction should the nurse provide to the client during this procedure?

1. Breathe normally 2. Hold still 3. Hold breath 4. Cough Correct Answer: 3 Rationale 1: Breathing normally would not be advised.

Rationale 2: The client needs to do more than hold still.

Rationale 3: The client should be instructed to hold his breath to prevent air from leaking into the pleural space while the tube is removed until an airtight seal can be applied using petroleum gauze.

Rationale 4: Coughing would not be advised.

Global Rationale: The client should be instructed to hold his breath to prevent air from leaking into the pleural space while the tube is removed until an airtight seal can be applied using petroleum gauze.

Breathing normally and coughing would not be advised. The client needs to do more than hold still.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation N U RS I N GT B . C O M Learning Outcome: 30.13 List m e a s u r e s t o p r o m o t e s a f e , effective care for clients with chest tubes.

Page Number: p. 1219 16. The nurse is instructing a client on the use of a peak flow meter. In which order should the nurse provide these instructions?

1. Inhale deeply 2. Clean the unit 3. Slide the indicator to zero 4. Blow out through the mouth 5. Attach mouthpiece to the meter Correct Answer: 5, 3, 1, 4, 2 Rationale 1: The client should be instructed to inhale deeply. Rationale 2: The unit should be cleaned weekly.

Rationale 3: Then the slide indicator should be placed on zero.

Rationale 4: The client should then blow out through the mouth as hard and fast as possible. Rationale 5: The client should be first instructed to attach the mouthpiece to the meter.

Global Rationale: The client should be first instructed to attach the mouthpiece to the meter. Then the slide indicator should be placed on zero. The client should be instructed to inhale deeply. The client should then blow out through the mouth as hard and fast as possible. The unit should be cleaned weekly.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 30.5 Describe the steps for peak flow measurement.

Page Number: pp. 1174-1175 17. The nurse is assisting a client with postural drainage. What should be included when explaining the process to the client? Select all that apply.

1. Expectorate secretions 2. Return to a sitting position slowly 3. Remain in each position for 3 to 15 minutes 4. Take a deep breath between position changes 5. The head of the bed will be in the flat position Correct Answer: 1, 2, 3, 4 Rationale 1: The client should be instructed to expectorate secretions.

Rationale 2: The client should be instructed to slowly return to a seated position. Rationale 3: The client should be instructed to remain in each position for 3 to 15 minutes.

Rationale 4: The client should be instructed to take a deep breath between position changes.

Rationale 5: The client should be instructed that the head of the bed will be in a downward angle.

Global Rationale: The client should be instructed to expectorate secretions, slowly return to a seated position, remain in each position for 3 to 15 minutes, and take a deep breath between position changes.

The client should be instructed that the head of the bed will be in a downward angle.

Cognitive Level: Applying

Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 30.6 Describe positions for postural drainage and chest percussion and vibration.

Page Number: p. 1219

CHAPTER 31 1. Which action by the nurse is appropriate when testing for Homans’ sign?

1. Pointing the client’s toes down 2. Having the client point the toes up toward the calf 3. Flexing the client’s toes as wide apart as possible 4. Rotating the client’s foot Correct Answer: 2 Rationale 1: Homans’ sign is tested when the client dorsiflexes the foot.

Rationale 2: Homans’ sign is tested when the client dorsiflexes the foot. It is considered positive if the client reports deep pain with this movement. But because it is positive in less than 50% of cases it is not frequently used.

Rationale 3: Homans’ sign is tested when the client dorsiflexes the foot.

Rationale 4: Homans’ sign is tested when the client dorsiflexes the foot.

Global Rationale: Homans’ sign is tested when the client dorsiflexes the foot. It is considered positive if the client reports deep pain with this movement. But because it is positive in less than 50% of cases it is not frequently used.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.6 Define the term ischemia.

Page Number: p. 1234 2. Which health problems are classified as venous thromboembolisms?

Standard Text: Select all that apply.

1. Deep vein thrombosis 2. Pulmonary embolism 3. Coronary artery thrombosis 4. Myocardial infarction 5. Aortic aneurysm Correct Answer: 1, 2 Rationale 1: Deep vein thrombosis is classified as a venous thromboembolism.

Rationale 2: Pulmonary embolism is classified as a venous thromboembolism.

Rationale 3: A coronary artery thrombosis is an arterial thromboembolism, not a venous thromboembolism.

Rationale 4: A myocardial infarction is the damage or death of heart muscle from the sudden blockage of the coronary artery by a blood clot.

Rationale 5: Aortic aneurysm is not a thromboembolism but a weakening of the aortic artery.

Global Rationale: Deep vein thrombosis and pulmonary embolism are both classified as venous thromboembolisms. A coronary artery thrombosis is an arterial thromboembolism, not a venous thromboembolism. Aortic aneurysm is not a thromboembolism but a weakening of the aortic artery. A myocardial infarction is the damage or death of heart muscle from the sudden blockage of the coronary artery by a blood clot.

Cognitive Level: Remembering Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.10 List at least four potential problems for clients requiring CPR and two suggested interventions for each problem..

Page Number: p. 1233 3. A client scheduled for surgery has a history of venous stasis problems. Which strategies should the nurse consider to reduce the risk of postoperative venous stasis?

Standard Text: Select all that apply.

1. Pneumatic compression device 2. Sequential compression device 3. Antiembolism stockings 4. Getting the client out of bed as soon as possible 5. Keeping the legs lower than the level of the heart Correct Answer: 1, 2, 3, 4 Rationale 1: Pneumatic compression devices help to compress the legs, improving venous return to the heart.

Rationale 2: Sequential compression devices help to compress the legs, improving venous return to the heart.

Rationale 3: Antiembolism stockings exert external pressure to compress the veins of the legs, decrease venous pooling in the extremities, and facilitate return of blood to the heart.

Rationale 4: Getting the client out of b e Nd Ua Rs Ss IoNoGn TaBs . Cp Oo sMs i b l e contributes to improving venous return by exercising the muscles, which squeeze the veins and improves blood return.

Rationale 5: Lowering the legs below the level of the heart would increase venous stasis, whereas elevating the legs will improve venous return.

Global Rationale: Pneumatic and sequential compression devices help to compress the legs, improving venous return to the heart. Antiembolism stockings exert external pressure to compress the veins of the legs, decrease venous pooling in the extremities, and facilitate return of blood to the heart. Getting the client out of bed as soon as possible contributes to improving venous return by exercising the muscles, which squeeze the veins and improves blood return.

Lowering the legs below the level of the heart would increase venous stasis, whereas elevating the legs will improve venous return.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 31.9 Describe how to measure for appropriate size graduated compression stockings.

Page Number: p. 1233 4. The nurse could safely delegate which task to the unlicensed assistive personnel (UAP)?

1. Removal of antiemboli stockings to wash the feet and legs, then reapply the stockings 2. Assessing the client's circulation to the feet every 4 hours while wearing antiembolism stockings 3. Evaluating for presence of Homans' sign 4. Measuring and fitting the client for antiembolism stockings Correct Answer: 1 Rationale 1: The UAP can safely remove and reapply antiemboli stockings.

Rationale 2: Only the nurse can assess.

Rationale 3: Only the nurse can evaluateN.URSINGTB.COM Rationale 4: It is best if the nurse measures the client and applies the antiembolism stockings for the first time to assure a proper fit.

Global Rationale: The UAP can safely remove and reapply antiemboli stockings. Only the nurse can assess and evaluate. It is best if the nurse measures the client and applies the antiembolism stockings for the first time to assure a proper fit.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Practice; Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 31.9 Describe how to measure for appropriate size graduated compression stockings.

Page Number: p. 1276

5. Which action by the nurse is least appropriate when applying antiemboli stockings?

1. Assisting the client to a lying position in bed 2. Turning the stocking right-side-out 3. Washing and drying the legs 4. Having the client point the toes Correct Answer: 2 Rationale 1: The client should be lying in bed.

Rationale 2: The nurse would turn the stockings right-side-out after pulling them over the ankle, so this step is done after beginning the application process, not before.

Rationale 3: The legs should be washed and dried.

Rationale 4: The client should point the toes.

Global Rationale: The nurse would turn the stockings right-side-out after pulling them over the ankle, so this step is done after beginning the application process, not before. The client should be lying in bed with pointing the toes. The legs should be washed and dried.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31.9 Describe how to measure for appropriate size graduated compression stockings.

Page Number: p. 1242

6. After fitting the sleeve of the sequential compression device onto the client's legs, which action should the nurse take next?

1. Documenting the procedure 2. Turning the machine on 3. Connecting the sleeve to the control unit 4. Adjusting the alarms Correct Answer: 3 Rationale 1: After the unit begins to cycle, the nurse should document the application of the device.

Rationale 2: Once the sleeves are in place, the tubing should be connected, the alarms set, and then the unit can be turned on.

Rationale 3: The sleeves should be placed before connecting to the unit to prevent kinking of the tubing.

Rationale 4: Once the sleeves are in place, the tubing should be connected, the alarms set, and then the unit can be turned on.

Global Rationale: The sleeves should be placed before connecting to the unit to prevent kinking of the tubing. Once the sleeves are in place, the tubing should be connected, the alarms set, and then the unit can be turned on. After the unit begins to cycle, the nurse should document the application of the device.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31.9 Describe how to measure for appropriate size graduated compression stockings.

Page Number: p. 1244 7. Which finding should the nurse report to the health care provider as soon as possible?

1. After beginning sequential compression device application, the client's toes are found to be cool to the touch and mottled, with absent pedal pulses.

2. After applying antiemboli stockings, the client says the stockings feel snug.

3. When applying antiemboli stockings, the nurse finds they are too small for this client.

4. The client asks the nurse to wait to apply the antiembolism stockings until after breakfast.

Correct Answer: 1 Rationale 1: If the client's toes become cool to the touch and mottled in appearance, and the pedal pulse disappears, the nurse should remove the compression device and notify the health care provider immediately. If the toes return to a normal appearance after discontinuation of the device, the health care provider should be notified, perhaps not immediately but as soon as possible, to explain what occurred when the device was turned on.

Rationale 2: The stockings are supposed to be snug, so this would be a normal finding.

Rationale 3: If the stockings are too small, the nurse would return those stockings and order a larger size.

Rationale 4: Whenever possible, try to apply the stockings before the client gets out of bed, but waiting until after breakfast would be a c Nc eUpRt aS bI Nl eG, TaBn .dC Oc eMr t a i n l y would not require health care provider notification.

Global Rationale: If the client's toes become cool to the touch and mottled in appearance, and the pedal pulse disappears, the nurse should remove the compression device and notify the health care provider immediately. If the toes return to a normal appearance after discontinuation of the device, the health care provider should be notified, perhaps not immediately but as soon as possible, to explain what occurred when the device was turned on. The stockings are supposed to be snug, so this would be a normal finding.

If the stockings are too small, the nurse would return those stockings and order a larger size. Whenever possible, try to apply the stockings before the client gets out of bed, but waiting until after breakfast would be acceptable, and certainly would not require health care provider notification.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: VI.B.4. Document and plan client care in an electronic health record AACN Essential Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network NLN Competencies: Quality and Safety: Practice; Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31.9 Describe how to measure for appropriate size graduated compression stockings.

Page Number: p. 1246 8. The nurse on a medical–surgical unit is caring for a client who complains of chest pain. Assessment findings include a blood pressure of 72/40, pulse rate of 40, and respiratory rate of 32. Which action by the nurse is the priority in this situation?

1. Calling a code 2. Calling the rapid response team 3. Calling the client's primary health care provider 4. Calling the emergency department (ED) and requesting they send a health care provider Correct Answer: 2 Rationale 1: The client is still breathing, so the nurse would not call a code.

Rationale 2: Because the client is in distress, the rapid response team should be assembled.

Rationale 3: Only after calling for the raNpUidRSreINspGoTnBs.eCtOeM am would the primary care provider be notified.

Rationale 4: The emergency department health care provider is generally busy with clients, and cannot respond to clients admitted to the hospital in most facilities.

Global Rationale: The client is still breathing, so the nurse would not call a code, but because the client is in distress, the rapid response team should be assembled. Only after calling for the rapid response team would the primary care provider be notified. The emergency department health care provider is generally busy with clients, and cannot respond to clients admitted to the hospital in most facilities.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality AACN Essential Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31.10 List at least four potential problems for clients requiring CPR and two suggested interventions for each problem.

Page Number: p. 1266 9. For which client would the rapid response team be least indicated?

1. Asthmatic client with a respiratory rate greater than 30 breaths per minute, oxygen saturation of 84%, and a heart rate of 142 beats per minute 2. A client with no history of seizures who has a sudden change in mentation and has a seizure 3. A client who suddenly begins to talk with difficulty and is not able to move the left arm and leg 4. The client with a history of angina who has a PRN order for nitroglycerin who reports crushing chest pain Correct Answer: 4 Rationale 1: The rapid response team should be called for the client with an acute asthma attack.

Rationale 2: The rapid response team should be called for a client with a new onset of seizures.

Rationale 3: The rapid response team should be called for a client demonstrating manifestations of a stroke.

Rationale 4: The client with a history of angina with a PRN order for nitroglycerin should be administered the medication, and the rapid response team would be called only if the drug were not effective in resolving the pain.

Global Rationale: The client with a history of angina with a PRN order for nitroglycerin should be administered the medication, and the rapid response team would be called only if the drug were not effective in resolving the pain. The rapid response team should be called for a client with an acute asthma attack, new onset of seizures, or experiencing a stroke.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality AACN Essential Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31.10 List at least four potential problems for clients requiring CPR and two suggested interventions for each problem.

Page Number: p. 1266

10. The nurse finds a client pulseless and not breathing. What tasks could the nurse safely assign to the unlicensed assistive personnel (UAP) in this situation?

Standard Text: Select all that apply.

1. Perform chest compressions.

2. Get the crash cart.

3. Call a code blue.

4. Administer emergency medications.

5. Bag the client using a bag-valve mask until the doctor arrives to intubate the client.

Correct Answer: 1, 2, 3, 5 Rationale 1: UAPs can be very helpful during a code, and can perform chest compressions if they are CPR-certified (generally a requirement of employment).

Rationale 2: The UAP could obtain the crash cart.

Rationale 3: The UAP could call a code.

Rationale 4: Medication administration can be performed only by the nurse.

Rationale 5: The UAP could bag the client if CPR-certified.

Global Rationale: UAPs can be very helpful during a code, and can perform chest compressions if they are CPR-certified (generally a requirement of employment). The UAP could obtain the crash cart, call a code, or bag the client if she were CPR-certified. Medication administration can be performed only by the nurse.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Practice; Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 31.11 Outline the steps in administering CPR with one rescuer and with two rescuers.

Page Number: p. 1276

11. While working on the orthopedic unit, the nurse finds an assigned client pulseless and not breathing. When the code team responds, which action by the nurse is appropriate?

1. Leaving the room and calling the family members to notify them of the sudden change in the client's condition 2. Getting the crash cart and emergency supplies that will be needed by the code team 3. Participating in the code in whatever role is necessary 4. Standing at the bedside and answering questions as they arise Correct Answer: 3 Rationale 1: The assigned nurse should not leave the room.

Rationale 2: Someone else can obtain the crash cart.

Rationale 3: Although the nurse assigned to the client needs to remain in the room and be available to provide a summary of the client's condition, the nurse can take a role as the medication nurse or perform CPR. Rationale 4: The nurse can do more than answer questions.

Global Rationale: Although the nurse assigned to the client needs to remain in the room and be available to provide a summary of the client's condition, the nurse can take a role as the medication nurse or perform CPR. The assigned nurse should not leave the room, and should have someone else, such as the chaplain or social worker, call the family and obtain the crash cart. The nurse can do more than answer questions.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care team AACN Essential Competencies: VII.9.Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations NLN Competencies: Teamwork: Practice; Function competently within one's own scope of practice as leader or member of the health care team Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31.11 Outline the steps in administering CPR with one rescuer and with two rescuers.

Page Number: p. 1267

12. The nurse is caring for a conscious adult client with an obstructed airway. When performing abdominal thrusts, which action by the nurse is appropriate?

1. Making a fist with one hand, with the thumb on top, and placing the thumb just below the xiphoid process 2. Using the side of the hand and placing it just above the xiphoid process 3. Grasping the fist with the other hand and placing the flat of the hand into the client's abdomen 4. Making a fist with one hand, tucking the thumb inside the fist, grasping the hand with the other fist, and pushing the fist above the victim's navel and below the xiphoid process Correct Answer: 4 Rationale 1: This would injure the client, and demonstrate incorrect technique.

Rationale 2: This would injure the client, and demonstrate incorrect technique.

Rationale 3: This would injure the client, and demonstrate incorrect technique.

Rationale 4: The nurse should make a fist with one hand and tuck the thumb inside the fist to avoid injuring the client. The other hand grasps the fist, which is pushed into the abdomen above the navel and below the xiphoid process.

Global Rationale: The nurse should make a fist with one hand and tuck the thumb inside the fist to avoid injuring the client. The other hand grasps the fist, which is pushed into the abdomen above the navel and below the xiphoid process. The other options would injure the client, and demonstrate incorrect technique.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31.12 Demonstrate performing the abdominal thrust. Page Number: p.

1265 13. When performing rescue breathing in a hospital, which is the preferred method for the nurse to use until the health care provider arrives to intubate the client?

1. Mouth-to-mouth 2. Mouth-to-mask 3. Bag-valve-mask method 4. The jaw-thrust maneuver Correct Answer: 3 Rationale 1: Mouth-to-mouth can be used if the bag-valve-mask device and/or airway is not available.

Rationale 2: Mouth-to-mask can be used if the bag-valve-mask device and/or airway is not available.

Rationale 3: The method preferred in the hospital would be using a bag-valve-mask device after placing an oropharyngeal airway to maintain an open airway.

Rationale 4: The jaw thrust maneuver is used to open the airway.

Global Rationale: The method preferred in the hospital would be using a bag-valve-mask device after placing an oropharyngeal airway to maintain an open airway. Mouth-to-mouth and mouth-to-mask can be used if the bag-v aNl vUeR- SmINasGkTdBe.CvO icM e and/or airway is not available. The jaw thrust maneuver is used to open the airway.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31.11 Outline the steps in administering CPR with one rescuer and with two rescuers.

Page Number: p. 1263 14. The nurse is attending a football game when another spectator reports chest pain and collapses. The nurse assesses the client and finds he is pulseless and not breathing. After the nurse calls for help, someone brings an AED. Which action by the nurse is the most appropriate?

1. Not using the device, because it needs to be plugged in and there is no electricity

2. Turning the machine on, placing the patches, and then plugging in the cable 3. Connecting the cables, placing the patches, and then turning on the machine 4. Placing the patches, turning on the machine, and then plugging in the cable Correct Answer: 2 Rationale 1: The machine should be turned on and then the patches should be placed. Only after the patches are in place and the nurse has assured that no one is touching the client should the cable be plugged into the machine. The machine will begin analyzing the rhythm and deliver a shock as soon as the cables are connected.

Rationale 2: The machine should be turned on and then the patches should be placed. Only after the patches are in place and the nurse has assured that no one is touching the client should the cable be plugged into the machine. The machine will begin analyzing the rhythm and deliver a shock as soon as the cables are connected.

Rationale 3: The machine should be turned on and then the patches should be placed. Only after the patches are in place and the nurse has assured that no one is touching the client should the cable be plugged into the machine. The machine will begin analyzing the rhythm and deliver a shock as soon as the cables are connected.

Rationale 4: The machine should be t u r nNeUdRoS nI NaGnTdBt.hCeOnMt h e patches should be placed. Only after the patches are in place and the nurse has assured that no one is touching the client should the cable be plugged into the machine. The machine will begin analyzing the rhythm and deliver a shock as soon as the cables are connected.

Global Rationale: The machine should be turned on and then the patches should be placed. Only after the patches are in place and the nurse has assured that no one is touching the client should the cable be plugged into the machine. The machine will begin analyzing the rhythm and deliver a shock as soon as the cables are connected.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31.13 Describe four steps in using the automatic external defibrillator (AED).

Page Number: p. 1263

15. The nurse is preparing to document care provided to a client who received rescue breathing while being transported to radiology. What should the nurse include in the documentation for this client?

Standard Text: Select all that apply.

1. Date and time of event 2. Factors that precipitated the event 3. Length of time with no breathing 4. Response to rescue breathing 5. Tasks assigned to the unlicensed assistive personnel Correct Answer: 1, 2, 3, 4 Rationale 1: When documenting this event in the medical record, the nurse will include the date and time the event occurred.

Rationale 2: When documenting this e v Ne nUt Ri Sn I Nt hGe TmB .eCdOi cMa l record, the nurse will include any factors that precipitated the event.

Rationale 3: When documenting this event in the medical record, the nurse will include the length of time that the client was not breathing.

Rationale 4: When documenting this event in the medical record, the nurse will include the client’s response to rescue breathing.

Rationale 5: It is unnecessary to document the tasks that were assigned to the unlicensed assistive personnel during this event.

Global Rationale: When documenting this event in the medical record, the nurse will include the date and time the event occurred, any factors that precipitated the event, the length of time that the client was not breathing, and the client’s response to rescue breathing. It is unnecessary to document the tasks that were assigned to the unlicensed assistive personnel during this event.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: VI.B.4. Document and plan client care in an electronic health record AACN Essential Competencies: IV.5. Use standardized terminology in a care environment that reflects nursing’s unique contribution to client outcomes

NLN Competencies: Quality and Safety: Practice; Carefully maintain and use electronic and/or written health records Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31.11 Outline the steps in administering CPR with one rescuer and with two rescuers.

Page Number: p. 1267 16. The nurse places lead aVR on a client. What tracing will this lead produce?

1. Activity between the center of the heart and left arm 2. Activity between the center of the heart and right arm 3. Activity between the center of the heart and the fourth ICS 4. Activity between the center of the heart and the left leg or foot Correct Answer: 2 Rationale 1: Lead aVL records activity between the center of the heart and left arm. Rationale 2: Lead aVR records activity between the center of the heart and right arm. Rationale 3: V1 records activity between the center of the heart and the fourth ICS. Rationale 4: Lead aVF records activity between the center of the heart and the left leg or foot.

Global Rationale: Lead aVR records a c t iNv Ui t Ry SbI eNt GwTeBe .nC Ot hMe center of the heart and right arm. Lead aVL records activity between the center of the heart and left arm. V1 records activity between the center of the heart and the fourth ICS. Lead aVF records activity between the center of the heart and the left leg or foot.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 31.16 Describe lead placement for a 12-lead ECG. Page Number: p. 1254 17. A client is newly diagnosed with heart failure. Which interventions should the nurse prepare to provide this client? Select all that apply.

1. Bed rest

2. Elevate legs 3. Oxygen therapy 4. Fluid restriction 5. Low sodium diet Correct Answer: 1, 3, 4, 5 Rationale 1: Bed rest during the most critical time may be ordered to reduce the workload on the heart.

Rationale 2: Elevating the legs is not routinely prescribed for a client with heart failure. Rationale 3: Oxygen therapy is essential to maximize the oxygen available to the tissues. Rationale 4: Fluids are restricted to decrease fluid volume and edema.

Rationale 5: Low sodium diet is prescribed to decrease fluid volume and edema.

Global Rationale: Bed rest during the most critical time may be ordered to reduce the workload on the heart. Oxygen therapy is essential to maximize the oxygen available to the tissues, as well as both reduced sodium intake and restricted fluid intake to decrease fluid volume and edema.

Elevating the legs is not routinely prescribed for a client with heart failure.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 31.5 Identify two interventions for treating heart failure.

Page Number: p. 1233

CHAPTER 32 1. During an assessment the nurse suspects that a client is experiencing a disorder of the cerebellum. What did the nurse assess to make this clinical determination?

1. Tremors 2. Auditory hallucinations 3. Loss of short-term memory 4. Poor hand-eye coordination Correct Answer: 1 Rationale 1: One dysfunctional behavior caused by the cerebellum is tremors. Rationale 2: A dysfunction in the temporal lobe can cause auditory hallucination. Rationale 3: A dysfunction in the temporal lobe can cause short-term memory loss. Rationale 4: A dysfunction in the parietal lobe can cause poor hand-eye coordination.

Global Rationale: One dysfunctional behavior caused by the cerebellum is tremors. A dysfunction in the temporal lobe can cause auditory hallucination or short-term memory loss. A dysfunction in the parietal lobe can cause poor hand-eye coordination.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.1 Review the structure and function of the cerebrum, cerebellum, and brainstem.

Page Number: p. 1283 2. The nurse is caring for clients on a medical-surgical care area. Which client observation should the nurse suspect is being caused by a metabolic disorder?

1. New onset of confusion 2. Poor appetite for breakfast 3. Pain rated as a 5 on a scale from 0 to 10 4. Increased sputum production in the morning Correct Answer: 1

Rationale 1: Alterations in level of consciousness reflect cerebral and metabolic disorders very quickly.

Rationale 2: A poor appetite is not necessarily caused by a metabolic disorder. Rationale 3: Pain is not necessarily caused by a metabolic disorder.

Rationale 4: Sputum production is not necessarily caused by a metabolic disorder.

Global Rationale: Alterations in level of consciousness reflect cerebral and metabolic disorders very quickly.

Poor appetite, pain, and sputum production are not necessarily caused by a metabolic disorder.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.2 Describe the unique metabolic demands of the central nervous system. Page Number: p. 1289 3. A client, recovering from a motor vehicle crash, has no damage to the neurologic system despite being thrown from the car. What anatomical feature most likely protected this client’s neurologic system?

1. Cervical vertebrae 2. Cerebrospinal fluid 3. Intervertebral cartilage 4. Thoracic and lumbar spinal curves Correct Answer: 2 Rationale 1: The cervical vertebrae are delicate structures that could have been severely injured in the accident.

Rationale 2: The brain is protected by cerebrospinal fluid (CSF), which circulates within the subarachnoid space to provide protective shock absorption.

Rationale 3: Intervertebral cartilage maintains the spinal structure. It is unlikely that the cartilage protected the client’s neurologic system.

Rationale 4: The thoracic and lumbar spinal curves are normal anatomical features and most likely did not help protect the client’s neurologic system.

Global Rationale: The brain is protected by cerebrospinal fluid (CSF), which circulates within the subarachnoid space to provide protective shock absorption. The cervical vertebrae are delicate structures that could have been severely injured in the accident. Intervertebral cartilage maintains the spinal structure. It is unlikely that the cartilage protected the client’s neurologic system. The thoracic and lumbar spinal curves are normal anatomical features and most likely did not help protect the client’s neurologic system.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.3 Outline the role of structures that protect the brain. Page Number: p. 1284 4. A client’s blood pressure is 180/120 mm Hg. How will the client’s neurologic system adapt to this increase in blood pressure?

1. Arteries in the brain dilate 2. Cerebrospinal fluid increases 3. Arteries in the brain constrict 4. Cerebrospinal fluid decreases Correct Answer: 3 Rationale 1: The brain has autoregulation, meaning it is able to regulate its own blood flow by arteriolar dilation when blood pressure falls.

Rationale 2: Cerebrospinal fluid production is not altered by blood pressure.

Rationale 3: The brain has autoregulation, meaning it is able to regulate its own blood flow by arteriolar constriction when blood pressure rises.

Rationale 4: Cerebrospinal fluid production is not altered by blood pressure.

Global Rationale: The brain has autoregulation, meaning it is able to regulate its own blood flow by arteriolar dilation when blood pressure falls or constriction when blood pressure rises.

Cerebrospinal fluid production is not altered by blood pressure.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.4 Discuss the brain’s ability to autoregulate cerebral blood flow. Page Number: p. 1284 5. A client recovering from a head injury has a blood pressure of 158/90 mm Hg and an intracranial pressure reading of 17 mm Hg. What is this client’s cerebral perfusion pressure?

Correct answer: 35.6 NP UP R)SIiN Rationale: Cerebral perfusion pressure (C sG caTlBc.uClO atM ed by subtracting the intracranial pressure (ICP) from the MAP (MAP - ICP = CPP). Mean arterial pressure is calculated by the equation 1/3(SBPDBP)+DBP = MAP. For this situation first calculate MAP: 1/3 (158-90) + 90 = 1/3 (158) = 52.6. Then use the equation MAP – ICP or 52.6 – 17 = 35.6.

Global Rationale: Cerebral perfusion pressure (CPP) is calculated by subtracting the intracranial pressure (ICP) from the MAP (MAP - ICP = CPP). Mean arterial pressure is calculated by the equation 1/3(SBP-DBP)+DBP = MAP. For this situation first calculate MAP: 1/3 (158-90) + 90 = 1/3 (158) = 52.6. Then use the equation MAP – ICP or 52.6 – 17 = 35.6.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.5 Calculate cerebral perfusion pressure (CPP) based on available data: mean arterial pressure (MAP) and intracranial pressure (ICP).

Page Number: p. 1285 6. The nurse is concerned that a client is experiencing an increase in intracranial pressure. Which anatomical structures most likely are affecting this pressure? Select all that apply.

1. Brain tissue 2. Lymph drainage 3. Venous integrity 4. Cerebrospinal fluid 5. Cerebral blood volume Correct Answer: 1, 4, 5 Rationale 1: Intracranial pressure is dictated by brain tissue, cerebral blood volume and cerebrospinal fluid.

Rationale 2: Intracranial pressure is not dictated by lymph drainage.

Rationale 3: Intracranial pressure is not dictated by venous integrity.

Rationale 4: Intracranial pressure is dictated by brain tissue, cerebral blood volume and cerebrospinal fluid.

Rationale 5: Intracranial pressure is dictated by brain tissue, cerebral blood volume and cerebrospinal fluid.

Global Rationale: Intracranial pressure is dictated by brain tissue, cerebral blood volume and cerebrospinal fluid. Intracranial pressure is not dictated by lymph drainage or venous integrity.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.6 Identify the three components that dictate intracranial pressure. Page Number: p. 1285 7. A client is demonstrating manifestations of increased intracranial pressure. Which finding supports that this increased pressure is being caused by an increase in brain tissue?

1. Oxygen saturation 86% 2. Mass in the parietal lobe

3. Subarachnoid hemorrhage 4. Fractured thoracic vertebrae Correct Answer: 2 Rationale 1: An increase in cerebral blood flow occurs with cerebral vasodilation due to hypoxemia.

Rationale 2: An increase in brain tissue occurs with a mass such as a tumor.

Rationale 3: An increase in cerebral blood flow occurs with a subarachnoid hemorrhage.

Rationale 4: An increase in CSF occurs with blockage of its outflow paths as could be caused by fractured vertebrae.

Global Rationale: An increase in brain tissue occurs with a mass such as a tumor. An increase in cerebral blood flow occurs in cerebral vasodilation due to hypoxemia or with a subarachnoid hemorrhage. An increase in CSF occurs with blockage of its outflow paths as could be caused by fractured vertebrae.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I. A. 1. Integrate uNnUd eRrSsItNa nGdTiBn.gC Oo M f mu lt ip le dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.7 List physical and environmental or contextual factors that increase intracranial pressure.

Page Number: p. 1285 8. A client has a history of normal pressure hydrocephaly. What physiological function most likely occurs to maintain this client’s intracranial pressure within normal limits? Select all that apply.

1. Displacing of brain tissue 2. Administer osmotic diuretics 3. Reducing the amount of cerebral oxygen 4. Compressing the cerebral venous system 5. Shunting of cerebrospinal fluid to the lumbar space Correct Answer: 1, 4. 5

Rationale 1: The brain can control increased intracranial pressure by displacing brain tissue.

Rationale 2: Administering osmotic diuretics is a pharmacological intervention to control increased intracranial pressure.

Rationale 3: Reducing the amount of cerebral oxygen will harm brain tissue.

Rationale 4: The brain can control increased intracranial pressure by compression of the cerebral venous system to reduce cerebral blood volume.

Rationale 5: The brain can control increased intracranial pressure by shunting CSF from the intracranial to the lumbar space, where CSF reabsorption is increased.

Global Rationale: The brain can control increased intracranial pressure by displacing brain tissue, compressing the cerebral venous system to reduce cerebral blood volume, and shunting CSF from the intracranial to the lumbar space, where CSF reabsorption is increased.

Administering osmotic diuretics is a pharmacological intervention to control increased intracranial pressure. Reducing the amount of cerebral oxygen will harm brain tissue.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.8 Discuss physiologic compensatory mechanisms that occur with an increased intracranial pressure.

Page Number: p. 1285 9. A client with increased intracranial pressure caused by a traumatic brain injury is in a coma. What approach should the nurse use to assess this client’s impaired consciousness?

1. Glasgow Coma Scale 2. Determine degree of brainstem reflexes 3. Assess pupillary response to light and accommodation 4. Use the Un-Responsiveness (FOUR) Score Coma Scale Correct Answer: 4 Rationale 1: A nonverbal client cannot respond to parameters assessed using the Glasgow Coma Scale.

Rationale 2: Brainstem reflex assessment would help determine if the client is brain dead.

Rationale 3: Pupillary response to light and accommodation determines the functioning of cranial nerves II and III. Rationale 4: Un-Responsiveness (FOUR) Score Coma Scale is used to assess coma in the neurologic client. This tool scores four components of impaired consciousness: eye response, motor response, brainstem reflexes, and respiration. It differs from the Glasgow Coma Scale by not requiring a verbal response.

Global Rationale: Un-Responsiveness (FOUR) Score Coma Scale is used to assess coma in the neurologic client. This tool scores four components of impaired consciousness: eye response, motor response, brainstem reflexes, and respiration. It differs from the Glasgow Coma Scale by not requiring a verbal response. A nonverbal client cannot respond to parameters assessed using the Glasgow Coma Scale. Brainstem reflex assessment would help determine if the client is brain dead. Pupillary response to light and accommodation determines the functioning of cranial nerves II and III. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care B . pC rOe M AACN Essential Competencies: IX. 1. CNoUnRdSuIcNt GcoT m h e n s i v e and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.9 Describe the process of assessing the neurologic client experiencing increasing intracranial pressure.

Page Number: p. 1294 10. The nurse suspects that a client with a brain tumor is experiencing increasing intracranial pressure. What findings did the nurse use to make this clinical determination? Select all that apply.

1. Extreme thirst 2. Projectile vomiting 3. Weak left hand grasp 4. Unresponsive right pupil 5. Blood pressure 180/48 mm Hg Correct Answer: 2, 3, 4, 5 Rationale 1: Extreme thirst is not a manifestation of increased intracranial pressure.

Rationale 2: Vomiting that is due to increased ICP typically occurs without nausea, is unexpected, is projectile, and is due to direct pressure on vagal motor centers located in the fourth ventricle in the medulla.

Rationale 3: A change in motor function such as a weak hand grasp is an indicator of increasing intracranial pressure.

Rationale 4: Changes in pupillary function is an indicator of increasing intracranial pressure. Rationale 5: A widening pulse pressure is an indication of increasing intracranial pressure.

Global Rationale: Vomiting that is due to increased ICP typically occurs without nausea, is unexpected, is projectile, and is due to direct pressure on vagal motor centers located in the fourth ventricle in the medulla. A change in motor function, changes in pupillary function, and a widening pulse pressure are indicators of increasing intracranial pressure.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmenNtUalRl Sy I aNnGdT cBu. CltOuM rally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.10 Explain the rationale for monitoring intracranial pressure (ICP). Page Number: p. 1299 11. The nurse is planning care for a client with increased intracranial pressure. Which intervention should the nurse add to this client’s care plan?

1. Keep the head of the bed flat 2. Provide with opioid analgesic for pain 3. Administer hypertonic saline as prescribed 4. Hyperventilate with 100% oxygen every 2 hours Correct Answer: 3 Rationale 1: The head of the bed should be at a 30 degree angle.

Rationale 2: Opioid analgesics should be used cautiously because they blunt the autonomic nervous system response to noxious stimuli.

Rationale 3: Brain volume can be reduced by decreasing cerebral edema with hypertonic saline.

Rationale 4: Hyperventilation can cause vasoconstriction with global or localized cerebral ischemia but may be used briefly as a bridge to more appropriate therapy.

Global Rationale: Brain volume can be reduced by decreasing cerebral edema with hypertonic saline. The head of the bed should be at a 30 degree angle. Opioid analgesics should be used cautiously because they blunt the autonomic nervous system response to noxious stimuli.

Hyperventilation can cause vasoconstriction with global or localized cerebral ischemia but may be used briefly as a bridge to more appropriate therapy.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 32.11 Explain rationale for therapies used to treat intracranial hypertension. Page Number: p. 1285 12. The nurse notes that a client has an elevated cholesterol level. Which health problem is this client at risk for developing?

1. Osteoarthritis 2. Ischemic stroke 3. Hemorrhagic stroke 4. Traumatic brain injury Correct Answer: 2 Rationale 1: Elevated cholesterol levels do not cause osteoarthritis.

Rationale 2: Ischemic strokes occur when arteries are blocked by blood clots or by the buildup of plaque and other fatty deposits. About 87% of all strokes are ischemic.

Rationale 3: Hemorrhagic strokes occur when a blood vessel in the brain ruptures, leaking blood into the surrounding tissues.

Rationale 4: Elevated cholesterol levels do not cause traumatic brain injury.

Global Rationale: Ischemic strokes occur when arteries are blocked by blood clots or by the buildup of plaque and other fatty deposits. About 87% of all strokes are ischemic. Elevated

cholesterol levels do not cause osteoarthritis or traumatic brain injury. Hemorrhagic strokes occur when a blood vessel in the brain ruptures, leaking blood into the surrounding tissues.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.12 Describe the difference between ischemic and hemorrhagic stroke Page Number: p. 1285 13. The nurse decides to use the Un-Responsiveness (FOUR) Score Coma Scale to determine a client’s level of consciousness. What client finding caused the nurse to make this decision?

1. Deafness 2. Fractured left leg 3. Prescribed opioid analgesics 4. Wears prescription eyeglasses Correct Answer: 1 Rationale 1: Un-Responsiveness (FOUR) Score Coma Scale is used to assess coma in the neurologic client. It differs from the Glasgow Coma Scale by not requiring a verbal response.

Rationale 2: The Un-Responsiveness (FOUR) Score Coma Scale is not indicated in a client with a fracture.

Rationale 3: The Un-Responsiveness (FOUR) Score Coma Scale is not indicated in a client taking opioid analgesics.

Rationale 4: The Un-Responsiveness (FOUR) Score Coma Scale is not indicated in a client wearing prescription eyeglasses.

Global Rationale: Un-Responsiveness (FOUR) Score Coma Scale is used to assess coma in the neurologic client. It differs from the Glasgow Coma Scale by not requiring a verbal response. The UnResponsiveness (FOUR) Score Coma Scale is not indicated in a client with a fracture, use of opioid analgesics or wearing prescription eyeglasses.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.13 Discuss limitations and alternatives to the use of the Glasgow Coma Scale in comatose clients.

Page Number: p. 1294 14. The nurse wants to assess consciousness, agitation, anxiety, sleep, and ventilatory synchrony in a client with a traumatic brain injury. Which scale should the nurse use for this assessment?

1. Ramsay Sedation 2. Riker Sedation-Agitation 3. AACN Sedation Assessment 4. Richmond Agitation-Sedation Correct Answer: 3 Rationale 1: The Ramsay Sedation Scale assesses arousability and is useful whenever sedative drugs or narcotics are administered, but cannot be used for the client receiving neuromuscular blocking drugs.

Rationale 2: The Riker Sedation-Agitation scale defines degrees of agitation.

Rationale 3: The AACN Sedation Assessment Scale is most comprehensive, evaluating five domains: consciousness, agitation, anxiety, sleep, and client-ventilator synchrony.

Rationale 4: The Richmond Agitation–Sedation Scale distinguishes between responses to verbal and physical stimuli. This 10-level scale has confirmed validity and reliability for use in sedated and nonsedated clients.

Global Rationale: The AACN Sedation Assessment Scale is most comprehensive, evaluating five domains: consciousness, agitation, anxiety, sleep, and client-ventilator synchrony. The Ramsay Sedation Scale assesses arousability and is useful whenever sedative drugs or narcotics are administered, but cannot be used for the client receiving neuromuscular blocking drugs. The Riker Sedation-Agitation scale defines degrees of agitation. The Richmond Agitation–Sedation Scale distinguishes between responses to verbal and physical stimuli. This 10-level scale has confirmed validity and reliability for use in sedated and nonsedated clients.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.14 Identify various assessment tools used to evaluate pain and sedation level in the nonverbal client.

Page Number: p. 1303 15. The nurse is caring for a client with a traumatic brain injury who has questionable cerebral cortex activity. Which finding is a definitive diagnosis for brain death?

1. Apnea 2. No gag reflex 3. No corneal reflex 4. No response to noxious stimuli Correct Answer: Rationale 1: The absence of respiratory drive definitively diagnoses brain death. Rationale 2: There are many conditions NthUatRcSaINn GcTauBs.CeOaM n absence of the gag reflex. Rationale 3: There are many conditions that can cause an absence of the corneal reflex. Rationale 4: There are many conditions that can cause no response to noxious stimuli.

Global Rationale: The absence of respiratory drive definitively diagnoses brain death. There are many conditions that can cause an absence of the gag reflex, corneal reflex, or no response to noxious stimuli.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.15 State criteria used to determine brain death. Page Number: p. 1295

16. A client’s ventriculostomy catheter has stopped draining. What should the nurse do?

1. Notify the health care provider 2. Inject heparin through the drain 3. Aspirate the drain with a 10 mL syringe 4. Flush the drain with sterile normal saline Correct Answer: 1 Rationale 1: Never flush a ventriculostomy. This would increase risk for infection.

Rationale 2: Instilling medications (including saline) is not within the scope of nursing practice Rationale 3: The nurse should not manipulate the drain.

Rationale 4: Instilling medications (including saline) is not within the scope of nursing practice Global Rationale: Never flush a ventriculostomy. This would increase risk for infection. Instilling medications (including saline) is not within the scope of nursing practice The nurse should not manipulate the drain.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological AdaptatiNoUn RSINGTB.COM QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation Learning Outcome: 32.16 Outline nursing responsibilities in the care of a client with an ICP monitoring system or ventriculostomy for cerebrospinal fluid drainage.

Page Number: p. 1304 17. The nurse determines that a client’s intracranial pressure waveform is normal. What did the nurse observe to make this clinical determination?

1. Three pressure peaks 4. Absence of pressure peaks 3. Synchronization with heart rate 2. Synchronization with respiratory rate Correct Answer: Rationale 1: A normal ICP waveform has three pressure peaks.

Rationale 2: An abnormal waveform would have absent pressure peaks.

Rationale 3: The intracranial pressure waveform is not synchronized with heart rate. Rationale 4: The intracranial pressure waveform is not synchronized with respiratory rate.

Global Rationale: A normal ICP waveform has three pressure peaks. An abnormal waveform would have absent pressure peaks. The intracranial pressure waveform is not synchronized with heart or respiratory rate.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.17 Identify components of a normal intracranial pressure (ICP) waveform.

Page Number: p. 1302

CHAPTER 33 1. The nurse working with a student nurse is providing care for a client requiring mechanical ventilation.

The student nurse asks the meaning of assist control. Which response by the nurse is the most appropriate?

1. "Assist control is a means of delivering ventilation that delivers a preset volume and/or pressure each time the client begins an inspiration."

2. "Assist control allows the client to breathe independently, but supplies a breath if the client does not begin an inhalation in a specified period of time."

3. "Assist control is used when weaning a client from the ventilator because the client must exercise the muscles of respiration in order to get a full breath."

4. "Assist control is often used when a client is receiving a paralytic agent."

Correct Answer: 1 Rationale 1: Assist control allows the client to begin inspiration, but the ventilator provides a preset pressure or volume to boost the client's tidal volume.

Rationale 2: If the ventilator is set to p r oNvUi dReS IaN bGrTeBa .t Ch OoMn l y when the client doesn't breathe, it is not assist control but Synchronized Intermittent Mandatory Ventilation (SIMV).

Rationale 3: Because the ventilator provides the breath begun by the client, it does not improve muscle function.

Rationale 4: Assist control would not be used for the client receiving a paralytic agent because he would be unable to initiate a breath.

Global Rationale: Assist control allows the client to begin inspiration, but the ventilator provides a preset pressure or volume to boost the client's tidal volume. If the ventilator is set to provide a breath only when the client doesn't breathe, it is not assist control but Synchronized Intermittent Mandatory Ventilation (SIMV). Because the ventilator provides the breath begun by the client, it does not improve muscle function. Assist control would not be used for the client receiving a paralytic agent because he would be unable to initiate a breath.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based

approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 33.13 Differentiate various ventilator support “modes.”

Page Number: p. 1342 2. The nurse is caring for a client with atelectasis. Which prescription from the health care provider should the nurse anticipate to correct this problem?

1. Increase oxygen concentration 2. Increase flow rate 3. Increase tidal volume 4. Set PEEP at 6 cm H2O Correct Answer: 4 Rationale 1: Increasing oxygen concentration would not impact atelectasis.

Rationale 2: Increasing oxygen flow rate would not impact atelectasis.

Rationale 3: Increasing tidal volume w oNu Ul dR nS IoNt Gp TreBv. CenOtMa i r wa y collapse after expiration.

Rationale 4: PEEP is often used to prevent further atelectasis because it maintains open alveoli between breaths.

Global Rationale: PEEP is often used to prevent further atelectasis because it maintains open alveoli between breaths. Increasing tidal volume would not prevent airway collapse after expiration. Increasing oxygen concentration or oxygen flow rate would not impact atelectasis.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 33.14 Discuss nursing care needs of the mechanically ventilated client.

Page Number: p. 1346 3. The nurse caring for a client requiring mechanical ventilation. Which action by the nurse would be inappropriate when providing care to this client?

1. Confirming airway placement by auscultating the lungs and checking the length marking of the tube at the lip 2. Assuring that tube cuff inflation is no greater than 15 cm H2O, and that there is no audible air leak 3. Assuring ventilator tubing is secured and does not pull on the client's airway 4. Verifying correct ventilator settings Correct Answer: 2 Rationale 1: Airway placement should be confirmed.

Rationale 2: Tube cuff inflation should remain at 20 cm H2O. Rationale 3: Ventilator tubing should be secure and not pull on the airway.

Rationale 4: Ventilator settings should be verified.

Global Rationale: Tube cuff inflation should remain at 20 cm H2O. Airway placement should be confirmed. Ventilator tubing should be secure and not pull on the airway. Ventilator settings should be verified.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 33.14 Discuss nursing care needs of the mechanically ventilated client.

Page Number: pp. 1342-1343 4. The nurse working in the intensive care unit is assigned a client requiring mechanical ventilation.

When responding to the ventilator alarm, the nurse sees a high-pressure alarm. Which nursing action is the priority?

1. Silencing the alarm 2. Removing the client from the ventilator and using a bag-valve device to oxygenate the client until the respiratory therapist can be summoned

3. Emptying the collected water from the ventilator tubing 4. Assessing the client Correct Answer: 4 Rationale 1: The alarm should not be silenced until the cause is determined.

Rationale 2: If the client is in distress, it might be necessary to remove the client from the ventilator and to bag the client until the cause of the problem can be located and corrected.

Rationale 3: If the client is comfortable, and assessment findings are within normal limits, the cause of the alarm could be water collecting in the tubing (which should be emptied).

Rationale 4: The nurse should treat the client and not the alarm, so the first action would be to assess the client quickly.

Global Rationale: The nurse should treat the client and not the alarm, so the first action would be to assess the client quickly. In most instances, depending on facility policy, if a client requires mechanical ventilation, he is placed on cardiorespiratory monitors with continuous oxygen saturation monitoring. The nurse would assess heart rate and oxygen saturation, and examine the client for any signs of distress. If the client is comfortable, and assessment findings are within normal limits, the cause of the alarm could be water collecting in the tubing (which should be emptied). However, if the client is in d i s Nt r Ue sRs S, IiNt G mTigBh.Ct ObM e necessary to remove the client from the ventilator and to bag the client until the cause of the problem can be located and corrected.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 33.14 Discuss nursing care needs of the mechanically ventilated client.

Page Number: p. 1346 5. Question 5 Type: MCSA Which task could the nurse safely delegate to the unlicensed assistive personnel (UAP)?

1. Changing ventilator settings according to the primary care provider's order

2. Moving the location of the endotracheal tube from one side of the mouth to the other side 3. Measuring airway cuff pressure 4. Assist with repositioning a client Correct Answer: 4 Rationale 1: Changing ventilator settings is never performed by the UAP, due to the need for scientific knowledge.

Rationale 2: Moving the endotracheal tube can be performed only by the nurse due to the need for quick action if the tube were to become dislocated.

Rationale 3: Airway cuff pressure is generally measured by the respiratory therapist or the nurse, never the UAP. Rationale 4: The UAP can offer valued assistance in moving or positioning clients.

Global Rationale: The UAP can offer valued assistance in moving or positioning clients. Changing ventilator settings is never performed by the UAP, due to the need for scientific knowledge. Moving the endotracheal tube can be performed only by the nurse due to the need for quick action if the tube were to become dislocated. Airway cuff pressure is generally measured by the respiratory therapist or N U R S IN G TB .CO M t h e n u r s e , n e v e r t h e UAP. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Practice; Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 33.14 Discuss nursing care needs of the mechanically ventilated client.

Page Number: p. 1348 6. The nurse is providing care for a client requiring mechanical ventilation. When the nurse enters the room at the beginning of the shift, the client's monitor displays a heart rate of 64 and oxygen saturation of 88%. Which nursing action is the priority?

1. Increasing the oxygen concentration and quickly assessing the client 2. Removing the client from the ventilator and hyperoxygenating and hyperventilating the client 3. Assessing the client for airway obstruction

4. Checking ventilator settings Correct Answer: 3 Rationale 1: The client might need the oxygen concentration increased however it should not be done before assessing the client.

Rationale 2: The client might need hyperoxygenated and hyperventilated however it should not be done before assessing the client.

Rationale 3: Assessing for airway obstruction should be done first.

Rationale 4: The ventilator setting may need checked but not before assessing the client.

Global Rationale: Assessing for airway obstruction should be done first. The client might need the oxygen concentration increased however it should not be done before assessing the client.

The client might need hyperoxygenated and hyperventilated however it should not be done before assessing the client. The ventilator setting may need checked but not before assessing the client.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.14 Discuss nursing care needs of the mechanically ventilated client.

Page Number: p. 1346 7. Immediately after moving the oral endotracheal airway to the other side of the client's mouth, the low pressure alarm sounds. What should the nurse do first?

1. Providing oral care 2. Suctioning the airway 3. Checking for correct tube placement 4. Checking tube cuff inflation

Correct Answer: 3 Rationale 1: Oral care can be done later.

Rationale 2: Suctioning should be done if secretions are present however this is not a cause for a low pressure alarm.

Rationale 3: In the event of a low pressure alarm the placement of the artificial airway needs to be assessed.

Rationale 4: The cuff pressure can be checked after tube location is confirmed.

Global Rationale: In the event of a low pressure alarm the placement of the artificial airway needs to be assessed. Oral care can be done later. Suctioning should be done if secretions are present however this is not a cause for a low pressure alarm. The cuff pressure can be checked after tube location is confirmed.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management aNcUroRsSsINthGeThBe.aClOthM-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 33.14 Discuss nursing care needs of the mechanically ventilated client.

Page Number: p. 1346 8. Question 8 Type: MCSA The nurse is caring for a client being weaned from the ventilator. When performing a spontaneous breathing trial, which item is not a priority assessment?

1. Mental status 2. Oxygen saturation 3. Vital signs 4. Ability to speak Correct Answer: 4

Rationale 1: The ability to speak during a weaning trial is not as important as mental status. Rationale 2: The ability to speak during a weaning trial is not as important as oxygen saturation. Rationale 3: The ability to speak during a weaning trial is not as important as vital signs.

Rationale 4: The client might have a fenestrated tube or speaking valve that allows the client to communicate, but if neither of these is in place, the client would not speak.

Global Rationale: The client might have a fenestrated tube or speaking valve that allows the client to communicate, but if neither of these is in place, the client would not speak. The ability to speak during a weaning trial is not as important as mental status, oxygen saturation, and vital signs, which indicate the client's tolerance of being removed from the ventilator.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: NursingNPUrRoSceINssG: TABs.CseOsM sment Learning Outcome: 33.15 Describe the process of weaning a client from mechanical ventilation to independent breathing.

Page Number: pp. 1344-1345 9. When weaning a client from the ventilator, what should the nurse document in addition to routine assessments performed for any client requiring mechanical ventilation with an artificial airway in place?

1. The details and length of the weaning trial 2. The client's oxygen saturation 3. The client's breath sounds 4. The client's respiratory rate Correct Answer: 1 Rationale 1: When weaning the client from mechanical ventilation, it is important to document the length of time the client tolerated being off the ventilator, and how the client tolerated the process.

Rationale 2: Oxygen saturation would be documented for any client receiving mechanical ventilation.

Rationale 3: Breath sounds would be documented for any client receiving mechanical ventilation.

Rationale 4: Respiratory rate would be documented for any client receiving mechanical ventilation.

Global Rationale: When weaning the client from mechanical ventilation, it is important to document the length of time the client tolerated being off the ventilator, and how the client tolerated the process.

Oxygen saturation, breath sounds, and respiratory rate would be documented on any client requiring mechanical ventilation.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: VI.B.4. Document and plan client care in an electronic health record AACN Essential Competencies: IV.5. Use standardized terminology in a care environment that reflects nursing’s unique contribution to client outcomes NLN Competencies: Quality and Safety: Practice; Carefully maintain and use electronic and/or written health records Nursing/Integrated Concepts: Nursing Process: Implementation NURSINGTB.CO Learning Outcome: 33.14sinDgisccaursesnneuerds of the mechanically ventilated client.

Page Number: p. 1345 10. The nurse is documenting care for a ventilated client. Which items are appropriate for the nurse to include in the documentation?

Standard Text: Select all that apply.

1. Assignment of suctioning to the unlicensed assistive personnel (UAP) 2. Client response to ventilator changes 3. Pertinent laboratory values, such as arterial blood gas results 4. Physical assessment findings 5. Pain rating using an appropriate pain rating scale Correct Answer: 2, 3, 4, 5 Rationale 1: It is not appropriate for the UAP to suction an intubated client requiring mechanical ventilation.

Rationale 2: When providing care to a ventilated client, the nurse will document the client’s response to ventilator changes.

Rationale 3: When providing care to a ventilated client, the nurse will document laboratory data such as arterial blood gas results.

Rationale 4: When providing care to a ventilated client, the nurse will document physical assessment data.

Rationale 5: When providing care to a ventilated client, the nurse will document pain level.

Global Rationale: When providing care to a ventilated client, the nurse will document response to ventilator changes, laboratory data such as arterial blood gas results, physical assessment data, and pain level. It is not appropriate for the UAP to suction an intubated client requiring mechanical ventilation.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: VI.B.4. Document and plan client care in an electronic health record AACN Essential Competencies: IV.5. Use standardized terminology in a care environment that reflects nursing’s unique contribution to client outcomes NLN Competencies: Quality and Safety: Practice; Carefully maintain and use electronic and/or written health records Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 33.14 Discuss nursing care needs of the mechanically ventilated client.

Page Number: p. 1345 11. A client in intensive care has a multi-lumen, balloon-tipped, flow-directed catheter in place. What hemodynamic measurements should the nurse expect from this catheter? Select all that apply.

1. Right atrial pressure 2. Mean arterial pressure 3. Pulmonary artery pressure 4. System vascular resistance 5. Pulmonary arterial wedge pressure Correct Answer: 1, 3, 4, 5 Rationale 1: A multilumen, balloon-tipped, flow-directed catheter is used to measure right atrial pressure.

Rationale 2: A multilumen, balloon-tipped, flow-directed catheter is not used to measure mean arterial pressure.

Rationale 3: A multilumen, balloon-tipped, flow-directed catheter is used to measure pulmonary artery pressure.

Rationale 4: A multilumen, balloon-tipped, flow-directed catheter is used to measure systemic vascular resistance.

Rationale 5: A multilumen, balloon-tipped, flow-directed catheter is used to measure pulmonary arterial wedge pressure.

Global Rationale: A multilumen, balloon-tipped, flow-directed catheter is used to measure right atrial pressure, pulmonary artery pressure, systemic vascular resistance, and pulmonary artery wedge pressure. This catheter is not used to measure mean arterial pressure.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: NursingNPUrRoSceINssG: TABs.CseOsM sment Learning Outcome: 33.1 List hemodynamic information obtained by means of a pulmonary artery (balloontipped flow-directed) catheter.

Page Number: p. 1313 12. The nurse notes that the transducer for a client’s hemodynamic monitoring catheter is above the level of the right atrium. What effect should the nurse expect because of the location of the transducer?

1. Lower readings 2. Higher readings 3. Monitor tracings will be flat lined 4. Inability to adequately zero the device Correct Answer: 1 Rationale 1: The transducer must remain level with client’s right atrium for accurate monitoring. Higher transducer position yields low readings.

Rationale 2: The transducer must remain level with client’s right atrium for accurate monitoring. Lower transducer position yields higher readings.

Rationale 3: Flat lined monitor tracings would be expected when the transducer is zeroed.

Rationale 4: The height of the transducer will not affect the ability to zero the transducer.

Global Rationale: The transducer must remain level with client’s right atrium for accurate monitoring. Higher transducer position yields low readings and lower transducer position yields higher readings. Flat lined monitor tracings would be expected when the transducer is zeroed.

The height of the transducer will not affect the ability to zero the transducer.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.2 Discuss the purpose and method for leveling and zeroing the monitor.

Page Number: p. 1318 13. The nurse is analyzing a client’s tracing for a pulmonary arterial wedge pressure. For which characteristic should the nurse analyze this tracing?

1. Dicrotic notch 2. Wandering baseline 3. Premature ventricular contractions 4. Higher and more pronounced pressure waveform, Correct Answer: 1 Rationale 1: A dicrotic notch on a pulmonary arterial waveform strip is evidence of the pulmonary artery measure stepping up.

Rationale 2: A wandering baseline is not desirable. The transducer should be zeroed.

Rationale 3: Premature ventricular contractions would be seen on the right ventricular pressure tracing.

Rationale 4: Higher and more pronounced pressure waveform indicating a tracing from the right ventricle.

Global Rationale: A dicrotic notch on a pulmonary arterial waveform strip is evidence of the pulmonary artery measure stepping up. A wandering baseline is not desirable. The transducer should be zeroed.

Premature ventricular contractions would be seen on the right ventricular pressure tracing. Higher and more pronounced pressure waveforms indicate a tracing from the right ventricle.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.3 Differentiate waveforms for pulmonary artery and pulmonary capillary wedge pressures.

Page Number: p. 1319 14. The nurse is preparing to take hemodynamic measurements on a client but notices the sign “do not inflate” on the transducer. What should this information indicate to the nurse? Select all that apply.

1. Blood returns from the balloon lumen 2. Catheter moved from original position 3. No resistance on the balloon when inflated 4. Syringe plunger failed to retract spontaneously 5.

N U RSI N G TB.COM Stopcock on the transducer needs to b e rep laced Correct Answer: 1, 3, 4 Rationale 1: Suspect balloon rupture if no blood returns from the balloon lumen.

Rationale 2: There is no reason to post a sign “do not inflate” for a catheter that has moved from its original position.

Rationale 3: Suspect balloon rupture if no resistance is encountered on inflation. Rationale 4: Suspect balloon rupture if the syringe plunger fails to retract spontaneously.

Rationale 5: There is no reason to post a sign “do not inflate:” if the stopcock on the transducer needs to be replaced.

Global Rationale: Suspect balloon rupture if no blood returns from the balloon lumen, no resistance is encountered on inflation, or the syringe plunger fails to retract spontaneously. There is no reason to post a sign “do not inflate” for a catheter that has moved from its original position or if the stopcock on the transducer needs to be replaced.

Cognitive Level: Analyzing Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.4 State three ways to troubleshoot pulmonary artery catheter problems.

Page Number: p. 1321 15. A client in the intensive care unit is having an arterial line inserted. For what should the nurse anticipate using this client’s line? Select all that apply.

1. Analyze acid-base status 2. Determine respiratory status 3. Evaluate treatment for alterations in arterial blood gases 4. Easy access to blood sampling for arterial blood gases and other lab values 5. Continuous measurement of the systolic, diastolic, and mean arterial pressures Correct Answer: 4, 5 Rationale 1: Arterial blood gases are used to analyze acid-base status.

Rationale 2: Arterial blood gases are used to determine respiratory status. Rationale 3: Arterial blood gases are used to evaluate treatments for alterations.

Rationale 4: Arterial lines provide easy access to blood sampling for arterial blood gases and other lab values.

Rationale 5: Arterial lines provide continuous measurement of the systolic, diastolic, and mean arterial pressures.

Global Rationale: Arterial lines provide easy access to blood sampling for arterial blood gases and other lab values and continuous measurement of the systolic, diastolic, and mean arterial pressures. Arterial blood gases are used to analyze acid-base status, to determine respiratory status, and to evaluate treatments for alterations.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health

and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 33.5 Describe the rationale for arterial blood pressure monitoring.

Page Number: p. 1326 16. A client is being evaluated for arterial line placement. What should the nurse do after compressing both arteries at the client’s right wrist?

1. Count the client’s radial pulse rate 2. Instruct the client to flex and extend the forearm several times 3. Instruct the client to clench and unclench the fist several times 4. Have unlicensed assistive personnel measure the blood pressure Correct Answer: 3 Rationale 1: The radial pulse rate is not counted.

Rationale 2: The forearm does not need to be flexed and extended.

Rationale 3: When conducting the modified Allen test, after compressing both arteries the nurse should instruct the client to clench and unclench the fist several times.

Rationale 4: The client’s blood pressure NdoUeRsSnINoG t Tn Be e. Cd Ot oM b e measured at this time.

Global Rationale: : When conducting the modified Allen test, after compressing both arteries the nurse should instruct the client to clench and unclench the fist several times. The radial pulse rate is not counted.

The forearm does not need to be flexed and extended. The client’s blood pressure does not need to be measured at this time.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.6 Outline the steps in performing the Modified Allen test.

Page Number: p. 1327

17. A client in the intensive care is prescribed every 1 hour serum electrolyte levels and arterial blood gases every 2 hours. What should be done to prevent this client from developing nosocomial anemia?

1. Use a blood conservatory process 2. Place blood obtained in cups of ice 3. Increase intravenous fluids by 50 mL/hr 4. Provided one half of the blood required for each test Correct Answer: 1 Rationale 1: A blood conservatory process helps to prevent nosocomial anemia.

Rationale 2: Placing blood specimens on ice is not a part of the blood conservatory process.

Rationale 3: It is beyond the nurse’s scope of practice to increase intravenous fluids without a healthcare provider’s order.

Rationale 4: Reducing the amount of blood for each test is not a part of the blood conservatory process.

Global Rationale: A blood conservatory process helps to prevent nosocomial anemia. Placing blood specimens on ice and reducing the amount of blood for each test are not parts of a blood conservatory process. It is beyond the nurse’s scope of practice to increase intravenous fluids without a healthcare provider’s order.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 33.8 Explain the procedure for obtaining a blood sample from an arterial line.

Page Number: p. 1330

CHAPTER 34 1. The nurse is providing postmortem. For which reason should the nurse elevate the client’s head?

1. Prevent rigor mortis 2. Prevent facial discoloration 3. Algor mortis 4. Post mortis Correct Answer: 2 Rationale 1: Rigor mortis is rigidity of the muscles.

Rationale 2: If the head is not elevated, the blood will begin to pool around the sides of the face, the earlobes, and the neck leaving it a deep, reddish purple.

Rationale 3: Algor mortis is cooling of the body.

Rationale 4: There is no such thing as post mortis.

Global Rationale: If the head is not elevated, the blood will begin to pool around the sides of the face, the earlobes, and the neck leaving it a deep, reddish purple. Rigor mortis is rigidity of the muscles. Algor mortis is cooling of the body. There is no such thing as post mortis.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Ethical Comportment; Value evidence-based approaches to yield best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34.11 Describe the steps in providing postmortem care.

Page Number: p. 1368 2. Which role is the nurse least likely to perform when working with families of dying clients?

1. Providing financial support 2. Providing emotional support

3. Assisting with connecting families with available resources 4. Assessing families’ coping and grieving process Correct Answer: 1 Rationale 1: The role of the nurse does not include providing financial support.

Rationale 2: A large part of the nurse's role is assisting the family to cope with the impending death.

Rationale 3: Nurses may help families connect with available resources to help them deal with financial issues.

Rationale 4: A large part of the nurse's role is assisting the family to cope with the grieving process.

Global Rationale: Although nurses may help families connect with available resources to help them deal with financial issues, the role of the nurse does not include providing financial support. A large part of the nurse's role is assisting the family to cope with the impending death, assessing their progress in the grieving process.

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.C.13. Acknowledge the tension that may exist between client rights and the organizational responsibility for professional, ethical care AACN Essential Competencies: IX.6. Implement client and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for client and family preferences NLN Competencies: Relationship Centered Care: Practice; Promote and accept the client's emotions; accept and respond to distress in client and self; facilitate hope, trust, and faith Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 34.3 Identify the factors that influence the outcome of the grieving process.

Page Number: p. 1359 3. When delegating postmortem care to unlicensed assistive personnel (UAP), it is essential that the nurse inform the UAP of which piece of information?

1. The tubes or other medical devices to be left in place 2. The disposition of the body after postmortem care is completed 3. The method to contact the family 4. The information to be documented in the medical record

Correct Answer: 1 Rationale 1: The nurse must inform the UAP of any tubes or medical devices to remain in place during postmortem care.

Rationale 2: Disposition of the body is relatively standard within facilities, and the nurse would not need to inform the UAP of this.

Rationale 3: The nurse would be responsible for notifying the family.

Rationale 4: The nurse would be responsible for documenting in the medical record.

Global Rationale: The nurse must inform the UAP of any tubes or medical devices to remain in place during postmortem care. Disposition of the body is relatively standard within facilities, and the nurse would not need to inform the UAP of this. The nurse would be responsible for notifying the family and documenting in the medical record.

Cognitive Level: Applying Client Need: Safe Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and sNuUpReSrvINisGinTgB.oCtOhM er members of the health care team NLN Competencies: Teamwork: Practice; Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 34.11 Describe the steps in providing postmortem care.

Page Number: p. 1371 4. The nurse is caring for a client diagnosed with a terminal illness and experiencing a great deal of pain.

After administration of IV analgesia, the client continues to complain of severe pain. Which action by the nurse is the most appropriate in this situation?

1. Explain to the client the need to wait for further medication to prevent overdosage complications.

2. Ask the family to help divert the client from the discomfort.

3. Call the health care provider, if necessary, to request an order for additional analgesia.

4. Wait an hour for the medication to take effect.

Correct Answer: 3 Rationale 1: Waiting would cause needless suffering for the client.

Rationale 2: The family should not be placed in the position of having to divert the client when the client is in pain.

Rationale 3: The nurse's role when caring for someone with a terminal illness is to make the client as comfortable as possible. Clients receiving narcotics regularly develop a tolerance for the drugs, and might require a larger dosage to get the same effects.

Rationale 4: IV medications do not take an hour to reach peak effect.

Global Rationale: The nurse's role when caring for someone with a terminal illness is to make the client as comfortable as possible. Clients receiving narcotics regularly develop a tolerance for the drugs, and might require a larger dosage to get the same effects. The family should not be placed in the position of having to divert the client when the client is in pain. IV medications do not take an hour to reach peak effect, and waiting that long would cause needless suffering for the client.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.6. Implement client and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for client and family preferences NLN Competencies: Quality and SafetyN: UKRnSoI NwGleTdBg. eC;OCMurren t best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34.10 Describe the three-step analgesic ladder for pain control for the dying client..

Page Number: p. 13630 5. The nurse is caring for a client who has just died. When performing postmortem care, which nursing actions are appropriate for this client?

Standard Text: Select all that apply.

1. Positing the client in a supine position 2. Placing the client’s arms crossed over the chest 3. Closing the client’s eyes 4. Inserting the client’s dentures in the mouth 5. Pulling the top linens to the client’s shoulder.

Correct Answer: 1, 3, 4, 5

Rationale 1: The client should be in the supine position.

Rationale 2: The arms are generally placed at the side or crossed over the abdomen before rigor mortis sets in.

Rationale 3: The client’s eyes should be closed.

Rationale 4: The client’s dentures should be placed in the mouth.

Rationale 5: The linens should be pulled to shoulder level.

Global Rationale: The client should be in the supine position, with the eyes closed, dentures in the mouth, and linens pulled to shoulder level. The arms are generally placed at the side or crossed over the abdomen before rigor mortis sets in.

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.6. Implement client and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for client and family preferences NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34.11 Describe the steps in providing postmortem care.

Page Number: p. 1368 6. Immediately after a client dies, who is the nurse responsible for notifying?

1. Family 2. Primary care provider 3. Funeral home 4. Coroner, if indicated Correct Answer: 2 Rationale 1: After the primary care provider is notified, the family should be called next.

Rationale 2: The first call made by the nurse should be to the primary care provider, who will decide whether the nurse should notify the family or to personally make the call.

Rationale 3: The family will inform the nurse of what funeral home will be used.

Rationale 4: The coroner will be notified at a later date, and the nurse will not need to make the call in most instances.

Global Rationale: The first call made by the nurse should be to the primary care provider, who will decide whether the nurse should notify the family or to personally make the call. After the primary care provider is notified, the family should be called next. They will inform the nurse of what funeral home will be used. The coroner will be notified at a later date, and the nurse will not need to make the call in most instances.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: VI.B.4. Document and plan client care in an electronic health record AACN Essential Competencies: IV.5. Use standardized terminology in a care environment that reflects nursing’s unique contribution to client outcomes NLN Competencies: Quality and Safety: Practice; Carefully maintain and use electronic and/or written health records Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34.11 Describe the steps in providing postmortem care.

Page Number: p. 1368 7. The nurse is providing care to a client who is diagnosed with a terminal illness. When meeting the physiological needs of this dying client, which items will the nurse include in the assessment process?

Standard Text: Select all that apply.

1. Determine if the client has advance directives.

2. Determine if the client is experiencing any physiological signs of impending death.

3. Ask questions to determine ways to support the client and family.

4. Ask the family if they want to view the body after death.

5. Provide adequate pain control.

Correct Answer: 1, 2, 3, 4 Rationale 1: The nurse must assess the client and family needs in order to meet the physiological needs of the client who is dying. Important items to include in the assessment process include determining if the client has advance directives.

Rationale 2: The nurse must assess the client and family needs in order to meet the physiological needs of the client who is dying. Important items to include in the assessment process include determining if the client is exhibiting any physiological signs of impending death.

Rationale 3: The nurse must assess the client and family needs in order to meet the physiological needs of the client who is dying. Important items to include in the assessment process include asking questions to the client and family to determine how to support them during the dying process.

Rationale 4: The nurse must assess the client and family needs in order to meet the physiological needs of the client who is dying. Important items to include in the assessment process include asking the family if they want to view the body after death.

Rationale 5: Although pain control is important, administering pain medication is not included in the assessment process.

Global Rationale: The nurse must assess the client and family needs in order to meet the physiological needs of the client who is dying. Important items to include in the assessment process include determining if the client has advance directives, determining if the client is exhibiting any physiological signs of impending death, asking questions to the client and family to determine how to support them during the dying process, and asking the family if they want to view the body after death. Although pain control is important, administering pain medication is not included in the assessment process.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.6. Implement client and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for client and family preferences NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.9 Discuss at least four nursing interventions that assist the client during the end-oflife process.

Page Number: p. 1362 8. The nurse is providing care for a client with terminal breast cancer. The client’s children ask if their mother will exhibit any signs and symptoms prior to death. When responding to the family, which statements regarding the expected clinical manifestations of impending death will the nurse include?

Standard Text: Select all that apply.

1. “Your mother’s jaw may sag.”

2. “Your mother may have difficulty speaking.”

3. “Your mother may have trouble swallowing.”

4. “Your mother may feel hot to the touch.”

5. “Your mother may begin to breathe only through her nose.”

Correct Answer: 1, 2, 3 Rationale 1: Clinical manifestations that occur prior to death include relaxation of the facial muscles, which can cause the jaw to sag.

Rationale 2: Clinical manifestations that occur prior to death include difficulty speaking. Rationale 3: Clinical manifestations that occur prior to death include trouble swallowing. Rationale 4: Prior to death, the skin feels cool to the touch, not warm.

Rationale 5: Clients often become mouth breathers prior to death, not nose breathers.

Global Rationale: Clinical manifestations that occur prior to death include relaxation of the facial muscles, which can cause the jaw to sag; difficulty speaking; and trouble swallowing. Prior NU R S I N G T B . C O M to death, the skin feels cool to the touch, not w ar m , a nd c lie nt s often become mouth breathers prior to death, not nose breathers.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.B.3. Base individualized care plan on client values, clinical expertise, and evidence AACN Essential Competencies: IX.6. Implement client and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for client and family preferences NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process:Implementation Learning Outcome: 34.9 Discuss at least four nursing interventions that assist the client during the end-oflife process.

Page Number: p. 1363 9. The nurse recognizes the client's death is impending when which assessment finding is noted?

1. Extremities appear mottled and cyanotic 2. Client requests a meeting with spiritual counselor

3. Heart rate and blood pressure increases 4. Increased appetite Correct Answer: 1 Rationale 1: Mottling and cyanosis of the extremities are imminent signs of death.

Rationale 2: Requesting a meeting with a spiritual counselor is not indicative of death, and is more likely to occur days to weeks before death, as the client emotionally prepares for death.

Rationale 3: Heart rate and blood pressure are more likely to decrease than increase.

Rationale 4: Appetite is more likely to decrease than increase.

Global Rationale: Mottling and cyanosis of the extremities are imminent signs of death. Requesting a meeting with a spiritual counselor is not indicative of death, and is more likely to occur days to weeks before death, as the client emotionally prepares for death. Heart rate, blood pressure, and appetite are more likely to decrease than increase.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological AdaptatNioUnRSINGT B.CO M QSEN Competencies: III.B.3. Base individualized care plan on client values, clinical expertise, and evidence AACN Essential Competencies: IX.6. Implement client and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for client and family preferences NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.9 Discuss at least four nursing interventions that assist the client during the end-oflife process.

Page Number: p. 1363 10. The spouse of a recently deceased client is observed crying and expressing anger to anyone who asks if any help is needed. In which stage of grieving is this spouse?

1. Resolution 2. Restitution 3. Idealization 4. Developing awareness Correct Answer: 4 Rationale 1: In resolution the mourner attempts to deal with the painful void created by the loss of a loved one. Then the mourner becomes more aware of his or her own body and bodily

sensations. Finally, the mourner begins to talk about the dead individual, recalling the dead individual’s attributes and personality and reminiscing about the memories they shared.

Rationale 2: In restitution, the various rituals of the culture, such as the funeral, attire, wake, particular folkways, and mores help to initiate the recovery process.

Rationale 3: In idealization all hostile and negative feelings toward the deceased are repressed. Rationale 4: In the stage of developing awareness the person may demonstrate anger and crying.

Global Rationale: In the stage of developing awareness the person may demonstrate anger and crying. In restitution, the various rituals of the culture, such as the funeral, attire, wake, particular folkways, and mores help to initiate the recovery process. In resolution the mourner attempts to deal with the painful void created by the loss of a loved one. Then the mourner becomes more aware of his or her own body and bodily sensations. Finally, the mourner begins to talk about the dead individual, recalling the dead individual’s attributes and personality and reminiscing about the memories they shared. In idealization all hostile and negative feelings toward the deceased are repressed.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX.6. Implement client and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for client and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.1 Discuss the stages of the grief process. Page Number: p.

1353 11. The nurse educator is reviewing Elisabeth Kubler-Ross’s stages of grief with a group of oncology nurses. In which order should the nurse review these stages?

1. Anger 2. Denial 3. Depression 4. Acceptance 5. Bargaining Correct Answer: 2, 1, 5, 3, 4 Rationale 1: Anger is the second stage of Kubler-Ross’s stages of grief. Rationale 2: Denial is the first stage of Kubler-Ross’s stages of grief.

Rationale 3: Depression is the fourth stage of Kubler-Ross’s stages of grief. Rationale 4: Acceptance is the final stage of Kubler-Ross’s stages of grief. Rationale 5: Bargaining is the third stage of Kubler-Ross’s stages of grief.

Global Rationale: Elisabeth Kubler-Ross’s stages of grief are denial, anger, bargaining, depression, and acceptance.

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 34.5 Describe the stages of grief outlined by Elisabeth Kübler-Ross. Page Number: p. 1353 12. After learning of having cancer a client begins to demonstrate psychological symptoms of grief.

What did the nurse most likely assess in this client?

1. Crying 2. Insomnia 3. Anorexia 4. Gastrointestinal disturbances Correct Answer: 1 Rationale 1: Crying is a psychological symptom of grief. Rationale 2: Insomnia is a somatic symptom of grief.

Rationale 3: Anorexia is a somatic symptom of grief.

Rationale 4: Gastrointestinal disturbances are somatic symptoms of grief.

Global Rationale: Crying is a psychological symptom of grief. Insomnia, anorexia, and gastrointestinal disturbances are somatic symptoms of grief.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity

Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.2 State the main characteristics observed in an individual experiencing grief.

Page Number: p. 1358 13. The nurse suspects that a new widow is demonstrating a morbid reaction to grief. What did the nurse observe to come to this conclusion?

1. Will not eat 2. Continually cries 3. Has not slept for several days 4. Has the deceased spouse’s symptoms Correct Answer: 4 Rationale 1: Anorexia is a somatic symptom of grief.

Rationale 2: Crying is psychological symptom of grief. Rationale 3: Insomnia is a somatic symptom of grief.

Rationale 4: A distorted reaction or acquiring symptoms of the deceased is considered a morbid reaction to grief.

Global Rationale: A distorted reaction or acquiring symptoms of the deceased is considered a morbid reaction to grief. Anorexia and insomnia are somatic symptoms of grief. Crying is psychological symptom of grief.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34.4 Explain three assessment parameters for observing psychological and somatic symptoms that accompany the grief process.

Page Number: p. 1358 14. The nurse reviews palliative care with a client experiencing a chronic illness. Which client statement indicates that teaching has been effective?

1. “I can be on palliative care for 6 months.”

2. “The expected outcome of palliative care improved quality of life.”

3. “Palliative care neither slows down nor speeds up the dying process.”

4. “Palliative care supports the philosophy that death is an integral part of the life cycle.” Correct Answer: 2 Rationale 1: The client can receive hospice care for 6 months or longer.

Rationale 2: The expected outcome of palliative care is the prevention of suffering and improved quality of life.

Rationale 3: Hospice neither slows down nor speeds up the dying process.

Rationale 4: Hospice supports the philosophy that death is an integral part of the life cycle.

Global Rationale: The expected outcome of palliative care is the prevention of suffering and improved quality of life. The client can rNeUceRiSvIeNhGoTsBp.iCcO e Mc a r e for 6 months or longer. Hospice neither slows down nor speeds up the dying process. Hospice supports the philosophy that death is an integral part of the life cycle.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 34.6 Explain what is meant by hospice and palliative care. Page Number: p. 1354 15. A client with a terminal illness is in the depression stage of the grieving process. What should the nurse do to help this client?

1. Offer support and reassurance to family 2. Encourage client to talk when ready to do so 3. Remain with client and share on a nonverbal level

4. Assist with contacting spiritual counselor or hospital chaplain Correct Answer: 3 Rationale 1: Offering support and reassurance to the family is an intervention for the acceptance phase.

Rationale 2: Encouraging the client to talk when ready to do so is an intervention for the denial phase.

Rationale 3: An intervention to support the client in the depression stage of the grieving process is to remain with the client and share on a nonverbal level.

Rationale 4: Contacting a spiritual advisor is an intervention for the bargaining phase.

Global Rationale: An intervention to support the client in the depression stage of the grieving process is to remain with the client and share on a nonverbal level. Offering support and reassurance to the family is an intervention for the acceptance phase. Encouraging the client to talk when ready to do so is an intervention for the denial phase. Contacting a spiritual advisor is an intervention for the bargaining phase.

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34.7 Discuss at least two nursing interventions for each stage of grief.

Page Number: p. 1359 16. A client is nearing death and begins to cry. What should the nurse do to provide emotional care to this client?

1. Stay physically close 2. Offer the client privacy 3. Remove all noxious odors 4. Move the bed near the window Correct Answer: 1 Rationale 1: Staying physically close to the client helps provide emotional care.

Rationale 2: Offering the client privacy enhances the client’s emotional needs. Rationale 3: Removing noxious odors improves the environment for the client. Rationale 4: Moving the bed near the window improves the environment for the client.

Global Rationale: Staying physically close to the client helps provide emotional care. Offering the client privacy enhances the client’s emotional needs. Removing noxious odors and moving the bed near the window improves the environment for the client.

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34.8 Explain what is meant by providing emotional care for the dying client.

Page Number: p. 1364 17. A client with terminal cancer is experiencing mild pain. What analgesic should the nurse provide for this client?

1. NSAID 2. Codeine 3. Morphine 4. Hydrocodone Correct Answer: 1 Rationale 1: According to the World Health Organization Analgesic Ladder for Pain Control an NSAID would be appropriate for mild pain.

Rationale 2: According to the World Health Organization Analgesic Ladder for Pain Control codeine is a step 2 medication.

Rationale 3: According to the World Health Organization Analgesic Ladder for Pain Control morphine is a step 3 medication.

Rationale 4: According to the World Health Organization Analgesic Ladder for Pain Control hydrocodone is a step 2 medication.

Global Rationale: According to the World Health Organization Analgesic Ladder for Pain Control an NSAID would be appropriate for mild pain. Rationale 2: According to the World Health Organization Analgesic Ladder for Pain Control codeine and hydrocodone are step 2 medications. According to the World Health Organization Analgesic Ladder for Pain Control morphine is a step 3 medication.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34.10 Describe the three-step analgesic ladder for pain control for the dying client.

Page Number: p. 1364