Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostend

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 01: Using Evidence in Nursing Practice Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. A nursing educator is explaining how the best clinical practices are determined. Which

statement best explains the purpose of evidence-based practice? a. It ensures that all patients receive holistic care. b. It provides a definite reason for providing care in a specific manner. c. It prevents errors when care is being delivered. d. It guarantees that care delivered is based on research.

ANS: B

Evidence-based practice is the use of the current best evidence in making patient care decisions. It applies to all types of health care professionals. Currently there is no method that can ensure that all patients receive holistic care, that all errors can be prevented, or that a guarantee exists that care given is based on research.

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2. Which question is a problem-focused trigger? a. What is known about reduction of urinary tract infections in the older adult with

diabetes? b. How can chronic pain best be described when the patient is nonverbal? c. How long can an intravenous catheter remain in place in an obese patient? d. What measures can the nurse take to reduce the rising incidence of urinary tract infections on the elder care unit?

ANS: D

A problem-focused trigger is a question faced when caring for a patient or a trend seen in a practice setting. In this example there is a problem (urinary tract infections) and a trend (on the elder care unit). The other questions are general information questions, not based on what is happening in a specific area or to a group of specific patients in an area or relating to an observed trend.

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3. What does the “I” indicate in a “PICO” question? a. Intervention of interest b. Incorporation of concepts c. Implementation by nursing d. Interest of personnel ANS: A

The “I” stands for intervention of interest, meaning what the nurse hopes to use in practice and believes is worthwhile or valuable. This could be a treatment for a specific type of wound or an approach on how to teach food preparation for a patient with impaired sight.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

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4. The nurse is conducting clinical research and needs to obtain relevant databases. Whom

should the nurse contact? a. The physician whose patients may be involved in the study b. The medical librarian c. The nurse manager of the unit where the study will be conducted d. The director of nursing of the facility ANS: B

The medical librarian is most knowledgeable regarding databases relevant to a study. The other individuals will know about the study but do not have the knowledge regarding relevant databases.

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5. Which database contains clinical guidelines systematically developed for a specific set of

circumstances involving a specific patient population? a. MEDLINE b. CINAHL c. Cochrane Data of Systematic Reviews d. The National Guideline Clearinghouse ANS: D

The National Guideline Clearinghouse is a database supported by the Agency for Healthcare Research and Quality. It contaiN nsUcRliSniIcaNl GgT u iB de.liCn O e sMsystematically developed about a plan of care for a specific set of clinical circumstances involving a specific patient population. The others are not as specific and have broader application and references.

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6. The nurse researcher is trying to determine the strongest type of research. Which type of

research would the nurse choose? a. Randomized controlled trials b. A qualitative study c. A descriptive study d. A case-controlled study ANS: A

Individual randomized controlled trials are close to the top of the research pyramid. Only systematic reviews and meta-analyses are higher. This type of study tests an intervention against the usual standard of care. The other types of studies are useful but do not give the same type of information as a randomized controlled trial provides.

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 7. What is the nurse attempting to determine when critiquing the evidence? a. If the potential study is ethical to conduct

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. If there is enough evidence to ask a PICO question and change practice c. If there are any experts in the clinical area to be researched d. If the study is cost-effective if a change in practice occurs ANS: B

Once a literature search is complete and data are gathered about the question, it is time to critique the evidence. The critique tells the nurse if there is enough evidence to answer the PICO question and change practice. The other questions are important to consider when doing the study but are not applicable to critiquing the evidence.

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8. Why is piloting a practice change after conducting a study the best approach to change? a. It ensures that all of the patients involved will benefit from the change. b. It helps identify any issues with implementation on a limited basis. c. It facilitates communication among all of the participants. d. It provides better acceptance by personnel reluctant to change.

ANS: B

Piloting a practice change involves implementing the change for a small group of patients over a limited period of time. This allows identification of issues with the implementation of the practice change(s) to determine if the change(s) result in beneficial patient outcomes. If the pilot is successful, it is easier to make the changes on a larger scale because the issues have been identified. It does not ensure that all patients involved will benefit, nor does it facilitate communication among participants. Difficulty making and accepting change may be experienced by some staff members, no matter how successful the pilot is.

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9. A study is being conducted comparing a group of normal-weight postmenopausal women not

receiving any hormone treatment with a group of obese postmenopausal women not receiving any hormone treatment to determine the incidence of changes in bone density of the lower spine (L4 and below). Which type of study would this be? a. Qualitative b. Case-controlled c. Descriptive d. Quality improvement ANS: B

A case-controlled study examines one group of subjects with a certain condition at the same time as another group of subjects who do not have the condition to determine if there is an association between the condition and predictor variables. A qualitative study examines individuals’ experiences with health problems and the contexts in which the experiences occur (e.g., a group of poststroke patients and how the attitude of the therapist affected their recovery). A descriptive study looks at specific concepts such as health care workers’ perceptions of infection control practices. Quality improvement is not a study but a collection of data reflecting trends and information about clinical conditions and problems.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF:

Cognitive Level: Analyze

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Safe and Effective Care

TOP: Nursing Process: Evaluation

10. Which question would be the best example of a knowledge-focused trigger? a. What is the best method for treatment of leg swelling when a patient is taking

gabapentin (Neurontin)? b. How can we decrease the incidence of skin cancer in adults over the age of 65? c. What is the current evidence for improving oral intake for cancer patients with

stomatitis? d. What is the maximum length of time our hospital allows irrigation kits to be used?

ANS: C

A knowledge-focused trigger is a question regarding new information about a topic. It does not have to be concerned with what is happening on a specific unit or with a specific group of people. The other questions are examples of problem-focused triggers in which a patient problem exists and an approach needs to be found for improving or eliminating the problem.

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11. In which database would biomedical and pharmaceutical studies be found? a. EMBASE b. PsycINFO c. MEDLINE d. CINAHL ANS: A

EMBASE contains biomedical and pharmaceutical studies. PsycINFO contains psychology and related health care disciplinNeU s.RM NB E. inCcO luM des studies in medicine, nursing, dentistry, SEIDNLGIT psychiatry, veterinary medicine, and allied health. CINAHL includes studies in nursing, allied health, and biomedicine.

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MULTIPLE RESPONSE 1. When collecting the best evidence, what should the nurse use as external evidence? (Select all

that apply.) a. Scientific literature b. Agency policy and procedure manuals c. Clinical practice guidelines d. National guidelines e. National benchmarks f. Quality improvement data ANS: A, D, E

Scientific literature such as computerized bibliographical databases, national guidelines, and national benchmarks provide external evidence. The other sources listed provide internal evidence.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

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TOP: Nursing Process: Implementation

2. The nurse is conducting research on decreasing the incidence of pressure areas. Which parts

of an evidence-based article would give the nurse enough information to determine if the article would be of help in the research? (Select all that apply.) a. Design of the study b. Narrative c. Abstract d. Literature review e. Results f. Introduction ANS: C, F

The abstract and the introduction together provide enough information to help the nurse know if the article will provide useful information for the PICO question being asked. The method or design of the study explains how the research study is organized. The narrative includes the purpose statement, methods or design, results or conclusions, and clinical implications. The literature review helps the researcher examine past research on the same topic. The results are embedded in the narrative and summarize the findings.

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MATCHING

Health care providers often confuse evidence-based practices, research, and performance or quality improvement act i v i t i e s .NTUhRe yS eIaN chGcToBn t.riCb uOt M e to the improvement of patient care in different ways. Match the description below with the type of activity it most closely represents. a. The nurse implements a set of guidelines to reduce falls after an extensive review of the literature. b. The nurse investigates a new falls reduction strategy and measures its ability to reduce falls. c. The nurse implements a process in her unit to ensure all patients receive a falls risk evaluation upon admission.

1. Performance improvement 2. Evidence-based practice 3. Research 1. ANS: C DIF: Cognitive Level: Apply REF: Page 3 OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation MSC: Performance improvement works to improve systems or processes so as to improve outcomes within a work unit or health care setting.

2. ANS: A DIF: Cognitive Level: Apply REF: Page 3 OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation MSC: Evidence-based practice applies existing evidence to change a practice (clinical, educational or managerial). It starts with a rigorous review and critique of the literature regarding current evidence-based practices.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 3. ANS: B DIF: Cognitive Level: Apply REF: Page 3 OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf MSC: Research involves generating new scientific knowledge that is generalizable to other patient populations or health care settings.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 02: Communication and Collaboration Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. The nurse interviews a female patient during admission. Which observation by the nurse

identifies congruency in the patient’s communication? a. Asserts she is eager to answer questions while reading a magazine b. States that she wants information while frequently changing the subject c. Asks the nurse to explain a surgical procedure while listening intently d. Explains that she is relaxed while continuously shifting in her chair ANS: C

The patient demonstrates congruency, or consistency, between her verbal statement asking for an explanation and her nonverbal cue of listening intently. The verbal and nonverbal messages match; each indicates that the nurse’s response is important to her. If she is eager to answer questions, the patient should focus on the nurse’s questions or note taking; reading a magazine is a distraction and indicates a lack of interest. Changing the subject may indicate discomfort or reluctance to address the issue. Continually shifting position may be an indication of anxiety.

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2. The nurse is interviewing a patient about his health history. Which statement by the nurse is

most likely to result in effective patient communication?

NURSINGTB. a. “I’m not sure why you’re here. Can you explain it to me?” b. “Tell me about things and people that are important to you.” c. “Tell me more about your pain. Where does it start?” d. “If you think it’s important, I’ll try to notify the provider.”

ANS: C

The nurse communicates effectively by using focused questions. This encourages the patient to give more information about the specific topic of concern. The remaining options are ineffective communication techniques because each impairs the exchange of information between the nurse and the patient. The patient may be unwilling to express concerns openly after the nurse expresses lack of understanding and empathy. The patient will also likely lose confidence in the nurse if the nurse expresses confusion about suitability of the patient’s presence. By asking what is important to the patient, the nurse loses focus of the objective of the communication and is likely to confuse the patient.

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3. After a male patient receives a diagnosis of a fatal disease, he expresses sadness and states

that he does not know what to do next. Which is the most effective response by the nurse to facilitate communication? a. Ask the patient what he finds comforting in his life.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. Reassure the patient that his family will take care of him. c. Refer the patient to a church for spiritual counseling.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf d. Tell the patient that hospice care is available immediately.

ANS: A

Because of the grim diagnosis, the patient expresses confusion and lacks a clear direction. To reduce anxiety, enhance coping skills, and facilitate communication, the nurse provides a calm atmosphere by redirecting and focusing the patient to identify comforting things. The nurse should use comfort measures, hoping that they will reduce tension so the patient can process information and make decisions. Discussing hospice is premature until end-stage disease and because the patient is not thinking clearly. The patient can benefit from a calming atmosphere and time to process the new information. Besides, informing the patient about hospice implies that end of life is imminent. Assuring the patient of family involvement requires consultation with the family first. Spiritual counseling may not be indicated for this patient if the patient does not wish to participate.

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4. A female patient sobs uncontrollably when talking about the recent death of a pet. Which

response should the nurse implement to best provide for her immediate needs? a. Sit with the patient quietly and allow her to cry. b. Provide tissues and promise to come back later. c. Ask why the patient is upset over the pet’s death. d. Encourage her to describe the day she got her pet.

ANS: A

Sitting with the patient demonstrates acceptance, caring, and value for the patient’s experience as she expresses her grief. This is more likely to promote effective communication later because the nurse establishes aNfoUuRndSaItiN onGoTfBtr.uC stObM y respecting, caring, and staying with her.

Providing tissues is indicated; however, leaving the room indicates that the nurse does not value what the patient is experiencing, the nurse does not care, or the nurse is uncomfortable with crying. Questions beginning with “why” ask the patient to justify feelings or actions and thereby can inhibit effective communication as she assumes a defensive position. The patient needs to be able to experience the grief. She will talk when she is ready.

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5. The nurse is preparing to begin the patient hand-off procedure for five patients. Who should

the nurse include in this process? a. Only the licensed nurses b. The unit health care personnel c. The entire interdisciplinary team d. The nurses and healthcare provider ANS: B

All the healthcare personnel on the unit who will be interacting with this group of patients should actively participate in the patient hand-off. This would include nursing assistive personnel (NAP) and the nurses. An interdisciplinary team usually meets when there is a problem with a patient and all the team members need to discuss approaches and plans with Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

and for a patient. The healthcare provider does not participate in the patient hand-off procedure. The provider makes rounds on a specific group of patients.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

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6. The nurse brings the patient’s medications into the room, and the patient shouts, “You don’t

care if I take these, so get out of my room!” Which response by the nurse is most likely to diminish the patient’s anger? a. “Who misinformed you about my feelings?” b. “You seem very angry about the medications.” c. “We know each other; why are you saying this?” d. “I cannot leave until you take these medications.”

ANS: B

To neutralize the situation, the nurse seeks to confirm an impression by sharing an observation about the patient’s actions and encourages the patient to communicate about the anger to help keep him or her in control and elicit more discussion about his or her emotional state. The nurse’s statement also expresses caring and respect for the patient. Questions beginning with “why” are confrontational and not likely to diminish anger. Confronting the patient with questions is more likely to escalate anger and force the patient to justify statements. When the nurse attempts to control the patient by stating that the medications must be administered before the nurse can leave the room, the nurse may succeed in administering the medications; however, controlling behavior is confrontational because the nurse engages the patient in a power struggle and misses an opportunity to explore the patient’s anger. Forcing the patient in this manner is unlikely to elicit patient cooperation in the future because the nurse has displayed a lack of caring and respect.

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7. The patient shouts at the nurse, “No one answered my call bell all night!” Which response

should the nurse use with this patient to restore therapeutic communication? a. “Shouting is going to disturb other patients.” b. “I see how that would make you very angry.” c. “Are you sure the nurses were avoiding you?” d. “The unit has many very sick patients right now.”

ANS: B

Regardless of whether the nurses answered the patient’s call bell during the night, the patient felt ignored. By empathizing with the patient’s distress and reflecting feelings, the nurse displays respect and understanding of his or her experience. Reprimanding the patient is humiliating and conveys the nurse’s lack of regard for the patient’s feelings. Quieting the patient is achievable by displaying empathy, caring, respect, and willingness to hear his or her complaints. Questioning the patient’s perception is demeaning and forces the patient to justify feelings, similar to asking a “why” question. Stating that the unit has very sick patients implies that the patient is not as important as the others are, potentially leads to patient feelings of guilt and shame, and is likely to impair therapeutic communication for making an issue of a lack of attention.

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 8. A male patient with a history of violence directed toward others becomes very excited and

agitated during the nurse’s interview. Which intervention should the nurse implement to foster therapeutic communication? a. Call the security staff for assistance. b. Ask the patient if he will use self-control. c. Lean forward and touch the patient’s arm. d. Assume an open, nonthreatening posture.

ANS: D

The nurse should use neutralizing skills and assume an open, nonthreatening posture that conveys respect and acceptance, creating an atmosphere in which the patient can communicate without feeling threatened or defensive. Depending on the extent of this nurse-patient relationship, the patient can be posturing as they get to know one another; however, before entering the room in the future, the nurse should plan for personal safety by keeping the door open and letting others know that he or she is with the potentially violent patient. Calling security in the patient’s presence is likely to aggravate the patient and escalate the potential for violence because it is humiliating, conveys the nurse’s rejection of the patient, and threatens to take all control away from him. Asking the patient if he will use self-control is reprimanding him, humiliating, and conveys rejection and lack of respect by the nurse. The patient can perceive leaning and touching as threatening.

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9. The nurse admits a patient who is complaining of severe abdominal pain and vomiting who is

nonverbal. What can the nurse do to communicate effectively with the patient? a. Use a communication aid b. Wait for family to arrive c. Call interpreter services d. Treat the pain ANS: A

Patients with sensory losses require communication techniques that maximize existing sensory and motor functions. Some patients are unable to speak because of physical or neurological alterations such as paralysis; a tube in the trachea to facilitate breathing; or a stroke resulting in aphasia, difficulty understanding, or verbalizing. Many types of communication aids are available for use, including writing boards, flash cards, and picture boards. The nurse needs to determine what will work for the patient. Waiting for family is unacceptable because the patient is in pain. Interpreter services are for patients who do not speak the language. The nurse should not just treat the pain without assessing the patient.

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10. The nurse is teaching the patient about weight management, and the patient wants to know

how the nurse manages to stay “so thin.” Which response should the nurse use to maintain therapeutic communication? a. State that nurses cannot discuss personal information with patients. b. Describe a daily routine of walking the family dog to the local park.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. Recognize the question and redirect the discussion to weight management. d. Explain that the patient needs a background in health care to use the nurse’s plan.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: C

After acknowledging the patient’s question, the nurse redirects the conversation to weight management because therapeutic communication is patient centered and goal oriented; however, the communication and the goal do not involve personal details about the nurse because therapeutic communication is not social conversation. Describing a daily routine reveals personal information that belies the nurse-patient relationship. Telling the patient that a healthcare background is needed to implement the nurse’s plan is condescending and conveys a lack of respect.

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11. A patient’s mother died several days ago. The patient begins to cry and states, “The pain of

her death is impossible to bear.” Which statement by the nurse is the most effective response? a. “I was depressed last year when my mother died, too.” b. “I know things seem bleak, but you are doing so well.” c. “I can see this is a very difficult time for you right now.” d. “Should I cancel your appointment with the cardiologist?”

ANS: C

The nurse conveys empathy and respect by acknowledging the patient’s grief. This is an effective response and is likely to enhance the nurse-patient relationship because it is patient centered, displays caring and respect, and helps to make the patient feel accepted. Relating personal details about the nurse’s life redirects the focus of the communication to the nurse and fails to support the objectives of the nurse-patient relationship. Responding with a comment about the patient’s progress and asking about the cardiologist’s appointment ignores the patient’s grief and co nveys Na UlaRckS I o fNrG esTpeBc.t C anOdMconsideration.

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12. A male patient who says that his parents died of heart disease early in life is waiting for

diagnostic testing results. He is biting his nails and pacing around the room. Which statement should the nurse use to clarify patient information? a. “I can see that you are anxious about dying.” b. “Tell me more about your family’s history.” c. “Do you have your parents’ medical records?” d. “I’m not sure that I understand what you mean.”

ANS: B

Asking for more information about the family’s history directs the patient to expand on a specific, pertinent topic and relate key details before moving to another topic. “Early in life” and “heart disease” need to be defined by the patient; “early in life” can indicate a wide range of ages, depending on the definition of “early,” and “heart disease” can mean conditions such as heart failure, coronary artery disease, valve disease, and arrhythmias. Until the patient discusses his particular concerns, the nurse cannot be sure about the source of his anxiety.

Asking for the records can display a lack of respect by implying that the patient is an unreliable source for information. Stating that the nurse is not sure what the patient means is vague, leaving the patient to guess what the nurse wants to know.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

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13. You are working with a patient who is cognitively impaired and you need to provide some

information to them. Which should the nurse implement in response to the patient’s condition? a. Present the interview in written form. b. Repeat the information. c. Have another person finish the interview. d. Focus on the patient’s physical complaints.

ANS: B

Use clear and concise verbal techniques to respond to the patient. Use simple language and speak slowly; use short, simple sentences. Ask yes or no questions, ask one question at a time, and repeat the information. The patient is unable to clearly communicate needs or concerns in the present state because he or she needs comfort and support in a threatening situation.

Having another person complete the interview may convey a lack of respect and lead to patient confusion if the other person does not make sure that the patient understands all the information.

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14. The patient tells the nurse, “I must be very sick because so many tests are being performed.”

Which statement does the nurse use to reflect the patient’s message? a. “I sense that you are very worried.” b. “You mention this so frequently.” c. “We should talk about this N mU oR reS .” d. “You think you must be very sick.”

ANS: D

The nurse reflects the patient’s message by focusing on the feelings the patient identifies, including nonverbal cues, and then clarifying the nurse’s perception with the patient. The nurse follows this statement by encouraging the patient to confirm the perception. Pointing out that the patient has stated this before can be misinterpreted to mean that the patient is forgetful or annoying. Stating that the nurse feels that the patient is worried is a suitable response but does not reflect what the patient actually said. Exploring the topic with the patient is a suitable response but does not reflect the patient’s actual statement.

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15. The patient tells the nurse, “I want to die.” Which is the best response by the nurse to facilitate

therapeutic communication? a. “Now why would you say a thing like that?” b. “Tell me more about how you’re feeling.” c. “We need to tell the provider how you feel.” d. “You have too much to live for to say that.”

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: B

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The patient’s statement warrants further investigation to determine how serious the patient is about dying and whether he or she has a plan. Research on suicide supports the claim that patients with well-established suicide plans are more likely to carry out the plan; thus details about the patient’s feelings on dying and suicide plans are important for preventing self-injury and planning medical therapy, nursing care, and patient safety. To elicit more information from the patient, the nurse allows the patient to expand on the statement, “I want to die” by stating, “Tell me more.” The statement displays concern for and value of the patient by acknowledging the patient’s message and encouraging him or her to continue. Safety is a major concern when a patient wants to die, and the remaining options are unlikely to further the discussion, keep the patient safe, or facilitate therapeutic communication.

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16. The nurse is explaining a procedure to a 3-year-old female patient. Which strategy should the

nurse use for patient teaching? a. Ask the patient to draw her feelings. b. Show needles, syringes, and bandages. c. Tell the patient about postoperative pain. d. Use dolls and stories to explain surgery.

ANS: D

Using dolls, stuffed animals, or puppets with stories is a suitable way to explain surgery to the 3-year-old patient because storytelling is a familiar communication method for the toddler’s developmental stage. A 3-year-old child is unlikely to understand an explanation about the surgery suited for an adult, and the discussion can frighten the child and upset the family or guardian. A 3-year-old child laN ckUsRthSeIfiNnG eT mB ot. orCaOnM d cognitive skills to draw an abstract concept. Needles, syringes, and bandages usually are not shown to patients of any developmental level because many people at various ages are fearful of needles and pain. A toddler is unlikely to understand and probably would be frightened by a discussion about postoperative pain.

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17. The nurse is caring for a patient who states, “I don’t feel well today.” Which is the best

follow-up action to the patient’s statement for the nurse to implement? a. Ask the patient to continue to describe the feeling. b. Measure the blood pressure and temperature. c. State that the patient’s diagnostic testing had normal results. d. Compare recent laboratory results with the prior results.

ANS: A

Because the patient’s statement is too vague, the nurse asks him or her to continue describing, “I don’t feel well today,” because many disorders begin with nonspecific complaints.

Depending on the details the patient shares, the nurse plans and implements nursing care individualized to his or her description. This is a better choice than taking vital signs or checking test results because principles of diagnostics mandate completing the patient history before objective data; a good diagnostician should be able to formulate a reasonable Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

prognostication about the patient’s actual health alteration with the history alone.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Analyze OBJ: NCLEX: Safe and Effective Care

REF: Page 14 TOP: Nursing Process: Implementation

18. The nurse is assessing a patient for pain. Which question is best for the nurse to ask when

determining aggravating factors for a patient’s pain? a. How long has the patient had pain? b. What increases the intensity of the pain? c. Where is the pain located specifically? d. What is the pain level on a scale of 0 to 10?

ANS: B

Aggravating factors make the pain worse or increase its severity, so the nurse asks about what increases the intensity of the pain to determine aggravating factors. The nurse asks the patient about the duration of the pain when asking how long the patient has had it. This is important to know but doesn’t explain any of the factors that either trigger the pain or make it worse.

Asking the patient to identify a specific spot for the pain determines its location but does not identify aggregating factors. Rating the pain on a scale transforms the patient complaint into objective data that are helpful in establishing trends and response to therapy.

DIF: Cognitive Level: Comprehend REF: Page 21 OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning 19. The nurse is caring for a patient who refuses to participate in physical therapy (PT) and states,

“I really don’t like to exercise.” Which response by the nurse is most likely to help engage the patient in PT? a. “It makes the pain worse, doesn’t it?” b. “What don’t you like about exercise?” c. “You really should do theseNeUxR erSciIseNsG .”TB.COM d. “Do you like to do any other activities?”

ANS: B

The nurse asks an open-ended question using the patient’s words to uncover information about the patient’s refusal to participate in PT by asking what the patient dislikes about exercise. Using the patient’s words conveys acceptance and value because the nurse listened closely enough to repeat what the patient said; in addition, the nurse is asking the patient to continue describing his or her pain to uncover factors that can be resolved or other issues requiring follow-up care and ultimately result in patient participation. Asking the patient a yes-or-no question such as, “It makes the pain worse, doesn’t it?” is unlikely to promote further discussion. Telling the patient to do the exercises is giving advice; rather the nurse can tell the patient the reason for the therapy and the benefits of doing it or the risks of not doing it. Asking about other activities moves the focus away from the patient’s need for physical therapy.

DIF: Cognitive Level: Application REF: Page 14| Page 17 OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation 20. The nursing staff is using the SBAR communication technique during patient hand-off

communication. The circumstances leading up to the current status would be explained by the nurses during which step of the technique?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. Situation b. Background

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. Assessment d. Recommendations ANS: B

The background explains circumstances leading up to the situation. The situation explains what is happening at the present time. The assessment phase identifies what the problem is thought to be. The recommendations explain how to correct the problem.

DIF: Cognitive Level: Remember OBJ: NCLEX: Safe and Effective Care

REF: Page 28-29 TOP: Nursing Process: Planning

21. The nursing staff is working with a postoperative patient from another culture who does not

understand or speak the English language well. Which approach by the nurse would be best? a. Act out what the patient needs to do. b. Obtain a medical interpreter. c. Assess how much the patient is able to communicate in his native language. d. Talk slowly when instructions are given.

ANS: B

A medical interpreter would be most helpful for effective communication. A translator restates the words from one language to another, whereas an interpreter decodes a patient’s words and provides meaning behind the message. Acting out what the patient needs to do is ineffective and may be embarrassing to both the patient and the nurse. Since the patient and nurse do not speak a common language, defining the patient’s ability to speak in his native language does not solve the communication problem. Talking slowly will not improve the patient’s ability to understand an unfamiliar language.

DIF: Cognitive Level: RemembN erURSINRGETFB : .PC agOeM15 OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning 22. The following statement best describes which phase of the nurse-patient relationship:

“Mr. James, we have reviewed the changes in your diet and insulin dosage to help you improve your HgA1c levels. I would like to see you back in 4 weeks.” a. Orientation phase b. Termination phase c. Interim phase d. Working phase ANS: B

In the termination phase, the nurse summarizes with the patient what they have discussed during interaction and/or interview, including goal and achievement. The orientation phase occurs at the beginning and creates the climate of trust. The working phase is where the information is gathered. There is no interim phase.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 20-21 TOP: Nursing Process: Assessment

23. The nurse is working toward discharging a patient. Which of following demonstrates patient

engagement during the discharge process?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. Teaching the patient how to use his equipment b. Having the patient establish daily goals c. Reviewing the discharge instructions with the patient

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf d. Including the family in the discharge planning ANS: B

All of the answers are important to the discharge process but having the patient set his own daily goals establishes true patient engagement. The other interventions are aimed at the patient and are not really engaging the patient but rather the nurse focusing interventions at the patient. Patient engagement requires that the patient’s preferences be incorporated.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 29-30 TOP: Nursing Process: Planning

MULTIPLE RESPONSE 1. During a home care visit, the patient experiences an angry outburst and hits the nurse on the

thigh and yells at her. The patient continues to be threatening. What are the appropriate initial actions by the nurse? (Select all that apply.) a. Call for a family member who lives down the street. b. Call law enforcement to take the patient to the hospital. c. Tie the patient to the bed. d. Yell at the patient to stop being threatening. e. Call the nursing agency. f. Use a calm, quiet voice when talking with the patient.

ANS: A, E, F

A nearby family member may be able to calm the patient. Notifying the nurse’s employing agency is essential. The agency needs to know the situation and can give some guidance.

Using a calm, quiet voice requires the patient to be quieter to hear what the nurse is saying. It NURSINGTB.C also denotes to the patient that the nurse is not a threat. The other actions are not appropriate yet. More assessment and intervention should be tried first. Restraining the patient without orders is never appropriate.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Safe and Effective Care

REF: Page 24 TOP: Nursing Process: Planning

2. The female patient scheduled for an invasive procedure the next day complains of headache

and nausea and knocks over a glass of water. Which intervention(s) should the nurse implement for therapeutic communication? (Select all that apply.) a. Explain the procedure briefly. b. Teach with the patient’s partner present. c. Give the patient written information. d. Tell the patient that she seems overwhelmed. e. Ask if this is her first hospitalization. f. State that the procedure can be cancelled.

ANS: A, B, C, D

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

To manage the situation, the nurse can provide a brief explanation of the procedure and build on the information later. The patient seems very anxious about the procedure, as demonstrated by knocking over the glass, but the nurse must confirm that suspicion because a migraine headache can be developing and the water can be a simple accident. Teaching with another person present is usually a good idea, lending emotional support to the patient and, together with the patient, listening to instructions and explanations. Providing written information is suitable as long as it is not the only information shared with the patient. To confirm any suspicions, the nurse validates conclusions before acting on assumptions. The other responses show a lack of respect for the patient and do not address her needs.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 14 TOP: Nursing Process: Planning

3. Which of the following pieces of information should be included in a hand-off to ensure

patient safety? (Select all that apply.) a. Code status b. Recent changes in patient condition c. Age d. Family visitation e. Use of oxygen ANS: A, B, E

It is important to include information on a patient’s background, assessment, nursing diagnosis, interventions (including the patient’s response), family information, discharge plans, and current priorities when handing off your patient to another unit or area. However, only code status, recent changes in patient condition, and use of oxygen directly impact patient safety.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 28 TOP: Nursing Process: Intervention

MATCHING

When interviewing a patient, it is important to determine additional information about each symptom the patient reports. Match the dimension of the symptom with the corresponding question to ask. a. Location b. Quality c. Severity d. Timing e. Setting f. Aggravating or alleviating factors 1.

2.

3.

4.

5.

“What is the worst it has been?”

“Does it occur in a particular place or under certain circumstances?”

“When does it change?”

“Does it move around?”

“What is it like? Sharp, dull, stabbing, aching?”

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 6. “How often does it happen?”

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 1. ANS: C DIF: Cognitive Level: Apply REF: Page 21 OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Assessment MSC: This question evaluates severity.

2. ANS: E DIF: Cognitive Level: Apply REF: Page 21 OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Assessment MSC: This question asks in what setting the symptom occurs.

3. ANS: F DIF: Cognitive Level: Apply REF: Page 21 OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Assessment MSC: This question addresses what makes it better or worse.

4. ANS: A DIF: Cognitive Level: Apply REF: Page 21 OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Assessment MSC: This question identifies the location of the symptom.

5. ANS: B DIF: Cognitive Level: Apply REF: Page 21 OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Assessment MSC: This question asks about the quality of the symptom.

6. ANS: D DIF: Cognitive Level: Apply REF: Page 21 OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Assessment MSC: This question asks when it occurs.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 03: Documentation and Informatics Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. The nurse discovers a medication error on another nurse’s documentation, so the nurse

completes an incident report. Which statement should the nurse include in the report? a. “Nurse mistakenly gave the wrong dose of medication for pain.” b. “Nurse gave incorrect dose of pain medication, but patient is all right.” c. “Morphine 10 mg IM given rather than morphine 5 mg IM as ordered.” d. “Physician will be notified of error when he makes rounds tomorrow.”

ANS: C

Stating that the patient received morphine 10 mg instead of 5 mg is a factual statement to include on an incident report because it is objective and provides no interpretation or conjecture from the nurse. The remaining choices are incorrect statements that do not accurately reflect what occurred. The physician needs to be notified as soon as the patient has been assessed, not the following day.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 42 TOP: Nursing Process: Implementation

2. The nurse is documenting the care of a patient. Which entry would be characteristic of

charting by exception (CBE) as a documentation method? a. The patient needed to be turned every hour because of increasing pain. b. The patient’s vital signs are stable. c. The patient’s gait was steady with assistance from physical therapy. d. There was no odor when the dressing was removed.

ANS: A

CBE allows the nurse to specify exceptions to normal nursing assessments efficiently without documenting the normal assessment data and reducing the amount of narrative writing in patient documentation. The emphasis is on recording abnormal findings and trends in clinical care. It is a shorthand method for documenting based on defined standards for normal nursing assessments and interventions. CBE simply involves completing a flow sheet that incorporates these standards, thus minimizing the need for lengthy narrative notes. Increasing pain would not be expected and would be outside the “normal” or “expected.”

DIF: Cognitive Level: Understand OBJ: NCLEX: Safe and Effective Care

REF: Page 39 | Page 41 TOP: Nursing Process: Assessment

3. The nurse is documenting on a patient with a respiratory problem. Which patient datum

documented by the nurse is the least objective? a. Cool and dusky skin b. Low flow rate oxygen c. 30 breaths per minute d. Very restless and drowsy Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: B

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Low flow rate oxygen is the least objective datum and the datum most subject to interpretation because the quantity of oxygen is not as precise as “liters/minute” or the “percentage” of oxygen. The remaining options provide more verifiable data.

DIF: Cognitive Level: Understand OBJ: NCLEX: Safe and Effective Care

REF: Page 40 TOP: Nursing Process: Assessment

4. The nurse runs into a co-worker whose family friend is a patient on the unit. The co-worker

asks about the friend’s health problems. Which is the correct response by the nurse? a. “Your friend told us to say nothing.” b. “Why don’t you ask your friend now?” c. “You know I can’t talk about the patients.” d. “Well, it was really a very difficult surgery.”

ANS: C

The nurse can’t talk about the co-worker’s friend or acknowledge the friend’s presence in the facility without breaching the friend’s right to privacy, so the nurse reminds the co-worker about confidentiality.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 36 TOP: Nursing Process: Planning

5. The nurse is providing home care for a patient with an infection that is not improving. The

patient refuses to see an infectious disease specialist. What should the nurse include in the documentation of the patient teaching provided? a. The discussion about the consequences of refusing to see a specialist and the patient’s response b. The explanation that avoi diN ngU tRhS eI spNeG ciT alB is. t wCiOll Mmost likely lead to a terrible outcome c. A hopeful explanation that this will most likely be the last medical specialist that the patient will need to see d. The recommendation that the patient should discuss the decision with the family ANS: A

The nurse documents the discussion about the consequences of refusing to see a specialist and the patient’s response. Documenting the factual information presented about the risks of refusing treatment and the patient’s specific response to it (continued refusal to seek a specialist) are key pieces of information to include. The nurse should neither try to scare the patient into seeing the specialist nor provide false hope that only one consultation will be required. As long as the patient is competent to make a decision, the nurse must accept his or her choice. It is a requirement to document the facts surrounding that choice.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 37 TOP: Nursing Process: Assessment

6. The nurse documents patient care using the SOAP format. Which should the nurse record

under the “P” section? a. AM fasting serum glucose level at 122 mg/dL b. Patient states, “I am too tired to walk today.”

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. 2 cm–diameter open area on left lateral heel d. Check response to pain medication in 1 hour.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: D

“P” in the SOAP format stands for “plan.” Checking the response to pain medication is recorded at “P” because the plan is a future strategy for nursing care and the nurse chooses nursing interventions to accomplish the plan. Patient statements are subjective data recorded at “S.” The serum glucose and the wound description are objective data, or facts, recorded at “O.” DIF: Cognitive Level: Comprehension OBJ: NCLEX: Safe and Effective Care

REF: Page 40 TOP: Nursing Process: Planning

7. At 9:15 AM the nurse repeatedly instructs the patient to remain in bed. At 9:30 the nurse

enters the patient’s room, finds the patient on the floor, and hears the patient say, “I need pain medicine.” Which should the nurse do to document this event? a. Label the late entry using the time of 9:15 AM b. Enclose the patient statement within quotations c. Document completion of an incident report d. Record medication before its administration ANS: B

The nurse encloses patient statements in quotations to indicate the patient’s precise statement.

Subjective information is documented using the patient’s words in quotes. The nurse should document instructions given at 9:15 and verify any indications of patient comprehension. A second entry noted at 9:30 documents finding patient on floor.

Completion of an incidence report is not documented in the patient record since it is an internal evaluation report. Administration of medication is only documented after it occurs to make sure that the documentation is accurate in terms of time and patient response.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 37 TOP: Nursing Process: Implementation

8. A nurse passes by a computer screen that has patient information that can be seen by visitors.

What is the appropriate action for the nurse to take at this time? a. Leave the computer screen alone. b. Try to find the nurse caring for this patient. c. Document this situation on an incident report. d. Close the computer screen.

ANS: D

The nurse should minimize or close the computer screen so patient information cannot be seen by visitors. He or she should talk with the nurse caring for this patient about what happened. It happens frequently and can be prevented easily. All facility staff have a responsibility to maintain patient confidentiality and should not leave a computer displaying patient information open. Incident reports are only filed when a patient experiences an adverse event.

This situation does not require an incident report.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 36 TOP: Nursing Process: Implementation

9. Nursing assistive personnel (NAP) finds a patient on the floor 30 minutes after the patient Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

ambulated with physical therapy. What information should be charted by the NAP on the incident report?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. b. c. d.

“Patient fell out of bed and landed on the floor.”

“Patient found on floor. Upper side rails up. Bed in low position.”

“Patient got dizzy and fell although ambulated with physical therapy earlier.”

“Patient unfortunately slipped and fell.”

ANS: B

Documentation should state facts: “Patient found on floor. Upper side rails up. Bed in low position.” Only objective data with no interpretation can be documented by the NAP. The NAP does not evaluate the situation. Words such as “unfortunately” are never used in documentation. The NAP found the patient on the floor and did not see the patient slip and fall.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 37 TOP: Nursing Process: Implementation

10. An incident report is completed as a result of the pharmacy sending the wrong medication to

the unit, even though the medication wasn’t administered. Why would the nurse initiate an incident report? a. To make sure that the pharmacy was blamed for the error and not the nurse b. To help the pharmacy identify risks and prevent this situation from occurring again c. To prevent the hospital from a medical malpractice suit d. To get the healthcare provider’s attention about ordering medications ANS: B

The incident report is a risk management tool that enables healthcare providers to identify risks within an agency, analyze them, and act to reduce the risks and evaluate the results. This is also true when deviations from standards occur and not only when actual adverse events happen. Alerting the p h a r m ac yNt oU tRh S i s It yNpGe T ofBe.rrCoO r sMhould help prevent it from occurring again. There was no problem with the healthcare provider’s order, only with how it was filled.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 42 TOP: Nursing Process: Implementation

11. The “PIE” format is used on the nursing unit. Which entry should the nurse place in the “E”

part of the format? a. Pain level 4/10 gnawing and constant. b. Lung sounds clear bilaterally. c. Patient states, “I don’t want the blood transfusion because of the problems I had before.” d. Pain level 2/10 30 minutes after receiving pain medication.

ANS: D

In PIE, E stand for evaluation. “Pain level 2/10 30 minutes after receiving pain medication” is an evaluation based on an action taken in response to a problem. None of the other options are evaluation statements.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 40 TOP: Nursing Process: Implementation

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 12. The nursing staff has been using the SBAR format to structure communication for the past

few months. Successful implementation of this system would be present if the nurse manager made which statement?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. b. c. d.

“There are fewer omissions in patient care than before implementing this system.”

“Fewer nurses are coming in late when they are scheduled to work.”

“The medications are given on time now.”

“The patient length of stay has decreased since last year.”

ANS: A

Noting fewer omissions in patient care would indicate successful implementation of the SBAR format. SBAR promotes the provision of safe, efficient, timely, and patient-centered communication. Staff timeliness, medication preparation, and length of patient stays are not affected by implementation of SBAR. DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 39 TOP: Nursing Process: Implementation

13. The nursing staff is assisting nursing students in learning military time for documenting.

Instruction by the nurses has been effective if the students identify that which entry reflects 40 minutes after midnight? a. 0040 b. 1240 c. 0004 d. 0400 ANS: A

0040 is 12:40 AM. 1240 is 12:40 PM. 0004 is 12:04 AM. 0400 is 4:00 AM. DIF: Cognitive Level: Understand OBJ: NCLEX: Safe and Effective Care

REF: Page 38 TOP: Nursing Process: Implementation

14. The nursing staff is using a worksheet that contains information for change-of-shift report and

facilitates access to information when referring to the patient’s computerized record. Which document is the nursing staff using? a. The graphic sheet b. The nursing Kardex c. The problem-oriented medical record d. The Joint Commission standards ANS: B

The nursing Kardex contains information for change-of-shift report and facilitates access to information when referring to the patient’s computerized record. It is not part of the patient’s permanent record and is often recorded in pencil so changes can be made to provide an updated status report of the patient. The graphic sheet contains places for frequently monitored situations done on a repeated basis such as vital signs, bathing, turning, and intake and output. The problem-oriented medical record is a method of organizing data by the patient problem or diagnosis. Each member of the healthcare team can document on the same problems and add new ones. The Joint Commission sets the standards for documentation of health care but has not developed a specific form for everyone to use.

DIF: Cognitive Level: Remember OBJ: NCLEX: Safe and Effective Care

REF: Page 41 TOP: Nursing Process: Planning

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 15. The following is an example of what part of the SBAR communication mnemonic?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

“Her blood pressure has decreased from 140/90 to 100/50 and she vomited 400 mL of bright red blood.” a. S b. A c. R d. B ANS: A

This is an example of S-Situation—what is happening at the present time. Background (explain the circumstances leading up to the situation). Assessment (what you think the problem is). Recommendation (what you would do to correct the problem) DIF: Cognitive Level: Apply REF: Page 39 OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation MULTIPLE RESPONSE 1. Electronic health records (EHRs) can improve patient care. The following is an example of an

alert in an EHR. (Select all that apply.) a. Notification of medication being overdue b. Change in patient’s blood pressure that exceeds parameters c. Order entered for a medication the patient is allergic to d. Routine lab orders e. Critical lab value ANS: A, B, C, E

Alerts in EHRs notify nurses of critical changes in data that affect patient care and can be used NURSINGTB.CO to help nurses prioritize care. Overdue medications, critical lab values, and medication allergies are some of the examples of standard alerts. Alerts can also be tailored to patients to monitor for changes in their vital signs above certain parameters. When electronic health record alerts are used in the nurse’s practice, patient outcomes can be improved.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 36 TOP: Nursing Process: Evaluation

2. The Joint Commission standards require all patients admitted to a healthcare facility to have

the following documented. (Select all that apply.) a. Self-care assessment b. Discharge planning needs c. Environment assessment d. Physical assessment e. Psychosocial assessment ANS: A, B, C, D, E

Current TJC (2012) standards require that all patients who are admitted to a healthcare facility have an assessment of physical, psychosocial, environmental, self-care, patient education, and discharge planning needs.

DIF: Cognitive Level: Comprehension REF: Page 37 Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Assessment

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 3. The following is an excerpt of a discharge planning note. What elements of discharge

planning are present in this example? (Select all that apply.)

“Discussed learning about insulin injection technique. Patient will administer his own injection next time.” a. Measurable patient goal b. Progress toward goal c. Need for referral d. Discharge date ANS: A, B

The information within a recorded entry must be complete, containing appropriate and essential information. There are criteria for thorough communication for certain health situations. For example, when recording discharge planning, measurable patient goals or expected outcomes, progress toward goals, and need for referrals are always included.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 38 TOP: Nursing Process: Assessment

4. In a POMR charting method of documentation, which of the following items are used? (Select

all that apply.) a. Progress notes b. Database c. Medical diagnosis d. Problem list e. Care plan ANS: A, B, D, E

The problem-oriented medical N reU coRrS d I( PNOGMTRB).i sCaOsMt r u c t u r ed method of documentation that emphasizes a patient’s problems. It is organized using the nursing process. Organization of data is by problem or diagnosis. Ideally each member of the healthcare team contributes to a single list of identified patient problems. Each recording includes a database, problem list, care plan, and progress notes.

DIF: Cognitive Level: Understand OBJ: NCLEX: Safe and Effective Care

REF: Page 39 TOP: Nursing Process: Assessment

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 04: Patient Safety and Quality Improvement Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. The nurse is caring for a 79-year-old male who has a non–weight-bearing cast on the left

lower extremity. The patient ambulates without using a walker despite repeated instruction from the nurse to call for assistance. Which response by the nurse is most likely to keep the patient from falling? a. Apply a vest restraint and offer frequent toileting. b. Plan fall prevention with patient, family, and healthcare provider. c. Inform family that the patient needs physical restraints. d. Document that the patient has a high potential for falling.

ANS: B

Planning an individualized fall prevention program with the help of the patient, family, and healthcare provider is more likely to reduce the patient’s risk of falls because he gains some control over the plan of care and still benefits from the input of the provider, family, and nurse and the fall prevention program. A combination of interventions is more useful in preventing falls. Including the patient in planning also gives him ownership of the plan, making it less likely that he will disregard a plan he helped to design. Vest restraints are associated with serious injuries and are not recommended for use. Documenting the patient’s risk is important because it communicates the information and records the nurse’s acknowledgment of the risk, but it is not as effective as engaging the patient in planning care as a prevention technique because it is indirect. Alternative methods of engaging the patient in a care plan that minimizes risks should be exhaNuU stR edSbIeN foGreTrB es.oC rtiOnM g to restraints.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Safe and Effective Care

REF: Page 48-49 TOP: Nursing Process: Implementation

2. The nurse plans a fall prevention program for a confused patient. Which task from the

program is suitable for the nurse to delegate to nursing assistive personnel (NAP)? a. Evaluating patient understanding of fall prevention plan b. Keeping the patient’s bed in the low position at all times c. Assessing the patient’s circulatory and respiratory status d. Instructing the patient’s family about alternatives to restraints ANS: B

The nurse may delegate keeping the bed lowered to the NAP because the NAP is trained to perform the task with proper nursing supervision. Skills used to prevent falls can often be delegated. The nurse does not delegate the remaining options because they involve aspects of the nursing process that require the advanced training of a nurse to perform.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 49 TOP: Nursing Process: Planning

3. The nurse plans care for a patient who requires physical restraint. Which is a suitable goal for

this patient?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. The patient remains free of any injury. b. The nurse checks the restraint every hour.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. The nurse uses the least restrictive restraint. d. The patient allows the nurse to apply restraints.

ANS: A

When restraints become necessary, the patient must remain free of injury; thus the nurse plans frequent neurovascular checks and removes the restraint on a regular basis to inspect the skin for pressure points and breakdown and perform range-of-motion exercises to maintain joint flexibility. Checking the restraint is a nursing intervention; it is not a goal because it is not patient centered. Using the least restrictive restraint can defeat the purpose of a restraint.

When a restraint is required, the nurse uses the proper restraint to keep the patient safe and facilitate the therapeutic regimen. This is not a suitable goal because it focuses on the nurse. If the patient or staff members’ safety is at risk, the nurse applies restraints without the patient’s permission.

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4. The nurse applies a physical restraint to the patient. Which entry should the nurse make after

applying physical restraints? a. Performed restraint application reluctantly b. Applied bilateral soft lamb’s wool wrist restraints; skin pink, moist, and intact c. Will perform a neurovascular assessment every 4 hours d. Checked provider’s prescription for prn restraints ANS: B

The nurse documents the type of restraint applied and the condition of the skin where the restraint was placed in the progress notes to communicate the information to the healthcare N eUnRt S Ments about the nurse. Neurovascular team. The nurse does not d o c u m suIbN jeG ctT ivB e. stC atO em assessments of a patient’s extremity must take place at least every 2 hours because skin breakdown can occur very quickly. The nurse does not accept prn prescriptions for restraints according to nursing standards and federal regulations.

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REF: Page 63 TOP: Nursing Process: Apply

5. The patient sustains a minor leg abrasion and stops breathing for a few seconds during a grand

mal seizure. Which is the best nursing documentation after the patient’s seizure? a. Type of muscle contractions b. Size and description of the abrasion c. Length of the patient’s apneic episode d. Description of the seizure in detail ANS: D

Describing the seizure in detail is the best documentation after a seizure because it is the most comprehensive item listed and includes the type of muscle contractions observed during the seizure, the description of injuries, how the injuries occurred, and the description of any breathing abnormalities.

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Cognitive Level: Analyze

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Safe and Effective Care

TOP: Nursing Process: Implementation

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 6. A patient at risk for falling is being ambulated. Which action by the nurse is most important to

prevent the patient from falling? a. Raising the bed to an appropriate working height b. Placing nonskid shoes on the patient c. Dangling the patient on the side of the bed for 10 minutes d. Turning on the brightest lights in the room ANS: B

Placing nonskid surfaces on the patient’s feet helps to prevent falls. The height of the bed should be as low as possible before attempting to have the patient stand. Dangling prevents dizziness, but the length of time differs, and it is not required for all patients. Adequate light is important, but the brightest lights are not needed.

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7. The nurse is orienting a group of new nurses and explaining the concept of sentinel events and

their causes. What should the nurse explain as the number one root cause of all sentinel event reports to The Joint Commission? a. Medication errors b. Falls c. Communication failures d. High patient-to-nurse ratios ANS: C

Communication failures are the number one root cause of all sentinel events reported to The Joint Commission. A sentinel event is an unexpected occurrence involving death, serious physical or psychological i n j u r Ny,UoRr S risIkNthGeTreBo. f. CAOltM hough the other elements may cause sentinel events, they are not the number one root cause.

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8. The nurse discovers smoke in the second floor utility room. What intervention should he or

she implement first? a. Find the fire extinguisher and try to extinguish the fire. b. Evacuate the entire second floor to the first floor lobby. c. Rescue any patients, visitors, or staff in immediate danger. d. Pull the nearest alarm box and call the telephone operator.

ANS: C

The first step after identifying an actual or potential fire is to rescue victims at risk for injury from the fire, including patients, visitors, or staff, to reduce injuries from the fire. The second step is to activate the alarm. The third step is to contain the fire: find the extinguisher and empty the container onto the fire or source of the smoke. Finally the evacuation begins if the fire is uncontrolled or the smoke is excessive. This follows the acronym RACE. DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 9. The daughter of a female patient tells the home health nurse that using the bathroom is

embarrassing for the patient and she refuses to use a call light when she needs to get up.

Which is the best response by the nurse? a. Ask the patient why she does not use the call light. b. Instruct the daughter to remain at the patient’s side. c. Tell the patient that home visits require patient cooperation. d. Discuss call light alternatives with patient and daughter.

ANS: D

Discussing call light alternatives with the patient and daughter is the best method of engaging the patient in planning nursing care. This recognizes the patient as the source of control and full partner in providing compassionate and coordinated care based on respect for the patient’s preferences, values, and needs. Including the patient in planning alternatives also gives her ownership of the plan and increases the likelihood of cooperation. Asking a “why” question is not an ideal response because it is confrontational and requires the patient to justify feelings.

Remaining with the patient is an impractical solution for home care.

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10. Although the interdisciplinary team is responsible for the safety of the patient, who has the

ultimate responsibility for making the patient’s bedside area safe? a. The nurse b. Housekeeping c. Nursing assistive personnel (NAP) d. The maintenance department ANS: A

The nurse has the ultimate responsibility for making the patient’s bedside area safe. Other personnel assist with their specific roles, but the nurse oversees the safety.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Safe and Effective Care

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11. The nurse listens to a family’s request to bring a few familiar items into the room of a patient

who is confused. How does the nurse justify the decision to allow personal items? a. Personal items can increase patient agitation. b. Personal items can restore cognitive function. c. Personal items are likely to alienate the patient. d. Personal items can comfort a confused person.

ANS: D

Personal items can comfort and calm a confused person because familiar items are part of the patient’s customary environment, patterns, and habits; in addition, these items personalize an otherwise strange environment and surround the patient with recognizable things. The personal items are likely to engage the patient but on their own do nothing to restore cognitive function.

DIF:

Cognitive Level: Analyze

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Safe and Effective Care

TOP: Nursing Process: Planning

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 12. The nurse plans a restraint-free environment but cannot find activities to engage an agitated

middle-aged patient. Which should the nurse implement to maintain the patient’s safety? a. Request help from interdisciplinary team members. b. Transfer the patient to a private room to protect others. c. Document that the patient is uncooperative and hostile. d. Ask the healthcare provider for a sedation prescription.

ANS: A

A nurse’s expertise does not include occupational therapy, so the nurse collaborates with other experts to meet the patient’s safety and psychosocial needs. After assessing the patient, the experts make recommendations, and the nurse incorporates the activities into the patient’s plan of care. Putting the patient in a private room decreases the risk of injury to other patients; but it isolates the patient, increases the need for distraction, and increases the risks to the staff and patient. Documentation should always be descriptive and never judgmental. In this case the nurse would document: “The patient stated, ‘Stay away.’” Sedation increases the risk of falls from potential adverse effects, including hypotension, dizziness, and confusion.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

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13. A patient has been wandering and is at risk for falling. Which approach by the nurse regarding

the use of chemical and physical restraints in the long-term care setting should be considered initially? a. Use nonprescription restraints first. b. Obtain with a telephone prescription. c. Implement alternative measures first. d. Notify patient’s family withNin 24ShIoN urGs.TB.COM UR ANS: C

According to the standards governing the use of restraints, the nurse must implement several alternative measures in a serious attempt to avoid applying restraints. The patient must be assessed by the healthcare provider before restraints are implemented unless the patient is a serious and imminent risk to self and others. The patient’s family is notified in a timely manner but is not an initial consideration.

DIF: Cognitive Level: Remember OBJ: NCLEX: Safe and Effective Care

REF: Page 54 TOP: Nursing Process: Planning

14. The nurse plans a safety program for the patients on a medical-surgical unit. Which patient

has the greatest likelihood of falling? a. A 79-year-old after a pacemaker battery replacement b. A 68-year-old anemic who is dehydrated and has heart failure c. A 21-year-old fresh postarthroscopy after a college football injury d. A 33-year-old post–right salpingectomy for ectopic pregnancy ANS: B

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The patient with anemia and dehydration with heart failure has the highest risk of falling. The patient will be taking other medications, including antihypertensive agents that increase the risk of falls caused by confusion, dizziness, or orthostatic hypotension. The replacement of a pacemaker battery in a stable patient is a low-risk, routine procedure. The 21-year-old recovering from the arthroscopy is most likely a healthy adult who is stable while ambulating.

The 33-year-old postsalpingectomy is most likely to be healthy but may be a little hypotensive if much bleeding occurred before surgery.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Safe and Effective Care

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15. The nurse finds the patient pulling on the nasogastric tube (NGT) and surgical drain and fears

that the patient will pull them out. Which nursing intervention should the nurse implement to maintain the patient’s self-esteem and avoid applying restraints? a. Cover or camouflage tubes and drains. b. Provide constant activity for the patient. c. Instruct family members to watch the patient. d. Keep the patient close to the nurses’ station.

ANS: B

The nurse keeps the patient busy with nursing care and activities that provide an effective distraction to limit awareness of the NGT and surgical drain; in this manner the nurse avoids the need for restraints and maintains the patient’s self-esteem. Covering or camouflaging the tubes is unlikely to be an effective method of avoiding restraints because the patient is likely to find the tubes despite the disguise. Engaging the family in the care of the patient is reasonable; however, the nurse does not rely on the family to provide nursing care. Keeping the patient out by the nurses’ stNatUioRnSaI llow he.nCuO rse to observe the patient closely; however, NGsTtB this is likely to lower the patient’s self-esteem because his or her problem is on public display.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

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16. The female patient wearing bilateral wrist restraints complains that her hands are numb; and

the nurse assesses pale, cool fingers. Which is the nurse’s priority intervention? a. Notify the provider quickly. b. Remove the wrist restraints. c. Try another type of restraint. d. Increase the restraint padding.

ANS: B

The patient displays clinical indicators of neurovascular impairment, and a delay in resolving the problem can result in tissue damage, so the nurse removes the restraint, thoroughly assesses the extremities, and plans nursing care. Before another type of restraint is applied, the nurse completes the assessment and notifies the provider as necessary. Increasing the padding is a reasonable intervention after the nurse’s assessment and provider notification.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Safe and Effective Care

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 17. The patient is having a generalized tonic-clonic seizure. To maintain the airway, which

intervention should the nurse implement after the patient’s motor activity ceases?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. b. c. d.

Apply chin-lift position.

Insert a curved oral airway.

Sit the patient in upright position.

Turn the patient on his side.

ANS: D

Patients who have been rolled onto their side during a major motor seizure are at greater risk for self-injury, such as a dislocated shoulder. Since patients are not breathing during a generalized tonic-clonic seizure, they are not at high risk for aspiration until the event ends.

Immediately following such a seizure, patients usually take a deep breath. Therefore, a patient should be rolled over onto his or her side immediately after the motor activity ceases. Chin-lift is an effective method of maintaining a patient’s airway; however, it does not protect the patient against aspiration. Oral airways are not inserted during a seizure unless the patient’s jaw relaxes enough to properly insert the airway without causing tissue damage. The upright position is contraindicated for airway maintenance.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

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18. The nurse is instructing a male patient who has a difficult-to-control seizure disorder on home

care issues. Which issue affecting safety is most important for the nurse to address with patient teaching before discharge? a. Avoiding substances containing alcohol b. Maintaining a current list of medications c. Keeping a supply of medications at work d. Purchasing lawn equipment with a safety switch ANS: D

The most important issue to address is to have him purchase any motorized lawn equipment with a safety switch that will stop the machine when the handle is released. Thus the patient avoids injury if he has a seizure while operating the equipment. Although the patient should avoid alcohol to decrease the risk of possible alcohol-drug interactions, and he should keep a list of current medications to avoid confusion over his therapeutic regimen, failure to do so poses a risk only to himself. Likewise, although keeping a supply of medication at work is a good idea, it is not a safety risk not to do so.

DIF: Cognitive Level: Analysis OBJ: NCLEX: Safe and Effective Care

REF: Page 70 TOP: Nursing Process: Planning

19. A child had surgery on his face and needs to keep his hands away from it. Which restraint

should the nurse use to accomplish this outcome? a. A jacket restraint b. Mitten restraints c. A mummy restraint d. Elbow restraints ANS: D

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse applies bilateral elbow restraints so the child cannot touch the operative area. They prevent elbow flexion. The child will still be able to hug the parent or hold onto objects.

Mitten restraints are inadequate because the hands could still access the face. A mummy restraint is used for short-term examination of a child. Although it does confine, the mummy restraint is more like swaddling. The use of jacket restraints has been discouraged because of safety risks associated with their use.

DIF: Cognitive Level: Remember OBJ: NCLEX: Safe and Effective Care

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20. The nurse participates in the investigation of an incident in the facility. As a result of the root

cause analysis, what would the nurse expect as the ultimate outcome? a. Identification of the person at fault b. An appropriate punishment for the individual who caused the event c. Reason the event occurred d. A plan for the prevention of this event ANS: D

A plan for prevention of a similar event happening again is the ultimate outcome of this investigation. The investigation will determine all contributing factors in the occurrence of the event, with the goal of identifying methods to prevent those failures from recurring.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 46 TOP: Nursing Process: Planning

21. The nurse is giving report to the next shift and describes how it is important to maintain a

regular schedule for Mr. Jones, a confused elderly man who wanders. Why is it important for this intervention to be maintainNedU?RS a. Regular routine helps nurses find the patient early if he wanders. b. Regular routine decreases his confusion. c. Regular routine decreases wandering. d. Regular routine decreases stress.

ANS: C

The Department of Veterans Affairs has many suggestions for managing the wandering patient, most of which are environmental adaptations. Some of these include hobbies, social interaction, and regular routines (Veterans Administration, 2010). Modifications of the environment are effective alternatives to restraints. Regular routines may reduce stress and confusion, but this patient’s main problem is wandering.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

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22. The nurse is caring for a patient who has brought in his own CPAP device to use at night.

What does the nurse need to do in addition to contacting Respiratory Therapy? a. Have the device inspected by the appropriate hospital department for safety. b. Have the patient take it home and get one from patient equipment. c. Tell the patient he cannot use it. d. Notify the physician.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: A

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

If a patient brings a device, it must be inspected for safe wiring and function before use through the process established by the agency. A patient should be able to use his own equipment such as CPAP since it is fitted for his own use. Although you can notify the physician, the device still must be safety inspected.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

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23. The nurse is caring for a patient and is exposed to a chemotherapy drug during IV

administration. Where can she obtain information about the drug that is necessary for an exposure-related incident? a. The nurse’s supervisor b. Poison control center c. MSDS sheets d. Employee health services ANS: C

Chemicals in medications (e.g., chemotherapy drugs), anesthetic gases, disinfectants, and cleaning solutions are potentially toxic. They injure the body after skin or mucous membrane contact, after ingestion, or when vapors are inhaled. Healthcare agencies provide employees access to material safety data sheets (MSDSs) for each hazardous chemical in the workplace.

An MSDS contains information about properties of the chemical (melting point, boiling point, flash point, etc.), toxicity, health effects, first aid, reactivity, safe handling, storage, disposal, protective equipment to use, and spill-handling procedure. The nurse’s supervisor, employee health services, or poison control center may also have the information, but they will go to the same place (the MSDS sheets) to obtain that information.

NURSINRGETFB .COM : Page 68

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TOP: Nursing Process: Implementation

MULTIPLE RESPONSE 1. The nurse is caring for a patient who just received a diagnosis of a seizure disorder. What

supplies should the nurse gather to have at the bedside? (Select all that apply.) a. A suction device with catheters b. Extra pillows to pad the bed c. A padded tongue blade d. Oxygen source and nasal cannula ANS: A, D

A suction device with catheters and an oxygen source with nasal cannula will help maintain the airway should it become a problem. Extra pillows on the bed could cause suffocation during a seizure; firm padding on the sides of the bed are recommended instead. Padded tongue blades are no longer used in the care of patients with seizures.

DIF: Cognitive Level: Understand OBJ: NCLEX: Safe and Effective Care

REF: Page 65 TOP: Nursing Process: Planning

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 2. A nurse notes smoke coming from a garbage can in an otherwise empty nursing station.

Which actions should the nurse take? (Select all that apply.) a. Activate the fire alarm.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. c. d. e. f.

Use a type A fire extinguisher.

Rescue the patients from the unit.

Put wet towels along the base of the doors.

Use a type B fire extinguisher.

Aim the nozzle at the top of the fire.

ANS: A, B

Activate the fire alarm first; then use a type A fire extinguisher to put out the fire. Aim the nozzle of the extinguisher at the base of the fire, not the top. The fire is just smoking; so there is no need to evacuate at this time. The patients are safer where they are since they are not in the area where the fire is smoldering. This small fire could be extinguished easily by the time wet towels are placed along the base of the doors.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

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3. Which of the following statements are examples of features that support a culture of safety?

(Select all that apply.) a. Acknowledging that hospitals are risk-free environments b. Encouraging a high degree of teamwork and collaboration c. Commitment of resources by the organization to address safety concerns d. An environment where employees can report errors without punishment e. A system that does not use incident reports ANS: B, C, D

The Agency for Healthcare Research and Quality (2012) has outlined key features for a culture of safety. These features are (1) acknowledgment of the high-risk nature of an IiN organization's activities and theNdUeR teS rm naGtiT onB. toCaO chMieve consistently safe operations, (2) a blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment, (3) encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems, and (4) organizational commitment of resources to address safety concerns. Incident reports are necessary to help identify errors and near misses to make corrections and improve safety.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

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4. The following is an example of an alternative to restraint use in patient care. (Select all that

apply.) a. Frequent observation of patients b. Involving patients and families c. Frequent reorientation d. Four side rails e. Lap belt with quick release ANS: A, B, C, E

Modifications of the environment are effective alternatives to restraints. More frequent observation of patients, involvement of family caregivers during visitation, and frequent reorientation are also helpful measures. Having all four side rails up is considered a restraint.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

A lap belt that the patient can release is not a restraint.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

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5. The Joint Commission restricts the use of restraints to the least restrictive device necessary to

prevent disruption of needed care. The order for restraints must include which of the following? (Select all that apply.) a. Type b. Duration c. Purpose d. Location e. Size ANS: A, B, C, D

Order must include purpose, type, location, and time or duration of restraint. Long-term care settings require informed consent from a family member prior to use. Orders may be renewed according to the time limits for a maximum of 24 consecutive hours. Size is determined by the nurse’s judgment.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

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MATCHING

While walking in the hallway with the nurse, the patient has a seizure. Match the nursing interventions with the step. a. Remove nearby furniture. b. Loosen restrictive clothing. c. Maintain the patient’s airway. d. Ease the patient to a safe location.

1.

2.

3.

4.

Step 1 Step 2 Step 3 Step 4

1. ANS: D DIF: Cognitive Level: Analyze REF: Page 65-67 OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation MSC: Because the patient is unsupported in the hallway, the nurse should first gently lower him or her to the floor to prevent injury from a fall.

2. ANS: C DIF: Cognitive Level: Analyze REF: Page 65-67 OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation MSC: Once the patient is on a stable surface, the nurse should take required steps to maintain his or her airway.

3. ANS: A DIF: Cognitive Level: Analyze REF: Page 65-67 OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation MSC: Next the nurse should remove nearby furnishings so the patient does not flail into them.

4. ANS: B DIF: Cognitive Level: Analyze REF: Page 65-67 OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation MSC: Finally the nurse should loosen restrictive clothing to prevent skin abrasions during the seizure Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf muscle contractions.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse enters the room and finds the patient sitting in a chair and just beginning to have a seizure. Match the nursing interventions with the step, beginning with the nurse’s first action. a. Call for additional help at the patient’s side. b. Maintain the patient’s airway. c. Clear away hazardous objects. d. Guide the patient to the floor.

5.

6.

7.

8.

Step 1 Step 2 Step 3 Step 4

5. ANS: A DIF: Cognitive Level: Understand REF: Page 65-67 OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation MSC: The nurse begins by calling for help while remaining with the patient to observe the seizure, maintain the airway, and prevent injury. The patient needs to be guided to the floor to prevent injury from falling off the chair.

6. ANS: D DIF: Cognitive Level: Understand REF: Page 65-67 OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation MSC: Once he or she is in a safe location, the nurse observes him or her for impaired airway or breathing.

7. ANS: B DIF: Cognitive Level: Understand REF: Page 65-67 OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation MSC: The nurse implements nursing care to maintain the airway such as positioning the head or jaw.

8. ANS: C DIF: Cognitive Level: Understand REF: Page 65-67 OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation MSC: Finally the nurse clears away objects that might lead to patient injury during the seizure, including furniture and equipmentN. URS

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 05: Infection Control Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. The patient is in isolation in a negative-pressure room for active tuberculosis. He coughs and

spews large amounts of blood-tinged sputum but is too weak to cover his mouth and nose with a tissue. Which is the most important intervention for the nurse to implement for self-protection while providing nursing care? a. Cover the patient’s mouth and nose snugly with a surgical mask. b. Wear an N-95 mask, gloves, face shield, and isolation gown. c. Place tissues and a contaminated waste container within reach. d. Use a properly fitted surgical mask and gloves to help with tissues.

ANS: B

Wearing suitable protective barriers is the most important intervention to implement because it protects the nurse from the airborne particles and the pathogens that can land on surfaces from droplets of the patient’s coughing. The nurse wears a mask suitable for airborne precautions to prevent inhalation of suspended Mycobacterium tuberculosis in the air and gloves, gown, and goggles to protect clothing and mucous membranes from contact with body fluids because of the patient’s poor hygiene due to his weakened state. Respirator masks are used in airborne precautions because these masks filter what the wearer inhales. The patient should wear a mask if he or she must leave the room because a surgical mask controls what the wearer exhales; a mask for the patient is not indicated in the isolation room. The nurse can inhale airborne particles through the pores of a surgical mask, regardless of how well it fits, because a surgical mask c o n t r oNl sUwRhSatIi N s eGxThB al. edC. OM DIF: Cognitive Level: Analyze OBJ: NCLEX: Safe and Effective Care

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2. The nurse is caring for several patients under contact precautions. Which option is possible for

the nurse to use if two of her patients have “like” infections? a. Double gloving b. Single gloving c. Cohorting d. Hand sanitizer only ANS: C

When a hospitalized patient has an infection, a nurse decides on the optimal room placement to minimize the chances of infection spreading to other patients. Two patients with “like” infections can be placed in the same room; this is called cohorting.

Double gloving is used during procedures to make it easier to remove one pair. Hand sanitizer is not effective against Clostridium difficile (“C. diff”) or when hands are visibly soiled.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

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3. The nurse bathes a patient who has an infection transmitted by the oral-fecal route such as C. Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

diff and notes a small tear in one glove. Which group of interventions does the nurse use for self-protection?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. b. c. d.

Finish the bath, apply fresh gloves, and use hand sanitizer.

Continue the bath and change gloves when finished.

Apply a new glove over the torn one to finish the bath.

Remove the gloves, wash hands, and apply new gloves.

ANS: D

For self-protection the nurse interrupts the bath to avoid additional exposure to a potential pathogen by removing the gloves, washing both hands with soap and water, and applying fresh gloves for protection against exposure so the nurse can finish the bath. The nurse risks infection by continuing the bath with a portal of entry on the glove. The nurse should perform hand hygiene before applying fresh gloves. Hand sanitizer is not effective with C. diff.

Applying clean gloves over the torn gloves encases the potential pathogens and increases the risk of exposure to the pathogen.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 76 TOP: Nursing Process: Implementation

4. A patient is in isolation in a negative-pressure room for tuberculosis, and the nurse notes that

the respirator mask is damaged slightly. What is the initial action that the nurse should take? a. Ask to switch the assignment. b. Check the mask for a tight seal. c. Borrow a mask from a co-worker. d. Use the mask if damage is minor.

ANS: B

Before using the mask to enter the patient’s room, the nurse checks the fit to ensure a tight seal because the purpose of this mask in airborne precautions is to filter inhaled air and thereby protect the nurse againN stUpR atS hoIgN enGsTsB us.pC enOdM ed in the air. The nurse can use the mask if the damage is minor and does not affect the seal. Co-workers do not share respirator masks because each employee is fitted individually. If the mask seal is affected, a new mask will be required. Switching assignments is not an appropriate request.

DIF: Cognitive Level: Understand OBJ: NCLEX: Safe and Effective Care

REF: Page 84 TOP: Nursing Process: Planning

5. The nurse completes care for the patient on droplet precautions. Which procedure does the

nurse implement to prevent transmitting the pathogen to other people? a. Removes gloves and mask at the bedside and gown in hallway b. Removes all personal protective equipment (PPE) in the soiled utility room c. Removes gloves first, gown second, and mask third in the patient’s doorway d. Removes mask first, gloves second, and gown third outside the patient’s room ANS: C

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse removes PPE to prevent self-contamination. He or she removes the gloves first to avoid contaminating the head, then removes the gown by unfastening neck ties and pulling it away and rolling into a bundle, then removing mask. These actions occur in the patient’s doorway to contain the pathogen and prevent transmission to people outside the room. The nurse risks contamination if the gloves and mask are removed at the bedside; if the mask is removed before the contaminated gloves, the nurse risks contaminating the head while untying the strings of the mask. PPE should be removed together, at the same location, and away from the source of contamination to facilitate containment of the pathogen. Removing PPE in the hallway or utility room would risk transmitting the pathogen to others.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 87 TOP: Nursing Process: Implementation

6. A patient on isolation precautions tries to leave the isolation room because of loneliness

despite repeated instructions to remain in the room. Which action should the nurse implement as a patient advocate? a. Allow visitors to remove masks while in the patient’s room. b. Talk with the patient about ways to reduce the sense of loneliness. c. Remind the patient that the isolation is for the patient’s benefit. d. Leave the door open slightly so the patient can see into hallway.

ANS: B

The nurse sets specific times to remain in the patient’s room as a patient advocate to help him or her develop coping strategies for handling the loneliness of isolation and provide periodic company. Visitors should not enter the room without a properly fitted respirator mask for their protection. The nurse can remind the patient about the purpose of isolation to help him or her understand the plan of care. T h Ne U doRoSr I caNnG noTtBre.mCaO inMajar because the risk of transmitting the infection is increased with the door open.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 75 TOP: Nursing Process: Planning

7. Gloves are effective protective barriers from pathogens when caring for patients in isolation.

Which patient factor associated with the gloves should the nurse investigate for patients in isolation? a. Patient resistance to therapy b. Transmission mode of organism c. Patient potential for latex allergy d. Virulence of infectious organism ANS: C

The patient potential for latex allergy is the most important patient factor related to using gloves with patients in isolation. Allergic reactions to latex may be triggered even if latex does not touch the patient. Wear unpowdered latex-free gloves. Several alternatives to latex gloves exist. If the patient is allergic to latex, the nurse can use nonlatex gloves to prevent hypersensitivity reactions. Neither virulence nor transmission mode of a pathogen is a patient factor.

DIF:

Cognitive Level: Understand

REF: Page 84

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Safe and Effective Care

TOP: Nursing Process: Assessment

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 8. The nurse is getting ready to provide a sterile dressing change. Which nursing action is

consistent with principles used to prepare a sterile field? a. Identify that items below waist height are contaminated. b. Use opened packages of dressing supplies within the same shift. c. Identify that sterile drapes have a 5.08 cm (2-inch) contaminated border. d. Replace bottle caps if the inside of the cap is not touched.

ANS: A

Items below waist level are considered contaminated and are discarded quickly to avoid contaminating the rest of the sterile field. Packages of sterile supplies must be sealed to be considered sterile. Sterile drapes have a 2.54 cm (1-inch) perimeter that is considered contaminated. Replace bottle caps if the inside of the cap and the edge of the bottle remain sterile.

DIF: Cognitive Level: Understand OBJ: NCLEX: Safe and Effective Care

REF: Page 90 TOP: Nursing Process: Assessment

9. The nurse teaches the patient the proper handwashing technique before discharge and asks for

a return demonstration. Which hand hygiene technique indicates that patient teaching by the nurse is effective? a. The patient washes hands with running water. b. Soap, water, and friction are used by the patient. c. The patient washes hands with very hot water. d. A basin with warm soapy water is used.

ANS: B

The patient understands that proper handwashing requires soap, water, and friction to remove microorganisms from the skin aNnUdRriS nsIeNthGeT mBa.wCaO y.MRunning water is insufficient to wash hands properly because water alone cannot remove as many microorganisms as soap and water can remove. The patient risks tissue damage, dry skin, and irritation from hot water.

Washing hands in a basin may remove surface debris, but the hands are not decontaminated because the debris remains in the rinse water.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 78 TOP: Nursing Process: Evaluation

10. The nurse cared for a patient diagnosed with tuberculosis (TB) 3 days ago. Which of the

following actions should the nurse implement in response to the potential exposure? a. Take a leave of absence. b. Have a chest x-ray taken. c. Request a sputum culture. d. Get a QFT-G blood test.

ANS: D

The CDC now recommends the QuantiFERON-TB Gold (QFT-G) blood test to determine the presence of TB antibodies followed by a sputum test or a chest x-ray to confirm the presence of Mycobacterium tuberculosis. A leave of absence is not necessary unless the nurse displays clinical indicators of TB such as fever, night sweats, weight loss, and coughing.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 84 TOP: Nursing Process: Planning

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 11. The nurse is caring for a patient who is 4 years old and in isolation. Which approach should

the nurse implement to reduce the patient’s anxiety? a. Put the child in a room with a locked door. b. Ask the parents to keep the child in the room. c. Explain isolation to the child by using a cartoon. d. Put the mask, gown, and gloves on in view of the child.

ANS: D

The nurse should let the child see her face before putting on the mask so the child knows who is behind the mask and is not frightened. The nurse could even bring a mask for the child to play with in the nurse’s presence to reduce anxiety. The nurse should explain isolation to the child and use educational material suitable to the patient’s developmental level. However, the child is unlikely to grasp the meaning and implications of isolation, necessitating repeated explanations and guidance. Although the nurse may ask for the parents’ help in keeping the child in the room, the nurse retains the responsibility for maintaining transmission precautions and the child’s safety. Locking the door is a restraint and puts the child at risk in an emergency.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 88 TOP: Nursing Process: Planning

12. In which of the following situations should the nurse use surgical asepsis? a. Performing urinary catheter care b. Inserting a nasogastric tube c. Inserting a Foley catheter d. Performing nasogastric tube care ANS: C

Nurses use surgical aseptic techniques at the patient’s bedside during procedures that involve inserting devices into normally sterile body cavities such as insertion of a Foley catheter. A nasogastric tube is not going into a sterile cavity. Clean technique is used for the other situations.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 74 TOP: Nursing Process: Planning

13. The nurse is caring for a 4-year-old child who has rubella. Which transmission precautions

should the nurse implement to prevent rubella exposure? a. Contact precautions b. Droplet precautions c. Airborne precautions d. Standard precautions ANS: B

The nurse implements droplet precautions for the patient with rubella because large droplets expelled by the patient during coughing, talking, or sneezing transmit the virus. Contact and airborne precautions are not indicated because rubella is not transmitted by direct contact or suspended particles in the air. Standard precautions are suitable for all patients but do not prevent rubella transmission without additional droplet precautions.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF:

Cognitive Level: Apply

REF: Page 83

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Safe and Effective Care

TOP: Nursing Process: Planning

14. The nurse evaluates the handwashing technique of nursing assistive personnel (NAP). Which

behavior by NAP requires additional training by the nurse? a. Rubs sudsy hands for 5 to 10 seconds b. Uses warm running water and soap c. Dries the hands from the fingers to the wrists d. Keeps the hands and forearms below the elbows ANS: A

The nurse improves the NAP’s handwashing technique by providing feedback to increase the length of hand scrubbing to 15 to 30 seconds for thorough removal of microorganisms. The nurse finishes the feedback by directing the NAP to rinse the hands under running water without recontaminating them. Using warm, running water and soap effectively loosens microorganisms from the skin and rinses them off the hands. Drying hands from fingers to wrists is good technique because the hands are dried from the cleanest to the least clean area.

Keeping the hands in a dependent position is good handwashing technique because it prevents hand contamination from water that touched the unwashed section of the arm.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 78 TOP: Nursing Process: Evaluation

15. The nurse assists the healthcare provider during the insertion of a central venous catheter.

Which is the most effective intervention for the nurse to implement to prevent patient infection? a. Adhere to the principles of surgical asepsis. b. Close the door of the sterile procedure room. c. Sterilize working surfaces fN oU r tR heSI prN ocGeT duBr. e.COM d. Restrict foot traffic into the sterile procedure room.

ANS: A

Adhering to principles of surgical asepsis is the best method of preventing an infection during a sterile procedure because it is the most comprehensive step. The remaining options are proper actions for the nurse who is adhering to the principles of the surgical asepsis.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Safe and Effective Care

REF: Page 74 TOP: Nursing Process: Implementation

16. The nurse sets up a sterile field and notes several tiny holes in the sterile drape of the table

that served as the wrap for the pack. What does the nurse do to facilitate completion of the procedure? a. Uses a sterile towel to cover the existing holes b. Replaces the entire sterile field and the supplies c. Moves the sterile supplies to a replacement drape d. Avoids using any of the sterile items near the holes ANS: B

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse removes the entire sterile field, including any supplies added to the setup, because the holes compromised the sterility of the pack and its contents; in addition, contacting the contaminated drape contaminates every sterile item added to the sterile field. Even if the contents of the pack remained sterile, once the drape was used as a sterile field, the field was contaminated by the holes. The nurse cannot proceed with a sterile procedure using a contaminated field despite the goal of facilitating the procedure. Ignoring the potential contamination increases the risk of infection.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 89 TOP: Nursing Process: Implementation

17. The nurse completes preparation of the sterile field to change a patient’s dressing when the

patient’s dinner tray arrives. Which action should the nurse take? a. Use the sterile field on another patient in another room. b. Change the dressing using clean technique to save time. c. Set the tray aside and proceed with the dressing change. d. Cover the setup with a sterile drape and let the patient eat.

ANS: C

The nurse should set the dinner tray aside and proceed with the dressing change. Discarding the sterile setup would waste both time and money. The nurse avoids moving the sterile field to another patient’s room to decrease the risk of contamination from air currents and accidental contact. The nurse should explain to the patient why the dinner tray is being set aside, efficiently finish the dressing, offer to rewarm the meal, delegate serving the tray to nursing assistive personnel (NAP), and thank the patient for patience and understanding. The timing of the dressing change should be rescheduled to prevent this from happening again.

NURSINRGETFB .COM : Page 89

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

TOP: Nursing Process: Planning

18. While setting up a sterile field for a procedure, the nurse knocks a linen-wrapped sterile

package to the floor. Which reaction allows the nurse to maintain safe practice? a. Inspect the package for tears. b. Brush away the visible debris. c. Record the procedure as clean. d. Replace the sterile package.

ANS: D

The nurse replaces the linen-wrapped sterile package dropped on the floor because touching the floor contaminates the package. If the package had a plastic wrapper, the contents may be usable, depending on agency policy, because dust and moisture do not penetrate plastic like they can penetrate the linen. Clean technique may not be substituted when sterile technique is required.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 93 TOP: Nursing Process: Implementation

19. The nurse helps the healthcare provider get supplies and monitor the patient during an

emergency insertion of a femoral line at the patient’s bedside. Which nursing behavior helps Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

to maintain the sterile environment? a. Avoid reaching over the field.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. Wear a sterile cap and booties. c. Use sterile examination gloves. d. Place a face mask on the patient.

ANS: A

The nurse avoids reaching over the sterile field to avoid contamination. A head cover and booties are not sterile, even when used during a sterile procedure. Sterile gloves are not indicated for the tasks the nurse is performing to assist the healthcare provider. There is no need to place a face mask on the patient for a procedure occurring on the upper thigh.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 90 TOP: Nursing Process: Evaluation

20. The nurse is preparing to put on sterile gloves. What should the nurse do to begin this

procedure? a. Pull the first glove up and over the nondominant hand. b. Place the fingers of the dominant hand under the cuff of the first glove. c. Let the cuff of the glove roll up over the hand for more coverage. d. Hold the inside surface of the first glove to pull over the hand.

ANS: D

To begin donning sterile gloves, the nurse slips the fingers of the nondominant hand into the glove to lift it and pull it over the dominant hand. As long as the cuff does not roll up and the glove remains intact, the exterior of the glove remains sterile.

DIF: Cognitive Level: Remember OBJ: NCLEX: Safe and Effective Care

REF: Page 94-95 TOP: Nursing Process: Planning

21. The nurse has just finished a sterile dressing change. Which technique should he or she use to

remove sterile gloves? a. Pull the first glove off with the sterile glove hand. b. Reach inside the first glove to pull it off quickly. c. Pull the edge of the glove down to create a cuff. d. Wipe off the gloves with an antiseptic wipe first.

ANS: A

To remove sterile gloves, the nurse pulls the first glove off with the opposite sterile hand and discards the glove; then he or she inserts a bare finger under the remaining glove to pull it down and inside out. The nurse discards this glove as well. He or she avoids reaching inside the first glove with a gloved hand to prevent self-contamination.

DIF: Cognitive Level: Remember OBJ: NCLEX: Safe and Effective Care

REF: Page 96 TOP: Nursing Process: Implementation

22. The nurse is caring for a patient with C. diff. What type of precautions should she use? a. Airborne b. Droplet c. Contact d. Protective Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: C

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse implements contact precautions because C. difficile spores live in the environment and on surfaces, including healthcare workers’ hands, and are spread through contact. There is no need for airborne or droplet precautions because C. difficile spores are not transmitted by those routes. Protective precautions are used for immunocompromised patients.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 82-83 TOP: Nursing Process: Planning

23. The nurse is preparing a sterile field with several items on it. Which action should the nurse

implement to maintain a sterile field? a. Flip sterile objects onto the sterile field. b. Put fluid holders near the edge of the field. c. Wear sterile gloves to open sterile packs. d. Open the inner flaps of the sterile packages first.

ANS: B

The nurse places holders for fluid near the edge of the sterile field, allowing the circulating nurse to pour fluids into the holders without reaching over and contaminating the sterile field.

Flipping sterile objects onto the sterile field increases the risk of contamination. Sterile gloves are unnecessary to open sterile packages because the outside of the package is clean; the nurse can use bare hands to open the package and retain package sterility. The nurse opens the outer flaps of sterile packages first because it is impossible to open the inner flaps first since they are covered with an outer wrap.

DIF: Cognitive Level: Comprehension OBJ: NCLEX: Safe and Effective Care

REF: Page 75, Box 5-2 TOP: Nursing Process: Planning

24. The nurse is orientating a nu r s iN n gU aRsS s iI stN a nGt T anBd.isCdOisMcussing handwashing principles. Which

statement from the nursing assistant indicates a good understanding of those principles? a. If my hands are visibly soiled, I cannot use an alcohol rub. b. I do not need to wash my hands if I have used gloves. c. I must always use soap and water after a dressing change. d. I can always use an alcohol rub instead of soap and water.

ANS: A

The nurse must always use soap and water when hands are visibly soiled or when caring for a patient with C. diff. Hand hygiene with an alcohol-based hand rub can be used in all other situations and also must be done after removing gloves.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 76 TOP: Nursing Process: Planning

25. The nurse is preparing to transfer a sterile voided urine specimen from the patient’s bathroom

to the laboratory. What supplies should he or she gather to complete this procedure? a. Clean gloves, biohazard bag, mask b. Plastic bag, gown, gloves c. Sterile gloves, gown, biohazard bag d. Clean gloves, plastic bag, biohazard label Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: D

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Clean gloves are used even though the specimen is sterile. After the outside of the container is dried, the clean gloves are removed; the specimen container is placed in a plastic bag, and a biohazard label is attached if not already printed on the bag. A mask or gown is not needed unless splashing is a possibility, and there is no information in the question about the chance of splashing. Sterile gloves are not needed to obtain a sterile voided urine specimen.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 74-75| Page 83| Page 86 TOP: Nursing Process: Planning

26. The nurse is preparing to enter a room for the patient on contact precautions. In which order

should she put on her personal protection equipment? a. Gloves, gown, cap, eyewear b. Gown, cap, eyewear, gloves c. Cap, eyewear, gown, gloves d. Eyewear, cap, gloves, gown ANS: B

The nurse should don her PPE in the following order: Gown, cap, mask (if worn), protective eyewear (goggles, face shield), and then gloves, which should pull over the sleeves of the gown.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 80-81 TOP: Nursing Process: Planning

MULTIPLE RESPONSE 1. Which of the follow elements aNreUpRrS esI enNtGinTtB he.cChO aiM n of infections? (Select all that apply.) a. Source of growth b. Mode of transmission c. Infectious agent d. Susceptible host e. Portal of exit f. Catalyst g. Port of entrance ANS: A, B, C, D, E, G

The presence of a pathogen does not mean that an infection will begin. An infection develops in a cyclical process called the chain of infection, which includes six elements: (1) an infectious agent or pathogen, (2) a reservoir or source for pathogen growth, (3) a portal of exit from the reservoir, (4) a method or mode of transmission, (5) a portal of entrance into the host, and (6) a susceptible host. An infection develops if the chain remains intact.

DIF: Cognitive Level: Comprehension OBJ: NCLEX: Safe and Effective Care

REF: Page 74 TOP: Nursing Process: Planning

2. The nurse is screening a patient for latex allergy. Which factors should she consider that place

the patient at a higher risk for latex allergies? (Select all that apply.) a. High latex exposure b. History of using condom catheters Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. Urogenital defects d. History of multiple childhood surgeries

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: A, B, C, D

Risk factors for latex allergies include spina bifida, congenital or urogenital defects, history of indwelling catheters or repeated catheterization, history of using condom catheters, high latex exposure (e.g., healthcare workers, housekeepers, food handlers, tire manufacturers, workers in industries that use gloves routinely), history of multiple childhood surgeries, and people with family history of allergies such as hay fever or hives.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 93 TOP: Nursing Process: Assessment

3. The nurse is orientating a new graduate nurse. Which statement by the orientee indicates a

high level of understanding about the principles of hand hygiene? (Select all that apply.) a. I need to perform hand hygiene before and after having direct contact with patients. b. I can use alcohol rub when my hands are not visibly soiled. c. I need to perform hand hygiene after I remove my gloves. d. I only need to wash my hands with soap and water when they are visibly soiled. e. I should perform hand hygiene before a sterile procedure.

ANS: A, B, C, E

Hand hygiene is performed before and after contact with patients, after removing gloves, and before performing sterile procedures. Alcohol-based rubs can be used except when hands are visibly soiled or when caring for patients with C. difficile.

DIF: Cognitive Level: Apply REF: Page 76-77 OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 06: Vital Signs Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. The patient’s oral temperature is 39° C. Which conclusion can the nurse make about the

patient on the basis of this information? a. The patient is febrile. b. The patient is afebrile. c. An infection is present. d. Inflammation is present.

ANS: A

A temperature of 39° C is above normal, and the patient with an above-average temperature is febrile. Afebrile indicates a lack of fever but does not necessarily imply a subnormal temperature. An infection often causes a fever in the patient, but a physical examination and laboratory work or culture are necessary before concluding that the patient has an infection. A patient with an inflammation can have a fever, but the patient can have an inflammation without being febrile.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 112 TOP: Nursing Process: Diagnosis

2. The nurse is preparing to obtain a set of vital signs. Which is the most important factor for the

nurse to consider when measuring patient vital signs? a. Documentation of vital signs requires timely and accurate recording. b. Normal limits are very narrow and are generally the same for all patients. c. Measuring equipment must be used correctly and appropriately. d. Environmental factors play a minor role on patient vital signs.

ANS: C

It is important that each device be used correctly and appropriately to ensure patient safety and to obtain correct, complete patient information. Improper equipment distorts the results, increasing the risk of patient injury. If data are obtained with improper equipment and patient treatment is based on the faulty data, the people who use the improper equipment and the faulty data are liable for the results. This is especially important when assessing temperature and blood pressure since a variety of devices are available for measuring these vital signs.

Documentation is an important part of taking vital signs; however, if the nurse uses improper equipment or technique to obtain vital signs, accurate and prompt recording is to no avail.

Depending on the parameter, the normal limits are not relatively narrow. The benefit of a wider normal range is that the body is able to respond to stress and recover while remaining within normal limits. Environmental factors play a significant role on vital signs (e.g., an overly warm room affects patient temperature).

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 99 TOP: Nursing Process: Implementation

3. A patient has a severe upper respiratory and ear infection and has been experiencing diarrhea.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Assessment of the temperature would be most accurate if the nurse checked the temperature using which site?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. b. c. d.

The rectum The axilla Under the tongue The tympanic membrane

ANS: B

The axilla is the only area listed where there is no infection or health issue and where there is no interference to its accuracy. The rectum is an inappropriate site because of the diarrhea.

The oral route, under the tongue, is an inappropriate site because of the severe upper respiratory infection. If the patient cannot breathe through the nose, mouth breathing occurs, and the mouth cannot be closed to create a seal for an accurate temperature measurement. The tympanic membrane is an inappropriate site because of the ear infection.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

REF: Page 101 TOP: Nursing Process: Assessment

4. The nurse is validating the measurement of an infant’s pulse by a nursing student. Which

method should the nurse use to obtain the most accurate count? a. Compress the bell of the stethoscope over the apex of the heart. b. Locate the pulsations in the antecubital space. c. Palpate the superficial artery on the medial side of the wrist. d. Place the thumb and forefinger along the ridge on the outer side of the wrist.

ANS: B

Counting the pulsations in the antecubital fossa from the brachial artery would give the most accurate count. Compressing the bell of the stethoscope turns it into a diaphragm; the bell is never compressed during use. Placing the thumb and forefinger along the ridge on the outer side of the wrist locates the r a dNi aUl R arS teI ryN, G thT eB pr.efCeO rreMd site for measuring an adult’s pulse.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 115 TOP: Nursing Process: Implementation

5. A patient born without arms needs to have a blood pressure assessment. Which artery should

the nurse use to most accurately obtain this measurement? a. Femoral b. Carotid c. Brachial d. Popliteal ANS: D

The nurse can use the popliteal artery to measure blood pressure by applying a properly sized cuff to the patient’s thigh. The femoral artery does not provide an area for assessment of the blood pressure. The brachial arteries are in the arm. The carotid artery, which is in the neck, is impossible to use for blood pressure measurement because applying cuff pressure to temporarily occlude both carotid arteries would stop blood flow to the brain and risk cerebral hypoxia.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 121-122 TOP: Nursing Process: Implementation

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 6. The nurse is running a blood pressure screening clinic at the community health center. Which

action should the nurse implement to obtain an accurate measurement of a patient’s blood pressure on an upper extremity? a. Use a cuff with a cuff width that is 40% wider than the circumference of the arm. b. Limit the cuff deflation rate to 10 mm Hg per second or heartbeat. c. Record the second Korotkoff sound as the systolic pressure. d. Apply the diaphragm of the stethoscope lightly over the brachial artery.

ANS: A

For accurate results, a properly sized blood pressure cuff is at least 40% wider than the circumference of the patient’s arm on which the blood pressure is measured. Deflating the cuff at 10 mm Hg is excessively fast. The systolic blood pressure is the first Korotkoff sound.

The diaphragm is placed firmly over the brachial artery to prevent environmental sound from interfering with blood pressure auscultation.

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REF: Page 105 TOP: Nursing Process: Implementation

7. The patient is unstable; so the nurse is using an electronic blood pressure device to measure

blood pressures every 15 minutes. What should the nurse do to verify the accuracy of the electronic blood pressure measurements? a. Check when the device was last calibrated. b. Know that the device adheres to current medical industry standards. c. Take a manual blood pressure within several minutes of the electronic reading. d. Verify that the systolic pressure is within 20% of patient baseline.

ANS: C

If the blood pressure readings fN roUmRtShI e eNlG ecT trB on.icCbOlM ood pressure measurement device are close to the patient’s blood pressure on auscultation using a sphygmomanometer, the nurse assumes that the electronic device is accurate. Knowing when the device was calibrated does not guarantee its current accuracy. Medical industry standards do not exist for electronic blood pressure devices. A systolic measurement accurate within 20% of the patient’s baseline is grossly inaccurate, and using such a measurement can potentially lead to catastrophic results.

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REF: Page 125 TOP: Nursing Process: Evaluation

8. A patient has an electronic blood pressure cuff that inflates every 15 minutes for a reading.

Which activity by the nursing student would require the nurse to intervene? a. The cuff is positioned carefully on the gown sleeve for comfort. b. The cuff is removed every 2 hours for a skin assessment. c. The alarm limits on the electronic device are checked frequently. d. The cuff is rotated to the other extremity every few hours as possible.

ANS: A

The cuff should be directly on the patient’s skin, not over the gown, for an accurate reading.

All other actions are appropriate.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 125 TOP: Nursing Process: Planning

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 9. The nurse delegates temperature measurement to nursing assistive personnel (NAP). For

which patient should the nurse instruct the NAP to use the tympanic thermometer? a. 10-year-old patient with a left leg fracture b. 12-hour-old infant in the newborn nursery c. 5-year-old patient with bilateral otitis media d. 15-year-old patient with postbilateral tympanoplasties ANS: A

The 10-year-old patinet is a suitable candidat for use of the typmanic thermometer if the NAP uses proper technique for positioning the sensor becaue of the age and condition of the child.

The anatomy of the ear canal makes it difficult to position the probe accurately in neonates.

Whenever ear infections are present, a tympanic thermometer can cause injury and record an inaccurate reading because of fluid, wax, or infectious material in the ear. Tympanic temperatures are prohibited when ear surgery has just been performed because they increase the risk for injury and infection.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 101, Table 6-2 TOP: Nursing Process: Planning

10. The nurse needs to measure the adult patient’s temperature, but the patient has just finished a

cup of coffee. Which is the best type of temperature for the nurse to obtain accurate results efficiently? a. Rectal b. Axillary c. Tympanic d. Disposable ANS: C

The nurse obtains a tympanic temperature because the hot coffee will affect an oral reading. A tympanic temperature is a more reliable indicator of body temperature than the oral reading because a tympanic temperature is a core temperature. Rectal temperatures for adult patients are reserved for occasions when continuous temperature monitoring is required or if no other core temperature site is available; in addition, rectal temperatures are embarrassing for an alert adult patient. Axillary temperatures are not as reliable as tympanic temperatures and do not reflect core temperature. Disposable thermometers are the least accurate method.

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REF: Page 101 TOP: Nursing Process: Planning

11. The nurse is preparing to obtain a rectal temperature. Nursing care is correct if the nurse

inserts the thermometer how far into the rectum of an adult? a. 1.3 cm (1/2 inch) b. 3.5 cm (1 1/2 inches) c. 5.1 cm (2 inches) d. 6.4 cm (1 1/2 inches) ANS: B

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse inserts the thermometer 2.5 to 3.5 cm (1 to 1 1/2 inches) to obtain a rectal temperature on an adult. The sensor tip will be deep enough into the rectum to eliminate environmental effects but not too deep to risk penetration or trauma to intestinal tissue. 1.3 cm (1/2 inch) is not far enough for an accurate reading. 5.1 and 6.4 cm (2 and 2 1/2 inches) are too far to insert the thermometer into an adult.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 109 TOP: Nursing Process: Implementation

12. While inserting a rectal thermometer, the nurse encounters resistance. What action should the

nurse take? a. Remove the thermometer immediately. b. Ask the patient to take a few deep breaths. c. Apply mild pressure to advance the thermometer. d. Remove the thermometer and reinsert gently.

ANS: A

If resistance is felt, the nurse should remove the thermometer probe. Applying pressure to advance the thermometer is contraindicated to prevent complications such as harm to the mucosa. If there is an obstruction or a large amount of stool, having the patient take a few deep breaths is useless. The obstruction or impaction will have to be dealt with first. If the nurse removes and then reinserts the thermometer, the stimulation reactivates the sphincter reflex. The resistance will more than likely still be present.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 109 TOP: Nursing Process: Planning

SpIaNniGcTteBm.pCerOatMure is 37.88° C (100.2° F) at 4 PM on the 13. The nurse notes that the patientN ’sUtR ym patient’s second postoperative day. What should the nurse do initially? a. Check the leukocyte count. b. Collaborate for cultures. c. Ask the patient to drink some fluid. d. Offer the patient another blanket.

ANS: C

The nurse should ask the patient to drink more fluid and cough and deep breathe because low-grade temperatures frequently indicate dehydration and atelectasis in postoperative patients; in addition, patient temperatures generally peak in late afternoon. The nurse evaluates the patient’s temperature again in 2 hours and expects to obtain a lower temperature.

If not, the nurse assesses the patient for infection and collaborates with the provider to plan care. Until the nurse tries fluid and verifies the temperature, collaborating for specimen cultures is premature; in addition, the provider potentially will not want to culture for a low-grade temperature.

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REF: Page 100| Page 112 TOP: Nursing Process: Evaluation

14. The nurse is teaching a family member how to check a teenager’s temperature using a

tympanic thermometer. Which step is most important for the nurse to include in order to Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

obtain an accurate reading? a. Pull the pinna down and back.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. Pull the pinna up and back. c. Place the probe loosely into the ear canal. d. Point the probe toward the eye.

ANS: B

To obtain a tympanic temperature using proper technique, the nurse inserts the thermometer tip into the ear, and pulls the pinna up and back for children older than 3. The tip must fit securely in the ear canal to block environmental effects. The tip of the thermometer should point toward the patient’s nose for proper positioning.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 110 TOP: Nursing Process: Assessment

15. A patient has been experiencing some circulatory issues, and an apical-radial pulse is ordered.

Nursing care is correct if which procedure is followed? a. One nurse counts the apical pulse at the same time another nurse counts the radial pulse. b. The nurse delegates this procedure to an experienced licensed practical nurse/licensed vocational nurse (LPN/LVN) and nursing assistive personnel (NAP) with 10 years’ experience. c. The nurse counts the apical pulse for 60 seconds and then the radial pulse for 60 seconds. d. The apical pulse is counted for 30 seconds, the radial pulse for 30 seconds, and the results are doubled.

ANS: A

The pulse rate must be counted for 60 seconds at the two sites at the same time by two different people. If the patient iN sU unRsS taI blNeGoT r eBx. peCrO ieM ncing problems, this cannot be delegated to NAP. The radial and apical pulses are counted at the same time by two different people.

The apical and radial pulses are counted for a full minute, not 30 seconds.

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REF: Page 118 TOP: Nursing Process: Assessment

16. The nurse is preparing to measure the patient’s blood pressure with an electronic blood

pressure device. Which concept is most important for the nurse to consider? a. Use the extremity closest to the nurse. b. The cuff size must match the extremity being used. c. The brachial artery is always the best one to use. d. The temporal artery is used if neither arm is available.

ANS: B

The cuff must be the appropriate size for the extremity used. If the thigh is used, the nurse must use a larger cuff. The extremity used has nothing to do with proximity to the nurse. It depends on the patient’s status. In some instances the brachial artery in the upper arm is not available for blood pressure assessment such as after a mastectomy, if the extremity is injured, or if an intravenous line is in place. The temporal artery is impossible to use for blood pressure measurement because the temporal arteries are on the lateral aspects of the skull.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 112 TOP: Nursing Process: Planning

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 17. The nurse is preparing to assess the apical pulse. At which location should the nurse listen to

obtain an accurate apical pulse on an adult patient? a. At the fifth intercostal space at the left sternal border b. At the fifth left intercostal space at the midclavicular line c. At the second intercostal space at the left midclavicular line d. At the second right intercostal space at the midclavicular line ANS: B

To auscultate an adult’s apical pulse, the nurse places the stethoscope at the left fifth intercostal space at the midclavicular line directly over the point of maximal impulse and the location for auscultating the mitral valve. The fifth left intercostal space at the left sternal border locates the tricuspid valve. The second intercostal space at the left midclavicular line locates the pulmonic valve. The second right intercostal space at the midclavicular line locates the aortic valve.

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REF: Page 102 TOP: Nursing Process: Assessment

18. The nursing assistant reports the following vital signs for four patients just evaluated. Which

patient should the nurse see first? a. 25 respirations per minute for a toddler b. 38 respirations per minute for a newborn c. 12 respirations per minute for an 8-year-old child d. 14 respirations per minute for an adult patient ANS: C

The 8-year-old child is the nurse’s priority because the rate is too slow for the patient’s developmental stage. The n o r mNa Ul rR anSgIeNfoGrTaBch.iC ldOisM20 to 30 breaths per minute. The range for respirations for a toddler is 25 to 32 breaths per minute; thus 25 breaths are within the normal limits. The range for respirations for a newborn is 35 to 40 breaths per minute; thus 38 breaths are within the normal limits. The range for respirations for an adult is 12 to 20 breaths per minute; thus 14 breaths are within the normal limits.

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REF: Page 120 TOP: Nursing Process: Assessment

19. At what distance above the antecubital fossa does the nurse position a blood pressure (BP)

cuff when using the brachial artery to measure BP? a. 2.5 cm (1 inch) b. 0.6 cm (1/4 inch) c. 1.3 cm (1/2 inch) d. 5.1 cm (2 inches) ANS: A

The nurse positions the BP cuff 2.5 cm (1 inch) above the antecubital fossa when using the brachial artery. This allows proper placement of the stethoscope.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 122 TOP: Nursing Process: Implementation

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

20. The patient is morbidly obese and the nurse uses a blood pressure (BP) cuff that is too narrow

for the patient’s arm. What problem will the nurse encounter because of the cuff used?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. b. c. d.

The Korotkoff sounds will not be heard.

Only a palpable BP can be obtained.

The stethoscope cannot be positioned correctly.

A false high BP reading will occur.

ANS: D

Using a cuff that is too narrow results in a false high BP measurement and makes care planning impossible. A properly sized cuff should be obtained as quickly as possible. Until it arrives, the nurse should continue to measure BP with the smaller cuff and observe the patient to ensure safety. Obesity potentially leads to diminished Korotkoff sounds. The assessment finding will warrant further investigation such as rechecking the blood pressure in several minutes. A palpable BP provides a systolic pressure only; the nurse obtains a palpable BP by inflating the cuff to occlude the artery and then palpating the brachial or radial pulse. The point at which the pulse returns is the systolic pressure. The nurse should have less difficulty positioning the stethoscope because the narrow cuff exposes more skin.

DIF: Cognitive Level: Application OBJ: NCLEX: Physiological Integrity

REF: Page 106 TOP: Nursing Process: Evaluation

21. The nurse is assessing a new orientee’s knowledge of when to take vital signs. The following

statement indicates a need for more education. a. I should take vital signs upon admission. b. I should take vital signs when there is any change in condition. c. I should take vital signs at the beginning and end of a blood transfusion. d. I should take vital signs if a patient reports feeling different.

ANS: C

Vital signs should be taken in aNllUoR fS t hIo sNeGs iTt uBa. t i oCnOs Mi n cl u d i n g before and after blood transfusions, but they also need to be taken during blood transfusions. The nurse would want to clarify that statement to make sure the nurse knows to check the vital signs during blood transfusions.

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REF: Page 100, Box 6-1 TOP: Nursing Process: Implementation

22. While positioning the patient for a routine blood pressure check, the patient asks the nurse

why a support was placed under the arm before the BP cuff was applied. Which response by the nurse is most accurate? a. “This method prevents any problems in obtaining an accurate reading.” b. “This method helps the arm relax so the reading will be correct.” c. “I want you to be as comfortable as possible during this time.” d. “Just sit back and relax and let me get this reading right now.”

ANS: B

Supporting the arm ensures the muscles are relaxed, improving the likelihood for an accurate reading. Comfort is important but not the primary reason for providing support. Many variables can cause an inaccurate reading, including the wrong cuff size or improper placement of the stethoscope. Telling the patient to just “sit back and relax” ignores the patient’s question and is not an appropriate response.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF:

Cognitive Level: Apply

REF: Page 121

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning

23. The nurse assesses the patient’s respirations and sees that they are abnormally shallow (i.e.,

two to three breaths followed by an irregular period of apnea). Documentation by the nurse would be correct if which phrase were used? a. Biot’s respirations b. Cheyne-Stokes respirations c. Kussmaul’s respirations d. Hyperpneic respirations ANS: A

This is an accurate description of Biot’s respirations. Cheyne-Stokes respirations have an irregular rate and depth characterized by alternating periods of apnea and hyperventilation.

Kussmaul’s respirations are abnormally deep but regular. Hyperpneic respirations are increased in depth and can often be seen during exercise.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 105 TOP: Nursing Process: Assessment

24. The nurse is caring for a lethargic, 18-year-old patient with a respiratory rate of 32 breaths per

minute. What is the first action the nurse should take? a. Place the patient in high-Fowler’s position. b. Assess the remaining vital signs. c. Reassess the respiratory rate. d. Notify the healthcare provider.

ANS: A

The patient’s head should be elN evUaR teS dIqN uiG ckTlyBt.oCpO roMmote better lung expansion. The remaining vital signs can be assessed after taking actions to improve the patient’s breathing.

The healthcare provider will be notified, but the nurse’s first responsibility is to the patient.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

REF: Page 119 TOP: Nursing Process: Implementation

25. You have delegated the task of obtaining a pulse oximetry reading to the NAP. Which of the

following statements by the NAP indicates a need for further education? a. “The pulse oximetry reading was 95%.” b. “The patient’s pulse rate was 78 according to the readout.” c. “I made sure the patient did not have nail polish on.” d. “I made sure the patient was not receiving a respiratory treatment.”

ANS: B

Pulse oximetry should not be used to obtain heart rates because they will not detect an irregular pulse. The patient’s nail polish should be removed and the patient should not be receiving respiratory treatments or PT during the readings because it can affect them. The readings are given in percentages.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 126 TOP: Nursing Process: Implementation

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 26. The patient’s oral temperature is 37.1° C (98.78° F) at 1 PM. Which of the following actions should the nurse take next? (Select all that apply.)

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. b. c. d.

Administer acetaminophen (Tylenol) 650 mg by mouth now.

Off the patient an additional blanket.

Document that the patient is normotensive.

Compare this with the patient’s prior readings.

ANS: C This temperature is within normal limits. Because the temperature reading is within normal limits, other intervnetions are not needed. Providing a blanket would increase the temperature. Comparing the temperature with other readings would be done if the temperature was outside of the normal range.

Treating the patient with acetaminophen would be done if the patient’s temperature was elevated and you had a healthcare provider order.

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REF: Page 112 TOP: Nursing Process: Implementation

MULTIPLE RESPONSE 1. The nurse is going to measure the patient’s pulse oxygen saturation. She knows pulse

oximetry readings can be influenced by several factors. (Select all that apply.) a. Nail polish b. Respiratory treatments c. Poor circulation to the site d. Tremors e. Hemoglobin levels ANS: A, B, C, D, E

There are many factors that can influence pulse oximetry readings, including nail polish on the fingers where the reading isNtU akReS n,IpN ooGrTcB ir. cuClaOtiM on to the extremities, tremors, and hemoglobin or hematocrit levels. It is important to select the correct site to take the reading to get the best accuracy.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 126 TOP: Nursing Process: Implementation

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 07: Health Assessment Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. The nurse admits the patient with mild chest pain from the emergency department. Which

should the nurse implement first to gain patient cooperation during a physical assessment? a. Explain the procedure and its purpose. b. Perform assessment in stages over the day. c. Complete assessment within 3 to 5 minutes. d. Assess painful areas before nontender areas.

ANS: A

First and foremost, the nurse should explain the procedure and its purpose. The patient is more likely to cooperate during a physical assessment if he or she knows what to expect and what the purpose of the procedure is. The nurse explains how the information is used to plan individualized nursing care. The information helps make the patient feel valued and important because the nurse engages him or her in the plan of care. In addition, the nurse reassures the patient about maintaining privacy. The nurse completes the assessment in as few stages as possible because he or she needs the assessment data to plan care. While the nurse will assesses painful and tender areas first because if pain is triggered, the nurse would want to stop the assessment and provide pain management, explaining the procedure should precede any assessment.. Assessment data are vital to manage pain successfully.

DIF: Cognitive Level: Apply REF: Page 156 OBJ: NCLEX: Physiological IntN egUriR tySINTGOTPB : .NCuO rsM ing Process: Implementation 2. The nurse assesses a patient with light skin and observes normally shaped nail beds exhibiting

pallor and a slight bluish color. Which should the nurse implement? a. Provide a warm heating pad. b. Collaborate with the healthcare provider. c. Assess patient oxygen saturation. d. Check for restricted venous return.

ANS: C

Nail beds in a patient with light skin are a view of the patient’s capillary bed at the periphery.

Pallor and a bluish color in the capillary bed indicate inadequate oxygenation because oxygenated blood is dark red resulting in pink nail beds. Generally application of heat and cold requires a prescription from a healthcare provider; moreover, the nurse needs to assess the patient and gather related data before being able to decide that warmth is indicated. The nurse needs to complete the assessment first, as long as the patient is in no immediate danger or experiencing distress, and to think critically before collaboration. If collaboration with the provider becomes necessary, the nurse presents a complete patient assessment. Restricted venous return usually leads to edema; severe peripheral edema leads to pallor; and cyanosis potentially occurs but is not common.

DIF: Cognitive Level: Apply REF: Page 142, Table 7.2 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 3. The nurse is performing a neurological assessment. Which patient behaviors demonstrate a

level of consciousness within normal limits? a. States name, age, and date but not location b. Is lethargic; responds logically to questions c. Responds verbally, but words are unintelligible d. Responds to questions spontaneously; is alert and oriented ANS: D

The patient who responds to questions spontaneously and is alert and oriented exhibits neurological findings that are within normal limits. The patient is conscious, responds to the environment, and has congruent thought processes. The patient who does not know the location is disoriented to place. Lethargy is not a normal finding despite correct responses.

Unintelligible speech is abnormal.

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REF: Page 174| Page 176 TOP: Nursing Process: Assessment

4. How often should the nurse perform a general assessment of the patient? a. At least every 4 hours b. As often as it is needed c. When the patient requests it d. At the rate set by agency policy ANS: B

The nurse performs a general assessment at the beginning of the shift and as often as needed afterward; however, the nurse frequently performs a focused assessment to make clinical judgments and problem solve. Every 4 hours is time consuming unless indicated by patient M an assessment, but the nurse is condition. Patients do not deterN mUinReSwIhN enGtT oBp. erC foOrm responsive to patient concerns and resolves the problem to the patient’s satisfaction. Agency policy generally requires an assessment at the beginning of the shift and supports the nurse’s decision to reassess the patient as needed at the nurse’s discretion.

DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 130 TOP: Nursing Process: Planning

5. The nurse is assessing a patient with a cast extending from just below the left knee to the toes.

Which assessment contains a desirable patient outcome? a. The toes are pink bilaterally. b. The cast is warm at the ankle. c. Paresthesia is present in the left foot. d. The cast is snug at the knee.

ANS: A

Bilateral pink toes indicate adequate oxygenation to the periphery and support the outcome, “Patient has pink and warm toes bilaterally while wearing cast.” This also implies that the cast fits properly without areas of constriction. An area of warmth on a cast potentially indicates an infection. Paresthesia indicates nerve compression or irritation; when this occurs with a cast in place on the affected extremity, it usually indicates swelling of the extremity, potentially leading to impaired perfusion. A tight cast potentially restricts blood flow and Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

compresses nerves, leading to tissue damage and paresthesias.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

REF: Page 161 TOP: Nursing Process: Assessment

6. The patient has an irregular, elevated, localized area of edema on the left forearm. Which term

should the nurse use when documenting? a. Tumor b. Wheal c. Macule d. Vesicle ANS: B

An irregular, elevated, localized area of edema is a wheal. The nurse documents the approximate size of the wheal. A tumor is a solid mass of abnormal growth larger than 1 to 2 cm (0.4 to 0.8 in). A macule is a flat change in skin pigmentation such as a freckle or petechiae. A vesicle is a round elevation of skin filled with serous fluid.

DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 143 TOP: Nursing Process: Assessment

7. The nurse is concerned with possible impaired peripheral perfusion after performing a

patient’s assessment. Which assessment datum about the patient’s lower extremities supports the nurse’s suspicion? a. The ankle bones are prominent. b. The skin is warm and pink bilaterally. c. The legs ache when in a dependent position. d. The peripheral pulses are absent on both legs.

ANS: D

Clinical indicators of impaired perfusion to a lower extremity include absent or diminished pulses, cool and dusky skin, and pain on exertion; if the disease is advanced, the patient potentially has pain at rest. Prominent ankle bones are normal. Warm pink skin is a clinical indicator of adequate tissue oxygenation. Aching in the lower extremities when in the dependent position is characteristic of venous insufficiency.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

REF: Page 162 TOP: Nursing Process: Assessment

8. The nurse is listening to the patient’s lungs. Which information should the nurse use to

document normal patient lung sounds? a. Rales in the right lower lobe b. No adventitious breath sounds c. Pleural friction rub in the left lung d. Inspiratory wheezing in the upper lobes ANS: B

A clinical indicator of normal lung sounds is a lack of adventitious breath sounds, meaning that the patient does not exhibit crackles, rhonchi, rubs, stridor, or wheezing. Rales are the same as crackles and indicate fluid or atelectasis in the alveoli. Pleural friction rubs are not normal and indicate inflammation of the pleural lining. Wheezing indicates constriction of the Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

airway as heard during an asthma attack.

DIF:

Cognitive Level: Comprehend

REF: Page 150

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment

9. The nurse is instructing a patient how to breathe during auscultation of the lungs. Instruction

by the nurse has been effective if the patient breathes in which manner? a. Takes rapid shallow breaths b. Breathes with the mouth open c. Coughs and then takes a deep breath d. Takes a deep breath and holds it ANS: B

The nurse instructs the patient to breathe with the mouth open because this facilitates air movement and amplifies patient lung sounds. In addition, the nurse instructs the patient to take slow deep breaths. Rapid shallow breaths quickly induce hypocarbia, leading to lightheadedness and fatigue, and impair auscultation of breath sounds because the sounds are too faint to assess. Coughing and deep breathing are instructions to facilitate the mobilization of pulmonary secretions. Holding the breath impairs the nurse’s ability to auscultate air movement for a respiratory assessment.

DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 153 TOP: Nursing Process: Implementation

10. A patient has the following intake: a cup of oatmeal, a half cup of ice, 3 ounces of apple juice,

and 6 ounces of coffee. What is the total intake the nurse should document on the intake portion? a. 210 mL b. 390 mL c. 600 mL d. 630 mL ANS: B

The oatmeal is not counted because it is not fluid. A half cup of ice = 120 mL because it equals 50% of the measured volume. The juice is 3 ounces = 90 mL, and 6 ounces of coffee = 180 mL. Therefore the total is 120 + 90 + 180 = 390 mL. DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 145 TOP: Nursing Process: Assessment

11. Nursing assistive personnel (NAP) are part of the patient care team. Which aspect of obtaining

health information can the nurse delegate to NAP? a. Auscultate apical pulse of a patient with acute angina. b. Take vital signs of a patient who might be discharged. c. Complete lung assessment of a patient with pneumonia. d. Clarify effects of antihypertensive therapy for a patient.

ANS: B

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The task of taking vital signs of a patient who may be discharged may be delegated to NAP. The patient with acute angina needs a nursing assessment to avert complications of impaired coronary artery blood flow. The nurse evaluates the patient to complete a nursing assessment and implement indicated therapy without delay. The nurse assesses the patient with pneumonia to auscultate breath sounds and evaluate the airway and oxygenation because the lungs fill with infectious exudate, impairing ventilation and increasing the risk of airway occlusion. The nurse evaluates the patient’s antihypertensive therapy as part of the patient’s plan of care and the nursing process.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 137 TOP: Nursing Process: Assessment

12. The nurse is teaching a nursing student the correct technique for assessing an apical pulse.

Which method when used by the student demonstrates she knows the correct location to take an adult patient’s apical pulse? a. Percusses the left ventricular wall b. Palpates along the left sternal border c. Directs the patient to lie in a supine position d. Listens at the fifth intercostal space at the point of maximal impulse (PMI) ANS: D

To locate the apical pulse, the nurse locates the fifth intercostal space on the left midclavicular line; this point should coincide with the patient’s PMI. Evaluation of the heart rarely includes percussion. Palpation along the left sternal border reveals cardiac thrusts and thrills; however, the apical pulse is not proximate to the sternal border. The nurse positions the patient with the head of the bed at 30 degrees for patient comfort and to facilitate cardiac assessment.

NURSINRGETFB .COM : Page 159

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment

13. The nurse is preparing to assess the patient’s abdomen. Nursing care is appropriate if which

maneuver is seen? a. The abdomen is auscultated after percussion. b. The nurse instructs the patient to extend the legs. c. The nurse inspects the abdomen before auscultation. d. The assessment begins with palpation, followed by auscultation.

ANS: C

For an abdominal assessment, the nurse begins with inspection followed by auscultation to prevent accidental stimulation of movement, potentially leading to inaccurate assessment data.

With inspection the nurse observes the abdominal surface for movement, scars, and pulsations; then he or she auscultates bowel sounds before potentially stimulating the bowels with palpation or percussion. The nurse has the patient bend at the knees to relax the abdominal wall, making abdominal palpation easier. Palpation never precedes auscultation of the abdomen.

DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 165 TOP: Nursing Process: Assessment

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 14. An older patient is being assessed by the nurse. Which finding does the nurse consider

abnormal when assessing the patient’s risk for fall?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. b. c. d.

Use of an assistive device Wearing glasses Failure of the Get Up and Go test Negative Romberg’s test

ANS: C

The Get Up and Go test is an assessment that should be conducted as part of a routine evaluation of older adults. The test detects people at risk for falling.

The Romberg’s reflex is normally negative, meaning that when the patient stands with feet together, arms down at sides, and eyes open (20-30 seconds) or closed (20-30 seconds), there is minimal to no swaying. Using an assistive device or wearing glasses does not put the patient at risk for falling unless they are not using their devices.

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REF: Page 176 TOP: Nursing Process: Assessment

15. The nurse assesses a patient with arterial occlusive disease in the lower extremities. Which

activity should the nurse implement in the patient’s plan of care? a. Use a Doppler device to locate pulses. b. Massage the feet and ankles twice daily. c. Elevate the legs slightly when in the chair. d. Measure the circumference of the thighs daily.

ANS: A

The nurse uses a Doppler device to locate peripheral pulses for a patient with arterial occlusive disease because arteries in this health alteration are often difficult to locate as they slowly narrow and impair oxygenated blood flow. Additionally the nurse assesses skin temperature, color, and s e n s at i oNnUt R oS esItaNbG lisThBb. asCeO linMe information. Massaging areas of impaired arterial perfusion is contraindicated because the patient is already at risk for breakdown. Although massage potentially increases blood flow to tissue, it is contraindicated at the ankles and feet because this skin covers many bony prominences. The legs of the patient with arterial occlusive disease usually need to be dependent to allow gravity to help pull oxygenated blood to the periphery. Elevating the legs promotes venous return and increases the difficulty of oxygenating the tissue because the vessels need to deliver oxygenated blood through inadequate arteries. Thigh measurement is indicated for thromboembolic events, venous insufficiency, or other disorders that impair venous return.

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REF: Page 162 TOP: Nursing Process: Implementation

16. A male patient with back pain asks why the nurse needs so many details about his history.

What is the most effective response by the nurse? a. “You seem reluctant to provide information.” b. “We need complete data to plan nursing care.” c. “It will take a short time to answer all questions.” d. “We need to determine contributors to your pain.”

ANS: B Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse explains that comprehensive data facilitate individualized patient care, lower patient risks of injury, and increase patient safety. Determining factors that contribute to the patient’s pain is part of a pain assessment and one of the details that help the nurse plan individualized patient care. Stating that the patient seems reluctant to provide information is placing an interpretation on his motives and may be completely off base if the patient is just trying to understand the process. Commenting that not much time is needed to answer the questions is not responsive to the patient’s question.

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REF: Page 130| Page 135 TOP: Nursing Process: Implementation

17. The nurse assesses an adult patient with a cardiopulmonary illness and hears a grating sound

over the lower lateral lung during inspiration that does not clear with coughing. What would the nurse most likely document as a result of the assessment findings? a. Rhonchi b. A pleural friction rub c. Wheezes d. Crackles ANS: B

A pleural friction rub is heard over the anterior lateral lung field if the patient is sitting upright. It has a grating quality that is best heard during inspiration. It does not clear with coughing. It indicates inflamed parietal pleura rubbing against visceral pleura. Rhonchi indicate fluid or mucus in larger airways causing turbulence in the airways. Rhonchi can sometimes be cleared by coughing. Wheezes are heard all over the lung fields and indicate a narrowed or obstructed bronchus. Crackles, formerly called rales, are most common in dependent lobes and indicate flN uiUdRinStI heNsGmTaB ll.aC irw OaMys. DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

REF: Page 152, Table 7.4 TOP: Nursing Process: Assessment

18. The nurse is assessing an older patient and finds the heart rate to be 62 and irregular.

Suddenly the patient complains of dizziness and “feeling faint.” Which action should the nurse take next? a. Ask the patient about valve replacement surgery. b. Apply 3 L of oxygen via nasal cannula. c. Notify the healthcare provider. d. Explain that this is a normal finding in older adults.

ANS: C

An irregular heart rate and dizziness are abnormal findings and symptoms, and the healthcare provider must be notified immediately for follow-up. An electrocardiogram (ECG) will be ordered along with other studies. History is important, but the current status is the priority. The usual amount of oxygen to be applied without an order is 2 L/min.

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REF: Page 164 TOP: Nursing Process: Implementation

19. The nurse assesses the patient admitted with constipation. Which assessment finding warrants Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

further investigation? a. No aortic bruit

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. Firm liver edge c. Bowel sounds audible d. Abdomen distended and taut ANS: D

A distended abdomen that is round and taut is a significant finding for a patient with constipation because it potentially indicates the accumulation of fluid, gas, tumor, or other material. This warrants the nurse’s attention because, if the accumulation of fluid or gas is caused by a bowel obstruction, the patient may need emergency care to prevent the bowel from rupturing and spilling intestinal contents into the peritoneum. No aortic bruits, a firm liver edge, and audible bowel sounds are normal findings.

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REF: Page 165| Page 168 TOP: Nursing Process: Evaluation

20. The nurse assesses the patient with altered musculoskeletal function. Which is the best reason

supporting the nurse’s motive for asking probing questions? a. Explore how the patient’s family reacts to the disability. b. Evaluate patient concerns about the problem at this time. c. Determine how the alteration affects the patient’s lifestyle. d. Validate the amount of physical rehabilitation completed.

ANS: C

Determining how the altered musculoskeletal function affects the patient’s lifestyle is the best reason for the nurse to ask probing questions. With skillful follow-up questioning, the nurse learns the most comprehensive information about the patient, including family reactions, patient concerns, and rehabilitation issues.

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REF: Page 179 TOP: Nursing Process: Evaluation

21. The nurse observes yellow sclerae while assessing the patient’s eyes. What does the nurse

look for to validate this finding? a. A history of pallor b. Jaundice c. Cyanosis d. Ecchymosis ANS: B

The nurse concludes that the yellow sclerae are indicators of jaundice, an accumulation of bilirubin in the skin. Pallor is skin without a pink cast. Skin with a bluish or dusky cast is an indicator of cyanosis. Ecchymosis is purplish to yellow green and results from subcutaneous bleeding.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 142 TOP: Nursing Process: Assessment

22. The nurse assesses the patient’s lungs to find high-pitched musical sounds on inspiration and

expiration. Which description does the nurse use to document the findings?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. Rhonchi b. Wheezes c. Crackles

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf d. Friction rub ANS: B

High-pitched musical breath sounds are wheezes that result from bronchospasm; the smaller the constricted airways, the higher the pitch of the wheeze. Rhonchi are low-pitched rumblings indicative of fluid in larger airways; rhonchi are potentially cleared with coughing.

Crackles are higher pitched and sharper sounding than rhonchi, indicating fluid or atelectasis in dependent lobes of the lungs. A friction rub is heard on inspiration and expiration but characteristically is a grating sound. A friction rub is frequently accompanied by pain and fever.

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REF: Page 152 TOP: Nursing Process: Assessment

23. The nurse is performing a cardiovascular assessment at the fifth intercostal space at the

midclavicular line. What would the nurse be attempting to check? a. S3 b. Point of maximal impulse (PMI) c. Murmur d. Visible pulsations ANS: B

The nurse expects to find the PMI at the fifth intercostal space at the midclavicular line because this is where the left ventricle is the closest to the chest wall. The nurse follows palpation of the PMI with auscultation of the apical pulse. If the patient’s heart is dilated or hypertrophic, the PMI shifts to the left toward the anterior axillary line. S3 or murmur auscultated near any heart valve is generally abnormal along with visible pulsations (called a lift or heave) coming from the N heUaR rt.S DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 159 TOP: Nursing Process: Evaluation

24. The nurse documents the patient’s swollen lower extremities and measures the depth of a

4-mm indentation made 1 minute ago. Which is the best description for the nurse to use to describe the patient’s lower extremities? a. 4+ pitting edema b. Mild pitting edema c. 4+ nonpitting edema d. Severe nonpitting edema ANS: A

4+ pitting edema is the best description of a lasting indentation of swollen legs at a depth of 4 mm. Mild and severe are subjective terms open to interpretation. Documentation must include that the edema is pitting because the indentation lingers for at least a minute.

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REF: Page 161 TOP: Nursing Process: Assessment

25. The nurse assesses the pupils of an older patient. What unexpected finding might the nurse Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

identify about the patient’s pupils? a. They are 3 mm in size. b. Both of them are round.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. There is a slight opacity. d. They respond to light spontaneously.

ANS: C

Normal pupils are round, clear, and equal in size and shape. Mild opacity in an older patient’s eyes is abnormal and potentially indicates cataract formation. A 3-mm size, roundness, and responsiveness to light are expected findings of an eye assessment, indicating that the oculomotor cranial nerve (III) is intact.

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REF: Page 147 TOP: Nursing Process: Assessment

26. The nurse assesses the adult patient’s spine. Which expected finding does the nurse identify

about the patient’s alignment and posture? a. Upper spine bent slightly b. Spine in straight alignment c. Slumping to nondominant side d. Dominant side of patient favored ANS: B

The anterior-posterior alignment of the spine should be a straight line from the skull to the sacrum. The other findings would be unexpected. An excessive thoracic curvature is kyphosis, which is common with vertebral compression fractures of the thoracic spine. Slumping to the nondominant side and favoring the dominant side are abnormal findings, indicating muscular weakness or abnormal spine alignment.

DIF: Cognitive Level: Apply REF: Page 139 OBJ: NCLEX: Physiological IntN egUriR tySINTGOTPB : .NCuO rsM ing Process: Assessment 27. The nurse assesses a possible melanoma on the patient’s skin. Which characteristic does the

lesion have that is consistent with a melanoma? a. Regular borders b. Larger than 6 mm c. Symmetrical borders d. Reddened coloration ANS: B

Melanomas are usually larger than 6 mm in diameter. In addition, melanomas are usually asymmetrical lesions with irregular borders and blue, black, or variegated coloring.

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REF: Page 142, Box 7-4 TOP: Nursing Process: Assessment

28. The nurse assesses the oral mucosa for pathological color changes. Which finding does the

nurse expect to see in the patient’s mouth, and why does the nurse expect to find it? a. Ecchymosis, because it often is bluish green b. Cyanosis, because it can occur as an ashen tongue c. Petechiae, because they are easily visible in all patients d. Erythema, because the gums should be pink and moist Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: B

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse can assess cyanosis, a late sign of hypoxia, in the mouth of a dark-skinned patient by examining the tongue for an ashen gray appearance. In fair-skinned patients, cyanosis is usually observed with pallor or a bluish-gray cast. The nurse expects to find ecchymosis in a fair-skinned patient, but it appears as yellowish green to purple. Petechiae are usually invisible in patients’ mouths. It is possible to observe erythema in the mouth, keeping in mind that the tongue can be beefy red in color.

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REF: Page 142, Table 7-2 TOP: Nursing Process: Assessment

29. The patient has iron deficiency anemia. Which is the nurse’s priority for prevention with

suitably planned nursing care? a. Pallor b. Jaundice c. Cyanosis d. Erythema ANS: C

The nurse’s priority is to prevent cyanosis because it is a late sign of hypoxia. The patient is most likely pale already, so the nurse cannot prevent pallor. Because the patient has a narrow margin between adequate oxygenation and hypoxia, the nurse’s priority is to prevent hypoxia until the patient’s iron stores and erythrocyte counts increase to restore pinkness to the skin.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

REF: Page 142, Table 7-2 TOP: Nursing Process: Planning

30. The nurse is assessing the temperature of the lower legs. Which method should the nurse use

to best assess the patient’s skinNteUmRpSeI raN tuG reTsB ub.jC ecOtiM vely? a. Oral thermometer b. Dorsum of the hand c. Tympanic thermometer d. Thumb and index finger ANS: B

To evaluate the patient’s skin temperature according to the nurse’s opinion, the nurse uses the dorsal aspect of the hand because this skin is thin and more sensitive to temperature changes.

An oral or tympanic thermometer evaluates temperature objectively. Thumb and index finger are not used to evaluate the skin temperature subjectively because these are the most frequently used fingers and the skin is likely to be thicker and less sensitive to slight temperature fluctuations.

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REF: Page 140 TOP: Nursing Process: Assessment

31. The school nurse alerts parents to observe for chickenpox. Which clinical indicator does the

nurse instruct the parents to observe for chickenpox? a. Wheals b. Nodules c. Pustules Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf d. Vesicles ANS: D

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

When chickenpox first erupts, the lesions are small, fluid-filled skin elevations called vesicles.

Wheals are irregular elevated areas found with mosquito bites. Nodules are an elevated but solid mass. The vesicles of chickenpox change to pustules as the illness wanes.

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REF: Page 143, Table 7-5 TOP: Nursing Process: Implementation

32. The patient is being assessed for a possible respiratory problem. In which position should the

patient be placed to facilitate chest expansion during a thoracic assessment? a. Prone b. Side-lying c. High-Fowler’s d. Dorsal recumbent ANS: C

The nurse helps the patient assume high-Fowler’s position to facilitate lung expansion during a thoracic assessment. The prone position would place the patient face down on the bed, making it impossible to see the chest expansion. The dorsal recumbent position is potentially contraindicated for some patients. Side-lying is a position used by the nurse to assess the posterior thorax of a patient who cannot cooperate with the examination.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 153 TOP: Nursing Process: Planning

33. The nurse is preparing to begin the thoracic assessment of a patient. What is the initial step of

the thoracic assessment? a. Percussion of the lateral thorax b. Palpation of the anterior thoNrU axRS c. Measurement of the respiratory rate d. Inspection of the posterior thorax ANS: D

The nurse begins a thoracic assessment by inspecting the posterior thorax to identify any factors that can impair chest expansion or cause respiratory distress. Lateral percussion is not used in a respiratory assessment because the biggest lung fields are across the patient’s back.

Palpation of the anterior thorax follows assessment of the posterior thorax. Measuring the respiratory rate follows the posterior thoracic inspection.

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REF: Page 153 TOP: Nursing Process: Implementation

34. The nurse begins to assess the patient’s respiratory system. Which assessment by the nurse

best determines the patient’s diaphragmatic excursion? a. Observation of respiratory effort b. Percussion over air-filled regions c. Auscultation of thorax symmetrically d. Palpation of chest inspiratory movement ANS: D Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse palpates the patient’s thoracic movement by placing hands on each side of the spine with thumbs adjacent to one another and instructs the patient to breathe deeply. On inspiration the nurse observes or measures the respiratory excursion, a reflection of the patient’s inspiratory volume. Observing respiratory effort reveals data on the work of breathing. The nurse percusses over areas of suspected fluid accumulation to determine the size of the fluid from consolidation from pneumonia or a pleural effusion. The nurse symmetrically auscultates the thorax to compare bilateral breath sounds.

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REF: Page 153 TOP: Nursing Process: Implementation

35. The nurse is preparing to auscultate the pulmonic area. At which site should the nurse place

the stethoscope? a. At the costovertebral angle b. Over the costochondral junction c. At Erb’s point d. On the left side at the second intercostal space ANS: D

The nurse locates the pulmonic area at the second intercostal space, on the left side at the midclavicular line. This location is useful for assessing the pulmonic valve. The costovertebral angle is at the inferior aspect of the sternum. The costochondral junction is the point where a bony rib meets the cartilage connecting the rib to the sternum. The third intercostal space, Erb’s point, is a useless location for cardiac or respiratory assessments.

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REF: Page 158 TOP: Nursing Process: Assessment

36. The nurse is performing an abdominal assessment. The technique is appropriate if the nurse

uses which method? a. Assesses the painful areas first b. Auscultates each quadrant for 5 minutes c. Palpates lightly to locate painful and tender areas d. Positions the patient with the arms behind the head ANS: C

The nurse lightly palpates the abdomen to determine any painful or tender areas so the patient does not worry about the nurse aggravating the pain and the nurse can conduct a comprehensive abdominal assessment. Assessing painful areas first can terminate the assessment if the assessment exacerbates patient pain. Auscultating for 5 minutes is excessive.

The nurse positions the patient with arms at the side and knees flexed to facilitate relaxation of the abdominal wall.

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REF: Page 169 TOP: Nursing Process: Assessment

37. The nurse admitted a patient with clear lungs and 2 days later determines that the patient has

fluid in the left lung. Which should the nurse implement next? a. Place the patient in high-Fowler’s position.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. Obtain a stat portable chest x-ray film. c. Notify the healthcare provider immediately.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf d. Complete a full respiratory assessment.

ANS: D

Because this is a new finding for the patient, the nurse facilitates suitable patient care by obtaining a comprehensive patient assessment to communicate to the healthcare provider.

There are no data indicating that the patient is in respiratory distress. The nurse needs an order for a chest x-ray film. The nurse should notify the healthcare provider promptly, but he or she needs to finish the complete respiratory examination first as long as the patient is not in acute distress.

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REF: Page 156 TOP: Nursing Process: Planning

38. The nurse assesses peripheral perfusion. Which does the nurse find in a patient with arterial

insufficiency? a. Edema b. Warm skin c. Palpable pulses d. Pain with exercise ANS: D

The patient with arterial insufficiency usually reports pain with exercise because the arteries to the lower extremities are insufficient to meet tissue oxygen demands. The tissue reverts to anaerobic metabolism with increased accumulation of carbon dioxide and lactic acid, precipitating pain in the tissues. The pain often improves with rest and dependent positioning.

Edema is consistent with venous insufficiency. Warm skin and palpable pulses are consistent with adequate arterial perfusion of tissues.

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REF: Page 164, Table 7-6 TOP: Nursing Process: Assessment

39. The nurse is performing a neuromuscular assessment. Which method should the nurse use to

evaluate muscle strength? a. Measure the muscle size. b. Perform range of motion. c. Apply pressure against resistance. d. Observe the patient’s gait and transfers.

ANS: C

The nurse applies pressure against the patient’s resistance to measure muscle strength to make the subjective evaluation safe. Muscle size usually is an indication of muscle strength in a patient who is conscious and cooperative. Range of motion indicates flexibility of joints.

Observing a patient’s gait is a valuable measure of the patient’s muscle strength but is not used initially because it increases the risk of patient injury.

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REF: Page 175 TOP: Nursing Process: Implementation

40. The nurse has been assessing the patient’s bowel sounds. Which action should the nurse Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

implement before notifying the healthcare provider if the bowel sounds are absent? a. Obtain an abdominal radiograph. b. Ambulate the patient.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. Assess related factors. d. Use an amplifying instrument.

ANS: C

If the patient has inaudible bowel sounds, the nurse assesses the patient for distention, the last bowel movement, and patient comfort to obtain a more complete assessment. The nurse needs an order for an abdominal x-ray film. Ambulating the patient can help in some situations, but further assessment is indicated at this time. Doppler devices are not useful to detect bowel sounds.

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REF: Page 168| Page 170 TOP: Nursing Process: Evaluation

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 08: Specimen Collection Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. The nurse obtains blood specimens in the clinic and prefers using an antecubital vein. Which

characteristics of the regional vein justify the nurse’s preference for the antecubital site? a. It is easily accessed in the hand. b. It causes less pain and bleeding. c. It is large and close to the surface. d. It is superficial and the most distal.

ANS: C

The nurse uses the regional vein in the antecubital area for blood draws because these veins are superficial, large, and well anchored; these characteristics increase the chances of a successful blood draw on the first puncture. The antecubital area does not include the hand.

Except for punctures in the hand, venipunctures tend to cause the same degree of pain and bleeding, regardless of the location. The most distal veins in the arm are located in the hand, and these veins are reserved for intravenous (IV) fluids.

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REF: Page 209 TOP: Nursing Process: Assessment

2. The healthcare provider orders a urine test. Which is the most important information for the

nurse to consider before collecting the urine specimen needed for the test? a. That the specimen collection precedes antibiotic administration b. That the urine aspirated from the collection bag is suitable c. Whether the urine test requires sending a sterile specimen d. Whether the patient can provide peri-care properly ANS: C

The most important information for the nurse to know is whether the specimen needs to be sterile. If the test requires a sterile specimen, the nurse uses sterile technique to collect an uncontaminated specimen. If not, collecting the specimen with clean technique is adequate.

The patient’s ability to cleanse the perineum, whether to use urine aspirate, and determining if specimen collection needs to precede the antibiotic are decisions answered by determining if the procedure needs to be sterile.

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REF: Page 182 TOP: Nursing Process: Assessment

3. The patient accidentally discards voided urine during a 24-hour urine collection. What should

the nurse do next? a. Instruct the patient to call for help before voiding. b. Consult with the laboratory for further instructions. c. Discard all urine and begin another 24-hour collection. d. State on the laboratory requisition that one specimen is missing.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

ANS: C

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The 24-hour specimen is invalid, so the nurse starts a new collection and reinforces instructions to the patient. A new container is obtained, and the collection is restarted. The nurse cannot send the specimen to the laboratory missing one specimen because the urine sent does not contain all urine from the last 24 hours.

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REF: Page 188 TOP: Nursing Process: Planning

4. The nurse is preparing to obtain a blood specimen. Which is the most important intervention

for the nurse to complete before obtaining a blood specimen? a. Verify patient identification. b. Perform patient skin preparation. c. Ask the patient for an arm preference. d. Tell the patient that the procedure is slightly painful.

ANS: A

The nurse verifies patient identification before obtaining the blood specimen and uses at least two patient identifiers to ensure accurate identification because the nurse exposes the patient to potentially life-threatening complications by mislabeling a specimen. Skin preparation occurs only after the patient has been identified correctly. The remaining interventions are helpful, but only after the patient has been correctly identified.

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REF: Page 207 TOP: Nursing Process: Implementation

5. You have delegated the task of obtaining a “double voided” specimen to the NAP. The

following statement indicates good understanding of the procedure by the NAP. a. “The patient voids first; theN nUI R caSthIeN teG riT zeBt. heCpOaM tient and test the second specimen.” b. “The patient gives me two specimens and I test both.” c. “The patient discards the first specimen, drinks water, then gives me a second specimen.” d. “The patient gives me two specimens, two hours apart for testing.”

ANS: C

A double voided specimen is when the first specimen is discarded and then the patient drinks a glass of water and then produces a second specimen for glucose testing. The other choices would indicate the NAP did not understand what a double voided specimen was and would indicate a need for further education. The skill of urine screening can be delegated to NAPs. DIF: Cognitive Level: Knowing OBJ: NCLEX: Physiological Integrity

REF: Page 189 TOP: Nursing Process: Implementation

6. The nurse evaluates the venipuncture site before leaving the patient’s room with the blood

specimen. Which nursing observation is an unexpected outcome? a. A dot of blood covers the venipuncture site. b. Heart rate is stable and regular at 80 beats/min. c. A soft subcutaneous lump appears at the venipuncture site. d. The patient complains of stinging with removal of the needle.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: C

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

A soft subcutaneous lump at the venipuncture site after withdrawing the needle potentially indicates hematoma formation; this is undesirable because it increases the risk of patient infection at the site and is likely to cause patient discomfort. A dot of blood can indicate leakage from the venipuncture site but is usually a benign finding indicating clot formation. A stable heart rate and rhythm is a highly desirable outcome of venipuncture. Stinging on removal of the needle is expected.

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7. During a home visit, the patient with diabetes mellitus tells the nurse that she is having a very

difficult time obtaining blood for glucose monitoring. Which intervention does the nurse use to help the patient obtain a good blood sample? a. Asks the healthcare provider to order a different monitoring device b. Instructs the patient to position the lancet on the side of finger or forearm c. Teaches the patient to find a good site and use it repeatedly d. Tells the patient to run warm water over the hand before testing ANS: B

The nurse eliminates all patient-related factors that potentially interfere with glucose monitoring such as technique, dexterity, vision, or lack of knowledge. Regardless of the device being used for glucose testing, if the patient has difficulty implementing the procedure, changing devices is potentially futile if the same mistakes are repeated. Thus the nurse assists the patient with proper lancet positioning on the side of the finger or forearm to obtain enough blood for glucose monitoring. If the patient lacks experience with the lancet, has a long history of glucose monitoring that causes accumulation of scar tissue at puncture sites, or avoids deep punctures becaus e No U f pRaS inI, N heGoTrBsh.eCrO eqMuires teaching to refine and reinforce the proper technique for obtaining a blood droplet. The nurse avoids suggesting warm water because patients with diabetes often have neuropathies and vasculopathies as complications of hyperglycemia; thus the patient is likely to have impaired tissue perfusion and sensation to extremities.

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8. The nurse is teaching a patient about the proper procedure for testing stool for occult blood.

The nurse’s teaching has been effective if the patient makes which statement? a. “I apply a very thick smear of stool onto the guaiac slide.” b. “The electronic meter calculates a reading within minutes.” c. “It is best if I get two separate samples from the same stool.” d. “I call my doctor for white paper with stool and developer on it.”

ANS: C

The patient is correct to say that more than one sample from the stool specimen is required for more conclusive results because occult blood from the gastrointestinal tract is not always equally dispersed through the stool. A thin smear is adequate for testing. An electronic meter is not used for guaiac testing. The stool is not placed on the paper until the patient is actually ready to test a sample.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 193 TOP: Nursing Process: Evaluation

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 9. The patient’s blood glucose level was 134 mg/dL at 7 AM and is now 61 mg/dL at 3 PM.

Which intervention should the nurse implement first? a. Assess the patient for confirmatory findings. b. Check calibration of the blood glucose meter. c. Administer insulin according to a sliding scale. d. Instruct the patient to have orange juice and crackers.

ANS: A

As long as the patient is not in acute distress, the nurse assesses the patient for hypoglycemia to determine whether the patient presentation matches the glucose results. If the nurse determines that the patient has clinical indicators of hypoglycemia, the nurse incorporates these findings to form a plan of suitable nursing interventions. Checking the calibration of the device is a reasonable intervention if it appears that there are no confirming findings for the reading. Insulin drives glucose into the cells, further decreasing blood sugar. Until the reading is confirmed, it is not clear that providing supplemental calories to elevate blood sugar is appropriate.

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10. A nurse is orienting another nurse to the procedures for collecting blood samples. Which

statement indicates that the orientee needs further education? a. “The tourniquet is placed so it can be removed by pulling one end.” b. “A health vein is elastic and rebounds on palpation.” c. “The specimen is labeled with the patient’s name.” d. “I clean the area with antiseptic s wabs first.”

NU RSINGTB .COM ANS: C

All specimens are labeled with two forms of patient identification. After you collect the specimen and in the presence of the patient, you must label the container itself (not the lid) with the same two identifiers (e.g., patient name and hospital identification number), specimen source, collection date and time, series number (if more than one specimen), and anatomical site if appropriate (e.g., wound culture from knee versus abdominal incision). The other statements are all accurate for the methods involved in obtaining a blood specimen.

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11. A female patient needs to provide a midstream-voided urine specimen for examination. What

teaching by the nurse would provide a valid specimen? a. Use a clean specimen cup for testing. b. Collect at least 125 to 150 mL of urine. c. Wash the perineal area with soap and water. d. Void some urine and then collect the sample.

ANS: D

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse instructs the patient to void a small amount of urine and then pass the sterile container under the urine stream to collect urine for a clean-voided urine specimen. A sterile specimen container, not a clean container, is used. Urine testing requires 30 to 60 mL of urine.

The nurse provides three antiseptic wipes or cotton balls or gauze soaked in antiseptic solution for perineal cleansing in preparation for the specimen collection.

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12. A patient is unable to void on demand for a clean-voided specimen. What is the appropriate

action by the nurse? a. Notify the provider that the patient has anuria. b. Palpate the suprapubic area for retained urine. c. Catheterize the patient to obtain the urine specimen. d. Offer fluids, if allowed, and wait about 30 minutes.

ANS: D

The nurse encourages the patient to drink fluids to fill the bladder so the patient can produce a clean-voided urine specimen. The nurse implements this first because it is noninvasive and it is the most likely cause of being unable to void. Notifying the healthcare provider of anuria is premature. Palpating the bladder to determine urine volume is inappropriate for this procedure. Catheterizing is an invasive procedure and increases the risk of patient infection.

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13. The nurse is monitoring the collection of a 24-hour urine specimen. What action by the nurse

will yield the most accurate tesN t rUe R suSltI s?NGTB.COM a. Keep the patient on the unit during the test. b. Keep the urine in a collection bottle in a container of ice. c. Save all urine from the time the test begins. d. Leave the collection bottle in the patient’s bathroom.

ANS: B

Keeping the urine on ice prevents it from decomposing. The ice needs to be maintained throughout the entire test. As the ice melts, the cold water is poured out, and more ice is replaced so the entire level of urine is below the level of ice. The patient can leave the unit during testing, and the nurse notifies receiving personnel to save all urine. The nurse instructs the patient to void just before beginning so the patient starts the test with an empty bladder.

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14. The patient has an indwelling urinary catheter. What step should the nurse take first to obtain

a urine specimen from this patient? a. Apply sterile gloves for the procedure. b. Insert a small needle into the drainage tubing. c. Clamp the drainage tubing for several minutes. d. Disconnect the catheter and drain the urine into the cup.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: C

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse clamps the clear drainage tubing below the self-sealing sampling port for 10 to 30 minutes before collecting a urine specimen from an indwelling urinary catheter to allow accumulation of fresh urine. Sterile gloves are needed for the perineal preparation for a voided urine specimen; this specimen will come from the catheter. Inserting a needle into the drainage tubing potentially causes a crack or a leak in the tubing because the tubing is not designed for puncturing. The nurse avoids disconnecting any sterile drain unless necessary.

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15. The nurse is teaching a NAP to test urine with a reagent strip for chemical properties. Which

technique demonstrated by the NAP would indicate understanding of the process? a. Immerse the reagent strip in urine for 1 minute. b. Compare reagent strip to the color chart on the bottle. c. Obtain the patient’s first voided specimen in the morning. d. Add a chemical tablet to the urine and then test with a reagent strip.

ANS: B

After immersing the reagent strip in the patient’s urine and removing quickly, the nurse waits the exact number of seconds recommended before comparing the strip to the color chart on the bottle. The nurse avoids comparing the strip too early because the chemical reaction necessary to complete the test takes time to process. The first voided specimen of the day is frequently used for testing; however, the nurse obtains a urine specimen according to the provider’s prescription. Reagent strips are one-step procedures.

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16. The nurse is preparing a patient with peptic ulcer disease for discharge to home. What

information does the nurse include in patient teaching about testing stool for occult blood? a. Positive results indicate active bleeding. b. It is necessary to eat poultry and fish before testing. c. Each stool specimen provides one sample for testing. d. Menstruation postpones the testing for occult blood.

ANS: D

When the patient is menstruating, testing for occult blood is ineffective because the test does not discriminate between menstrual blood and occult blood from the gastrointestinal tract. The nurse instructs the patient to wait until blood flow ceases, provide self-care of the perineum, and then test for occult blood. Positive results indicate the presence of blood but do not distinguish between new or old blood. The nurse observes the stool to assess the age of the blood more accurately because active bleeding tends to be bright red, whereas old blood is dark red. However, if the active bleeding occurs in the stomach, the blood in the stool will look old (dark) because the blood ages as it travels through the gastrointestinal system. The patient does not have to eat fish or poultry before testing but avoids red meat because it potentially increases the redness of stool. Each stool specimen provides two samples for testing.

DIF: Cognitive Level: Apply REF: Page 190 Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 17. A patient in the doctor’s office needs a throat culture. What should the nurse implement to

obtain a proper sample? a. Instruct the patient to lie flat and tilt head. b. Apply pressure on the posterior tongue. c. Avoid touching the swab to any inflamed areas. d. Obtain the specimen before or 1 hour after meals.

ANS: D

The nurse obtains a throat specimen before or 1 hour after a meal to reduce the risk of emesis because many patients cough or gag from the oropharyngeal stimulation. The patient sits upright and tilts the head back for the test. The nurse applies pressure to the anterior tongue only because posterior pressure often stimulates emesis. The nurse obtains a swab of the inflamed area, which is the area most likely to be infected.

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18. The nurse is obtaining a nasal culture using a commercially prepared culture tube. After

placing the swab in the culture tube, what should the nurse do next? a. Take the swab and mix it in reagent to check for color changes. b. Place the swab into a culture tube and add a reagent to the tube. c. Label the specimen and enclose it in a plastic biohazard bag. d. Place the swab into the tube, close it securely, and keep it warm.

ANS: C

Specimens must be properly labeled to avoid diagnostic and therapeutic errors. The nurse cannot evaluate the results of the culture; the fluid captures the microorganisms, and the technician mounts the fluid on N slU idR esSaInN dG viTsuBa. lizCeO s Mt h e specimen under the microscope. The nurse avoids adding reagents to the tube, then refrigerates the specimen after properly releasing the fluid.

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19. The nurse is obtaining a sputum specimen from a patient without using suction. What should

the nurse have the patient do to produce enough sputum for a sample? a. Instruct the patient to obtain specimens over 4 hours. b. Try to obtain a sample immediately after eating. c. Rinse the mouth with water to loosen the mucus. d. Take several deep breaths and forcefully cough into a sterile container.

ANS: D

The nurse instructs the patient to take three to four deep breaths before expectorating; the series of deep breaths helps to mobilize secretions and increases the chance of obtaining sputum in a sufficient quantity. The nurse instructs the patient to produce 5 to 10 mL of sputum and sends the specimen directly to the laboratory before potential degradation. A specimen obtained immediately after a meal is likely to be contaminated with food or saliva.

The nurse offers clear water for oral rinsing before asking the patient to provide a sputum specimen because toothpaste or mouthwash potentially kills pathogens that cause infection Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

and skews the results of the culture.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 198 TOP: Nursing Process: Implementation

20. While the nurse tries to obtain a sputum specimen from the patient who has pneumonia, the

patient becomes short of breath, and the respiratory rate increases. Which intervention does the nurse implement next? a. Completes the sputum collection quickly b. Clears the patient’s airway with suctioning c. Provides prescribed supplemental oxygen d. Instructs the patient to lie flat and breathe deeply ANS: C

The nurse stops the procedure; provides supplemental oxygen; and instructs the patient to take several slow, deep breaths to restore oxygen saturation. Collection of the sputum is now secondary to the oxygenation level. The patient must be stabilized first; then the collection can continue. Suctioning is only appropriate when the airway is compromised. The nurse helps the patient to semi-Fowler’s or high-Fowler’s position, whichever is most comfortable for the patient, to facilitate chest expansion. The nurse avoids the supine position because lying flat increases the work of breathing.

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21. The nurse is trying to obtain urine from a pediatric patient for a urine culture. What is the

smallest amount of urine the nurse needs to obtain from a patient for a urine culture? a. 3 mL b. 5 mL c. 10 mL d. 20 mL ANS: A

The smallest amount required for a urine culture is 3 mL. DIF: Cognitive Level: Knowledge OBJ: NCLEX: Physiological Integrity

REF: Page 187 TOP: Nursing Process: Implementation

22. The nurse is reviewing the findings from a basic analysis of gastric secretions. What

information would the nurse expect to find? a. Negative occult blood b. Black coloration of gastric secretions c. Clumps or clots of blood d. “Coffee-ground” secretions ANS: A

The nurse expects to find no evidence of gastric bleeding with gastric secretion analysis because the normal stomach lining is a thick layer of mucus. Black coloration, clumps or clots of blood, or “coffee-ground” secretions are all unexpected findings and are evidence of bleeding.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 194 TOP: Nursing Process: Assessment

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 23. The nurse notices a change in wound drainage and gets an order for a culture. Nursing care is

appropriate if which technique is used? a. Obtain samples of both skin and wound exudate. b. Rotate sterile swabs at a deep point in the wound. c. Use older secretions for a more valid specimen. d. Move the swabs back and forth across the wound.

ANS: B

To obtain a wound culture, the nurse rotates the sterile aerobic and anaerobic swabs deep within the wound to obtain a sample of wound exudate that potentially has not yet reached the wound edges. Moving the swab in a back-and-forth motion risks cross-contamination. The nurse avoids contaminating the wound culture with normal skin flora. The nurse also avoids using older secretions from the wound because the older secretions do not reflect the status of the wound.

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24. The nurse needs to repeat a venipuncture. To minimize any patient harm, where should the

nurse insert the needle? a. In the same arm of the patient closer to the heart b. In the left arm of a patient with a history of axillary surgery c. In the right arm of patient with a right mastectomy d. In the left arm of a patient with a left arteriovenous shunt ANS: A

The nurse can use the same extremity as before but must choose a site closer to the patient’s .hCeOnMurse avoids inserting a needle into an heart to avoid leakage and p a t i eNnUt R diS scIoN mG foTrtB .T extremity that had axillary surgery because this extremity is at high risk for vascular complications already. A mastectomy tends to impair lymphatic drainage and venous return from the affected side. Arteriovenous shunts and fistulas are delicate structures, so the nurse avoids any unnecessary manipulation of the arm.

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25. The nurse is preparing to obtain a blood specimen. Which step should the nurse implement

when preparing for venipuncture? a. Tie the tourniquet in a knot. b. Use the tourniquet for at least 1 minute. c. Place the tourniquet 5 to 10 cm (3 to 4 inches) above the selected site. d. Apply the tourniquet tight enough to occlude distal pulses.

ANS: C

The nurse places the tourniquet around and above the selected site by 5 to 10 cm (3 to 4 inches) and tightens the tourniquet enough to occlude venous return but not distal pulses. A slipknot or a Velcro strip should be used for a quick, one-handed release of the tourniquet.

The nurse should try to have the tourniquet in place for no longer than a minute, depending on the patient. The nurse is able to occlude the venous return without occluding arterial blood Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

flow because the arterial system is a higher pressure system and thus requires more pressure to stop blood flow than a vein requires.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 208 TOP: Nursing Process: Implementation

26. The nurse is preparing to draw a blood sample. Which technique should the nurse implement

when performing venipuncture? a. Insert the needle, bevel up, at a 45-degree angle. b. Select a vein that is rigid, cordlike, and prominent. c. Insert the needle at once after scrubbing the skin with alcohol. d. Pull the skin taut by placing the thumb about 2.5 cm (1 inch) below the site.

ANS: D

The nurse stabilizes the vein and minimizes rolling by pulling the vein with the thumb positioned about 1 inch below the insertion point to prevent contaminating the site. The needle is inserted at a 15- to 30-degree angle. The best vein to select will be prominent and straight with no signs of swelling or hematoma. The vein should rebound when palpated. The nurse allows the alcohol to dry before inserting the needle because the process kills microorganisms and the needle can carry alcohol into the puncture and increase the pain.

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27. A newly diagnosed patient with diabetes is being taught the procedure for obtaining a blood

glucose specimen. What information should the nurse include in patient teaching about the procedure for capillary puncture? a. Puncture the center of the fingertip. b. Allow the alcohol to dry completely. c. Hold the finger upright for N thU eR puSnIcN tuG reT . B.COM d. Squeeze the finger to increase blood flow.

ANS: B

The nurse instructs the patient to allow the alcohol or other antiseptic time to dry before puncturing the skin because the drying kills the microorganisms and the needle can carry alcohol into the puncture, increase the pain, and skew the results. The least painful sites to puncture the fingertip are on the sides. The patient should be told to hold the finger in a dependent position before puncturing to engorge the fingertip with blood. Squeezing the finger has the potential to skew the results of the testing.

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28. A test for occult blood is to be done tomorrow. Patient teaching by the nurse has been

appropriate if the patient chooses which menu for dinner tonight? a. Hamburger, noodles, dinner roll with butter, broccoli b. Beef stew, rice, garlic bread, applesauce c. Macaroni and cheese, mixed vegetables, apple slices d. Pork chop, mashed potatoes with gravy, peas, ice cream ANS: C

A meatless diet helps to prevent a false-positive result when testing for occult blood. There is Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

no meat in the menu selection, and it contains several high-fiber choices. No meat should be eaten within 24 hours of the test to prevent a false-positive result.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 190 TOP: Nursing Process: Planning

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 09: Diagnostic Procedures Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. The patient asks the nurse why an x-ray film with contrast medium is needed. How should the

nurse respond? a. “Most patients ask me that question.” b. “It enhances visualization of the internal structures.” c. “It guarantees total accuracy of the x-ray film interpretation.” d. “Let me have you speak to the radiologist.”

ANS: B

The radiologist uses contrast medium to visualize internal structures not seen with regular x-ray films. The dye saturates the affected area for the x-ray film, and the image stands out against the tissue without dye. Because the healthcare provider and radiologist know the normal contour and appearance of internal structures, they can spot abnormalities such as filling defects, tumors, fistulas, and fractures. The nurse needs to be direct and answer the patient’s question.

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REF: Page 218 TOP: Nursing Process: Planning

2. A contrast medium study is being scheduled. Which statement by the patient during the

assessment warrants further investigation by the nurse? a. “I’m allergic to shellfish.” b. “I have small veins in my left arm.” c. “I’m really worried about the test results.” d. “I need to urinate in the middle of the night.”

ANS: A

The nurse needs to establish whether the patient is truly allergic to shellfish, indicating sensitivity to iodine. The antiseptic used for the test has an iodine base and might cause a reaction; if so, the nurse or provider uses chlorhexidine or another agent for the skin preparation before the study. In addition, because many contrast mediums have an iodine base, the provider needs to choose an alternative dye. Establishing the nature of the reaction is important because the information provides valuable data for the radiologist to aid in choosing the proper contrast medium. It also establishes baseline data necessary when preparing for postprocedure nursing care. Small veins and urinary patterns do not pose potential problems for this type of test. Although the nurse should provide the patient with information to ease anxiety about the test, the allergy information is key to patient safety during this procedure.

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REF: Page 218-219 TOP: Nursing Process: Planning

3. A patient is being monitored in the left femoral artery 2 hours after an angiogram. What

assessment by the nurse is of greatest priority? a. The patient is a little sleepy and can’t remember the procedure.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. The left pedal and posterior tibial pulses are palpable. c. The patient hasn’t voided yet.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf d. Both of the patient’s feet are cool and pink.

ANS: B

The radiologist inserts the angiographic catheter in the groin for a femoral angiogram.

Because a major vessel is accessed for the procedure, the patient has a high risk for postprocedure bleeding and thromboembolic events. For early detection of postangiographic bleeding, the nurse monitors the patient for subcutaneous discoloration, a change in the pulses distal to the insertion site, and bright red bleeding. The peripheral pulses detect a thromboembolic event early, which helps to prevent tissue damage or loss. It would not be unusual for a patient to be sleepy and amnesic after this procedure. If both feet are cool, it is probably because of room temperature since nothing invasive was done on the patient’s right side.

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4. The patient is being monitored by the nurse during a gastroscopy. Which patient data need to

be communicated to the healthcare provider doing the procedure? a. The patient has been placed in the left lateral position. b. An anterior gastric erosion ulcer is present. c. The blood pressure has dropped 30 mm Hg. d. The patient is lethargic but can follow directions.

ANS: C

Inserting the endoscope can stimulate the vagus nerve, potentially leading to a slower heart rate and hypotension. Left lateral Sims’ position is suitable for gastroscopy. The patient should be drowsy with the medication used but able to follow basic directions. The nurse and healthcare provider use the ga sN t riUc Re S r oIs iNo nG iTd B en.t iCfi O e dMd u ri n g the gastroscopy to plan nursing care and patient therapy.

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5. The nurse provides patient teaching before a lumbar puncture. Which information does the

nurse include about patient activity during the procedure? a. “We’ll want to know if you are hurting.” b. “I’ll place you in a semi-Fowler’s position.” c. “It is essential to remain still during the procedure.” d. “We’ll restrict your fluids after the test is done.”

ANS: C

The nurse instructs the patient to maintain the lateral position and lie without moving during the procedure, especially while the provider inserts the needle, because the goal is to put the needle in the subarachnoid space. Unexpected patient movement potentially leads to needle misplacement, patient injury, and increased risk of postprocedural headache and infection from leaking cerebrospinal fluid. The local anesthetic injection stings, and insertion of the needle potentially elicits a sharp, stabbing, or shooting pain that causes patients to flinch. The nurse assists the patient to maintain the position and offers reassurance and information. The nurse instructs the patient to indicate verbally that pain is present during the procedure but not Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

to move. Unless fluids are contraindicated, providers typically prescribe flat positioning and normal fluid intake following the procedure.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 227 TOP: Nursing Process: Implementation

6. A patient has had increasing respiratory difficulty as a result of abdominal cancer. Which

information does the nurse provide to the patient about the purpose of having a paracentesis? a. It will relieve pressure and some of the discomfort in your abdomen. b. It will allow for analysis of the thoracic fluid for cytology. c. Fluid from the lung will be examined. d. The examination will allow for extraction of a sample of bone marrow.

ANS: A

Paracentesis is the removal of abdominal fluid for examination and relief of pressure from severe ascites. The removal of the fluid can increase patient comfort. A thoracentesis removes fluid from the chest cavity. Lung fluid is not obtained during a paracentesis. A bone marrow aspiration recovers bone marrow cells.

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7. The nurse is explaining the procedure for a paracentesis. Which intervention by the nurse can

help prevent a complication of the procedure? a. Have the patient hold the breath for a few seconds. b. Ensure that the patient voids before the procedure. c. Place the patient in a supine position. d. Check vital signs every 2 hours after the procedure.

ANS: B

The nurse instructs the patient to void before the paracentesis because an empty bladder reduces the risk of an accidental bladder puncture. The patient doesn’t need to hold his or her breath. The nurse helps the patient into a sitting position because sitting decreases the size of the peritoneal cavity. Vital signs are measured every 15 minutes for 2 hours.

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REF: Page 227 TOP: Nursing Process: Implementation

8. A patient develops low back pain radiating to both sides of the body after a femoral approach

has been used for a cardiac catheterization. What should the nurse do while contacting the healthcare provider? a. Ambulate the patient to see if the pain diminishes. b. Monitor the vital signs every 5 minutes. c. Encourage oral intake of fluids as desired by the patient. d. Sit the patient in a high-Fowler’s position.

ANS: B

The patient is experiencing retroperitoneal bleeding, which is an emergency. Surgery will most likely be required; therefore the patient needs to be NPO and kept in a position that supports the blood pressure best, which is supine. The patient’s status must be monitored frequently because of the severity of the situation.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

REF: Page 223 TOP: Nursing Process: Evaluation

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 9. The patient arrives in the postanesthesia care unit after a cardiac catheterization via the left

femoral artery to assess the right atrium. Which patient datum is the nurse’s priority to assess perfusion of the affected extremity after the procedure? a. Checking the left femoral region for bleeding b. Monitoring patient vital signs every 15 minutes c. Applying direct pressure at the patient’s intravenous (IV) site d. Palpating the right pedal pulse for pulsations ANS: A

To access the right heart, the provider used a femoral approach, which is the site where bleeding would occur after the procedure. The nurse measures vital signs every 15 minutes after a cardiac catheterization; however, unless the femoral vein is bleeding, the vital signs provide secondary evidence about the perfusion to the affected extremity. The nurse palpates the unaffected extremity as a comparison for the affected extremity. Applying pressure is a nursing intervention and will not provide patient data regarding perfusion.

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10. The nurse prepares a patient for a pulmonary angiogram. What information should the nurse

include in patient teaching to prevent a postprocedure hemorrhage? a. The chemicals in the dye injection help prevent hemorrhage. b. The patient will be sleepy; so movement will be minimal. c. The patient’s affected leg will be immobilized after the procedure. d. Postprocedure analgesia will manage patient discomfort.

ANS: C

The nurse explains that the patient’s hips and knees will be kept straight and positioned for little movement for 2 to 6 hours after the procedure. The nurse also explains that flat straight extremities allow adequate hemostasis to prevent postprocedure bleeding by protecting the integrity of the insertion site. Sleepiness is expected after the procedure and is not involved in prevention of a postprocedure hemorrhage. The contrast dye and postprocedure analgesia will not interfere with the ability of the blood to clot.

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REF: Page 222 TOP: Nursing Process: Planning

11. The nurse is caring for the patient immediately after an angiogram has been finished. Which

action does the nurse take to prevent a complication of this procedure? a. Limit the patient’s total fluid intake. b. Encourage early patient ambulation. c. Elevate the head of the bed 30 degrees. d. Apply constant pressure to the insertion site.

ANS: D

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Significant pressure applied to the insertion site of the angiographic catheter helps to ensure hemostasis and prevent a postangiographic hemorrhage. The pressure is kept in place for many hours because angiograms always involve the access of major vessels and thus increase the risk of hemorrhage. The nurse complements pressure at the insertion site with continuous visualization of the site and assessment of peripheral perfusion to the affected extremity. Fluid intake increases after an angiogram to flush the dye from the system quickly to prevent renal damage. Following the angiogram, the patient is kept supine.

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12. The nurse cares for a patient who had an angiogram of the aorta with a contrast medium

approximately 4 hours ago. Which is the priority patient assessment for the nurse to monitor for early detection of an allergic reaction to the dye? a. Pallor b. Pruritus c. Tachycardia d. Cool skin ANS: C

The nurse monitors the patient’s respiratory and cardiac status for any indication of a hypersensitivity reaction to the dye. Other clinical indicators include flushing, itching, and urticaria. Pallor is usually an indicator of altered cardiovascular status. Pruritus and cool skin may be an indication of allergic reactions; however, they are not as high on the patient’s hierarchy of needs as breathing.

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13. The nurse admits the patient to rule out leukemia and prepares him for definitive diagnostic

testing. Which is the best question to ask the patient before the procedure? a. “Do you ever feel claustrophobic?” b. “Are you allergic to iodine or shellfish?” c. “Have you ever had an electrocardiogram?” d. “Can you lie on your stomach for 20 to 30 minutes?”

ANS: D

To rule out leukemia, the patient needs to have a bone marrow biopsy to examine the marrow for malignant white blood cells. A bone marrow biopsy requires the patient to lie in the lateral or prone position when the provider chooses to obtain the bone marrow specimen from the iliac crest. These positions provide access to the hip and allow the provider to apply enough pressure to reach the marrow with the hollow core needle. If the patient cannot tolerate the positioning, the provider can choose the sternum. Allergies to shellfish and iodine are of key interest when performing tests that use contrast medium. Claustrophobia is important to determine before computed tomography or magnetic resonance imaging. The nurse asks about previous electrocardiograms to compare with current electrocardiograms.

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REF: Page 224 TOP: Nursing Process: Planning

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 14. The nurse is teaching an older patient before a bronchoscopy. What information is the most

important for the patient to know to prevent a possible postprocedure complication? a. Deep breathe during the insertion of the bronchoscope for easy passage of the scope. b. Do not eat or drink anything after the procedure until the nurse says it is safe to drink. c. Turn on your right side while the bronchoscope is passed through the nose and throat. d. Avoid food and fluids for at least 3 hours before the procedure.

ANS: B

The nurse cautions the patient to avoid taking anything by mouth after the bronchoscopy until approved by the nurse because the nurse determines when the gag reflex returns. The healthcare provider sprays a local anesthetic agent to depress the gag reflex before passing the bronchoscope. Ingesting oral food or fluid potentially causes choking or aspiration with a depressed gag reflex. The patient is NPO for 8 hours before the bronchoscopy to help prevent aspiration of gastric contents. Intravenous sedation is often used to relax the patient, allowing for easy passage of the bronchoscope. The bronchoscope passes through the oropharynx into the trachea, not through the nose.

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15. The patient arrives in the intensive care unit after a bronchoscopy. Which patient assessment

is the nurse’s priority? a. Status of the gag reflex b. Level of sedation c. Circulatory status d. Respiratory status ANS: D

Respiratory status is the priority assessment in the immediate postprocedure period because bronchoscopy includes manipulation of a scope through the trachea and bronchi, potentially stimulating bronchospasm, laryngospasm, and respiratory distress. Cardiovascular status, or circulation, is the next patient priority on the hierarchy of needs. After the respiratory and cardiovascular assessments, the nurse assesses the patient’s neurological status and sedation level to monitor for return of function. The nurse assesses the gag reflex before administering anything by mouth.

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REF: Page 230 TOP: Nursing Process: Assessment

16. The nurse is preparing to position a patient for a gastroscopy. Which action should the nurse

implement before getting the patient into position? a. Remove the patient’s dentures. b. Suction the oral cavity. c. Provide a sip of clear fluid. d. Position the patient upright in bed.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: A

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse assists the patient in removing dentures before the procedure to protect the dentures, prevent accidental dislodgement, and facilitate patient comfort. Suctioning is not indicated before positioning. The nurse positions the patient in the left lateral Sims’ position during the procedure and in the semi-Fowler’s or the recovery position after the procedure.

The patient should be NPO prior to the procedure.

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REF: Page 235 TOP: Nursing Process: Planning

17. An older patient with renal insufficiency has been NPO for 8 hours before a bronchoscopy.

When the patient returns from the test, which patient datum is the nurse’s priority assessment? a. Hydration status b. Level of orientation c. Skin integrity status d. A reaction to contrast medium used ANS: A

Older patients are especially prone to dehydration, and the risk increases after a prolonged NPO period because the nurse withholds food and fluid to prepare the patient for the procedure. The patient’s urinary output needs to be watched after hydration has been established. Emptying the stomach decreases the risk of aspiration of gastric contents during and after the procedure. Disorientation is a reasonable assessment for an older adult who has received inadequate fluid and risks dehydration; it may be a clinical indicator of dehydration.

The risk of skin breakdown is increased with dehydration. It is not as important as early detection of dehydration because preventing dehydration helps to prevent skin breakdown. A contrast medium is not used during a bronchoscopy. The procedure is a direct visualization.

NURSIN G T B .COM

DIF: Cognitive Level: Analyze R E F : Page 224 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment 18. A patient is having a contrast medium study and has several allergies. During the injection of

the dye, the patient complains of having a brief, severe hot flash and slight chest pain. What nursing action is most indicated? a. Ask the patient how he or she is feeling since the dye was injected. b. Tell the patient that many patients feel the same way. c. Assess the patient’s vital signs while reassuring him or her. d. Explain to the patient that this is a normal sensation for this test.

ANS: C

Obtaining objective data is the best indicator of the patient’s status. Asking the patient how he feels may be helpful, but it results in only subjective data. Telling the patient that others feel the same way is nontherapeutic. The patient concern should be answered honestly and completely. Many of the contrasts such as those for angiography can cause a sensation of warmth shortly after the injection, but specific evaluation of the patient’s status is required.

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REF: Page 221 TOP: Nursing Process: Implementation

19. The nurse is caring for a patient who had a lumbar puncture (LP) 1 hour ago. The patient is Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

drowsy and his pupils are dilated. After notifying the healthcare provider, what should the nurse do?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. b. c. d.

Maintain airway and monitor vital signs.

Reduce total fluid intake.

Lie the patient flat.

Maintain pressure on the LP site.

ANS: A

A patient undergoing an LP can develop an excessive loss of CSF, which causes reduced LOC, dilated pupils, and increased BP. The nurse should notify the healthcare provider, monitor vital signs, and prepare to transfer the patient to the ICU. The patient should not be flat because that would compromise the airway. Pressure on the site will not stop the leak, and the patient should have not fluids restricted.

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REF: Page 229 TOP: Nursing Process: Implementation

20. The nurse is preparing a tired older patient for a thoracentesis. Which ability should the nurse

assess for when determining if the patient can tolerate the procedure safely? a. Cough only when requested. b. Swallow and clear the throat. c. Remain sitting but motionless. d. Inhale during needle insertion.

ANS: C

The nurse should assess the patient’s ability to remain motionless in a sitting position during the procedure so the provider can precisely place the needle in the fluid without puncturing adjacent structures inadvertently, including the heart and great vessels. The nurse instructs the patient to avoid coughing and throat clearing during a thoracentesis to prevent accidental injury. The nurse instructs the pNaU tiR enSt I toNhG oT ldBh. isCoO r Mh e r breath during a thoracentesis to prevent accidental injury to adjacent thoracic structures.

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21. A patient asks the nurse why being NPO for 6 to 8 hours before a contrast study is necessary.

Which response by the nurse is most accurate? a. “Decreasing the hydration status decreases the chance of an allergic response to the contrast medium.” b. “Excessive hydration causes dilution of the contrast medium, which does not permit as clear a picture of the area as needed.” c. “It reduces the chance of postprocedure infection.” d. “Nausea is prevented if the stomach is empty.”

ANS: B

Excessive hydration causes dilution of the contrast medium, making structures more difficult to see. The hydration status has not affected the chance of an allergic response to the contrast medium. Postprocedure infection is rare with a contrast study, and being NPO has nothing to do with its occurrence. Having an empty stomach does not prevent nausea. Nausea may result from the contrast medium used for the study.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 220 TOP: Nursing Process: Planning

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 22. A patient is recovering after receiving sedation for a contrast medium study and has a score of

1 using the Modified Ramsay Sedation Scale. What action by the nurse is most appropriate at this time? a. Document these normal findings. b. Prepare to increase the oxygen flow. c. Administer a drug-reversal agent. d. Listen to the breath sounds.

ANS: A

A score of 1 is the highest score possible and reflects optimum recovery. There is no need to increase the oxygen flow based on the patient’s optimum status. A drug-reversal agent is not needed based on current assessment data. There are no data that point to the need to assess breath sounds at the current time.

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REF: Page 217, Table 9-1 TOP: Nursing Process: Evaluation

23. An hour after a patient has a thoracentesis, the patient’s oxygen saturation is 88, and

respiratory rate is 34. What actions by the nurse are priorities? a. Raise the head of the bed and call the nursing supervisor. b. Give oxygen to the patient and notify the physician. c. Look at the chest excursion and notify respiratory therapy. d. Open a chest tube insertion kit and notify the patient’s family.

ANS: B

The patient most likely has a punctured lung and needs respiratory support. He or she must not be left alone. Oxygen is needed, and the physician must be notified immediately. Raising the head of the bed does not incNrU eaRseStI heNG floTwBo.fCoO xyMgen. Further assessment is not a priority until the oxygen is on and either the physician or respiratory therapy is at the bedside. The nurse should not assume that a chest tube will be inserted. The tray must be kept closed until immediately before being used. The physician needs to be called before the family is called.

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24. The nurse is caring for a patient who received opioids for sedation during his procedure. After

the procedure the patient experiences oversedation that required the administration of a reversal agent. Which agent would the nurse administer? a. flumazenil b. naloxone c. Benadryl d. epinephrine ANS: B

If a patient is oversedated, be prepared to administer emergency medications or reversal agents (e.g., naloxone [Narcan] [reversal of opioids] or flumazenil [Romazicon] [reversal of benzodiazepines]). Other support drugs may also be given. Benadryl would be given for an allergic reaction.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 217 TOP: Nursing Process: Implementation

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf MULTIPLE RESPONSE 1. A patient is going to have a cardiac procedure that requires moderate sedation. The nurse is

explaining to the patient what is included in the pre-sedation assessment. Which statement(s) indicates the nurse has a good understanding? (Select all that apply.) a. “Have you arranged for someone to drive you home after the procedure?” b. “How frequently do you drink alcohol?” c. “Have you had any problems with anesthesia before?” d. “Do you have any drug allergies?” e. “Do you currently use any drugs? How frequently have you used drugs in the past?” f. “Is there a family history of drug use or abuse?”

ANS: A, B, C, D, E

One of the risks for moderate sedation is if it progresses past the point and becomes deep sedation. Because of this risk, only trained individuals can give the sedation and a pre-assessment is completed to help ensure patient risk factors are known. The patient’s level of tolerance for the sedatives used can be affected by his or her history of drug and alcohol use. The patient must also arrange for someone to take him or her home after the procedure.

Current drug allergies will prevent an allergic reaction. Past family history does not impact the patient.

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REF: Page 217-218 TOP: Nursing Process: Assessment

utU ”R veSrI ifiNcaGtiToB n. prCoO ceMdure to a nursing orientee. Which 2. You are describing the “time-oN statement by the orientee indicates a good level of understanding? (Select all that apply.) a. The time-out is done at the start of every invasive procedure. b. The time-out prevents wrong site errors. c. The time-out prevents wrong patient errors. d. The time-out is done by the surgeon. e. The time-out is required by The Joint Commission (TJC).

ANS: A, B, C, E

The time-out verification procedure is required by TJC and is done before every invasive procedure by the physician and all involved personnel. This is a safety procedure that prevents wrong patient, wrong site, and wrong procedure errors.

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3. The nurse is caring for a patient post cardiac catheterization who experiences a vasovagal

response when his sheaths are removed and pressure is applied. Which of the following symptoms is the patient likely to experience? (Select all that apply.) a. Feeling faint b. Light-headed c. Flushing d. Dizzy e. Itching Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: A, B, D

A patient experiences a vasovagal response (occurs at the time of femoral puncture or after the procedure when femoral pressure is applied). Symptoms include feeling faint, dizzy, light-headed, and possible loss of consciousness for a few seconds. Bradycardic pulse is caused by stimulation of the vagus nerve via baroreceptors. Itching and flushing occur with contrast dye.

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REF: Page 237 TOP: Nursing Process: Assessment

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 10: Bathing and Personal Hygiene Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. The patient has been hospitalized for several weeks and is very depressed. She doesn’t want to

bathe or brush her teeth. What approach should the nurse take to best meet the needs of this patient? a. Collaborate for a psychiatric consultation. b. Instruct the patient on the benefits of hygiene. c. Have family bring grooming products to the patient. d. Encourage the patient to assist with personal hygiene.

ANS: D

Encouraging the patient to participate in personal hygiene is the best approach. Bathing promotes relaxation with the feeling of being clean, in addition to enhancing one’s appearance and sense of well-being. The patient also benefits from the physical activity, which helps to regain endurance, muscle strength, and range of motion lost during a prolonged illness.

Because the patient is recovering from a lengthy illness and experiencing justifiable feelings, it is premature to obtain a psychiatric consultation. Explaining reasons for bathing and teeth brushing does not address the immediate needs of the patient (i.e., being clean). Having the patient help with hygiene is more focused on the immediate needs of a depressed patient.

Often the physiological effects of prolonged hospitalization, such as depression, cause lack of attention to physical needs. Bringing grooming products to the patient can reinforce feelings of inadequacy and poor self-image, inducing the patient to think that her personal appearance is offensive.

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2. The patient is able to sit in the chair while the bed is being made. What nursing process step

should the nurse implement for bed making? a. Keep the bed in the low position. b. Pull the blanket up to the head of the bed. c. Instruct the patient to hold the side rail. d. Delegate the task to nursing assistive personnel (NAP).

ANS: D

The nurse delegates making an unoccupied bed to the NAP because the assistants are specifically trained in bed making and because the patient is stable enough to sit in a chair while the bed is made. This frees the nurse to perform tasks requiring skills specific to registered nurses.

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3. The patient is in pain and doesn’t want the head of the bed raised. Which method should the

nurse use to change the patient’s bed linens?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. Ask the patient to raise the lower body to remove the soiled linen. b. Keep the top sheets over the patient and slowly roll him or her to each side.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. Keep the patient on the left side and get extra help to remove soiled linens quickly. d. Fanfold the top linen to the bottom of the bed and replace with clean linen.

ANS: B

Because the patient is in pain and can’t get out of the bed, the nurse makes the bed using the occupied bed technique. To maintain patient comfort and privacy, the nurse keeps the patient covered while rolling from side to side slowly to prevent dizziness while exchanging the soiled and clean linens. The soiled linens are folded toward the center of the bed and tucked under the patient; then the fresh linens are applied. When the first side is completed, the patient is gently rolled over the ridge of linens in the center so the other side may be accessed.

The soiled linens are then removed, and the fresh linens are smoothed over and tucked in.

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REF: Page 263 TOP: Nursing Process: Implementation

4. A male patient states that his back is itching. What should the nurse do initially to relieve the

patient’s discomfort? a. Administer an anti-itch cream. b. Assess the patient’s skin condition. c. Remind the patient to shift positions. d. State that hospital sheets are scratchy.

ANS: B

The nurse addresses the patient’s itchy back by inspecting and assessing the patient’s back for hives, a rash, or redness; the nurse uses the data to formulate a plan of care to relieve the itching. The nurse does not have complete patient data to justify administering an anti-itch cream or recommend shifting positions until the assessment is completed. Hospital sheets should not be scratchy or stiff sNinUcR eS thI isNwGoT ulBd.inCcO reMase the risk of skin irritation and breakdown.

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5. The nurse instructs the spouse of an elderly patient who is on bed rest on how to provide a

complete bed bath. What does the nurse include in the patient/family teaching? a. Prevent dryness with bath oil and baby powder. b. Clean the anus vigorously and dry with a towel. c. Wash the perineal area with warm running water. d. Daily bed baths can cause skin damage.

ANS: D

The nurse cautions the patient’s spouse that daily bathing can lead to dry skin and irritation for someone on complete bed rest because skin becomes thin, fragile, and prone to bruising and tears. Bath oil is not recommended for a bed bath because it is likely to soak into the bed linens and attract debris, increasing the need for changing linens. Powder is usually not indicated because the patient could inhale fine dust particles and because it is a drying agent.

The nurse instructs the patient’s spouse to keep the perineum clean and dry; however, vigorous cleansing can lead to dry skin and irritation, potentially resulting in skin breakdown.

Perineal cleansing with warm running water is impractical for home care.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF:

Cognitive Level: Apply

REF: Page 243

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation

6. The nurse bathes an unconscious patient. Which action should the nurse implement to

maintain infection control during a bed bath? a. Use long strokes and lotion to massage both legs. b. Perform a complete assessment of the patient’s skin. c. Wash each eye carefully, rinsing all traces of soap. d. Soap the entire front of the patient’s body and then rinse.

ANS: B

The nurse assesses the patient’s skin during a bed bath because the skin is a major part of the innate defense of the body against microorganisms. The nurse identifies areas of the patient’s skin with a potential for breakdown and plans preventive or restorative nursing care. Lower extremities are not massaged to prevent dislodging a potential thrombus. Warm water only is used to cleanse the eyes because soap is likely to cause patient discomfort if it seeps into the eyes. The nurse washes and rinses smaller areas of the body to complete a bed bath because wetting a large surface area can cause vasoconstriction and shivering in the patient from the cooling effects of evaporation.

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REF: Page 243 TOP: Nursing Process: Implementation

7. The nurse is preparing to bathe the patient. Which patient statement would best communicate

a desired outcome as a result of the nurse’s bathing and skin care? a. “The daily baths are great for my dry skin.” b. “The cold water felt good during the bath.” c. “I enjoyed the vigorous massage of my feet.” d. “I feel more relaxed than I N haUvR eS alI l dNaGy.T” B.COM ANS: D

Feelings of relaxation and cleanliness are positive in nature and thus are part of a desirable outcome for patient bathing. Daily bathing is discouraged for dry skin because, for patients with rashes, scaling, redness, cracking, or thin, fragile skin, bathing can remove vital skin moisture. Bath water should be warm, not cold. Gentle massage can be done, but not of the feet. Usually the back, shoulders, and sacral area are gently massaged after the bath.

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8. The patient’s skin is thin and tight. Which approach should the nurse implement to maintain

skin integrity? a. Increase bathing to three times daily. b. Use very mild soap or a prepackaged bath. c. Avoid lotions to help retain skin moisture. d. Massage the skin briskly to increase circulation.

ANS: B

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The skin needs to be moist and supple for strength and elasticity. A lack of moisture is causing the patient’s tight skin, so the nurse plans care to retain surface oils and moisture.

Very mild soap or a prepackaged bath product is less likely to remove surface oils vital to retaining skin moisture and is part of a skin care program that includes providing adequate internal hydration, nutrition, and hygiene using products and techniques to enhance the patient’s moisture retention. Bathing three times daily is excessive for a patient with thin, tight skin and potentially increases the risk of skin breakdown by stripping the skin of surface oils and moisture. Hydrating the surface of the skin is less effective than providing adequate hydration to the patient internally for moisture retention, but it is part of a total skin care program. Brisk massaging is contraindicated for thin, tight skin.

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9. The patient has an endotracheal tube (ET) and is unresponsive to painful stimuli. Which

action should the nurse implement while providing oral care? a. Use suction to remove oral secretions. b. Test the gag reflex with squirts of water. c. Clean the teeth with a medium toothbrush. d. Prevent patient toothbrush biting with an airway.

ANS: A

Oral care is safely provided to patients without a gag reflex by using suction. As secretions build from brushing the teeth and rinsing, the nurse suctions them with a clean, blunt-tipped suction catheter because suctioning helps to prevent fluid buildup in the trachea, which can lead to aspiration. The gag reflex is not tested when a patient has an ET and is unresponsive to painful stimuli. A soft toot hb ruNshUoRr StoIoNt hGetTt eBi.s C prOefMerred for cleaning teeth. The ET is the patient’s airway. If the patient is biting the ET, the ventilator settings need to be changed, or the patient’s condition is changing. The pressure alarm on the ventilator will sound if the patient bites the tube; however, the nurse leaves the alarm on to prevent patient injury. An airway is used to prevent the patient from biting the tube.

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REF: Page 256 TOP: Nursing Process: Planning

10. The nurse assists a patient with oral care. The patient is 1 day postoperative after nasal

reconstruction. Which is the most important intervention for the nurse to implement to maintain integrity of the oral cavity? a. Scrape the tongue to remove thick secretions. b. Instruct the patient to use a fluoride mouthwash. c. Teach the patient to brush the teeth twice daily. d. Assist the patient to maintain adequate hydration.

ANS: D

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The most important intervention for this patient to maintain integrity of the oral cavity is to provide adequate hydration because the mouth is a vital component of the innate defense of the body against microorganisms. The patient cannot breathe through the nose for several days after nasal reconstruction because of edema and nasal packing, and the nose is integral to warming and humidifying inhaled air, so the mouth dries out quickly as the patient is forced to mouth breathe. If the mouth becomes dry, the mucous membranes become dry and stick to oral structures, the risk of oral lesions and erosion increases, and the ability of the mouth to destroy harmful invaders to the body decreases. An oral care plan for hydration includes humidified oxygen; frequent sips of decaffeinated beverages, water, ice chips, and hard candy; and frequent, gentle oral care. The remaining options are part of an oral care plan but are not as effective as maintaining hydration to preserve the oral mucous membranes. The other interventions help the patient with comfort and general dental health and reduce microorganisms in the mouth.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

REF: Page 255 TOP: Nursing Process: Implementation

11. A patient who is postoperative wants to put in his dentures. Which is an effective nursing

intervention related to the dentures to minimize the risk of gum irritation that can lead to infection? a. Store the dentures in a clean, dry container. b. Scrub the dentures with mint toothpaste. c. Check to see that the dentures are a snug fit. d. Use dental floss to clean between each tooth.

ANS: C

Preventing infection for a postN opUeR raStiI veNpGaTtiB en.tCisOa major concern because the patient has at least two risk factors for infection: being hospitalized and being postoperative. The nurse includes checking the fit of the dentures to ensure a snug bond between the gums and the dentures and to prevent pressure points, soreness, and the formation of oral lesions that can irritate the gums and lead to infection. The dentures need to be snug enough to establish a strong bond to the patient’s gums. But the nurse does not want the dentures to fit too tightly because the pressure can lead to oral breakdown and impairment of the innate defenses of the body. To maintain an even, snug fit, the nurse stores the dentures in a clean, moist container to prevent warping. Scrubbing the dentures cleans the surface of buildup, debris, and the microorganism count, but the nurse should use a commercial denture product. Dental floss is not used on dentures.

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REF: Page 257 TOP: Nursing Process: Implementation

12. An unconscious male patient’s beard has become soiled with blood and adhesive tape residue.

What should the nurse do initially to maintain the patient’s hygiene? a. Trim the beard to a short, manageable length. b. Shampoo the beard at the bedside and comb out debris. c. Determine if there are contraindications to trimming the beard. d. Use baby powder to soak up debris; comb debris out.

ANS: C Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse ensures that trimming or removing the beard is acceptable to the patient’s family because several cultures forbid removal of facial hair. In addition, patients can spend years growing a beard and want to keep it. The patient is likely to become angry and dissatisfied when he realizes that his beard is gone. Trim the beard only if permission is given.

Shampooing the beard is impractical and likely to soak the bed and patient in the process.

Baby powder is an ineffective method of cleaning hair.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 260 TOP: Nursing Process: Implementation

13. The nurse is preparing to shave a patient’s beard. Which approach is best for the nurse to use? a. Soften the beard with a cool, wet washcloth. b. Hold the razor at a 90-degree angle to the skin. c. Remove the hair in the direction of hair growth. d. Maintain the patient in a prone position for shaving.

ANS: C

To shave the patient, the nurse moves the razor in the direction of hair growth to avoid razor cuts and abrasions. A warm, moist washcloth is used to soften facial hair for removal. The nurse holds the razor at a 45-degree angle to the skin. The patient is placed in the semi-Fowler’s or supine position for shaving for easy access to the facial hair.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 260 TOP: Nursing Process: Implementation

14. The nurse is providing a bath for a patient at risk of deep vein thrombosis. Which technique

should the nurse use? a. Use short, light strokes wheNnUwRaS shIinNgGtT heBl. egCsO . M b. Use long, firm strokes when washing the legs. c. Use circular strokes up and down the legs. d. Pat the legs gently with a warm, wet washcloth.

ANS: A

The nurse uses short, light strokes when washing the legs to prevent dislodging any clots if present. Long, firm strokes are contraindicated because the pressure exerted against the walls of the veins could dislodge clots if present. Circular strokes up and down the legs are not used to clean the legs. The strokes move toward the heart to promote venous return. Patting the legs with a warm, wet washcloth would be ineffective in cleaning.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 250 TOP: Nursing Process: Planning

15. The nurse determines that the patient is physically incapable of maintaining his personal

hygiene. What is the most appropriate nursing approach for this patient? a. Explain how important it is for the patient to care for himself or herself. b. Assess the patient’s psychological status. c. Encourage the family to take over his or her personal hygiene. d. Encourage the patient to help in any way possible.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: D

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The patient’s participation in any way possible can help his or her self-esteem, improve function, and increase endurance. Because of the patient’s diminished ability, assistance is needed and should be provided. The family should be encouraged to help with hygiene only if the patient wants them to help and in ways that are appropriate.

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REF: Page 243 TOP: Nursing Process: Planning

16. The patient with type 1 diabetes mellitus and peripheral arterial disease receives a bed bath.

Which foot care technique should the nurse use for this patient? a. Soak the feet in warm water. b. Allow the feet to stay moist. c. Use warm water to cleanse the feet. d. Cut the nails in a curved shape.

ANS: C

The nurse uses tepid water to cleanse the feet of a patient with diabetes and impaired perfusion to a lower extremity gently to avoid injury to the foot from hot water, scrubbing, or harsh cleansing agents. Foot soaks are contraindicated for patients with diabetes. The feet are dried carefully after cleansing to prevent fungal overgrowth and irritation. Toenails are cut straight across to prevent ingrown toenails. A podiatrist cuts the nails to prevent patient injury.

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REF: Page 250| Page 262 TOP: Nursing Process: Planning

17. An older adult is admitted for a respiratory infection and is found to have very dry skin with

several areas exhibiting some cracking. What question is most important for the nurse to ask the patient? a. “Are you able to reach your feet when you bathe?” b. “Would you like me to give you a back massage?” c. “Do you get chilled easily when you bathe?” d. “How often do you usually bathe?”

ANS: D

Older adults have skin that is dry and can easily become cracked. Bathing too often can cause this problem. This is the most important question to ask based on the assessment data. The other options do not relate to assessing the patient’s skin.

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REF: Page 245 TOP: Nursing Process: Planning

18. The nurse identifies several abrasions on the patient’s skin. Which intervention should the

nurse use for the patient? a. Apply antibiotic ointment. b. Allow to dry with room air. c. Shave the immediate area. d. Wash the area with soap and water.

ANS: D Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Washing an abrasion with soap and water is a suitable nursing intervention. Soap helps to emulsify dirt, debris, and microorganisms; water helps to remove these potential contaminants. The nurse uses warm water under low pressure to débride the wound if necessary. An antibiotic ointment is not indicated because the wound is not infected. Research exists to support the claim that wounds heal faster and with less scarring under occlusive dressings. Shaving is inappropriate at this time.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 244, Table 10-1 TOP: Nursing Process: Planning

19. The nurse offers personal hygiene to a very modest patient. Which does the nurse implement

to maintain patient dignity and respect? a. Uses the patient’s personal care products b. Explains hospital policy and procedure c. Provides care at scheduled times as promised d. Determines cultural and personal preferences ANS: D

The nurse questions a modest patient about cultural and personal hygienic customs and preferences beforehand to display respect and caring. This helps to ensure that nursing actions facilitate patient hygienic preferences and avoids creating patient psychosocial or physical discomfort while providing hygiene. The patient may use personal care products as long as there is no contraindication. Explanations of policies and procedures are patient expectations and an aspect of patients’ rights, a legal and ethical matter, more than a display of respect. The objective is to provide culturally sensitive hygienic care for a modest patient; providing care at a given time is less important than the nature of the care.

NURSINRGETFB .COM : Page 243

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning

20. A female patient is on bed rest. In which position should the nurse place her to provide

perineal care? a. Prone b. Supine c. Dorsal recumbent d. Fowler’s ANS: C

The nurse uses the dorsal recumbent position to provide perineal care for a female patient because this position provides the most access to the perineum while maintaining patient privacy. The prone position is not recommended because bath water will flow in retrograde fashion and contaminate the vagina and urinary meatus with microorganisms from the anus.

The supine and Fowler positions are not recommended because they do not allow the best access to the perineal area.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 253 TOP: Nursing Process: Implementation

21. The nurse is caring for four patients with different diagnoses. Which patient should the nurse Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

shave with an electric razor? a. The hypertensive patient

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. The patient with diabetes mellitus c. The patient with a closed head injury d. The patient with a pulmonary embolus ANS: D

A patient with a pulmonary embolus receives anticoagulant therapy to prevent the formation of additional emboli and allow the clot to dissolve. The nurse avoids shaving patients receiving anticoagulants with a razor to prevent prolonged bleeding of potential facial cuts from the razor. Hypertension, diabetes mellitus, and a closed head injury are unlikely to require precautions for prolonged bleeding caused by anticoagulation. Anticoagulation is usually not indicated for hypertension and is contraindicated for a closed head injury. If the patient’s brain bleeds, intracranial pressure increases and potentially results in a devastating, life-threatening injury.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 260 TOP: Nursing Process: Assessment

22. The nurse assesses the incontinent patient’s perineal skin and notes redness. What does the

nurse include in the patient’s plan of care to individualize nursing care? a. Minimize exposure of the perineum to soap and water. b. Apply an anti-inflammatory agent to the affected area. c. Allow adequate time for the patient to use the bedside commode. d. Remove the incontinence brief and expose the skin to air for an hour.

ANS: B

To maintain skin integrity, reduce inflammation, and prevent deterioration of the affected area, the nurse applies an anti-inflammatory agent after gentle cleansing. The affected area must be cleansed promptly a ft eNr U exRpS osIuN reGtT oB ur. inCeOoM r fecal matter; to minimize skin trauma, the nurse uses mild soap and rinses thoroughly with a gentle touch. Removing the incontinence brief is usually impractical; it can remain in place to contain urine and fecal matter, with prompt perineal care after exposure to urine or fecal matter. The risk of skin breakdown from incontinence does not improve with exposure to air because the basic problem is frequent skin exposure to irritating waste products and not an anaerobic environment. The nurse allows every patient adequate time to use the commode, bedpan, or bathroom, but, since this patient is incontinent, toileting time is not an issue.

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REF: Page 253 TOP: Nursing Process: Implementation

23. The nurse is planning to delegate foot care to the NAP for three of her four patients. Which

patient should she do the foot care for? a. Postoperative hip fracture b. Diabetic patient c. Post head injury d. Pneumonia patient ANS: B

The skill of foot and nail care may be delegated to nursing assistive personnel (NAP) except for patients with diabetes or patients with peripheral vascular disease or circulatory Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

compromise.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 262 TOP: Nursing Process: Implementation

24. The nurse is getting ready to shampoo her patient’s hair. She notices bites behind the ears and

on the hairline and she suspects lice. After she notifies the healthcare provider, what is the next step? a. Shampoo the hair as planned. b. Do not shampoo the hair. c. Put the person in isolation. d. Use a medication shampoo per agency policy.

ANS: D

The CDC recommends treatment for persons diagnosed with an active infection (CDC, 2013).

Over-the-counter or prescription treatment may be needed. Machine wash and dry clothing and linens in hot water. Nit combs can be used in combination with medicated shampoo.

Change bed linens according to facility policy and follow facility infection-prevention guidelines.

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REF: Page 258, Table 10-2 TOP: Nursing Process: Implementation

MULTIPLE RESPONSE 1. The nurse is orientating a NAP about bathing patients. Which statement by the NAP indicates

a good understanding of the process? (Select all that apply.) a. “I should let the nurse know if I see any redness on the patient’s skin.” b. “I should make sure I do noNt U leR avSeIthNeGpTatBie.nC t uOnMattended with side rails down.” c. “I should provide female perineal care with the patient on their side.” d. “I should report any unusual perineal drainage.” e. “I can disconnect the IV tubing to put on the gown.”

ANS: A, B, D

The skill of bathing can be delegated. The nurse instructs the NAP about reporting early signs of impaired skin integrity, including redness or pallor; reporting perineal drainage, discomfort, or tenderness; proper ways to position male and female patients with musculoskeletal limitations and indwelling catheters; and reporting fatigue or report of pain. The IV should be threaded through the gown. The female patient should be placed in the dorsal recumbent position for perineal care.

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REF: Page 246 TOP: Nursing Process: Implementation

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 11: Care of the Eye and Ear Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. The nurse prepares to remove the patient’s soft contact lenses. Which intervention should the

nurse implement to remove the lenses without traumatizing the cornea? a. Irrigate the eye with 50 mL of a sterile saline solution. b. Pull the lid down and instruct the patient to blink. c. Pinch the sides of the lens together and pop it out. d. Move the lens to the sclera and compress the lens gently.

ANS: D

To remove a soft contact lens from a patient’s eye, the nurse moves the lens to the sclera and gently compresses it. This maneuver disrupts the surface tension holding the lens to the eye, allowing the nurse to lift the lens off the eye without traumatizing the cornea. The nurse avoids flooding the eye with irrigation solution because it increases the risk of losing the lens.

The nurse asks the patient to blink to eject a hard lens. The nurse avoids pinching the lens since that would risk corneal trauma.

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2. The nurse irrigates the patient’s eye after the patient splashes an irritating liquid into it. Which

intervention does the nurse implement to prevent injury during eye irrigation? a. Positions the patient in high-Fowler’s position during the procedure NURSINGTB.CO b. Prevents the tip of the irrigating system from contacting the eyeball c. Reassures the patient that the eye cannot be closed during irrigation d. Allows the irrigating solution to run from the outer to the inner canthus ANS: B

The nurse prevents additional injury to the patient’s eye during the eye irrigation by maintaining the irrigation system tip away from the eye. The nurse positions the patient in the side-lying position on the side of the affected eye to control the flow of irrigation solution.

The patient is allowed to blink periodically during the irrigation. The nurse directs the irrigation solution to flow from the inner to the outer canthus to prevent contamination of the eye from a contaminated area.

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REF: Page 273 TOP: Nursing Process: Implementation

3. The nurse and the patient discuss the patient’s need for a hearing aid. What information does

the nurse include in patient teaching? a. An in-the-ear hearing aid is easy to manipulate. b. The patient’s specific needs and abilities are determining factors. c. The choice of a hearing aid is basically a financial matter. d. Behind-the-ear models are inferior to the other types.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: B

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The patient’s specific needs and abilities are the determining factors in selecting a model of hearing aid for use. Hearing aids are available in many styles to suit a patient’s individual needs. In-the-ear hearing aids are a poor choice for a patient with impaired manual dexterity because they are small. Behind-the-ear hearing aids are suitable for mild-to-profound hearing loss. Choosing a hearing aid is partially a financial decision, but not all models suit a patient’s needs effectively.

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REF: Page 280, Table 11-1 TOP: Nursing Process: Implementation

4. The nursing assistive personnel (NAP) reports that the hearing-impaired patient is usually

alert and oriented with the hearing aid in place, but the patient is not responding to verbal communication this morning. What action should the nurse implement first? a. Document that the patient’s neurological status is poor. b. Assess the patient for clinical indicators of a stroke. c. Remove the hearing aid and clean it with a stiff brush. d. Instruct NAP to check the hearing aid battery.

ANS: D

Because the patient is usually alert and oriented, the nurse realizes that the most likely cause of the patient’s change in hearing is a defective hearing aid battery. The nurse directs the NAP to check the battery first because this is also a simple factor to eliminate. After checking the batteries, the nurse instructs the NAP to clean the hearing aid with the brush supplied by the manufacturer, which is the brush that the patient uses regularly. The nurse does not know yet whether the patient’s neurological status is poor. The NAP reports clinical indicators of normal neurological function, making a stroke unlikely.

NURSIN G T B .COM

DIF: Cognitive Level: Analyze R E F : Page 282 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment 5. The nurse instructs the patient on how to care for the hearing aid at home. What information

should the nurse include in patient teaching to prevent damage to the hearing aid? a. Store the hearing aid with a desiccant. b. Wash the hearing aid in hot soapy water. c. Keep the hearing aid in the bathroom. d. Clean the hearing aid with a pipe cleaner.

ANS: A

The nurse instructs the patient to store the hearing aid in a dry container with a desiccant to keep moisture and heat away from the device because moisture and heat can destroy the delicate electronic components of the hearing aid. The nurse instructs the patient to avoid immersing the hearing aid and inserting objects into it. The nurse also instructs the patient to avoid storing the hearing aid in the kitchen or bathroom to prevent exposure to moisture and heat.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

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6. The nurse is preparing to remove cerumen from an older adult’s ear. Nursing care is Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

appropriate if the nurse uses which procedure? a. Applies slight negative pressure to the ear canal

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. Asks the patient not to move while the ear is being irrigated c. Cleans the ear canal with a soft cotton swab to remove any remaining cerumen d. Instills cool irrigating fluid to break down the cerumen in the ear canal ANS: B

The nurse prepares the patient by explaining the procedure, including the need to remain still while the ear is being irrigated. To prevent damage to the tympanic membrane, negative pressure is never applied to the ear canal. The nurse avoids inserting a cotton swab into the ear canal because it is likely to push cerumen further into the ear. Cool irrigating fluid is contraindicated because it can cause nausea and vertigo.

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REF: Page 277 TOP: Nursing Process: Evaluation

7. The patient asks the nurse to irrigate both ear canals to improve hearing and comfort. The

patient has bilateral brown ear drainage and a history of a right mastoidectomy and perforation of the left tympanic membrane. Which intervention should the nurse implement first? a. Inform the patient that the ears are infected. b. Perform an otoscopic examination of the canals. c. Collaborate with the audiologist about a hearing aid. d. Irrigate the ear canals with warm saline solution.

ANS: B

The nurse completes the ear assessment with an otoscopic examination of the ear canals to provide comprehensive patient data to the healthcare provider. The nurse wants to observe cerumen, the tympanic membrane, and origin of the drainage in both ears. He or she avoids irrigating an ear with drainage N beUcR auSseItNhG eT d rBa i.n aCgOe Mi m p l i e s that the tympanic membrane is impaired. The nurse avoids sharing a diagnostic conclusion with the patient because he or she does not know that the ears are infected. The nurse’s scope of practice does not provide for collaboration with the audiologist about the need for a hearing aid. This is done by the healthcare provider after a thorough assessment to determine the patient’s plan of care and therapeutic regimen.

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REF: Page 276 TOP: Nursing Process: Planning

8. The nurse assesses a 3-year-old patient with a dried bean in the left ear canal. Which action

should the nurse implement? a. Wait for the bean to fall out. b. Examine the ears with an otoscope. c. Collaborate with the healthcare provider. d. Irrigate the ear to flush out the bean.

ANS: C

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse inspects the ears visually without the aid of an otoscope to complete the nursing assessment and then collaborates with the healthcare provider to remove the bean. The bean is not likely to fall out because it is more likely to increase in size by being in the moist environment of the ear canal. The nurse avoids an otoscopic examination because inserting the otoscope into the ear canal is likely to affect the bean and make it harder to remove. The nurse avoids irrigating the patient’s ear canal because the positive pressure from the irrigation solution is likely to affect the bean and make it harder to remove. In addition, a dried bean will absorb water, and its size will increase, further aggravating its removal.

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9. The nurse irrigates the patient’s right ear with saline solution to improve hearing. Which

unexpected outcome of ear canal irrigation does the nurse prevent by preparing the irrigation solution properly? a. Patient hearing acuity remains stable. b. Patient senses that irrigant is slightly warm. c. Patient complains of nausea and vertigo. d. Patient drainage contains brown particles.

ANS: C

The nurse expects to irrigate the patient’s ear canal without causing patient discomfort, pain, nausea, or vertigo by warming the irrigation solution before instilling it. The nurse expects the patient to sense the warmth of the irrigation solution; this is an expected outcome. Irrigation drainage from the ear containing brown particles is consistent with clinical indicators for effective ear irrigation because this is evidence of cerumen removal; this is an expected finding if cerumen was in the eN arUcRanSaI lN beGfoTrB e. thC e OprMo ced ure . Failure of patient hearing to improve after irrigation is a possible unexpected outcome, but it is not influenced by warming of solution.

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REF: Page 277 TOP: Nursing Process: Implementation

10. The nurse is instructing a patient on the procedure to remove a rigid contact lens. Instruction

by the nurse is correct if the patient uses which technique? a. Slides lens onto the sclera and pinches off the lens b. Draws periorbital skin taut and asks the patient to blink c. Uses a bulb syringe and applies suction to the lens d. Squeezes the upper and lower lids together to pinch the lens ANS: B

To remove a hard lens from a patient’s eye, the nurse draws the skin surrounding the eye tightly and instructs the patient to blink. Pulling the skin creates mild tension, which the eyelid uses to dislodge the lens from the cornea. Sliding a contact lens onto the sclera and pinching off the lens is the procedure to remove a soft contact lens. To prevent a corneal abrasion, the nurse avoids using suction to remove a contact lens. He or she avoids squeezing the eyelids together to prevent eye and conjunctival trauma from the hard lens.

DIF:

Cognitive Level: Apply

REF: Page 274, Box 11-1

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 11. After removing a soft contact lens, the nurse observes that the sides of the lens are sticking

together. Which intervention should the nurse implement before storing or reinserting the lens? a. Thoroughly soak the lens in saline solution. b. Rub the contact lens briskly to remove the debris. c. Pry the lens apart gently with a fingertip. d. Use the cleaning solution on the lens; then replace or store it.

ANS: A

A soft contact lens sticks together because it is dry. The nurse rehydrates the lens with saline solution; and the lens becomes soft, supple, less sticky, and suitable for the patient to wear or to store. Hard and soft contact lenses should never be rubbed because rubbing is likely to damage the lens. The nurse avoids prying apart the lens to prevent lens damage. Cleaning solution for lenses is intended to remove residue and debris from the lens but is not intended as a source of lens hydration. After using the cleaning solution, the nurse rinses the lens in saline solution before storage or reinsertion.

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REF: Page 274, Box 11-1 TOP: Nursing Process: Planning

12. The nurse admits a patient who wears a hearing aid for surgery. Which method should the

nurse use to assess the patient’s hearing acuity with the hearing aid in place? a. Whisper very softly behind the patient. b. Cover the patient’s unaffected ear before talking. c. Send the hearing aid to the audiologist for analysis. d. Check patient response using a normal voice level.

ANS: D

The nurse needs to determine the patient’s hearing ability with the hearing aid in place and both ears available to hear. The nurse speaks with the patient in a normal tone of voice, assesses the patient’s ability to respond properly, and asks the patient whether this is baseline hearing acuity. If the patient has difficulty hearing the nurse with normal conversation, the nurse conducts a more detailed assessment and ensures that the hearing aid battery is good.

The nurse performs the assessment before surgery to alert the surgical team to the patient with a sensory impairment so an alternative method of communication may be identified.

Whispering is a hearing acuity test used to evaluate a patient without hearing aids. The nurse avoids sending the hearing aid to an audiologist because the nurse is able to determine whether the patient can hear.

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REF: Page 279 TOP: Nursing Process: Assessment

13. The nurse plans care for the patient in acute care. Which is the priority nursing diagnosis for a

patient with altered sensory perception? a. At risk for injury b. Deficient knowledge c. Impaired communication d. Impaired social interaction Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: A

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The patient with a sensory impairment is at high risk for injury because many methods of communication with the patient cannot be used or need alteration to accommodate the impairment. The sensory impairment may render the patient unable to follow important directions, visualize hazards, or provide information to the healthcare team. However, the nurse’s priority is to maintain safety first and then to manage the communication impairment to prevent injury effectively. Deficient knowledge is a suitable nursing diagnosis for the patient who has a sensory impairment in acute care because the patient is likely to miss important information and is unaware of potential solutions to the problem. The patient with a sensory impairment frequently has impaired social interaction, so this is a reasonable nursing diagnosis. However, safety is always more important than psychosocial issues.

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REF: Page 279 TOP: Nursing Process: Diagnosis

14. The family of an older adult brings the patient to the healthcare provider because the patient

seems to be confused or depressed at times. What approach by the nurse can best obtain valuable information about the underlying problem? a. Talk to the patient in a normal voice while standing away from him or her. b. Whisper questions to the patient to determine if the questions can be understood. c. Ask the family to explain the activity patterns of the patient. d. Ask the family for a list of what the patient usually eats.

ANS: A

The nurse can determine if the patient has a hearing impairment by standing a distance from him or her and speaking in a normal tone of voice. Hearing loss can cause the patient to be depressed or seem to be confused. The focus of the assessment needs to be on the patient, not the family. Whispering is inappNroUpRriSatI eN beGcT auBs. e Ct hOi sMi s not a level at which communication usually occurs. The patient’s activity level can be affected by many things other than hearing.

The dietary pattern of the patient is not important at this time.

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REF: Page 282 TOP: Nursing Process: Assessment

15. The nurse plans care for a newly admitted female Muslim patient who is blind. Which is the

priority nursing action for this patient? a. Touch the patient before talking to her. b. Talk with the patient before touching her. c. Assign only female caregivers to this patient. d. Obtain a history of what the patient can eat.

ANS: C

It is unacceptable for caregivers of the opposite sex to touch a patient of the Muslim faith. It is essential that only same-sex caregivers be assigned to this patient. Although it is important to talk with the patient before touching her, the assignment of same-sex personnel is priority.

DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 271 TOP: Nursing Process: Planning

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf MULTIPLE RESPONSE

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 1. The nurse plans care for a patient who has a hearing deficit. What actions when taken by the

nurse indicate a good understanding of appropriate care? (Select all that apply.) a. Face the patient before beginning to speak. b. Keep the lights dimmed low. c. Speak in a slow, clear, and loud voice. d. Eliminate external voices. e. Do not talk over the patient.

ANS: A, D, E

When patients have a hearing deficit, be sure they understand what you communicate to them.

Always face the patient before beginning to speak and make sure there is enough light for the patient to see your lips. Eliminate external noises; speak in a slow, clear, normal tone of voice.

Do not speak in a loud voice. Ask patients what communication styles they prefer. Never talk over or exclude a patient from conversation or decisions.

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REF: Page 279 TOP: Nursing Process: Planning

2. The nurse is establishing a discharge teaching plan for a diabetic patient with visual

impairment who is seen in urgent care for an ankle sprain. Which self-care tasks will need additional adjustments to accommodate for the visual impairment? (Select all that apply.) a. Taking medications b. Testing blood glucose c. Applying ice pack to ankle injury d. Applying Ace wrap to ankle e. Taking insulin ANS: A, B, E

When patients have visual impairments, they may have difficulty with tasks requiring visual detail (e.g., reading prescriptions or syringes). This increases the risk of improper administration of medications in the home setting. Applying ice packs and wrapping with an ace wrap do not require any high degree of visual acuity and do not pose a safety concern.

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3. The nurse is orienting a new graduate nurse about eye irrigation. Which statement indicates a

good level of understanding of the procedure? (Select all that apply.) a. “I should irrigate from inner to outer canthus.” b. “I should tell the patient not to blink.” c. “I should always remove the contact lenses first.” d. “I should hold the lids open by putting gentle pressure to the lower bony orbit.” e. “I should irrigate until clear or prescribed amount of time is reached.”

ANS: A, D, E

The eye is irrigated from the inner to outer canthus. The patient is allowed to blink periodically, which can help move secretions from the upper conjunctival sac. You should determine if the patient is wearing contact lenses. Do not remove contact lenses unless there is a rapid swelling, there is a chemical injury, or you cannot get rapid medical attention. You can Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

remove them later if they do not flush out during irrigation. Continue irrigation with prescribed solution, volume, or time or until secretions are cleared.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 272 TOP: Nursing Process: Planning

4. The nurse is performing eye care for a comatose patient. Which interventions indicate the

nurse has a good understanding of the appropriate care needed? (Select all that apply.) a. The nurse cleans the eye with water or saline. b. The nurse uses an eyedropper to instill the prescribed lubricant. c. The nurse wipes away excess lubricant moving from outer canthus to inner canthus. d. The nurse applies eye patches when the blink reflex is absent. e. The nurse changes the eye patches every 8 hours.

ANS: A, B, C, D

To prevent damage to corneas in a comatose patient, eye care is performed. The nurse cleans the eyes with water or saline, wiping from inner canthus to outer canthus, using a separate wash cloth or cotton ball for each eye. Lubricant is applied using an eye dropper, wiping excess from inner canthus to outer canthus. Eye patches are used when there is no blink reflex and are changed every 4 hours.

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5. The nurse is assessing an elderly patient’s ability to understand how to properly care for his

hearing aid. Which of the following statements indicate further education is needed? (Select all that apply.) a. “I can wear my hearing aid in the shower.”

OiMm.” b. “I should take it out when INgU oRtoStI heNpGoToB l t. oC sw c. “I can wear my hearing aid when I get my hair done.” d. “I need to make sure I don’t leave them in a hot car.” e. “I should store the batteries in a dry, safe place.”

ANS: A, C

Patients should be instructed to avoid exposure of hearing aids to extreme heat, cold, or moisture. Do not leave in case near stove, heater, or sunny window. Do not use with hair dryer on hot settings or with sunlamp. Do not wear when bathing, during excess sweating, or when shampooing at a hair stylist. Do not use hairspray or other hair care products while wearing hearing aids. Store batteries in a dry, safe place away from pets and children. Always keep a set of unused batteries in the home.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 12: Promoting Nutrition Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. The patient has weakness of the left arm and hand after a stroke. Which is the best nursing

intervention to help maintain the patient’s self-esteem during feeding? a. Delegate feeding to nursing assistive personnel (NAP) to minimize the amount of food spilled. b. Encourage the patient to self-feed as much as possible. c. Ensure that foods are pureed so they may be consumed through a straw. d. Collaborate with speech therapist to improve the patient’s communication.

ANS: B

The nurse maintains and enhances the patient’s self-esteem by encouraging the patient with positive reinforcement, acknowledging the patient’s progress with self-feeding, and engaging him or her in conversation during feeding. Feeding the patient may reinforce feelings of inadequacy, worthlessness, or embarrassment. Taking food by straw may be contraindicated and increase the risk of aspiration, depending on the patient’s neuromuscular coordination for chewing and swallowing. Ensuring effective patient communication is expected nursing care for any patient in any setting; however, speech therapy is not indicated.

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2. A patient has not eaten since admission to the long-term care facility 2 days ago. Which is the

NURSINGTB.C

best initial intervention for the nurse to prevent malnutrition in this patient? a. Make a diet request to the healthcare provider for full liquids. b. Ask the patient’s daughter why the patient will not eat. c. Remind the patient that nutrition is essential to better health. d. Assess the patient for possible reasons for the lack of intake.

ANS: D

The nurse gathers additional information by using the nursing process to prevent malnutrition for a new patient in the long-term care facility. Identifying barriers to nutrition begins with obtaining objective and subjective data by which the nurse gathers valuable nutritional information, including muscle function, teeth, cognition, and patient food preferences.

Requesting a diet change is premature and not based on assessment data. Asking the daughter for information reveals the daughter’s opinion, anecdotal information, and possibly biased observations about the patient. The use of the word “why” is also not therapeutic. Reminding the patient about nutrition may be a useless intervention if his or her cognition is low, if he or she has a sensory or communication disorder, or if he or she is depressed. In addition, the patient can interpret this as an insult to his or her intelligence.

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REF: Page 285, Table 12-1 TOP: Nursing Process: Implementation

3. A patient with a neurological disease has difficulty swallowing. Which should the nurse Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

include in the plan of care? a. Limit oral intake to clear liquids.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. Allow adequate time for the feeding. c. Ask family members to coach the patient. d. Maintain low-Fowler’s position for meals.

ANS: B

The nurse plans an adequate amount of time for patient feeding to address complications from impaired swallowing. With nursing supervision and encouragement and in a relaxed manner, the food is prepared properly; the patient chews food thoroughly, swallows as necessary, and takes short breaks while feeding. Clear liquids may be contraindicated for the patient.

Thickener may need to be added, depending on the patient’s status. Family coaching may pressure, misdirect, or shame the patient; increase the risk of aspiration or choking; and decrease the patient’s appetite. Low-Fowler’s position is contraindicated for swallowing difficulties and feeding because an upright position facilitates swallowing.

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4. The nurse plans care for a patient with impaired swallowing. Which outcome would be

appropriate for the nurse to include in the patient’s plan of care? a. The patient holds food in the pockets of the mouth. b. The nurse observes no movement of the larynx during swallowing. c. The patient maintains a stabilized weight for 3 consecutive days. d. The patient swallows four times after each mouthful.

ANS: C

A suitable outcome for a patient with impaired swallowing is that weight stabilizes over 3 days. This indicates that the patient is ingesting and absorbing sufficient nutrients to avoid weight loss. Holding amounts oNfUfoRoSdIinNtG heTpBo.ckCeOtsMof the mouth indicates difficultly moving the food for chewing and swallowing. Movement of the larynx normally occurs during swallowing. Swallowing four times for each mouthful is not a desirable outcome of nursing care because this behavior is consistent with neuromuscular dysfunction of chewing or swallowing.

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REF: Page 294 TOP: Nursing Process: Planning

5. The patient with impaired swallowing begins to choke while eating. Which action should the

nurse implement? a. Suction the airway until clear. b. Turn the patient to a prone position. c. Leave the room to get assistance. d. Instruct the patient to take deep breaths.

ANS: A

The nurse suctions the oropharynx of a patient with dysphagia who chokes while eating to maintain the airway, the highest priority on the patient’s hierarchy of needs. A positioning change is not indicated unless the patient starts to vomit or becomes unresponsive; then the nurse places the patient in the recovery position. The nurse should not leave the patient until the choking is resolved and the patient is stabilized. The patient should not take deep breaths, Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

which may draw in food and aggravate choking.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 295 TOP: Nursing Process: Planning

6. An older patient has been eating approximately 50% of each meal for several days. Which

action should the nurse take to increase the patient’s nutritional intake? a. Serve the food at room temperature. b. Check for an altered taste perception. c. Encourage the patient to eat with a friend. d. Provide soft, bland foods and snacks.

ANS: B

The nurse assesses the patient for altered taste perception because the acuity of several senses deteriorates with aging, including the senses of taste and smell; these sensory functions are important for food enjoyment and the appetite. To promote health and well-being, the nurse recognizes that the patient is at risk for malnutrition and assesses him or her to gather data for planning care because well-nourished patients are more likely to have positive health outcomes. Serving food at room temperature is an intervention. The nurse should find out more information through assessment and then plan appropriately. Eating with a friend can make eating more enjoyable, but, if a physiological reason exists, the reason needs to be addressed first. This option is also an intervention, not an assessment. Serving bland foods is not appropriate at this time. If there is an alteration in ability to taste and smell, bland foods might not be most appetizing to the patient.

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7. A male patient with a neurological injury is learning how to feed himself. Which method

should the nurse implement to N beUstRfS acIilN itG atT eB le. arC niOnM g? a. Delay self-feeding until the hand tremors subside. b. Show the patient a video of a man feeding himself. c. Provide one piece of adaptive equipment at a time. d. Instruct the patient while assisting him during eating.

ANS: D

To best facilitate patient learning, the nurse provides verbal instructions while demonstrating feeding techniques to explain each step, provide insight, and clarify directions. A vivid portrayal of feeding techniques appeals to visual learners, and the nurse reinforces the mental image with narration. Showing a video demonstration alone would not meet the needs of the patient for support and encouragement. Depending on the nature of the injury, the hand tremors can be permanent; so the patient needs to learn self-feeding with hand tremors. All required equipment for self-feeding should be provided to determine which is best for the patient because self-feeding with inadequate equipment can set up the patient for failure. In addition, some pieces of equipment such as a knife and fork are meant to be used simultaneously as needed.

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8. The nurse admits a patient who follows the Hindu faith. Which food should the nurse Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

withhold to maintain the patient’s dietary practices in accordance with this faith? a. Pork chops

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. Noodles c. Rice d. Tea ANS: A

The nurse should avoid pork chops. Buddhists and Hindus are generally vegetarians because of their respect for life and belief in transmigration of the soul.

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REF: Page 287, Box 12-2 TOP: Nursing Process: Planning

9. The nurse prepares a dietary plan for a patient who practices Orthodox Judaism and notes that

no Jewish holidays are approaching. What choices does the nurse plan to exclude from the patient’s menu? a. Caffeinated tea b. Grilled cheese sandwich c. Milk products d. Lobster chowder ANS: D

The patient practicing Orthodox Judaism cannot eat shellfish; so the nurse eliminates lobster from the patient’s dietary plan. Orthodox Jewish dietary guidelines do not restrict dietary intake of dairy products except that dairy products are not eaten at the same meal with meat.

The patient’s religious practices allow caffeine in the diet. All followers of Judaism avoid eating leavened bread such as regular bread during Passover but may have it the rest of the time unless fasting.

DIF: Cognitive Level: RemembN erURSINRGETFB : .PC agOeM287 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning 10. The nurse assists the patient who had a recent cerebral vascular accident (CVA or stroke) with

drinking water, and the patient begins to choke. Which intervention is the best choice to meet the patient’s priority need? a. Provide oxygen. b. Suction the patient. c. Call for assistance. d. Recline the patient.

ANS: B

The patient’s priority needs, in order, are airway, breathing, and circulation (ABCs), so the nurse’s priority action is to maintain the airway. To accomplish this, the nurse suctions the patient to prevent an airway obstruction. After the airway is clear, the nurse can provide supplemental oxygen as prescribed if the patient continues to have difficulty or has oxygen desaturation from choking. If the patient continues to have difficulty, the nurse should call for help to obtain emergency equipment. The nurse can place the patient in the recovery position after choking if the patient loses consciousness, continues to choke, or starts to retch or vomit.

Reclining the patient is contraindicated because it increases the risk of aspiration.

DIF:

Cognitive Level: Analyze

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 11. The nurse receives a report stating that the patient, who is 5 feet tall, has a nutritional deficit.

Which physical clinical indicator consistent with a nutritional deficit does the nurse expect to observe in the patient? a. Long, shiny hair b. Pale conjunctivae c. Pink oral mucosa d. Weight of 104 pounds ANS: B

Pale conjunctivae are a clinical indicator of a nutritional deficit consistent with a low serum hemoglobin or hematocrit. The hematological deficiencies result in a low oxygen-carrying capacity and a deficient number of red blood cells in the blood. This decreases the ability of the erythrocytes to oxygenate the tissues adequately, thereby resulting in pale mucous membranes. Conjunctivae should appear reddish pink. Long, shiny hair and pink oral mucosa are clinical indicators of a patient who consumes an adequate diet. A female patient who is 5 feet tall should weigh at least 100 pounds.

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REF: Page 286 TOP: Nursing Process: Assessment

12. The nurse wants to know if the nursing plan of care is effective for a male patient with

malnutrition. Which assessment finding indicates to the nurse that the plan is effective? a. The tongue is large with a smooth surface. b. Eighty percent of food was consumed at his last meal. c. He weighs 185 pounds at 5 feet 6 inches tall. d. He has reddish-pink mucous membranes.

ANS: D

Reddish-pink oral and conjunctival mucous membranes are indications of a well-nourished person because this color is consistent with well-oxygenated tissue resulting from adequate amounts of hemoglobin and erythrocytes. A malnourished person is likely to have pale mucous membranes because the individual does not receive adequate nutrition in the diet to provide the body with the necessary iron to synthesize hemoglobin, amino acids to manufacture protein, and other nutrients to manufacture red blood cells in adequate amounts.

The tongue is a vivid pink or deep red, with papillae present in adequately nourished individuals. Generally consuming 80% of meals is an acceptable dietary intake; however, a malnourished person usually needs to eat the entire meal on a consistent basis to restore and maintain health and wellness. The recommended weight for a male who is 5 feet 6 inches is 142 pounds, indicating that this patient is overweight. Obese individuals are frequently malnourished but gain weight by eating foods that are high in fat and calories and low in nutrition.

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13. The healthcare provider prescribes a dental-soft diet for the patient. Which food selection

should the nurse provide for the patient? a. White toast with peanut butter b. Pancakes with sliced bananas Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. Scrambled eggs with bacon d. Baked lasagna with meat sauce

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: B

Pancakes with sliced bananas are a suitable food choice for patients on a dental-soft diet because this diet requires foods that are very easy to chew, require minimal chewing, or allow the patient to eat without teeth. Scrambled eggs are appropriate, but not the bacon. Toast requires chewing, which is unacceptable on the dental-soft diet. Cooked pasta with meat sauce would be allowed on a soft diet but not on a dental-soft diet for which chewing may be a problem.

DIF: Cognitive Level: Comprehension OBJ: NCLEX: Physiological Integrity

REF: Page 289 TOP: Nursing Process: Planning

14. The healthcare provider has started the patient on a clear liquid diet. Which item should the

nurse provide for the patient? a. Orange juice b. Ice cream c. Cranberry juice d. Vegetable juice ANS: C

Cranberry juice is a suitable choice for a patient on a clear liquid diet because this product is made with juice, flavored water, and possibly a sweetener. It is possible to actually see through the liquid. Orange juice, vegetable juice, and ice cream are all dense liquids that the nurse cannot see through. They are suitable for a full liquid diet.

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15. The nurse plans care for four patients and assigns patient feeding to nursing assistive

personnel (NAP). Which patient should the nurse watch during mealtime? a. The patient who refuses most of the meals served b. The patient who is learning to use adaptive utensils c. The patient who swallows four times for each piece of food d. The patient who is taking ice chips on the first postoperative day ANS: C

The patient who swallows four times for each piece of food exhibits signs of dysphagia and is at high risk for aspiration. Until the nurse assesses the patient for dysphagia, consults with other members of the healthcare team, and collaborates on a plan of care, he or she must assume responsibility for the patient’s aspiration precautions. The nurse instructs the NAP to observe for choking and coughing after mealtime is over. The NAP may be instructed to assist the patient who refuses most meals by encouraging the patient, avoiding coercion to get the patient to eat, and reporting the amount of food eaten by the patient. With training and instruction, the NAP would also be able to assist the patient learning how to use adaptive utensils. The NAP is able to assist the postoperative patient with ice chips.

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16. The nurse teaches the patient about eating a soft diet at home. After teaching, the nurse asks Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

the patient for an example of a suitable food on a soft diet. Which patient choice does the nurse accept as suitable for a soft diet?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. b. c. d.

Hot oatmeal with low-fat milk Tomato stuffed with tuna salad Lean steak with a baked potato Thin spaghetti with tomato sauce

ANS: D

Food on a soft diet must be low in fiber, easily digested, easy to chew, and simple to cook; thus thin spaghetti with tomato sauce is suitable. A soft diet is slightly different from a mechanical soft diet because soft-diet foods must be low in fiber and mechanically soft foods can contain fiber that are pureed or ground. The oatmeal is rich in fiber and is considered a high-fiber food. The fresh tomato needs to be chewed as does the tuna salad. The tuna salad has the mayonnaise, which provides quite a bit of fat. The meat must be chewed and is not easily digested. The baked potato usually requires the addition of butter or some fat and is also high in fiber.

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17. The nurse at a community center is preparing a program for elderly people at risk for

malnutrition who need community resources. Which is the best action for initiating the nurse’s program? a. Review each individual’s height, weight, and health history. b. Teach low-cost menus and methods for a balanced diet. c. Post flyers with instructions for obtaining free vitamins. d. Provide telephone numbers of food banks and free meals.

ANS: A

To start a community nut rition Np U roRgrSaI mN, tGheT nBu.r sCeOa M p p l i e s the nursing process and implements the first step, data gathering, to determine community needs. The nurse gathers suitable data for planning the program by screening elderly people for malnutrition and people at risk for malnutrition using a nutritional screening tool. The nurse analyzes the data, including height, weight, and health history to tailor the overall program; organizes suitable resources; plans for individual nutritional assistance; and matches people who are malnourished or at risk with community resources such as food banks, free meals, and Meals on Wheels. The remaining choices do not help the nurse identify people at risk for malnutrition. Teaching about a balanced diet is a prevention technique, and obtaining free vitamins and providing contact information may help people find community resources but doesn’t identify their risk levels.

The healthcare provider recommends vitamins to supplement a well-balanced diet, not to replace it.

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18. The nurse prepares to insert a small-bore intestinal feeding tube. Which instruction does the

nurse provide to nursing assistive personnel (NAP) to assist with preparation? a. Immerse the feeding tube in an ice bath. b. Cut a 10.2-cm (4-inch) piece of adhesive tape. c. Inspect the patient’s nares for irritation.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf d. Remove the guidewire from the feeding tube.

ANS: B

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse instructs the NAP to cut a 10.2-cm (4-inch) strip of adhesive tape to secure the feeding tube to the patient’s nose while the nurse supervises the NAP’s action. Icing a feeding tube is never recommended because it would only make the tube stiffer and harder to insert.

The nurse is responsible for patient assessment before tube insertion because it requires clinical judgment and critical thinking. The guidewire remains in the feeding tube until placement is confirmed with an x-ray film.

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19. The nurse prepares to insert a small-bore feeding tube into a patient. Which step of the

procedure does the nurse expect during the insertion? a. Advance the tube 20 to 25 cm (7.9 to 9.8 inches). b. The tube coils in the oropharynx. c. The patient has trouble swallowing. d. The patient looks slightly cyanotic.

ANS: A

The nurse anticipates advancing the tube by 20 to 25 cm (7.9 to 9.8 inches) into the patient’s gastrointestinal tract to position it in the correct location for feeding. The nurse expects the feeding tube to descend into the esophagus in a straight line along the posterior oropharynx. It is expected that the patient will swallow without difficulty to facilitate tube passage through the esophagus. The patient is expected to mouth breathe and maintain adequate oxygenation during the feeding tube insertion.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

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20. The nurse cannot advance the small-bore intestinal feeding tube into the patient’s oropharynx.

What nursing action will facilitate tube advancement without complications? a. Attempt to insert the tube into the other naris. b. Advance the stylet and then thread the tube over it. c. Remove the stylet, check it for kinks, and reinsert it. d. Use another stylet to move the tube into position.

ANS: A

The nurse attempts to insert the feeding tube and stylet into the opposite naris after encountering difficulty in the first naris because a physical obstruction is the most likely cause of the problem. The nurse avoids advancing the stylet if the feeding tube does not cover it because the unguarded stylet is likely to cause tissue trauma to the patient’s nasal passageways or oropharynx. Once the stylet is removed from the feeding tube, it cannot be reinserted without damaging the tube. Using a second stylet is contraindicated for tube manipulation.

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21. The nurse inserts a gastric feeding tube into the patient. Which method used by the nurse is

most accurate to verify placement of the patient’s feeding tube?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. Gets a pH of 4.0 from the feeding tube aspirate b. Obtains a pH of 7.0 from the gastric aspirate

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. Listens at the tube distal to the pyloric sphincter d. Locates the tube above the cardiac sphincter ANS: A

The nurse inserts a gastric feeding tube and expects to confirm tube placement in the stomach; the nurse verifies gastric placement by measuring the pH of the aspirate and expects it to be 4.0 or less because hydrochloric acid from gastric parietal cells acidify gastric contents.

Feeding tube aspirate of 7.0 is most likely from the intestines. A gastric feeding tube is above the pyloric sphincter, the sphincter that controls gastric emptying into the duodenum. The cardiac sphincter is above the area where a pH sample could be obtained.

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22. The nurse assesses the patient who receives continuous enteral nutrition through a

nasointestinal tube. What is the priority intervention by the nurse if the patient’s bowel sounds are inaudible? a. Document “absent bowel sounds.” b. Gradually decrease the rate of the tube feeding. c. Monitor the patient for possible diarrhea. d. Stop the feeding and notify the healthcare provider.

ANS: D

The nurse stops the tube feeding and collaborates with the healthcare provider after assessing a patient who receives a continuous tube feeding with no evidence of peristalsis. Without peristalsis, the formula accumulates in the stomach, and eventually the patient can vomit, increasing the risk of aspiration. The nurse should document that bowel sounds are inaudible because he or she cannot at t es t Nt oUtRheS aIbNs eGnTceBo.f Cp O erMis t al s i s but relies on clinical indicators consistent with decreased peristalsis. Any patient receiving tube feedings receives nursing assessments for diarrhea and constipation; in addition, if the patient has diarrhea, bowel sounds are likely to be loud, frequent, and high pitched.

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23. The nurse is unable to aspirate any residual volume from the patient who receives intestinal

tube feedings at a rate of 200 mL every 6 hours by intermittent gavage. Which action should the nurse implement? a. Insert a nasogastric tube. b. Withhold the next feeding. c. Notify the patient’s healthcare provider. d. Administer the next feeding.

ANS: D

The nurse expects to aspirate no residual volume from the patient who receives intermittent intestinal tube feedings because the small intestines are unable to sequester fluid. The placement of this type of tube is verified by x-ray film; and, if nothing is aspirated afterward, it is assumed that placement of the tube is correct.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 24. The nurse prepares the patient for discharge to home with instructions to self-administer

nasointestinal tube feedings. Which does the nurse include in patient teaching? a. Infuse the formula at room temperature to avoid abdominal cramping. b. Increase the amount of free water with persistent diarrhea or constipation. c. Flush the tube with 500 mL of water after each tube feeding. d. Allow the formula to infuse until the bag empties completely.

ANS: A

Tube feedings infused into the stomach or intestines bypass food warming that takes place as food passes through the mouth and esophagus; thus the nurse instructs the patient to infuse the formula at room temperature to avoid abdominal cramping. The patient should report diarrhea or constipation to the healthcare provider before implementing additional fluids since these may be indications of other complications of tube feedings. Flushing with 500 mL of water after each tube feeding is probably excessive and risks causing fluid volume overload in the patient. Because nasointestinal feedings generally infuse continuously, the nurse instructs the patient to replace the feeding bag and tubing every 24 hours and flush the tubing before and after each new infusion. The nurse instructs the patient to infuse the same can of formula for up to 8 hours without adding formula over the infusion period.

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25. The patient is receiving nasointestinal tube feedings by continuous drip from an open system.

Which procedure should the nurse use when caring for this patient? a. Administer medication with a 10 mL-syringe. b. Change the feeding tube bag every 8 hours. c. Add enough formula to theNbU agRtS oI laNstG2T4Bh. ouCrO s.M d. Check the placement of the tube with a 60-mL syringe.

ANS: D

The nurse checks tube placement and administers medication with a 60-mL syringe. The feeding tube bag is changed every 24 hours to prevent bacteria buildup in the system. The maximum time that formula can hang in an open system is 8 hours. The 10-mL syringe would cause excessive positive pressure into the feeding tube.

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26. The nurse aspirates fluid from the nasointestinal tube. Which finding requires the nurse to

plan follow-up nursing interventions? a. The aspirated liquid totals 5 mL of greenish fluid. b. The feeding tube collapses with negative pressure. c. The nurse aspirates a small amount of the formula. d. The aspirated liquid appears pale and straw colored.

ANS: D

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse plans follow-up nursing interventions after aspirating pale and straw-colored fluid because intestinal aspirate should be green, indicative of the bile concentration of the fluid.

Because the aspirate is inconsistent with clinical indicators for intestinal fluid, the nurse investigates further to verify tube placement before instilling anything into the nasointestinal tube. The nurse expects to aspirate a small amount of greenish fluid indicative of bile in the fluid. This also indicates placement of the nasointestinal tube in the intestines because the intestines cannot hold large amounts of fluid as the stomach can. The nasointestinal tube is expected to collapse with negative pressure because it is a soft pliable tube. A small amount of formula aspirated is not a problem and does not require follow-up. It is acceptable.

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27. The nurse instructs the patient to self-administer nasointestinal tube feedings at home. Which

is the best instruction to include in patient teaching about aspirating the tube? a. Withhold tube feedings if unable to obtain aspirate. b. Check tube placement by instilling air into the tube. c. Administer the tube feedings at 7.22° C to 10° C (45° F to 50° F). d. Report aspirate with a pH less than 6.0 to the provider.

ANS: D

The nurse instructs the patient to report a pH less than 6.0 of the intestinal aspirate because this fluid should be alkaline and have a pH greater than 6.0 from exposure to intestinal fluid and bile. If a patient who is able to competently handle administering a nasointestinal feeding at home aspirates and obtains no fluid, the nurse assumes that the infusion is operating without difficulty because no aspirate is an expected finding. The nurse avoids instructing the patient to instill air to verify tubNeUpRlaScI em t; B ho.w er, he or she instructs the patient to instill NeGnT CeOvM 30 mL of air before aspirating gastric fluid to displace the fluid and facilitate aspiration. Tube feeding formula should be at room temperature to avoid abdominal cramping.

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28. The nurse is planning care for the patient receiving nasogastric tube feedings. What

reassessment information would best indicate to the nurse that a successful therapeutic regimen has been established? a. Respirations are 28 to 32 breaths/min. b. The residual volume is less than 100 mL. c. A 4-pound weight loss has occurred over 1 month. d. Urine output has increased from 10 to 15 mL/hr.

ANS: B

A clinical indicator of a successful therapeutic regimen is a residual volume below 100 mL because the nurse understands that this means that the gastric feeding is stimulating the stretch receptors in the stomach to empty gastric contents into the duodenum and precipitate intestinal peristalsis. The peristaltic action moves the formula through the gastrointestinal tract to prevent formula accumulation in the stomach. Tachypnea in a patient with gastric tube feedings warrants further investigation by the nurse because tachypnea is consistent with clinical indicators for aspiration. Significant weight loss that is not the result of decreased Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

fluid volume is consistent with delivering inadequate calories and protein to prevent muscle wasting. The nurse expects urine output between 30 and 50 mL/hr, depending on the patient.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

REF: Page 305 TOP: Nursing Process: Evaluation

29. The nurse is caring for a patient on intermittent gavage tube feedings. Over what period of

time should the nurse infuse each feeding? a. Up to 8 hours b. Up to 24 hours c. 10 to 15 minutes d. 30 to 45 minutes ANS: D

The nurse allows the intermittent tube feeding to infuse over 30 to 45 minutes by gravity to reduce the risk of abdominal discomfort, vomiting, or diarrhea induced by bolus or excessively rapid formula infusions. Infusions of 8 or 24 hours defeat the purpose of an intermittent infusion because the therapy is mimicking normal eating patterns. Infusions of 10 to 15 minutes are too rapid and increase the risk of aspiration.

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30. After 2 days of administering the patient’s continuous nasogastric tube (NGT) feeding at 35

mL/hr successfully, the nurse aspirates 150 mL of formula. Which should the nurse implement first? a. Return the aspirate and continue with the feeding. b. Flush the tube with 30 mL of normal saline solution. c. Return the aspirate and reevaluate patient in 1 hour. d. Collaborate about the as p ir N at U eR wS ithItNhG eT prB ov.iC deOr.M ANS: A

Best evidence suggests that a single high gastric volume residual GRV should be monitored for the following hour, but enteral feeding should not be stopped or withheld for an isolated high GRV, so the nurse returns the 150-mL aspirate, documents the event, and communicates the finding to the next nurse. If on several occasions the nurse aspirates more than 150 mL, the nurse notifies the provider. Excessive NGT aspirate warrants further investigation by the nurse at that time and requires the nurse to assess the patient carefully on restarting the feeding. The nurse flushes the NGT after discarding the excessive NGT aspirate to maintain tube patency. The nurse returns the aspirate if the volume is less than 200 mL. There is no reason to contact the provider at this point.

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31. The patient receives three different medications through a nasogastric tube (NGT). Which

fluid volume does the nurse anticipate instilling to administer medications by NGT properly? a. 30 mL b. 60 mL c. 120 mL d. 150 mL Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: C

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse expects to instill at least 120 mL of fluid to administer three medications by NGT because he or she flushes the tube with 30 mL of water before and after each medication, resulting in four flushes or 120 mL. DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

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32. The nurse prepares to insert a patient’s nasogastric tube (NGT) for tube feedings. Which

patient assessment requires the nurse to collaborate with the patient’s healthcare provider before initiating the feeding? a. An intact gag reflex b. An occluded right naris c. Impaired swallowing d. Absent bowel sounds ANS: D

The nurse collaborates with the provider before initiating tube feedings for a patient without bowel sounds because any formula infused is likely to accumulate in the stomach and greatly increase the patient’s risk of aspiration. Even so, peristalsis is normally stimulated as food accumulates in the stomach, activates stretch receptors, and stimulates peristalsis in the small and large intestines. Indications for NGT feedings exist for patients with and without a gag reflex. The nurse attempts NGT insertion into the left nostril when the right nostril is occluded. Patients with impaired swallowing are suitable candidates for NGT feedings.

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33. The patient receives a p r e s c r i p tNi oUn Rf oSrIt uNbGe Tf eBe d.i C n gOsM. Which does the nurse implement while

inserting a nasogastric tube for this patient? a. Advances the nasogastric tube while the patient swallows b. Instructs the patient about self-care of the feeding tube c. Eases insertion by icing down the nasogastric tube d. Measures the length from the patient’s nose to the sternum ANS: A

The nurse instructs the patient to swallow while the tube advances because the coordinated muscular action of the esophagus helps to direct it down through the cardiac sphincter and into the stomach. The nurse can provide patient teaching after the tube insertion because instruction provided before the insertion is unlikely to be retained. Briefly immersing the end of the tube in warm water eases insertion by softening the end of the tube for passage through the nasal passageway. The nurse measures the length of the nasogastric tube properly by measuring from the tip of the nose to the earlobe to the xiphoid process.

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34. The nurse prepares to insert a nasointestinal tube into a patient. Which does the nurse

implement for proper tube placement? a. Measures from the nose to the earlobe to the xiphoid process Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. Removes the guidewire after verifying placement c. Places the patient on the left side until verifying placement

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf d. Anchors the tube with tape after insertion ANS: B

The nurse maintains the guidewire in place until intestinal placement is verified because, once it is removed, it cannot be reinserted. If the tube needs repositioning, the nurse cannot manipulate it effectively. The nurse measures from the tip of the nose to the earlobe to the xiphoid process and adds 20 to 30 cm for a proper length. Positioning the patient on the left or right side does not facilitate migration of the tube into the intestines. The nurse anchors the nasointestinal tube in place after placement in the jejunum is verified.

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35. The nurse is determining whether an order for a nasogastric tube feeding is appropriate.

Which patient diagnosis would prevent the nurse from initiating a tube feeding? a. Septicemia b. Pancreatitis c. Gastric ileus d. Head trauma ANS: C

Gastric ileus, or gastroparesis, is a contraindication to nasogastric tube feedings because infused formula into the stomach is likely to remain in the stomach and accumulate. This increases the risk of aspiration and endangers the patient’s airway. The duty the nurse owes the patient is to withhold a tube feeding until bowel sounds are present. Pancreatitis, sepsis, and head trauma are indications for tube feedings as long as the patient has peristaltic action.

DIF: Cognitive Level: RemembN erURSINRGETFB : .PC agOeM297 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Evaluation 36. Before administering a continuous nasointestinal tube (NIT) feeding, the nurse verifies

placement of the patient’s NIT and flushes it with water. Which step should the nurse perform next? a. Instill the formula immediately after removing it from refrigeration. b. Infuse the formula over 10 to 15 minutes. c. Raise the syringe 18 inches above the insertion site. d. Attach the feeding bag to the proximal end of the NIT. ANS: D

For a continuous tube feeding, the nurse attaches the feeding bag tubing to the proximal end of the NIT to begin the infusion and connects the tubing through the infusion pump. Cold formula can cause cramping. Formula should be administered at room temperature. A continuous infusion infuses around the clock; if the feeding is an intermittent infusion, the nurse administers it over 30 to 60 minutes. The nurse administers a continuous infusion with a feeding bag; intermittent infusions can be administered with a syringe.

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf MULTIPLE RESPONSE

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 1. The nurse instructs the caregiver to administer the patient’s intermittent tube feeding. Which

does the nurse include in caregiver teaching? (Select all that apply.) a. Maintain tube patency with frequent irrigations. b. Keep the feeding tube capped between feedings. c. Complete feeding before checking tube placement. d. Store opened cans of formula in the refrigerator.

ANS: B, D

The nurse instructs the caregiver to cap the feeding tube for an airtight seal between feedings to prevent the contents of the tube from drying and occluding the tube. Flushing a feeding tube too frequently is associated with tube occlusion. The nurse confirms tube placement before infusing the formula. The nurse instructs the caregiver to refrigerate opened cans of formula. Bacteria grows at room temperature once the cans are opened, spoiling the formula.

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2. The nurse instructs the new orientee to care for the gastrostomy site. Which items should the

nurse include in her teaching? (Select all that apply.) a. Cleanse the site with Betadine. b. Place the dressing under the external bar. c. Assess the site for evidence of drainage or infection. d. Apply a thin layer of skin barrier to exit site.

ANS: C, D

The site should be cleansed with soap and water and assessed for excoriation, drainage, infection, or bleeding. The nurse should apply a barrier protective cream if ordered. The dressing goes over the ex t ern alNbUarR. S PlI acNinGgTiB t u.nC deOrMthe bar can cause tissue erosion.

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 13: Pain Management Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. The nurse teaches the patient progressive self-relaxation techniques. Which should the nurse

implement first? a. Direct the patient to envision sailing on a sailboat. b. Instruct the patient to increase respiratory rate and depth. c. Establish the patient’s ability to participate and cooperate. d. Darken the patient’s room significantly and close the door.

ANS: C

The nurse begins by assessing the patient’s ability to participate and cooperate to tailor the teaching techniques and vocabulary to him or her. This increases the likelihood of the patient benefiting from the instruction. Envisioning pleasant things is part of teaching guided imagery but is not the initial step. After assessing the patient, the nurse provides a brief overview of the technique and sets a proper learning environment. Deep respirations are an indication of relaxation; however, instructing a patient to breathe in a certain way does not induce relaxation.

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2. The nurse massages the patient to promote relaxation. Which is a suitable intervention for the

nurse to implement during the massage? a. Use the friction technique over the spine. b. Assess for pain, anxiety, and discomfort. c. Instruct the patient to sit upright and forward. d. Knead the patient’s scalp with warm lotion.

ANS: B

The nurse’s goal during a massage is to keep the patient comfortable and relaxed and induce a lingering sense of well-being and relaxation at the completion of the massage. If the patient is in pain, anxious, or uncomfortable, relaxation does not occur until the noxious stimuli are eliminated. The nurse asks the patient about pain and comfort during the massage and does not wait for the patient to offer such statements. The friction technique (i.e., strong, circular strokes enhancing perfusion at the skin’s surface) is contraindicated for bony prominences such as the spine because the regional skin is already thin and under tension by nature of its location over a bone. Sitting upright and forward can be contraindicated or uncomfortable for the patient. Occasionally the patient’s scalp is massaged with a few drops of oil on the fingertips; it is impossible to knead the scalp because the scalp is devoid of large, thick muscles.

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3. The patient awakens at 3:00 AM requesting pain medication, but the nurse does not Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

administer additional pain medication. What justifies the nurse’s decision to withhold the medication?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. b. c. d.

The patient had a reaction to aspirin 5 years ago.

The nurse wants to help the patient avoid drug addiction.

The patient is asleep when the nurse returns with analgesia.

The patient wants pain medication every 3 3/4 hours exactly.

ANS: C

The nurse receives contradictory messages about the patient’s pain level because the patient is relaxed enough to fall asleep again. To avoid oversedation and complications, the nurse withholds the medication but assesses the patient for other indicators of pain before leaving the room. The nurse promptly administers pain medication if other indicators of pain are present or when the patient awakens. Frequently nurses feel a duty to protect patients from drug addiction and to withhold pain medication when they suspect that the patient exhibits addictive behavior or asks for too much pain medication. Experts, including The Joint Commission, agree that healthcare professionals should rely on the patient’s report of pain.

The patient has the right to effective pain management, and the nurse is bound ethically to provide pain relief when the patient asks for it. If the patient asks for pain medication every 3 3/4 hours, he or she may be watching the clock. Many healthcare professionals describe this behavior as “drug seeking,” meaning that the patient is seeking pain medication for unrelated reasons; this description labels the patient unfairly. This behavior can also indicate inadequate pain relief or the onset of a new patient health problem. For these reasons this type of patient request for pain medication warrants further investigation. To manage this situation, the nurse remembers the patient’s right to pain relief and the nurse’s role as patient advocate.

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4. The patient has hypotension, reN ceUivReS sI asNm oid analgesia as the prescription allows, and GuTcBh .opCiO

continues to have difficulty sleeping at night because of pain. Which should the nurse implement to relieve pain and improve sleep? a. Encourage controlled breathing. b. Provide a glass of wine at bedtime. c. Give a sedative 1 hour before sleep. d. Increase fluids and reposition the patient.

ANS: A

The nurse encourages the patient with controlled breathing exercises that serve as a distraction to increase relaxation, decrease pain, and promote sleep. The nurse applies a nonpharmacological relaxation technique because the patient has hypotension and additional analgesia is likely to lower the blood pressure further, potentially leading to serious complications, including loss of consciousness, decreased perfusion to vital organs, and cardiopulmonary arrest. Alcohol is contraindicated for use with opioids; in addition, alcohol consumption is likely to lower the blood pressure by vasodilation. The nurse avoids administering a sedative because hypotension is an adverse effect of most sedatives and sedatives will aggravate the patient’s hypotension. The nurse increases fluid if the patient has a fluid volume deficiency; however, restoring fluid balance is unlikely to promote relaxation to relieve pain and improve sleep. Until the patient’s hypotension is resolved, the nurse repositions him or her in the supine position or with the head slightly elevated to prevent increasing venous return from the head to the heart.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 5. The nurse wants to use massage to promote relaxation. In which patient diagnosis would

massage be potentially contraindicated? a. Spinal cord injury b. Hypertension c. Acute asthma d. Crohn’s disease ANS: A

Massage may be contraindicated after spinal cord injuries or surgery to head and neck because of risk of further injury. Patients with hypertension, acute asthma, and Crohn’s disease potentially benefit from a massage as relaxation therapy.

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6. The patient has metastatic bone pain from cancer with nausea and vomiting after receiving

periodic opioid analgesia intravenously. Which can the nurse implement to manage the patient’s pain effectively without nausea and vomiting? a. Dispense the opioid 30 minutes after providing food. b. Combine the opioid with an antiemetic or antihistamine. c. Collaborate with the healthcare provider for around-the-clock analgesia. d. Replace the analgesic with a nonsteroidal anti-inflammatory agent.

ANS: C

Metastatic bone pain can be very difficult to control for a patient with cancer. The nurse collaborates with the provider to convert intravenous (IV) opioid administration to around-the-clock (ATC) d o s i n gN bUeRc aSuIs eNAGTTCB a.dCmOi nMi s t r a t i o n maximizes the pain relief and minimizes most side effects and drug toxicity. Administering opioids with food is an effective technique to avoid nausea and vomiting but usually only when the opioid is given by mouth.

Although administering an antiemetic and/or an antihistamine with an opioid analgesic is a reasonable method of managing the patient’s nausea and vomiting, the periodic schedule is not as effective as ATC dosing. Nonsteroidal antiinflammatory agents may be used in combination with opioids for bone pain, but they do not replace the opioids.

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7. The patient receives opioid analgesia with naproxen (Naprosyn) after a total abdominal

hysterectomy. Which patient datum is the nurse’s priority? a. The patient has not had a bowel movement since surgery. b. The patient declines a massage after analgesic administration. c. Respiratory rate drops from 22 to 16 breaths/min. d. The patient receives famotidine (Pepcid) for esophageal reflux.

ANS: D

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

A patient history of esophageal reflux is usually a contraindication for nonsteroidal antiinflammatory drug (NSAID) administration because of the increased risk of bleeding from prostaglandin inhibition. Constipation is a complication of surgery and opioid analgesia, but the nurse manages patient constipation by increasing patient ambulation and intake of fiber, fluid, and stool softeners. Declining a massage after receiving pain medication potentially indicates that the patient is satisfied with her comfort and relaxation status. Respirations at 16 breaths/min are within normal limits.

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8. The nurse prepares an oral opioid analgesic for the patient who has dementia and pain. After

checking the patient’s medication administration record (MAR) for the last administration time and the patient’s response to pain medication, the nurse chooses the correct analgesic and compares the patient’s picture and wristband to the medical record. Which is the most important intervention for the nurse to implement before administering pain medication to the patient? a. Fill the pitcher with water. b. Record the administration time. c. Check the medication dose. d. Help the patient to sit upright.

ANS: C

The most important intervention is to check the MAR and verify the correct dose before administration to prevent adverse effects and toxicity. This is important from a safety standpoint and follows the rights of medication preparation and administration. Filling the water pitcher can be delegated N toUnRuS rsI inN gG asTsiBst.ivCeOpM ersonnel (NAP). Assisting the patient to a particular position may be required, but it is not the most important intervention in medication administration. Administering the correct dose is much more important. The nurse should be focused on safety during the preparation and administration of medication. Medication documentation occurs after the medication is administered.

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9. The nurse decides that collaboration with the healthcare provider is needed to review and

possibly adjust the dose of analgesic for an 87-year-old patient. What is the rationale for this request? a. Older adults have higher risks of injury with intramuscular (IM) injections. b. Analgesics aren’t necessary for older adults because of decreased pain sensation. c. Impaired cognition impairs reporting of pain by older patients. d. Liver and kidney metabolism is usually slower in older adults.

ANS: D

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

As the adult ages, hepatic and renal clearance of medication usually decreases or slows, so medication has a longer duration of action, and doses exert a stronger effect than in younger people. The nurse helps to maintain patient safety and prevent injury by collaborating to adjust the dose of the analgesic. Risk of injury from an IM injection refers to the route of administration and is not dependent on the dose. Nothing in the question indicates that an IM injection is the mode of administration. The nurse uses the patient’s self-report of pain felt to help determine the need for pain relief; reporting pain refers to patient assessment. This option does not address the reason for adjusting the dosage.

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10. The patient who receives morphine sulfate intravenously by patient-controlled analgesia

(PCA) tells the nurse that the pain level is 8 on a scale of 0 to 10. Which is the best intervention for the nurse? a. Check the volume of morphine in the PCA syringe. b. Check the frequency of patient-controlled dosing. c. Collaborate with the provider to increase basal rate. d. Instruct the family to activate the patient-controlled dose.

ANS: B

The PCA dose includes a basal rate to establish and maintain a therapeutic morphine serum level and a supplemental dose of morphine, the patient-controlled dose, for patient pain management. The nurse checks the frequency of patient self-dosing to gather additional information for a nursing assessment. If the patient is not supplementing the basal dose, the nurse instructs the patient to use the patient-controlled dose by directing the patient to depress the PCA button for pain controN l.U TR heSnIuN rsGeTalBlo.wCsO3M 0 minutes to 1 hour to evaluate the plan. If the patient is using the PCA properly, the patient may benefit from an increased basal rate. If the patient is depressing the PCA button, the syringe of morphine may be empty; however, the PCA has an alarm to indicate low volume, and the nurse monitors the volume for narcotic control and intake and output (I&O), so it is unlikely that an empty syringe will be the problem. Collaborating with the provider to increase the PCA dose is premature because the nurse has not completed an assessment or implemented nursing interventions that potentially resolve the patient’s pain. The nurse avoids instructing the family to assist the patient because PCA is for patient use only, and families are unauthorized users of the patient’s PCA. DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

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11. The nurse cares for several postoperative patients using patient-controlled analgesia (PCA)

pain management with a combination of an opioid and a local anesthetic agent on the first postoperative day. Which patient should the nurse assess first? a. A patient after a bowel resection for recurrent colon cancer b. A patient after an internal fixation of an ankle fracture c. A first-time hospitalized patient after amputation of a leg d. A patient with emphysema who had a lung tumor resection ANS: C Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse assesses the patient with the amputation first. Since this is the patient’s first hospitalization, it is unknown how he or she will react to the pain medications, and they can cause respiratory depression. The patient with chronic obstructive pulmonary disease (COPD) is probably the second patient the nurse assesses because the disease is pulmonary. If the patient hypoventilates because the pain is too great, he or she is likely to retain additional carbon dioxide, inadequately oxygenate, and potentially have respiratory acidosis and respiratory failure. The other patients would be assessed as soon as possible.

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12. The nurse assesses the patient who is 2 days postoperative to determine the need for

continuing patient-controlled analgesia (PCA). Which information should the nurse use to decide that the patient is ready for oral administration of analgesia? a. Patient is hypoventilating. b. Pain level ranges from 2 to 4. c. Sedation level is consistent. d. BP is 168/96, HR 110, RR 26.

ANS: B

The nurse uses the patient’s pain level ranging from 2 to 4 to help determine that oral analgesia is suitable for him or her because the patient’s pain level is consistently below the mid-range on the pain scale. PCA is more suitable for moderate-to-severe pain, and oral analgesia is more suitable for low-to-moderate pain. Hypoventilation is an adverse effect of opioid analgesia, regardless of the administration method. Hypoventilation indicates that the patient potentially receives an excessive dose of opioid or that the dose remains inadequate and the patient is hypov entilati N ngUtRo Sp I reN veGnTt pBa. inC. O AMconsistent sedation level is vague and provides little information about patient status. It can indicate a serious neurological impairment or excessive dosing and warrants further investigation. An elevated blood pressure, heart rate, and respiratory rate are nonverbal indicators of pain and indicate inadequate pain relief. However, these readings alone give no indication of the best route for administration of analgesia.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

REF: Page 328 TOP: Nursing Process: Evaluation

13. The patient who receives patient-controlled analgesia (PCA) with an opioid analgesic reports

that the pain level is 9 on a scale of 0 to 10. Which does the nurse implement to increase patient pain control? a. Elevates the head of the bed (HOB) to 30 degrees b. Increases the interval between demand doses c. Increases the demand and the basal doses d. Checks patient manipulation of the PCA button ANS: D

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse checks to ensure that the patient understands and executes depression of the PCA button for on-demand doses. If the patient does not operate the button or does so ineffectively, he or she receives inadequate pain control. The nurse can elevate the HOB if the patient is oversedated and difficult to arouse unless it is contraindicated. By elevating the HOB, the nurse repositions and enables the patient to receive more environmental stimulation. The patient receives less medication when the time between demand doses is increased. The nurse avoids increasing the basal rate and demand dose simultaneously to prevent oversedation because increasing each rate of administration increases the total potential dose twice.

DIF: Cognitive Level: Application OBJ: NCLEX: Physiological Integrity

REF: Page 336 TOP: Nursing Process: Implementation

14. The nurse receives the patient in the postanesthesia recovery unit and assesses the epidural

analgesic infusion. Which is the nurse’s priority? a. The filter needle is attached to the catheter tubing. b. The distal end of the tubing is attached to the catheter. c. The infusion contains an opioid and a local anesthetic. d. The pump settings match the provider prescription.

ANS: C

Combining an opioid with a local anesthetic agent increases the patient’s risk of complications from epidural analgesia because adding another agent exposes the patient to the risks of both medications, risks from drug-drug interactions, and risks of epidural analgesia. The filter needle is used to remove microscopic debris as the medication is withdrawn from the medication vial and is removed before injecting the medication into the infusion fluid. A filter needle piggybacked into the epidural catheter is likely to increase the pressure necessary to pump the infusion through the N caUthReS teI r aNnGdTaB ct. ivC atO e Mt h e high-pressure alarm on the infusion pump. The nurse should replace the filter needle with a standard needle or needleless adapter.

Attaching the distal end of the tubing to the epidural catheter is correct. Matching the pump settings to the provider prescription is expected nursing behavior.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

REF: Page 328| Page 337 TOP: Nursing Process: Planning

15. A patient is receiving care for a soft tissue sports injury. Which explanation by the nurse

explains part of the treatment using the acronym PRICE? a. “I’ll be alternating ice and heat to the injured area.” b. “You’ll be exercising with ice packs for a while.” c. “Rest is indicated before and after cold treatments.” d. “The cold therapy decreases venous congestion.”

ANS: D

PRICE means protect from further injury, rest, ice, compression, and elevation, the standard treatment for a sports injury. The treatment decreases venous congestion as follows: rest decreases the gravitational pull on fluid to the extremity; ice vasoconstricts to limit edema, bleeding, and inflammation; compression prevents venous pooling; and elevation increases the gravitational pull on fluid from the affected region. Applying heat to an injury is usually contraindicated because it increases blood flow to the affected tissue. Exercise after a sports injury is applicable in selected cases and follows RICE therapy. The nurse usually Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

recommends rest with a sports injury, but this is not the intended meaning of RICE.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Comprehension OBJ: NCLEX: Physiological Integrity

REF: Page 350 TOP: Nursing Process: Assessment

16. The patient complains of a slight burning-like pain and numbness on the skin under a cold

compress. Which action should the nurse take immediately? a. Reassure the patient that some numbness is expected. b. Assess the entire patient before continuing the treatment. c. Remove the compress and assess the affected area. d. Provide a warm blanket for the patient’s treatment.

ANS: C

Although sensation in the affected region changes during cold therapy, the nurse should first remove the compress and assess the area in response to the patient complaint. The patient will first sensation feel cold, followed by analgesia, burning skin pain, and numbness. Tingling is often associated with numbness as an indication of nerve impairment; thus the nurse assesses the patient before continuing therapy. The patient’s skin potentially benefits from passive rewarming and another nursing assessment to rule out tissue damage. Numbness in the affected region is associated with an increased risk of adverse effects from cold therapy. The nurse wants the patient to feel the cold and analgesic phases of cold therapy sensations. He or she assesses the tissue before discontinuing the cold therapy. Providing a blanket is a reasonable intervention as cold therapy begins to prevent shivering. However, although shivering consumes massive amounts of oxygen, the blanket is unlikely to affect the sensation of tissue treated with cold therapy.

DIF: Cognitive Level: Application OBJ: NCLEX: Physiological Integrity

REF: Page 350| Page 353 TOP: Nursing Process: Planning

17. The nurse teaches the patient inNaUmRbS uI laN toG ryTcBar.eCtoOaMpply ice packs to an injured knee. What

instructions should the nurse include in patient teaching? a. Leave the ice on for no more than 5 minutes. b. Remove the ice pack when the ice melts completely. c. A cold pack has the potential to cause tissue damage. d. Apply ice for an hour and then apply a heating pad.

ANS: C

The nurse should explain that prolonged application of ice can lead to tissue damage from prolonged vasoconstriction. The patient should be instructed to apply the ice for 10 to 20 minutes, then remove the ice for 30 minutes and check affected tissue before repeating the cycle to prevent tissue damage. Applying ice for 5-minute increments is subtherapeutic treatment. The nurse avoids teaching the patient to leave the ice in place until it melts because it is likely to result in ice application exceeding 20 minutes and increase the risk for tissue damage. Application of ice for 1 hour exceeds the 20-minute recommendation to prevent tissue damage.

DIF: Cognitive Level: Application OBJ: NCLEX: Physiological Integrity

REF: Page 351 TOP: Nursing Process: Implementation

18. The school nurse provides first aid to the 10-year-old student with a new uncomplicated arm

fracture. The nurse wants to provide nonpharmacological pain relief and minimize regional Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

edema. Which first-aid treatment does the nurse provide for the patient? a. A cold compress

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. A covered ice bag c. An aquathermia pad d. A moist heat compress ANS: B

The nurse applies an ice bag with a cover between it and the student’s arm to reduce pain, swelling, and bleeding because cold therapy provides a regional anesthetic effect and vasoconstricts to limit regional blood flow. The nurse protects the student’s arm from thermal injury by wrapping the ice bag before the application. A cold compress is inadequate to provide regional vasoconstriction for a fractured arm. Heat application from an aquathermia pad or a moist compress is contraindicated for the fracture because both therapies increase blood flow and promote vasodilation. The fluid pressure in the area can increase from the heat to increase patient pain, bleeding, and edema.

DIF: Cognitive Level: Application OBJ: NCLEX: Physiological Integrity

REF: Page 350 TOP: Nursing Process: Implementation

19. The nurse plans care for four patients receiving heat therapy. Which patient admission

diagnosis presents the highest risk of injury to an extremity? a. Osteoarthritis b. Nephrolithiasis c. Chronic bronchitis d. Peripheral neuropathy ANS: D

The patient admitted for a peripheral neuropathy has the highest risk for a heat therapy injury because he or she has impaired sensation to the extremities, meaning that the patient has ThBis.pCaO difficulty sensing pain, heat, anNdUpR reS ssIuN reG .T tieMnt is more likely to incur tissue damage from heat therapy because he or she has impaired ability to sense excessive heat. The patient with osteoarthritis can have a slightly higher risk of thermal injury from heat therapy if patient mobility is impaired because a self-protective mechanism is withdrawal from noxious sensations such as excessive heat. Patients with nephrolithiasis, kidney stones, and chronic bronchitis can be suitable candidates for heat therapy because these diagnoses are unrelated to peripheral perfusion, sensation, or movement.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

REF: Page 348 TOP: Nursing Process: Assessment

20. The nursing assistive personnel (NAP) reports that the patient is dizzy during a warm sitz

bath. Which action should the nurse take before moving the patient? a. Check the patient’s pulse rate. b. Dry off the patient completely. c. Ask the patient if he or she is able to ambulate. d. State that dizziness is common.

ANS: A

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse should assess the patient’s pulse rate to determine if the patient is stable enough to either continue the bath or ambulate back to bed with assistance. Unless a sphygmomanometer is readily available, taking the pulse is a good clinical indicator to evaluate hypotension indirectly because when the blood pressure falls, the heart rate increases to maintain the cardiac output. The patient should remain in place until the nurse assesses him unless he has a cardiovascular or chronic pulmonary condition and is shivering. If one of these conditions is present, the nurse and the NAP should dry off the patient, provide warm clothing, and return him to bed. Dizziness is a common response to a warm bath for patients who are older or who have cardiovascular, neurovascular, or chronic pulmonary conditions, but the nurse needs to assess the patient before deciding what is happening.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 348 TOP: Nursing Process: Planning

21. The nurse admits a patient with left hand and wrist cellulitis. Which action does the nurse take

when applying dry heat to the area using an aquathermia pad? a. Keeps the fluid chamber in the device empty b. Covers the pad with a towel or pillowcase c. Positions the patient directly on the pad d. Sets the aquathermia temperature at 36.6° C (98° F) ANS: B

To implement dry heat with an aquathermia pad, the nurse covers the pad with a layer of insulation to help prevent skin exposure to excessive heat that potentially leads to maceration.

The nurse sustains the fluid in the aquathermia pad reservoir because the heat that it provides radiates from warm fluid circulating through the pad. The nurse avoids positioning a patient directly on an aquathermia padNfoUrRhS eaIt N thGerTaB py.bCeO caMuse it increases the risk of burns and tissue maceration. An aquathermia pad is usually set at 40.5° C (105° F).

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 346 TOP: Nursing Process: Implementation

22. In the postanesthesia care unit the nurse applies an ice bag to the patient’s leg at the surgical

site. Which therapeutic effect does the nurse expect from this treatment? a. Decreased pain and diaphoresis b. Decreased bleeding and vasoconstriction c. Vasodilation and decreased blood flow d. Increased oxygenation and increased inflammation ANS: B

The nurse applies cold therapy to the patient’s surgical site for regional vasoconstriction, which also decreases bleeding. Diaphoresis commonly occurs with dry heat therapy, but decreased pain can occur with cold or heat therapy, depending on the type of injury. Cold therapy causes vasoconstriction, not vasodilation, and blood flow is decreased as a result of vasoconstriction.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 350 TOP: Nursing Process: Planning

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 23. The patient received treatment for a sprained ankle and is receiving home care instructions

regarding cold therapy. Which instructions should the nurse include?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. Place the gel pack on the ankle for 30 minutes every 4 hours for the first 48 hours

after the injury. b. Wrap the ankle with a lightweight cloth before applying the ice bag to it. c. Wrap the elastic bandage firmly before applying the ice to the ankle. d. Immerse the foot in a pan of ice water every 4 hours for as long as the patient can

wiggle his toes.

ANS: B

The patient needs to prevent direct exposure of the skin to the ice bag. The gel pack must be wrapped before being put against the ankle. The elastic bandage can interfere with circulation if wrapped too tightly, and the wrap itself can prevent the cold from being effective.

Immersion would require the patient to place his foot in a dependent position, which can increase swelling.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 351 TOP: Nursing Process: Planning

MULTIPLE RESPONSE 1. The nurse assesses the patient and realizes that patient pain is interfering with postoperative

therapies. Which does the nurse determine before using medication and relaxation techniques simultaneously to reduce patient pain? (Select all that apply.) a. The patient has used guided imagery in the past successfully. b. Nonpharmacological relaxation methods appeal to the patient. c. The patient moves in the bed and disrupts the nurse incessantly. d. The provider plans to discharge the patient to home in 2 days. e. The patient understands wrN GaTtiBon. C i ttUenR iSnI foNrm o nOrMelaxation techniques. f. The patient cannot receive additional analgesia for unresolved pain.

ANS: A, B, C, F

An integrated approach using pharmacological and nonpharmacological therapies is the most effective method of pain management. Patients who potentially benefit the most from integrated therapies share certain qualities, including successful use of nonpharmacological therapies in the past. A patient who uses relaxation techniques such as guided imagery and massage is more likely to find these techniques appealing as long as the patient achieves success with the technique. Another patient likely to benefit from an integrated approach is the patient with anxiety or fear; excessive movements and disruptions are indications of a problem, including anxiety or fear, which potentially the patient cannot identify. A patient who cannot receive additional pain medication despite continuing pain is likely to benefit from integrated therapy as well. The discharge date is unrelated to assessing the patient before relaxation and guided imagery. The nurse can explain and demonstrate relaxation therapies and guided imagery without the patient reading.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 319 TOP: Nursing Process: Planning

2. The nurse caring for a female patient 1 day after a thoracotomy assesses that the patient is in

pain, but the patient states that she has no pain. Which does the nurse use to confirm the Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

patient’s pain?(Select all that apply.) a. Facial grimacing during linen changes

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. c. d. e. f.

Eats a full liquid diet without assistance Uses the incentive spirometer every hour Patient’s culture forbids complaints of pain Has received nothing for pain since surgery Heart rate 110, blood pressure 169/90

ANS: A, D, E, F

To confirm the pain assessment for a patient who states that she has no pain, the nurse looks for information consistent with a patient in pain. The patient’s verbal message and nonverbal cues are contradictory because facial grimacing is a hallmark sign of pain and discomfort, especially when the patient moves. A potential explanation for the inconsistent verbal and nonverbal messages is that the patient’s culture forbids admitting to pain, necessitating the use of other pain indicators. A thoracotomy usually has a painful postoperative course because the surgical incision is stretched every time the patient breathes; thus a patient who receives no analgesia on the first postoperative day is very unusual. Tachycardia and hypertension are good clinical indicators of pain when the patient expresses contradictory messages about pain.

The blood pressure increases because the patient becomes tense and contracts muscle, increasing the force necessary to drive blood through the vasculature. The heart rate increases from the stress response to pain and the resultant surge of epinephrine from the sympathetic nervous system. Eating and breathing deeply are inconsistent with a patient in pain.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

REF: Page 317-318 TOP: Nursing Process: Assessment

3. The nurse assesses a patient who has an epidural catheter for patient-controlled analgesia

(PCA) on the second postoperative day. Which patient data does the nurse group together to establish the nurse’s priority? (N SeUleRcS t aIllNtG haTtBb. elC onOgMto the group.) a. Temperature 38.1° C (100.6° F) b. Patient ready for oral analgesia c. Low tension on epidural catheter d. Respiratory rate 14, sedation level 1 e. Epidural drainage looks like medication f. Hemoglobin 15 mg/dL, leukocytes 14,500 ANS: A, E, F

According to the nursing process, the nurse groups interrelated data together to draw a conclusion. This patient is febrile with leukocytosis and clear epidural drainage, clinical indicators of a potential infection. Because fluid is leaking from the insertion site, microorganisms have a potential portal of entry, even though the fluid is of unknown origin.

The nurse collaborates with the provider to discontinue the epidural catheter, initiate therapy to eradicate potential infection, and provide adequate pain management by another route. If the fluid is cerebrospinal fluid (CSF), the patient is at risk for a devastating neurological infection and sepsis. Patient readiness for oral analgesia is not as important to patient health and well-being as dealing with the potential infection. Low tension on the catheter, a respiratory rate within normal limits, and a low sedation level are desirable patient data. They are not disregarded by the nurse in formulating nursing care but are less important than a potential infection. The nurse plans nursing care to enhance positive patient assessments to promote health and well-being.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

REF: Page 339 TOP: Nursing Process: Diagnosis

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 4. The nurse prepares patient-controlled analgesia (PCA) for a postoperative patient in the

postanesthesia recovery unit (PACU). To rule out contraindications to therapy, which should the nurse assess before the patient receives PCA?(Select all that apply.) a. Consider patient cognitive level. b. Evaluate patient communication. c. Confirm two separate intravenous (IV) infusions. d. Determine patient physical ability. e. Assess for history of constipation. f. Verify patient medication allergies.

ANS: A, B, D, F

The nurse assesses the patient’s cognitive level to verify suitability of PCA for pain management. If the patient cannot understand instructions, PCA will have little value to the patient in managing pain. The nurse evaluates communication to ensure patient ability to relate pain levels effectively; if the patient does not speak English or is cognitively impaired, the nurse establishes a method of nonverbal communication to determine pain level and effectiveness of therapy. The nurse ensures the patient’s physical ability to depress the PCA button. He or she checks patient allergies to medication before initiating PCA to prevent hypersensitivity reactions. One IV infusion is sufficient for PCA if the infusion is continuous or only infuses the PCA. If PCA is infused through the same tubing as intermittent infusions, the nurse risks bolus administration of the opioid and possibly the local anesthetic agent; this increases the risk of respiratory depression. Constipation does not contraindicate the use of PCA. DIF: Cognitive Level: Apply REF: Page 332 OBJ: NCLEX: Physiological IntN egUriR tySINTGOTPB : .NCuO rsM ing Process: Planning MATCHING

The nurse prepares to administer pain medication to a patient. Place the following nursing interventions in order, beginning with the initial action of the nurse to administer pain medication safely. a. Compare routes on an equianalgesic chart. b. Determine the patient response to analgesia. c. Ask the patient to rate the pain a scale of 1 to 10. d. Check the last analgesia administration time.

1.

2.

3.

4.

Step 1 Step 2 Step 3 Step 4

1. ANS: C DIF: Cognitive Level: Apply REF: Page 329 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning MSC: When changing to another route, the nurse refers to the opioid equianalgesic chart to ensure equal potency of two or more routes of the same medication. This helps to make sure that the patient receives the same-strength dose when the administration route changes.

2. ANS: D DIF: Cognitive Level: Apply REF: Page 329 Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf MSC: After administering the analgesic, the nurse asks the patient to quantify the pain, to evaluate the effectiveness of the analgesic, and allows a suitable time interval after administration.

3. ANS: A DIF: Cognitive Level: Apply REF: Page 329 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning MSC: The process begins as the nurse asks the patient to quantify the pain to help assess the need for analgesia and establish baseline data.

4. ANS: B DIF: Cognitive Level: Apply REF: Page 329 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning MSC: To avoid the risk of adverse effects and administering pain medication before the interval specified on the prescription, the nurse checks the medication administration record (MAR) for the last administration time of the analgesic.

The nurse prepares to administer patient-controlled analgesia (PCA) to a patient. Rank the nursing interventions in sequential order. a. Allow the patient to depress the PCA system button before infusion begins. b. Prime the tubing with medication from the drug reservoir. c. Instruct the patient that lockout time prevents overdose. d. Insert the PCA tubing into the injection port nearest the patient.

5.

6.

7.

8.

Step 1 Step 2 Step 3 Step 4

5. ANS: B DIF: Cognitive Level: Apply REF: Page 333 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning MSC: The nurse initiates PCA administration by explaining the purpose and demonstrating the RiSlyItoNeGnT function of PCA to the patient andNfU am suB re.pC atO ieM nt understanding of PCA and to fulfill a patient right to information and informed consent.

6. ANS: C DIF: Cognitive Level: Apply REF: Page 333 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning MSC: Part of patient preparation for PCA is to provide an opportunity for the patient to try the PCA button before beginning the infusion.

7. ANS: A DIF: Cognitive Level: Apply REF: Page 333 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning MSC: The nurse properly programs the PCA infusion device according to agency policy and then primes the PCA tubing before inserting it into the intravenous (IV) port.

8. ANS: D DIF: Cognitive Level: Apply REF: Page 333 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning MSC: To avoid filling a long length of IV tubing with opioid medication, the nurse uses the port closest to the patient; the shorter the distance between the medication and the patient, the lower the amount of medication in the tubing, and the smaller the potential dose of accidental bolus administration.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 14: Promoting Oxygenation Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. A patient just had his tracheostomy suctioned. Which change in the patient’s status would the

nurse expect to see immediately after suctioning was completed? a. The heart rate changes from 84 to 92. b. The respiratory rate remains the same. c. The oxygenation saturation changes from 92 to 98. d. The patient’s respiratory effort increases gradually.

ANS: A

Suctioning significantly increases the heart rate for 4 to 5 minutes following the procedure.

The respiratory rate varies normally, and there would be a variation from before the procedure when the patient needed suctioning and afterward. There is a significant decrease in the oxygen saturation for 4 to 5 minutes following the procedure. The patient’s respiratory effort would be easier after suctioning.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 377| Page 380 TOP: Nursing Process: Assessment

2. A patient in respiratory distress is admitted to critical care. Which type of mask would the

nurse anticipate using to deliver the highest FIO2 without intubation? a. Simple b. Venturi c. Partial rebreather d. Nonrebreather ANS: D

The nonrebreather is the mask that can deliver the highest possible FIO2 without intubation.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 358| Page 360 TOP: Nursing Process: Planning

3. A patient with a major chest injury was originally alert and oriented after recovery from

surgery but is now becoming apprehensive and dizzy. What action should be taken by the nurse immediately? a. Notify the healthcare provider. b. Perform a cardiopulmonary assessment. c. Elevate the head of the bed to 60 degrees. d. Provide the patient with pain medication.

ANS: B

Apprehension, dizziness, anxiety, a decreased ability to concentrate, and fatigue are indicators of impaired gas exchange. The nurse needs to assess the patient’s cardiopulmonary status, including vital signs and pulse oximeter. The healthcare provider will be notified if there is a need for additional intervention. Elevating the head of the bed may be helpful, but the patient Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

needs to be assessed immediately. Pain medication could decrease the respiratory system, which is already showing an adverse status.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 359 TOP: Nursing Process: Assessment

4. An older adult patient with a nasal cannula and extension tubing is able to get out of bed

independently. What teaching by the nurse is indicated for this patient? a. Put on slippers whenever walking. b. Take off the oxygen if only going to the bathroom. c. Be careful not to trip over the extra oxygen tubing. d. Increase the flow rate a little before getting out of bed.

ANS: C

This older patient is at risk for tripping and falling over the extension tubing. Slippers need to be worn when ambulating, but the risk for tripping and falling is priority. The patient should keep the oxygen on as long as the extension tubing reaches. The oxygen rate is considered medication and should not be changed by the patient.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 356| Page 357 TOP: Nursing Process: Assessment

5. An oxygen cylinder is turned on, and the gauge registers in the green range. What action

should the nurse take at this time? a. Apply the oxygen as ordered. b. Notify the respiratory therapy department. c. Obtain a new cylinder of oxygen. d. Adjust the flowmeter slightly below what is ordered.

ANS: A

The gauge should register in the green range, which indicates that there is an adequate amount of oxygen in the cylinder. The respiratory therapy department oversees oxygen administration, but there is no reason to contact them because there is no problem. The cylinder of oxygen being used is fine and does not need to be replaced at this time. The oxygen rate is considered medication and should not be changed.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 359-360 TOP: Nursing Process: Implementation

6. A patient with newly diagnosed asthma is asking why peak flow measurements are being

ordered. What is the best response by the nurse? a. They measure the minimum force used to breathe in during the breathing process. b. They measure the maximum flow that occurs when one quick, forced expiration is taken. c. They measure the amount of circulating oxygen in the alveoli during breathing. d. They indicate the stability of your overall health.

ANS: B

The peak expiratory flow measurements are objective indicators of the patient’s current status and the effectiveness of the treatment. Decreased peak expiratory flow rate (PEFR) may indicate the need for further interventions such as increased doses of bronchodilators or antiinflammatory medications. The measurements focus on expiration, not inspiration, and do Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

not reflect the amount of circulating oxygen in the alveoli. The peak expiratory flow measurements reflect only the respiratory system, not the overall health.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 366 TOP: Nursing Process: Implementation

7. A patient with chronic bronchitis is not responding well to the chest physiotherapy (CPT) and

asks the nurse what might be done to help bring up more secretions. Which response by the nurse is most appropriate? a. “Your healthcare provider will probably increase the number of treatments but make them a little shorter.” b. “Your healthcare provider may try a nebulizer treatment 20 minutes before CPT to begin loosening the secretions.” c. “You’ll probably need to do more coughing exercises; I’ll help you with them.” d. “Your healthcare provider will probably order a sputum specimen to see what the problem is.”

ANS: B

Scheduling the CPT after bronchodilator enhances movement of secretions out of airways.

Making the treatments shorter and more frequent won’t help bring up more secretions.

Coughing exercises alone won’t help produce more secretions. Obtaining a sputum specimen is used to identify organisms and would not help the patient’s toleration of the CPT. DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 372 TOP: Nursing Process: Implementation

8. The nurse prepares to perform oropharyngeal suctioning on an adult. Nursing care is

appropriate if which wall suction pressure is used? a. 40 to 60 mm Hg b. 60 to 80 mm Hg c. 80 to 100 mm Hg d. 100 to 150 mm Hg ANS: D

The wall suction setting for adults is 100 to 150 mm Hg. The wall suction setting for infants is 40 to 60 mm Hg. The wall suction setting for children is 60 to 100 mm Hg. The setting of 100 to 150 mm Hg is not specifically indicated for any age group.

DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 376 TOP: Nursing Process: Implementation

9. Nasotracheal suctioning is performed on a patient who is unable to take deep breaths. What

action by the nurse would best meet the patient’s needs before suctioning? a. Increase the oxygen rate of the nasal cannula. b. Elevate the head of the patient’s bed. c. Hyperoxygenate with ventilation attached to a mask. d. Gently flex the patient’s neck.

ANS: C

Hyperoxygenating before suctioning can minimize postsuctioning hypoxemia if a patient is unable to take a deep breath. The oxygen rate cannot be changed without an order from the healthcare provider. Elevating the head of the bed can allow lung expansion but does little if Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

the patient is unable to take deep breaths. Hyperextending the neck opens the airway; flexing the neck closes the airway.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

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10. While the nurse prepares to suction the patient’s tracheostomy tube, the patient coughs up

mucus, which is visible at the opening of the tube. Which action by the nurse is most appropriate at this time? a. Hyperoxygenate this patient. b. Suction the visible secretions. c. Listen to the lung sounds. d. Wipe the mucus off with tissue.

ANS: B

The secretions need to be suctioned to remove them; then the patient would be hyperoxygenated. There is no reason to push secretions into the patient. Listening to the lung sounds will be done after suctioning to determine the effectiveness and whether the patient’s airway is clear. Wiping the secretions with a tissue would bring nonsterile tissue to the opening of the tube, which is contraindicated. The fibers could also go down the tube.

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11. The nurse is attempting to prevent ventilator-associated pneumonia (VAP) in a newly

intubated patient. Which activities would best support this goal? a. Brushing teeth with chlorhexidine at least every 8 hours b. Maintaining the endotracheal pressure at 10 cm H2O c. Positioning the patient flat during tube feedings d. Repositioning the patient evNeU ryR4ShIoNuG rsTB.COM ANS: A

Oral care with chlorhexidine decreases the colonization of bacteria. Brushing the teeth also helps removes plaque, which can harbor bacteria. The endotracheal cuff pressure should be at 20 cm H2O to decrease movement of secretions to the lower airways. The patient should be elevated during tube feedings to prevent aspiration, which can lead to VAP. The patient needs to be repositioned every 2 hours.

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12. A patient with a water-sealed chest tube unit is connected to suction. Patient care is correct if

the nurse takes which action? a. Monitors the bubbling of sterile water in the water-seal chamber b. Strips the tube every 2 hours for 15 seconds to prevent clots c. Clamps the chest tube when transporting the patient d. Keeps two toothed clamps at the bedside for an emergency ANS: A

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Intermittent bubbling is normal during expiration when the air is being evacuated from the pleural cavity. Continuous bubbling during both inspiration and expiration indicates a leak in the system. Stripping the tube increases negative pressure within the tube and is generally not recommended. The chest tube system is kept unclamped when transporting the patient. The clamps must be toothless or have guards on them to prevent puncture of the chest tube or tubing.

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13. The patient with a mediastinal tube placed 22 hours ago has produced 350 mL of drainage

since insertion. Which action by the nurse would be most appropriate? a. Notify the healthcare provider of excessive bleeding. b. Document the drainage output in the patient record. c. Place extra dressings and tape over the insertion site. d. Clamp the mediastinal tube once each shift.

ANS: B

The amount of drainage is within normal range and should be documented in the patient record. A total of approximately 500 mL in the first 24 hours is within expectations. There is no excessive bleeding; therefore the healthcare provider does not need to be notified. There is no need to reinforce the insertion site with extra dressing material. Clamping the mediastinal tube is not indicated.

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14. The nurse is preparing to assistNthUeRpShI ysNicGiaTnBin.tChO eM remo v al of a chest tube. Which item

would the nurse anticipate being placed over the insertion site as soon as the chest tube is removed? a. Petroleum gauze on a pressure dressing b. Gauze with Elastoplast c. 2  2–inch gauze with tincture of benzoin d. Steri-Strips under a bioclusive dressing ANS: A

First the petroleum gauze is placed over the wound to prevent any leakage of air. Gauze with Elastoplast would be used at the end of the dressing of the wound. Steri-Strips and 2  2– inch gauze with tincture of benzoin are not used during the removal of a chest tube.

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15. The nurse sees that a patient with a chest tube has intermittent bubbling in the water-seal

chamber 4 hours after the chest tube was inserted. What action by the nurse is most appropriate at this time? a. Notify the physician. b. Check for an air leak. c. Listen to the lung sounds.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf d. Document the findings.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: D

Intermittent bubbling is expected while air is being evacuated from the pleural cavity. The actions of notifying the physician, checking for an air leak, and listening to the lung sounds are not required since the chest tubes appear to be functioning correctly.

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16. The nurse assesses arterial blood gas results from the 88-year-old patient who receives oxygen

at 3 L/min by nasal cannula. The PaO2 at 8 AM was 84 mm Hg, and at 10 AM it was 82 mm Hg. Which action should the nurse take? a. Collaborate with the provider to use an oxygen mask. b. Plan follow-up nursing care for patient hypoxemia. c. Request that the laboratory confirm the patient’s results. d. Continue with the current therapy and nursing care.

ANS: D

The nurse continues with the current therapy and nursing care because the difference between oxygen values is insignificant, probably representing a normal variation in patient PaO2 occurring from minute to minute. The nurse continues to monitor the patient closely because the PaO2 is approaching the lower limit for an acceptable arterial blood oxygen tension.

Collaborating for a mask is unnecessary because the patient’s PaO2 is within normal limits.

The patient’s oxygen tension is at the lower acceptable range for arterial blood.

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17. The nurse is working with a paN tieUnR tS reI ceNivGinTgBo.xC ygOeM n. What can the nurse delegate to nursing

assistive personnel (NAP) during the administration of oxygen? a. Adjusting the flow rate of the oxygen b. Reporting changes in patient’s behavior c. Instructing the patient about oxygen at home d. Assisting during endotracheal intubation ANS: B

The NAP needs to be instructed to report to the nurse changes in vital signs or pulse oximetry and changes in the patient’s anxiety or behavior. The nurse should adjust the flow rate of the oxygen since oxygen is considered a medication. The nurse must also provide the patient teaching. The nurse assists the provider during endotracheal intubation because the procedure is sterile, can require the nurse to administer emergency medication, and requires critical thinking and clinical judgment.

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18. A home care patient receives oxygen by nonrebreather (NRB) mask. Which does the nurse

include when teaching the caregiver about the oxygen delivery system? a. Keep the plastic bag at the end of the mask inflated continually. b. Adjust the oxygen flow rate with the valve in front of the mask.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. Offer fluids frequently and apply moisturizer to prevent dry skin. d. Remove the elastic head strap to prevent skin breakdown at the ears.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: A

To prevent inhalation of carbon dioxide, the nurse instructs the caregiver to maintain an inflated bag at the end of the mask because it serves as an oxygen reservoir for the patient. If the bag deflates, the patient is at risk of inhaling excessive levels of carbon dioxide. The nurse regulates the oxygen flow rate by adjusting the flowmeter on the oxygen source; the NRB mask does not have a mixing valve. It does not dehydrate the patient. It requires a tight seal for effective therapy.

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19. The nurse hears the patient’s stridor from the hallway and notes that the patient’s oxygen

saturation has decreased to 92%. Which nursing intervention does the nurse implement first? a. Adjust the patient’s position. b. Suction the oropharynx. c. Insert an artificial airway. d. Review the last arterial blood gases (ABGs).

ANS: A

The nurse implements a noninvasive intervention to enhance the patient’s airway before instituting an invasive measure because, although the patient’s airway is impaired, he or she continues to oxygenate fairly well but is working very hard to do so. By quickly adjusting the patient’s position to maximize gas exchange and chest expansion, the nurse intervenes and gains additional valuable data for planning additional nursing care. Suctioning is contraindicated for stridor because it can aggravate stridor to laryngospasm. The nurse avoids inserting an airway because the patient has stridor, an airway impairment in the trachea. If the patient needs an artificial airway, the nurse needs to provide an endotracheal tube or tracheostomy to restore his or her airway because the obstruction is beyond the reach of an oral airway. The nurse avoids ABGs because valuable data are already available for patient assessment; ABGs are not necessary yet.

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20. The nurse suctions the patient’s endotracheal tube, and the patient becomes hypoxic. Which is

the priority nursing intervention to increase patient oxygenation? a. Assess breath sounds. b. Discontinue suctioning. c. Instruct the patient to cough. d. Ventilate the patient manually.

ANS: D

If the patient becomes hypoxic, the nurse ventilates him or her manually with supplemental oxygen to increase oxygenation. The nurse implements measures to oxygenate the patient quickly to avoid adverse and potentially life-threatening complications, including arrhythmias and cardiopulmonary arrest. He or she assesses the patient after providing supplemental oxygen and before seeking assistance because the hypoxia is most likely transient. The nurse discontinues suctioning to stop the decline in patient oxygen saturation; however, this action alone does not increase oxygenation. Instructing the patient to cough is a reasonable response Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

to hypoxia, especially if the patient has pulmonary secretions; however, manual ventilation provides supplemental oxygen in addition to ventilation to increase patient oxygenation.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

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21. The patient uses continuous positive airway pressure (CPAP) at home and tells the home care

nurse that the mask fits too tightly. Which action is most important for the nurse to take? a. Changing the mask to a simple face mask b. Teaching the patient about maintaining a tight fit to face c. Enlarging several of the air holes on the mask d. Loosening the straps of the mask for the patient’s comfort ANS: B

The nurse teaches the patient that the mask of the CPAP must fit tightly to prevent collapse of the upper airway because the device is unable to establish positive airway pressure without a tight seal. The nurse cannot make the decision to change the type of mask used. A simple face mask allows air to leak. Loosening the straps allows air to leak from the system so positive pressure never builds. If the CPAP has holes, they are integrated into the system; so the nurse should not enlarge them because it alters the function.

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22. The nurse institutes oxygen therapy for the patient. Which goal should the nurse set as a

positive patient outcome of airway maintenance? a. Increased pulse rate b. Increased restlessness c. A complaint of slight lethargy d. An oxygen saturation of 9 5N%URS ANS: D

Oxygen saturation at 95% is a positive patient outcome of oxygen therapy because it indicates a PaO2 between 80 and 100 mm Hg, which is within normal limits. The nurse expects normal sinus rhythm, heart rate between 60 and 100 beats/min, and a nonrestless patient, indicating adequate oxygenation. Patients can become tachycardic as a compensatory mechanism for hypoxemia; older patients exhibit restlessness as an initial indicator of hypoxemia.

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23. The patient is lethargic and unable to clear oral secretions effectively. How does the nurse

manage the suctioning of the oropharyngeal secretions from the patient? a. Uses a Yankauer suction device b. Loosens oral secretions with normal saline solution c. Suctions the nose, mouth, and throat with a catheter d. Uses a clean catheter to suction the nose and mouth ANS: A

A Yankauer suction device is a strawlike tube that can effectively suction oral secretions. The nurse avoids instilling saline solution into the patient’s oropharynx to prevent aspiration.

Suctioning the nose and throat is not indicated. A sterile catheter is used for nasopharyngeal Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

suctioning to prevent contamination of the nasal passages or trachea.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 373 TOP: Nursing Process: Implementation

24. The nurse suctions the patient’s artificial airway. For which adverse effect related to

suctioning should the nurse monitor during the procedure? a. Fatigue b. Anxiety c. Coughing d. Dysrhythmias ANS: D

Artificial airways require airway suctioning, which poses risks such as cardiac dysrhythmias; laryngeal spasm; and bradycardia, which is associated with stimulation of the vagus nerve.

Fatigue can occur after suctioning because suctioning induces coughing and transient hypoxemia. Suctioning is often unsettling for patients because it takes the patient’s breath away, literally, and usually induces coughing and gagging.

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25. The nurse uses a closed-system (in-line) endotracheal (ET) suctioning system for the patient.

Which does the nurse implement to prevent airway interference? a. Inserts the catheter between ventilator cycles to avoid airway interference b. Inserts the catheter 25.4 cm (10 inches) and applies continuous suction during withdrawal c. Visualizes the black line in the sheath of the catheter before completing the procedure d. Withdraws the suction catheter and discards it after completing the procedure ANS: C

The nurse visualizes the black line of the catheter after withdrawing the suction catheter from the ET because the black line indicates that the catheter is completely removed from the airway. The nurse inserts the catheter from suctioning during patient inhalation to avoid respiratory cycle interference for suctioning. The catheter is inserted until resistance is met to avoid suctioning in the main left or right bronchi. The closed-system suctioning system allows the nurse to use the same catheter for repeated patient suctioning by using sterile technique.

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26. The nurse performs tracheostomy care for the patient. Which instruction does the nurse give

to nursing assistive personnel (NAP) to implement while changing the ties of the tracheostomy tube? a. Prevent the patient from coughing out the tube. b. Don sterile gloves before providing assistance. c. Inject sterile saline solution into the tracheostomy. d. Hold the tracheostomy tube securely in place.

ANS: D Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse instructs the NAP to hold the tracheostomy tube firmly in place to prevent accidental dislodgement and to maintain a gentle hold because excessive pressure can induce patient coughing. The NAP wears clean gloves to hold the tracheostomy tube in place.

Injecting sterile saline solution into the tracheostomy tube is contraindicated.

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27. A patient admitted for asthma is weak and tired. Which patient position should the nurse use

for patient performance of a peak expiratory flow rate (PEFR)? a. Standing b. Side lying c. High-Fowler’s d. Reclining in chair ANS: C

The nurse uses high-Fowler’s position to promote optimum lung expansion. Standing for patient performance of PEFR to facilitate chest expansion would be unsafe. Side lying and reclining in a chair for PEFR measurement are not ideal because these positions impair chest expansion.

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28. The nurse teaches the patient controlled coughing. Which should the nurse include in patient

teaching for effective coughing? a. Cough in a low-Fowler’s position hourly.

IN b. Inhale and cough deeply wiN thUtR heSm ouGthToBp.enC.OM c. Self-reposition and cough every 4 hours. d. Breathe in quickly 3 to 4 times vigorously.

ANS: B

The nurse teaches the patient to inhale deeply to mobilize pulmonary secretions and to cough deeply to expectorate the secretions. Low-Fowler’s position is contraindicated for coughing because it is too low to facilitate expectoration and because many patients are unable to tolerate a low position. Coughing and repositioning every 4 hours are inadequate. The patient should be taught to inhale slowly and cough with force.

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29. The nurse fills the suction control chamber with water to the 20-cm line while setting up a

water-seal chest drainage system. Which rationale does the nurse use to explain this intervention? a. Creates a method for counting respirations b. Compensates for leaks in tubing connections c. Maintains up to 20 cm of intrapleural pressure d. Facilitates bubbling for pressure over 20 mm Hg Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: C

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Lungs inflate as a result of negative intrapleural pressure pulling parenchymal tissue to the chest wall and a thin layer of serous fluid holding it to the chest wall. A 20-cm amount of water in the water-seal chamber limits negative intrapleural pressure to 20 cm and prevents parenchymal tissue damage; the water prevents positive pressure from entering the intrapleural space and compressing the lungs. Positive pressure destroys negative intrapleural pressure. Respirations are counted by watching the chest rise and fall. Compensatory mechanisms for leaking within the system do not exist; the only remedy is to tighten the connections. Bubbling occurs with an air leak in the water-seal drainage system.

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30. The nurse notes that the patient’s chest tube pulled out by 5.1 cm (2 inches) during turning

and repositioning. Which should be the initial action by the nurse? a. Instruct the nursing assistive personnel (NAP) to apply pressure for 5 minutes. b. Replace the water-seal drainage system with a sterile waterless unit quickly. c. Hold a towel firmly over the site and send for petrolatum gauze. d. Push the tube into place and apply an occlusive sterile dressing.

ANS: C

The nurse secures the tube in place with a clean towel (or closest handy clean material) and sends the NAP for sterile petroleum gauze. The nurse securely wraps the gauze around the base of the chest tube insertion to re-create an airtight seal so negative intrapleural pressure can be restored. The nurse should collaborate with the healthcare provider for a chest x-ray film to evaluate the status of the lung after the accident. The nurse applies pressure to the site to prevent the wound from drawing in room air because this intervention requires clinical judgment and critical thinking N toUsR eaSl I thN e GwTo uBn.d Cc O o mM p l e t e l y. A standard or a waterless system is suitable for the patient’s water-seal drainage; however, neither system is effective therapy until the airtight insertion site is reestablished. The portion of the tubing pulled out is now contaminated and should not be pushed into place.

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COMPLETION 1. When patients require respiratory support such as artificial airways, they are often unable to

speak. A(n)

is a useful tool to aid in communication.

ANS:

Alphabet chart Alphabet charts, pen and paper, slates, and magnetic pen boards are examples of common communication tools. Use positive verbal and nonverbal communication with direct eye contact and ask questions one at a time that only require yes or no responses. Be sure that lighting is adequate and background noise is at a minimum when communicating.

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 2. A

contains a one-way valve with a reservoir, which does not allow exhaled air to enter the reservoir bag. It prevents inhalation of room air.

ANS:

Nonrebreathing mask Device of choice for short-term high FiO2 delivery. Can be combined with a nasal cannula to provide higher FiO2.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity 3. Use of

or

REF: Page 360 TOP: Nursing Process: Implementation

will help prevent nasal irritation from a nasal

cannula.

ANS:

isotonic saline nasal spray, water-soluble lubricant water-soluble lubricant, isotonic saline nasal spray The nurse should cleanse the area, observe for skin breakdown and apply isotonic saline nasal spray or a water-soluble lubricant to the area.

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 15: Safe Patient Handling, Transfer, and Positioning Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. A patient’s physical mobility is impaired because of paralysis of both lower extremities.

Which is the best method for the nurse to use to place the patient in semi-Fowler’s position? a. Help the patient push up in bed by bending his or her knees. b. Raise the head of the bed to 45 degrees and pull the patient to it. c. Roll the patient to one side using pillows to support his or her back. d. Pull the patient to the head of the bed (HOB) using a drawsheet and then raise the HOB. ANS: D

With the assistance of another staff member and using a drawsheet, the nurse bends the patient’s knees to reposition the legs, pulls the patient to the HOB, elevates the HOB to 45 degrees, and removes wrinkles from the drawsheet. The patient is unable to push up because of paralysis. Elevating the HOB first increases the force needed to move the patient up in the bed and the risk of injury. Rolling the patient to the side achieves Sims’ or lateral position or assists with logrolling; rolling the patient may be necessary to place the drawsheet under him or her before moving the patient up in bed.

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2. The nurse is caring for a patient after a motor vehicle accident and instructs the patient to

NURSINGTB.

avoid turning independently because the spine is unstable. Which explanation should the nurse use to explain the purpose of the safeguards in relation to the patient’s injury? a. They prevent a sudden deterioration in vital signs. b. They keep the neck and spine in straight alignment. c. They facilitate efficient, comprehensive assessment. d. They help to maintain straight alignment of the legs.

ANS: B

The nurse does not allow the patient to turn to the side unassisted because an unstable spine cannot maintain normal alignment since the integrity of one or more vertebrae is disrupted. If the patient moves, he or she risks exacerbating the spinal cord injury by abnormal movements of vertebral bone fragments. To maintain patient safety, the nurse turns the patient by logrolling and thereby keeps the head, neck, and spine in straight alignment, thus preventing bone fragments from shifting and potentially increasing the damage. Keeping the patient in the supine position is ideal for maintaining hemodynamic stability and facilitating assessments. The primary purpose of logrolling is to maintain alignment of the neck and spine.

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3. The nurse and an assistant are moving a dependent patient from the supine to the lateral Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

position. Which should the nurse implement to begin repositioning? a. Support the upper arm and leg with pillows.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. Move the patient away from the center toward a side of the bed. c. Elevate the patient’s head with two or three pillows. d. Wedge a pillow under the abdomen and chest.

ANS: B

The nurse and assistant move the patient to one side of the bed to create space on the bed for turning and avoid dangling the patient’s arms and legs over the side of the bed. The nurse supports the upper arm and leg after the patient is turned. Usually one pillow under the head is suitable for the lateral position; two or three pillows hyperflex the patient’s head. If necessary, a pillow is wedged under the patient’s chest and hips to support the patient in the lateral position, allowing him or her to relax in this position.

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4. After 3 hours in the supine position, an older patient tells the nurse that he or she is stiff and

too uncomfortable to move. Which is the best nursing intervention to maintain skin integrity? a. Find an assistant to help move the patient to lateral position now. b. Express concern about the discomfort and promise to come back. c. Assess the patient’s need for pain medication before repositioning. d. Explain how important repositioning is for preventing pneumonia.

ANS: C

Lying motionless is common behavior for patients in pain. This older patient is likely to have thin, fragile skin and by not moving for 3 hours, has an increased risk of skin breakdown from tissue hypoxia. The nurse assesses the patient’s pain and determines a need for pain medication before attempting to reposition him or her. To preserve skin integrity and promote patient comfort, the nurse moveNsUthReSpIatNieGnT t tB o.anCoOthMer position to facilitate the flow of oxygen-rich blood to the tissue, to assess the entire back for skin breakdown, and to provide hygiene if necessary. Expressing concern about the pain does nothing to assess or treat the discomfort. Explaining the need to reposition to prevent pneumonia is helpful when the patient is comfortable enough to pay attention to what is being said.

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5. The patient with a hemiparesis is very hesitant to transfer from the bed to the chair with a new

nurse’s help. Which action should this nurse take first to accomplish the transfer? a. Explain how the transfer of the patient will be done safely. b. Ask questions about how the patient usually transfers. c. Document that the patient declined help for the transfer. d. State that the healthcare provider ordered a transfer.

ANS: B

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

By applying the nursing process, the nurse probes gently to gather information about the patient’s reluctance to transfer, including the methods used to complete other transfers, how many transfers have occurred, and events during the transfers that left the patient fearing or dreading further transfers. The nurse takes these data and plans nursing care in response. If the nurse assumes that the problem is fear, the patient’s true needs may not be met by even the most detailed explanation of safety measures. The first response should be to assess the problem and develop a plan of action. Refusal to transfer should be documented only if, after every effort to understand and address the patient concerns, the patient continues to refuse. By stating that the healthcare provider ordered a transfer, the nurse passes responsibility for transferring to the healthcare provider. This is unprofessional. The patient can feel coerced to transfer by the nurse’s implication that the patient has no choice; this is a legally tenuous position for the nurse to assume.

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6. The nurse is helping a patient set a goal for ambulating after surgery. Which outcome

statement for this patient with generalized postoperative weakness is best? a. The patient transfers self safely from the bed to the chair 3 times daily. b. The nurse will maintain his or her physical mobility after surgery. c. The patient will remain safe from falls and postoperative anxiety. d. The patient transfers self safely from bed to chair 4 times daily within 2 days.

ANS: D

The best goal for a patient with postoperative weakness is that the patient transfers safely 4 times a day within 2 days because it is specific, patient oriented, measurable, and time limited.

Any nurse who reads this outcoNmUeRkSnI ow heBs.pC ecOifM ic expectations for the patient. In addition, NsGtT the outcome focuses on improving the patient’s ability and strength. Transferring 3 times daily is a reasonable outcome but lacks a time limit. Altered physical mobility and at risk for falls are nursing diagnoses; the nurse lacks specific data to support these diagnoses.

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7. The nurse assists the patient with transferring from bed to chair by using a transfer belt.

Which is the first instruction that the nurse gives to the patient after properly positioning him or her? a. “Place your arms around my neck to stand up.” b. “Bend both knees slightly when standing up.” c. “Hold the transfer belt for stability during transfer.” d. “Rock to help stand while pushing up with your hands.”

ANS: D

A rocking motion and pushing up with the hands moves the patient’s body in the direction of the transfer. The nurse is also rocking, and together they move as a unit. Having the patient hold the nurse around the neck increases the risk of injuring the nurse during a transfer. The nurse flexes at the knees and hips to lower his or her center of gravity; this is a more powerful force for transferring and decreasing the risk of back injury than standing upright and leaning toward the patient. The patient wears the transfer belt, and the nurse grabs the belt from Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

underneath as the patient rocks forward. The nurse’s force on the belt and the nurse’s and patient’s weight shifting work as a unit to assist the patient to a standing position.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Comprehend OBJ: NCLEX: Safe and Effective Care

REF: Page 405 TOP: Nursing Process: Implementation

8. While the nurse is attempting to transfer a patient to a standing position, the patient cannot get

off the bed. Which is the initial intervention for the nurse to implement? a. Return the patient to a safe position on the bed. b. Put a second transfer belt on the patient. c. Get additional personnel to help with the transfer. d. Assess the patient for unknown weakness.

ANS: A

The initial intervention for the nurse is to return the patient to a safe position. This follows Maslow’s hierarchy of needs. The nurse would then reassess for weakness because this action decreases the risk for patient injury and frees the nurse to evaluate the problem. The nurse should assess the patient’s fatigue, pain and discomfort, muscle strength, understanding of the patient’s role in standing, and willingness to participate. The nurse organizes the data that he or she gathers, draws conclusions, and plans care. Further assessment is indicated after the patient is safe.

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9. The nurse successfully transfers a patient from the bed to the chair and back. What

information is most vital for the nurse to include in the progress notes? a. The visitors involved in assisting the patient to transfer b. Home care instructions for the patient about transferring c. The patient’s blood pressurN eU beRfS orI eN anGdTaB ft. erCeO acMh transfer d. A description of the patient’s response to each transfer ANS: D

The nurse documents the patient’s response to each transfer in objective terms to record the events and subjective terms to relate the patient’s response to communicate information.

Factors to consider in the documentation are breathing difficulties, dizziness, balance, muscle strength, patient complaints, type and degree of assistance the patient requires to transfer, and progress toward goals and outcomes. To prevent patient and visitor injuries, visitors should not assist the patient to transfer. Home care instructions are suitable before discharge. Patient blood pressure is recorded on the graphic flow or vital signs sheet.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Safe and Effective Care

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10. The nurse wants to transfer a patient from the bed to the chair by using a mechanical lift. The

patient has difficulty following directions, and the nurse cannot find help. Which is the most important action for the nurse to implement? a. Assure the patient that the lift is safe. b. Use two safety chains on a canvas sling. c. Delay the transfer until help is found. d. Double-check the wheel locks on the lift.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: C

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

To maneuver the patient safely with a mechanical lift, the nurse must find an assistant to help on the opposite side of the bed and help hold the chair as the nurse lowers the patient onto it.

Whenever a patient has difficulty comprehending or following directions, additional help needs to be obtained. Reassuring the patient about the safety of the lift is appropriate but is less important than ensuring his or her safety on the lift. The chains attach to the sling, providing a strong bond between the lift and the sling, but they are not specifically designated as safety devices. Double-checking the wheel locks on the lift is important to patient safety, but the nurse should not even begin this transfer until an assistant is available.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Safe and Effective Care

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11. The nurse is teaching other caregivers about using a mechanical lift. What should the nurse

include in the instructions focusing on patient safety? a. Place the base of the lift under the side of the bed. b. Use extra-long chains to support the patient’s torso. c. Ask the patient to hold the head up while in the sling. d. Instruct the patient to hold the chains during the transfer.

ANS: A

The nurse ensures patient safety while transferring a patient with a mechanical lift by securing the base of the lift under the side of the bed. The base will also be set at its widest point for stability. The longer chain is used to support the patient’s legs. The patient lies in a supine position with the head relaxed on a small pillow if necessary. The nurse instructs the patient to cross the arms on the chest because the sling wraps around the patient very tightly, potentially resulting in injury.

N U RSIN G T B .COM

DIF: Cognitive Level: Compreh en d R E F : Page 408 OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation 12. The nurse transfers the patient from the bed to the chair using a mechanical lift. Which should

the nurse do before leaving the patient’s room to ensure patient safety? a. Remove the sling from under the patient. b. Document patient response to the transfer. c. Secure the call bell within the patient’s reach. d. Return the base of the lift to its original position.

ANS: C

To prevent patient injury from unnecessary reaching or attempts to get up, the nurse places the call bell close to the patient, makes sure that the patient can use the call bell, asks what the patient needs, and assesses the patient for safety before leaving the room. The sling remains under the patient while the patient is sitting in the chair as long as it does not increase the risk of skin breakdown or patient discomfort. With the sling in place, the nurse facilitates transferring the patient to the original position. The base may be left open and stored over the bed while the patient is in the chair. Once the patient is back in bed, the lift is returned to the original position and removed from the room.

DIF: Cognitive Level: Comprehend REF: Page 409, Standard Protocol (front of text) OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 13. A 225-pound patient is unconscious and needs to be transferred from the bed to the stretcher.

Which action is most critical for the nurse to initiate before moving the patient? a. Obtain a friction-reducing device and at least two other staff members. b. Instruct a nurse to stand at the head of the patient. c. Suspend the intravenous (IV) lines and Foley catheter from the stretcher. d. Wrap the patient in a sheet to prevent injury to the arms and legs.

ANS: A

The nurse effectively manages patient safety by using a friction-reducing device and at least three people to move a patient who is this weight. Suspending the Foley catheter from the stretcher is fine, but the IV lines must be hung from the stretcher for proper infusion. The patient must be observed closely during the transfer; wrapping the patient in a sheet obscures critical observations that can prevent accidents and injury to the patient.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 407 TOP: Nursing Process: Implementation

14. The nurse is preparing to place a patient in the prone position. What action should the nurse

take during the positioning? a. Place a pillow under both knees. b. Put a footboard against both feet. c. Insert a pillow under the abdomen. d. Straighten the arms at the patient’s sides.

ANS: C

The nurse places a small pillow under the patient’s abdomen when the patient is in the prone position to relieve stress on the lower back. The knees are not elevated with a pillow in the prone position. If excessive preNssUuR reSoInNthGeTkB ne.eC s Oo cMc u r s , the entire anterior surface is padded to relieve the pressure, maintain normal body alignment, and prevent hyperextension at the knees. A footboard is used for patients in the supine position to prevent footdrop. The nurse flexes the patient’s arms and positions them at the shoulder level.

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15. While transferring a patient who has been bedridden for several weeks, the nurse notes that

the patient becomes fatigued rapidly. What assessment data does the nurse expect to find to validate the patient’s changing status? a. Increased pulse and increased respirations b. Decreased pulse and increased respirations c. Increased pulse and decreased respirations d. Decreased pulse and decreased respirations ANS: A

The patient’s body is responding to the increased workload on the heart and lungs and is manifested by elevations in both the pulse and respirations.

DIF: Cognitive Level: Remember OBJ: NCLEX: Safe and Effective Care

REF: Page 401 TOP: Nursing Process: Assessment

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 16. A weak but motivated patient is ambulating for the first time. Which nursing intervention is

most likely to facilitate patient participation in ambulation and ensure patient safety?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. b. c. d.

Ask the patient if this weakness has occurred before.

Obtain a full set of vital signs before moving the patient.

Encourage the patient to hold onto you [the nurse] or the handrails in the hall.

Perform a quick assessment, including patient fatigue while talking.

ANS: D

An assessment of the patient will give the nurse a better idea of how stable he or she is. It is better to go a shorter distance and return safely. Even if the patient has been weak before, the nurse must focus on his or her status at the present time. Pulse, respiration, and blood pressure can give a baseline, but temperature does not need to be taken at this time. There is more to the assessment than this before ambulating a patient for the first time. The nurse does not encourage the patient to hold onto him or her because it increases the risk of the nurse’s injury. The patient can use the handrails if present, but they do not guarantee safety.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Safe and Effective Care

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17. The patient will be transferred to the chair an hour after receiving pain medication. Which

activity should the nurse delegate to nursing assistive personnel (NAP)? a. Determine the patient’s current pain level. b. Record the vital signs before ambulation. c. Position the gait belt around the patient. d. Place thick, warm socks on the patient.

ANS: C

The NAP can place the gait belt on the patient. Whenever there is doubt about a safe transfer, the transfer or gait belt should be used. The nurse determines the patient’s pain level because it requires nursing assessment aNnU dRnuSrI siN ngGjTuB dg.mCeO ntMafter medication is given. The nurse checks the vital signs because the patient just had medication and a lot of assessment must be completed before ambulating the patient. Socks afford little protection for ambulation, especially in a hospital where many potentially dangerous substances and equipment are used.

The patient needs either shoes or special socks with nonslip strips.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

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18. The nurse is teaching a patient’s family how to maintain personal safety and prevent injury

when lifting or moving the patient. Which concept should the nurse include in the instructions? a. Carry the weight above the waist. b. Keep the patient close to the mover. c. Bend at the waist for heavy lifting. d. Tighten the stomach and back muscles.

ANS: B

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Decrease the force required to lift or move a patient by keeping the patient close to the person moving the patient. The mover provides a more stable base for moving a patient by keeping the patient close to the mover’s center of gravity; if the patient’s weight is higher than that of the mover, the mover becomes top heavy and more unstable and needs more force to move the patient. Bending at the waist increases the distance between the mover and the patient, making the mover’s foundation less stable and less powerful. To move a significant weight without injury, the nurse tightens the abdominal and gluteal muscles in preparation for work.

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19. The nurse teaches the caregiver to maintain the patient’s safety when transferring to a chair.

Which teaching should the nurse include to address the weakness of the patient’s right side? a. Place the chair to the patient’s right side after sitting the patient on the edge of the bed. b. Place the chair to the patient’s left side after sitting the patient on the edge of the bed. c. Place the chair wherever the patient wants it after sitting the patient on the edge of the bed. d. Place the chair wherever the caregiver wants it after sitting the patient on the edge of the bed.

ANS: B

The nurse instructs the caregiver to place the chair on the patient’s strong side for safety and support.

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20. You are moving a patient onto a stretcher using a slide board. Two nurses are positioned on

the side of the stretcher. Where is the third nurse positioned? a. On the side of the stretcher b. At the head of the bed c. At the foot of the bed d. On the side of the bed without the stretcher ANS: D

Two nurses position themselves on the side of the stretcher while the third nurse positions self on the side of the bed without the stretcher.

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MULTIPLE RESPONSE 1. You are orienting a new NAP about the steps of proper body mechanics. Which of the follow

statements are correct steps? (Select all that apply.) a. Avoid twisting.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. Bend at the knees. c. Tighten stomach muscles as you lift. d. Straighten the legs.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf e. Keep the weight close to the body.

ANS: A, B, E

You want to avoid twisting. You want to bend at the knees to maintain center of gravity and keep the trunk erect and the knees bent as you lift. Keep the weight close to your body. Do not straighten the legs. You tighten your stomach muscles before you lift.

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2. Which of the following patients are at higher risk of complications from improper

positioning? (Select all that apply.) a. The patient who is post hip fracture who has osteoarthritis b. The patient who has COPD c. The patient who is a paraplegic d. The patient who suffered a stroke e. The patient with Alzheimer’s ANS: A, C, D, E

Patients with alterations in bone formation or joint mobility, impaired muscle development, and central nervous system (CNS) damage may experience motor impairment, proprioceptive loss, or cognitive dysfunction, all of which affect mobility.

DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 400 TOP: Nursing Process: Planning

3. You are getting ready to transfer your patient from the bed to a chair for the first time after

surgery. Which of the followinN gU arR eS im anBt .t oCaOs sMe s s ? (Select all that apply.)

IpNoGrtT a. Sensory status b. Temperature c. Upper arm strength d. Postural hypotension e. Cognitive status f. Pain level ANS: A, C, D, E, F

To provide for a safe transfer it is important to assess sensory status, including central and peripheral vision, adequacy of hearing, and presence of peripheral sensation loss. This will impact the ability of the patient to contribute to a safe transfer. Patients with visual and hearing losses need transfer techniques adapted to deficits. Immobile patients can have decreased muscle strength, tone, and mass, which affects the ability to bear weight or raise the body. Assess presence of weakness, dizziness, or orthostatic (postural) hypotension.

Rationale: Determines patient’s risk of fainting or falling during transfer. The move from a supine to a vertical position redistributes about 500 mL of blood; immobile patients may have decreased ability for the autonomic nervous system to equalize blood supply, resulting in orthostatic hypotension. Assess the patient’s cognitive status, including ability to follow verbal instructions. Assess the patient for pain (e.g., joint discomfort, muscle spasm) and measure level of pain using a scale from 0 to 10. Offer prescribed analgesic 30 minutes before transfer. Temperature does not affect the transfer process.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF:

Cognitive Level: Apply

REF: Page 401

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Safe and Effective Care

TOP: Nursing Process: Planning

4. You are transferring a patient and he or she sustains an injury during the transfer. What steps

must you take? (Select all that apply.) a. Stay with the patient. b. Notify the healthcare provider. c. Complete an occurrence report per agency policy. d. Evaluate the incident. e. Provide supportive care to the patient.

ANS: A, B, C, D, E

If a patient sustains an injury during transfer it is important to: –Stay with patient and notify the healthcare provider immediately.

–Provide necessary supportive care until the patient is stable.

–Evaluate incident that caused injury (e.g., assessment inadequate, change in patient status, improper use of equipment, insufficient number of caregivers to assist).

–Complete occurrence report according to agency policy.

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REF: Page 409 TOP: Nursing Process: Planning

COMPLETION 1. Workers in

and occupations suffer the most lost-time cases of general musculoskeletal pain and back pain.

ANS:

nursing, support staff support staff, nursing DIF: Cognitive Level: Remember OBJ: NCLEX: Safe and Effective Care

REF: Page 399 TOP: Nursing Process: Implementation

2. The most effective way to prevent musculoskeletal injuries when positioning patients is to

teach

and

.

ANS:

proper body mechanics, use of patient-handling equipment use of patient-handling equipment, proper body mechanics DIF: Cognitive Level: Remember OBJ: NCLEX: Safe and Effective Care

REF: Page 399 TOP: Nursing Process: Implementation

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 16: Exercise & Mobility Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. The nurse delegates helping the older patient ambulate with a walker without wheels to

nursing assistive personnel (NAP). Which instructions should the nurse provide to the NAP? a. Show the patient how to slide the walker a few steps ahead. b. Check the patient for non-skid shoes before using the walker. c. Be sure that the patient places all weight on the front of the walker. d. Ensure that the patient is wearing soft slipper socks while walking.

ANS: B

The nurse instructs the NAP to check the patient for supportive, non-skid shoes to prevent injury to the patient’s feet and provide sure footing while using the walker. The patient should be instructed to lift the walker and set it into place to advance. Sliding is not safe because it does not provide a stable foundation and is more likely to lead to patient falls. The patient should not place all weight on the front of the walker because this will cause the walker to tip.

The patient should be instructed to place weight in the center of the walker for stability. Soft slipper socks do not provide adequate support for the ambulating patient and are more likely to lead to falls.

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2. The nurse instructs the patient, who has right-sided weakness, to use the cane during

NURSINGTB.CO

ambulation and assesses the patient’s use of the cane. Which assessment should the nurse address before the patient ambulates with the cane? a. The cane makes a tapping sound each time the patient touches it to the floor. b. The patient holds the cane in the unaffected hand for support. c. The patient holds the cane 10 to 15 cm (4 to 6 inches) to the side of the left foot. d. The patient ambulated 4 times with the cane in physical therapy.

ANS: A

The cane should have a rubber tip on the end and should be silent when the rubber tip contacts the floor, indicating that the rubber is intact; if the cane clicks each time it hits the floor, the rubber cannot effectively maintain the patient’s stability. Using the cane on the unaffected side is proper technique for ambulating with a cane. Holding the cane 10 to 15 cm (4 to 6 inches) to the side of the unaffected foot is appropriate. The patient’s history of cane use is valuable information for subsequent instruction and gives the nurse a basis for comparison.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 438 TOP: Nursing Process: Assessment

3. A patient is being moved into a dangling position before ambulating. To decrease the chance

of orthostatic hypotension, what activity can the patient do? a. Sit on the side of the bed for a minute before standing up. b. Take several deep breaths while moving into the dangling position.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. Push up from the bed into the dangling position on the side of the bed. d. Stretch all of the muscles in the body.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: A

Sitting on the side of the bed stabilizes the redistribution of the blood during the position change. Deep breathing helps lung expansion but does not affect the change in the blood distribution during position changes. Pushing up from the side of the bed helps the patient transition to standing, but it doesn’t prevent orthostatic hypotension. There are many muscles throughout the body that cannot be stretched voluntarily.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

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4. The nurse is preparing to increase the amount of ambulation that the patient is able to tolerate,

to prepare for discharge. Which is the best method for the nurse to assess a patient’s ability to ambulate? a. Interview the patient’s visitors. b. Talk with the patient about the distance to ambulate. c. Review the patient progress notes. d. Measure the distances ambulated.

ANS: B

Mutual goal setting between the nurse and the patient is a beginning point. Watching the patient ambulate is essential, but working with the patient is beneficial. Even if the patient’s visitors are healthcare professionals, the nurse must assess the patient before taking action.

Reviewing progress notes provides valuable baseline data for comparison to the nurse’s assessment; however, the nurse assesses the patient to determine the nurse’s future care.

Measuring the distance covered by the patient is valuable information and is one part of the data the nurse gathers for the nursing assessment.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

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5. The healthcare provider prescribes partial weight bearing of the left leg for the postoperative

patient. Which instruction should the nurse include in patient teaching? a. Prevent the left leg from touching the floor at all times. b. Rest the left leg gently on the floor to stand with crutches. c. Distribute weight equally to each leg while crutch walking. d. Step with the left leg first to ascend the stairway with crutches.

ANS: B

The nurse instructs the patient to rest the left leg on the floor without applying any weight to it when standing with the crutches to avoid full weight bearing on the affected leg. Equal distribution of weight is weight-bearing activity, and this is contraindicated for the patient.

The patient steps with the unaffected leg first to provide a stable method for ascending stairs.

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6. The nurse is planning to perform range-of-motion exercises on a patient who has had a stroke

and has mobility issues. Which of the following principles should she make sure she follows? a. Complete the exercises in a bottom-up approach.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. Repeat each movement 8 times during the exercise period. c. Always use gloves.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf d. Complete the exercises in a head-to-toe sequence.

ANS: D

Complete exercises in head-to-toe sequence. Repeat each movement 5 times during the exercise period. Inform the patient how these exercises are performed and how they can be incorporated into activities of daily living (ADLs). Use gloves if wound drainage or skin lesions are present.

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7. The nurse teaches a patient who is alert and oriented to use a cane for left leg weakness.

Which does the nurse include in patient teaching? a. Use a firm grip to grasp the cane with the right hand. b. Place the cane about 30.5 cm (12 inches) in front of the right leg. c. Distribute weight evenly between the cane and the left leg. d. Move the right leg forward first, the cane next, and left leg last.

ANS: A

The nurse instructs the patient to hold the cane on the unaffected, or right, side to broaden the patient’s base of support because using the unaffected side offers more support. The cane should be placed 15 to 25 cm (6 to 10 inches) in front of the unaffected leg. The patient is instructed to distribute the body weight between both legs, to begin walking by moving the affected leg first to be even with the cane, and then to move the unaffected leg forward past the cane. This method provides support for the affected leg with the cane, and realigns the patient’s center of gravity.

DIF: Cognitive Level: Apply NURSINRGETFB : .PC agOeM438 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation 8. The nurse instructs the patient how to incorporate range-of-motion exercises into activities of

daily living (ADLs). With which of the patient’s joints can the nurse perform the most movements for the ADLs? a. Hip b. Shoulder c. Ankle d. Wrist ANS: A

The hip can be moved into flexion, extension, internal rotation, external rotation, abduction, and adduction while performing ADLs. The shoulder can be moved into flexion, extension, and abduction. The ankle can dorsiflex and plantar flex. The wrist can be moved into flexion, extension, abduction, and adduction.

DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 428 TOP: Nursing Process: Planning

9. Nursing assistive personnel (NAP) are working with patients performing range-of-motion

exercises. Which activity can the nurse delegate to NAP? Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. Determine the patients’ current pain level. b. Assist stable patients with their range-of-motion exercises. c. Force the joint motion gently a slight bit with each session.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf d. Place thick socks on patients before exercising the lower extremities.

ANS: B

The nurse can delegate range-of-motion exercises to NAP because training and education have been provided to allow them to perform the task safely. The nurse determines the patient’s pain level because it requires nursing assessment and nursing judgment. The joint motion should never be forced when performing range-of-motion exercises. Placing thick socks on patients before exercising the lower extremities has no purpose and is not done with range-of-motion exercises.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

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10. A patient’s pulse has gone from 78 at rest to 98 after ambulating. What nursing action is

indicated at this time? a. Ask the healthcare provider to order a wheelchair for the patient. b. Plan an adequate rest period before and after ambulating. c. Sit the patient on the bed for 15 minutes before ambulating. d. Increase the amount of range-of-motion exercises done daily.

ANS: B

The patient’s pulse rate has elevated over 20% of the baseline, which indicates a poor response to the level of activity. Rest needs to be provided immediately before and after the period of ambulation, or the amount of ambulation should be decreased until the patient adjusts to the activity. The patient would not be ambulating if riding in a wheelchair and would not build up tolerance to activity. Dangling helps decrease orthostatic hypotension but not activity intolerance. Range-of-motion exercises help with joint movement, not activity tolerance.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

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11. The nurse teaches the patient’s caregiver how to respond if the patient begins to fall while

ambulating. Which instruction does the nurse provide to minimize potential injury to the patient and the caregiver? a. Get the nearest chair and put it behind the patient. b. Ease the patient to the side to protect his or her head. c. Straighten your leg and help the patient slide to the floor. d. Hold onto the gait belt and pull the patient close to you.

ANS: C

If the patient complains of dizziness or begins to fall, instruct the caregiver to extend a leg under him or her and allow him or her to slide down the leg and gently reach the floor. This is the best method of preventing injury to the patient and caregiver because the caregiver engages strong muscles to act as an angle between the patient and the floor, slowing the speed of the patient’s descent. If the caregiver has to release the patient to get the chair, the patient is left unstable and is likely to suffer a fall or injury. The caregiver risks personal injury trying to direct the patient’s fall unless strong muscles such as the legs are used. The nurse uses back muscles to hold the gait belt with a patient fall and risks a serious back injury from twisting Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

and reaching in the process.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

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12. The patient ambulates with two axillary crutches, and the nurse notes that the patient’s weight

is resting on the axilla. Which should the nurse do to prevent patient injury? a. Document that the patient is using the crutches properly. b. Encourage the patient to minimize the weight on the axilla. c. Fit the patient for crutches while he or she wears shoes. d. Increase the layer of padding to the top of the crutches.

ANS: C

The crutches may be too long for the patient, or the patient may be barefoot; thus, the best action for the nurse is to measure the patient again for crutches with shoes on both feet to prevent radial nerve damage at the axilla and to instruct the patient to wear shoes when using the crutches. The patient does not appear to be using the crutches properly and should be instructed to avoid all pressure on the axilla. Increasing the padding along the top of the crutches would actually increase the problem of axillary pressure by increasing the height of the crutches.

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13. The patient is postoperative day 1 after surgery on the right knee and is to begin to walking

with crutches using the three-point gait. Which does the nurse correct for the patient when ambulating with crutches? a. Moves the right crutch first, left crutch second, and right leg last b. Begins in the tripod position and bears all weight on the left leg c. Slips three fingerbreadths bN etUwReS enItN heGcTruBt. chCpOaM dding and the patient’s axilla d. Flexes elbows at approximately 20 degrees while walking with crutches ANS: A

The three-point gait requires the patient to advance both crutches at the same time with the affected leg while the unaffected leg bears the body weight. This technique allows the patient to avoid weight bearing on the affected leg by using a stable base of support. Moving the right crutch and then the left crutch is not the correct coordination for a three-point gait. The other options are correct for using a three-point gait.

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14. The nurse is instructing a patient with a right hip replacement to descend stairs by using

axillary crutches. Which should the nurse include in patient teaching? a. Use the handrail on the right side. b. Shift the weight to the left leg to begin. c. Keep crutches very close to the hips. d. Place the left leg on the stair below first.

ANS: B Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse instructs the patient to begin in the tripod position and thus shift the body weight to the unaffected leg to maintain balance and a base of support. The patient uses both crutches, one on each side, to descend a stairway to provide a wide base of support and avoid hopping down each step on one foot. The crutches should be held 15 cm (6 inches) laterally to provide a wider base of support. The nurse instructs the patient to position the crutches on the stair below before shifting weight to the crutches and moving the right leg forward.

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15. The patient is currently learning how to use crutches so there is minimal weight on the

affected leg. Which type of crutch-walking technique will the nurse be reinforcing? a. Two-point gait b. Three-point gait c. Partial weight bearing d. Swing-through gait ANS: C

Partial weight bearing or touch-down weight bearing more closely resembles normal walking, except that less weight is placed on the affected leg. None of the other techniques would be appropriate for the goal of minimizing weight on the affected leg.

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16. The nurse is measuring vital signs when the patient, who is standing, complains of dizziness.

What is the nurse’s priority intervention? a. Call for immediate assistanN ceU. RS b. Help the patient to lie on the floor. c. Help the patient to a seated position. d. Inform the patient that the dizziness will pass.

ANS: C

The nurse helps the patient sit after the complaint of dizziness to prevent a fall. If necessary, the nurse then calls for help. Safety is always the priority when giving care. Sitting helps restore the patient’s blood pressure to normal levels, relieving the dizziness. Assisting the patient to the floor is indicated for seizures but not for complaints of dizziness. Telling the patient that the dizziness will pass is a reasonable response after the patient has been seated.

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MULTIPLE RESPONSE 1. The nurse is working on establishing a balance strategy training program (BSTP) for patients

in a long-term care facility. Which of the following should she expect? (Select all that apply.) a. The patients will have an increase in functional ability. b. The fall rate will decrease.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. The BSTP activities include tossing small bean bags. d. The patients will have weekly sessions to practice activities. e. The activities require a lot of work to integrate into the daily resident program.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf f.

Patients will become more independent.

ANS: A, B, C, F

A balance strategy training program (BSTP) is designed to improve a patient’s balance. Once balance is improved, patients have the potential to be more active, improve functional abilities, and in some situations be more independent.

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2. The nurse is explaining to a nursing student the importance of making sure the patient is

wearing his sequential compression devices (SCDs) when in bed. Which of the following statements indicates a good understanding of the purpose of SCDs by the student? (Select all that apply.) a. SCDs mimic the natural act of walking. b. SCDs pump blood into deep veins. c. SCDs prevent venous stasis. d. SCDs are used to prevent DVTs. ANS: A, B, D

SCDs pump blood into deep veins, thus removing pooled blood and preventing venous stasis.

Another device, the venous plexus foot pump, promotes circulation by mimicking the natural action of walking.

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COMPLETION 1. Range-of-motion (ROM) exercises are

independently and

if the patient is able to perform the exercise if the exercises are performed for the patient by the caregiver.

ANS:

active, passive ROM refers to the amount of rotating, bending, or twisting that a joint allows (Edlin and Golanty, 2010). ROM exercises may be active, passive, or active assisted.

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2. Contraindications for the use of elastic stockings or sequential compression devices (SCDs)

include open skin

and recent skin

.

ANS:

lesions, graft It is important to assess for contraindications to the use of elastic stockings or SCDs such as open skin lesions, skin grafts, and decreased circulation to lower extremities.

DIF:

Cognitive Level: Comprehend

REF: Page 432

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 17: Traction, Cast Care, and Immobilization Devices Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. The nurse prepares to place the patient in skin traction. Which is the nurse’s main concern

before applying the skin traction? a. Obtain informed consent from patient. b. Verify that the patient assessment is complete. c. Prepare a sterile field for pin insertion. d. Assemble the overhead frame and pulleys.

ANS: B

The priority nursing intervention before the patient goes into skin traction is to ensure that the patient assessment is completed because the nurse relies on baseline data collected before the procedure to compare with postprocedure neurovascular and skin assessments. Without baseline data, the nurse cannot determine whether assessment findings after application of skin traction are new findings or the patient’s baseline status. The healthcare provider provides informed consent to the patient because he or she performs the procedure. The nurse prepares a sterile field for pin insertion for application of skeletal traction, not skin traction.

Assembling the overhead frame is generally a function performed by technical personnel. If the nurse must be involved, frame assembly can wait until after patient assessments are complete.

DIF: Cognitive Level: Apply REF: Page 452 OBJ: NCLEX: Physiological IntN egUriR tySINTGOTPB : .NCuO rsM ing Process: Planning 2. The patient is in Buck’s traction for a fractured femur. What should the nurse do to minimize

any muscle spasms of the affected leg? a. Apply traction gradually, gently, and completely. b. Assess the affected leg with the “four Ps” criterion. c. Eliminate potential pressure points from the traction. d. Ensure unobstructed countertraction to the patient’s pelvis.

ANS: A

Muscle spasms associated with a fracture occur because nerves are irritated by bone fragments and occur more frequently at the initiation of therapy. The nurse attaches weight to the traction slowly, gradually, and completely to help prevent and eliminate muscle spasms of the affected leg. The weight, hanging freely, usually creates enough pull on the muscle to release the spasm without increasing pain. Countertraction to the pelvis is contraindicated in Buck’s traction. Assessing the four Ps (pounds, pull, pulleys, and pressure) ensures that traction is applied correctly. Eliminating potential pressure points is important but not related to muscle spasms.

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3. A patient complains of a slight tingling in the toes of the affected leg 2 hours after the Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

application of Buck’s traction with a foam boot with Velcro straps. Which nursing intervention will prevent potential complications related to the patient complaint?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. b. c. d.

Apply warm blankets to the feet and reassess.

Check the fit of the traction device near the knee.

Medicate the patient for pain with an opioid analgesic.

Reassure the patient that this is a common complaint.

ANS: B

Tingling in tissue distal to a potential constriction indicates neurovascular impairment caused by nerve compression or irritation. The nurse should inspect the patient’s knee area because this area is most likely to be affected by pressure from the traction device. Nursing intervention can prevent a potential complication of neurovascular impairment such as nerve damage by detecting the source of the pressure and eliminating the pressure. Warm blankets might be applied to increase regional tissue warmth and comfort, but they do not address the possible constriction. Although effective for pain, opioid analgesic agents are ineffective therapy for tingling unless administered in excessive doses that alter the level of consciousness. Addressing the cause of the tingling is more important. It is inappropriate to assure the patient that the complaint is common since tingling is a sign of nerve compression and the compression needs to be alleviated.

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4. The nurse assesses the traction boot for a proper fit. Which observation by the nurse verifies

that the patient has a properly fitting Buck’s traction boot? a. The heel rests firmly on the inner heel padding of the boot. b. The leg slips out of the boot after applying weight. c. The pain level increases from a level of 6 to 7 on a scale of 10. d. The traction boot fits snuglN yU wR ithSoIuN t pGrT esB su.reCpOoMints.

ANS: D

The nurse observes a snug fit without prolonged exposure to pressure for leg protection against traction forces; the boot maintains adequate neurovascular function and provides effective traction to the affected region. The nurse should also observe a well-seated heel in the boot and baseline neurovascular assessment findings. Padding at the heel of a traction boot is contraindicated because the boot is manufactured to distribute pressure over the heel and leg. If the leg slips out of the boot when weight is applied, the boot is too loose. After application of the traction, pain should decrease.

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5. The nurse assesses a patient 22 hours after skeletal traction was applied to the femur. Which

clinical finding is inconsistent with the patient’s baseline data but acceptable to the nurse? a. A decreased sensation in the affected foot b. An increase in patient anxiety after procedure c. Lower leg pallor with a weaker pedal pulse d. A small amount of clear drainage from the pin sites ANS: D Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Clear drainage after pin insertion is an acceptable clinical finding after an invasive procedure because it reflects the process of drainage produced with punctures. Decreased sensation is consistent with clinical indicators for neurovascular impairment from nerve compression or irritation. Lower leg pallor and a weaker pedal pulse indicate compression of the affected leg from edema and the original trauma. Patient anxiety related to a procedure is more common before the procedure; however, exposure to new therapy can cause patient anxiety.

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6. The nurse is teaching a patient about pin site care. Which of the following should the nurse

include in patient teaching for self-care at home? a. Use a new sterile applicator for each pin. b. Wrap the pins with sterile gauze saturated in an antibiotic. c. Use a new clean swab for each pin site. d. Use cotton swabs with hydrogen peroxide to clean the pins.

ANS: A

The nurse teaches the patient to cleanse each pin with an individual sterile applicator using the prescribed antiseptic. If gauze is placed around the pin, it must remain dry. Only sterile objects such as applicators may touch the pin sites. Hydrogen peroxide is no longer used because of potential damage to healthy skin around the pin.

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7. The nurse is caring for a patient who is in skeletal traction for a femoral fracture and notes that

patient assessment data i n cl ud eNdUyR s pSnI eaN, G h yTpBox.i C a, OpM et e chi al rash on chest, and hypotension.

Which should the nurse implement? a. Initiate emergency treatment measures and call the healthcare provider at once. b. Medicate the patient for severe pain and reevaluate in 30 minutes. c. Place the patient in semi-Fowler’s position and listen to bowel sounds. d. Review the list of patient medications and ask about any coughing.

ANS: A

These patient data are consistent with clinical indicators for a pulmonary embolism; accordingly the nurse institutes emergency treatment for the patient to restore adequate oxygenation, ventilation, and perfusion and preserve vital organ function. If the patient is stable enough for transport, the healthcare team provides empirical treatment, including supplemental oxygen, fluid resuscitation, and anticoagulation, before performing diagnostic tests to determine the nature of the patient’s problem. The patient is not complaining of pain.

If chest pain occurs from the pulmonary embolus, the nurse can administer morphine sulfate intravenously to provide pain relief but not at the expense of the respiratory rate or blood pressure. Asking the patient about coughing and repositioning in a semi-Fowler’s position are reasonable nursing interventions but are not a priority at this time. The most important nursing intervention is to initiate emergency care related to the symptoms of embolism.

DIF: Cognitive Level: Apply REF: Page 469 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 8. The nurse provides discharge patient teaching for a patient with an external skeletal fixation

device on a leg fracture. What does the nurse include in patient teaching? a. Increase your intake of vitamins and red meat to heal the bone more quickly. b. Notify the healthcare provider if there is a change in the color of the pin site drainage. c. Cleanse the pin site once in the morning and before bed with mild soap and water. d. Increase the speed at which you ambulate around the house to prepare for increased physical activity.

ANS: B

Any change in drainage from the pin site needs to be reported to the healthcare provider since it could indicate an infection. Vitamins and red meat help provide good nutrition, but more than that is needed for proper bone healing. Soap and water are not used to cleanse the pin site; only prescribed solution applied with sterile applicators is used. As long as the patient is steady when ambulating and ambulates regularly, the speed at which he or she moves is irrelevant. Sufficient activity prevents complications caused by immobility.

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9. During the removal of a synthetic cast to the lower leg, the patient complains of heat inside

the cast. Which response by the nurse is most appropriate to the patient? a. “Do you feel some heat inside the cast?” b. “The heat that you feel inside the cast is expected.” c. “What is your pain level on a scale of 0 to 10?” d. “The heat that you feel will dissipate by tomorrow.”

ANS: B

The nurse instructs the patient that the heat is normal and is generated by the vibrating saw.

Reflecting the patient’s message is a reasonable response; however, the nurse responds properly by informing the patient that the heat is expected. A pain assessment is a reasonable response but does not address the patient complaint. The nurse should also state that the heat should diminish as the cast dries or within 20 to 30 minutes.

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10. The nurse is preparing an 11-year-old patient to have a synthetic cast placed on the arm after a

fracture. What question should the nurse include to promote the child’s acceptance of the cast? a. “Are you right or left handed?” b. “Would you like a green or a blue cast?” c. “How do you usually do in school?” d. “Do you like to play sports after school?”

ANS: B

A colored cast is often more appealing to children and aids in maintaining the appearance of the cast. Dominance doesn’t apply to the application of the cast. It will deal more with how the child adjusts with activities of daily living. School performance should not be impeded by Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

the cast, even if on the dominant arm, and sports activities after school will be limited because of the injury; neither of these issues promotes acceptance of the cast.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 153 TOP: Nursing Process: Planning

11. The patient receives a plaster cast for an ulnar fracture. What would the nurse expect to see on

the first day after cast application? a. The fingers are slightly edematous. b. The fingers are cool, pale, and dry. c. The fingertips blanch slowly. d. Skin is bulging over the cast edge.

ANS: A

The nurse expects mild edema after a fracture as evidence of the immune response to tissue trauma. It should be 1+ or less. Cool, pale, dry skin and slow blanching are consistent with clinical indicators of impaired perfusion; the nurse expects adequate perfusion with warm, pink, dry skin and swift blanching. Bulging skin at the top of a cast is consistent with clinical indicators for excessive edema; the nurse does not expect this patient datum because excessive edema potentially impairs perfusion and nerve function from tissue compression.

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12. A 5-year-old child comes to the healthcare provider for cast removal. Which of the following

should the nurse implement to minimize the child’s fears of the cast saw? a. Premedicate with an opioid analgesic. b. Encourage the caregiver to leave the room. c. Instruct the caregiver to avoid restraint. d. Show that the saw does notNcU utRiS ntI oN skGinT. B.COM ANS: D

The nurse demonstrates that the saw does not cut into skin to help minimize the child’s fear of the noisy saw and provide first-hand evidence of how the saw functions. The nurse avoids administration of an opioid because the procedure is unlikely to cause pain. The nurse encourages the caregiver to remain with the child during cast removal to provide the child with the security of the caregiver’s presence and to be available immediately after successful cast removal. The caregiver is advised to restrain the child gently to maintain patient safety during the cast removal.

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13. The patient asks what to expect immediately after removal of a long leg cast. What is the most

accurate response by the nurse? a. “The skin will look smooth and moist.” b. “You will be able to stand on both legs easily.” c. “Your joints will have full range of motion.” d. “The skin will be dry and scaly but intact.”

ANS: D Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Skin cells normally sloughed off with basic hygiene accumulate under a cast, giving the skin a scaly appearance on cast removal; the accumulating cells cause the area to itch while the cast is in place. Bathing, gentle exfoliation, and moisturizing lotion remove dead cells within a few days of cast removal to restore the normal appearance of the skin. Because muscles atrophy with lack of use, patients generally do not have complete weight-bearing ability or full range of motion after cast removal. Depending on the nature of the injury, patients increase weight bearing over days or weeks until it returns to baseline function. The joints will be stiff from immobilization as a result of casting.

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14. The patient tells the nurse that the top of the plaster cast feels rough and is scratching the skin.

Which intervention should the nurse implement? a. Explain that this is an expected outcome. b. Trim away sharp areas and edge with tape. c. Medicate the patient with a prescribed analgesic. d. Speak with the healthcare provider about a cast change.

ANS: B

All plaster casts have rough edges before they are “finished,” and the nurse finishes the edge to prevent skin breakdown and infection. To finish the cast, the nurse carefully trims away the thin, uneven edge and reinforces the edge with tape. If the cast is finished with stockinette, the healthcare provider folds the stockinette over the edge of the cast and makes a final loop with the casting material around the cast to hold the stockinette in place. Pain medication can become necessary; however, the priority is to prevent skin breakdown and infection. The discomfort will resolve after thN eU edRgS e Ii sNf iGn T i sB h e.d CaO n dMe d e m a subsides. A cast change is not indicated.

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15. The nurse provides teaching for the family of a 5-year-old patient who has a one-and-a-half

hip spica cast. Which of the following recommendations should the nurse include in patient teaching? a. The patient can sit in a chair with a dry cast if propped carefully. b. Large casts dry from the outside to the inside. c. Several people are needed to safely turn and move the patient. d. Turn and position the patient with the abduction bar.

ANS: C

The nurse instructs the patient’s family to involve several people when turning or moving the patient to prevent injury and maintain cast integrity because the combined weight of the patient and cast material can make the patient too awkward and heavy for one person to handle safely. Patients are unable to sit in a hip spica cast because the hip and legs are casted in straight alignment. Casts dry from the inside to the outside. The nurse instructs the family to avoid using the abduction bar for turning because the bar is designed to maintain leg position. Turning or positioning with the bar increases the risk of damaging the integrity of the cast and causing patient injury.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF:

Cognitive Level: Apply

REF: Page 456

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation

16. The nurse completes patient teaching about synthetic cast care at home. What does the nurse

instruct the patient to report about the cast? a. If it becomes dry and stiff b. Any softening of the cast c. If the exterior becomes soiled d. If the exterior feels rough ANS: B

The nurse instructs the patient to report any defects in cast integrity. If the cast softens, it loses its ability to maintain bone alignment; the nurse instructs the patient to report this because it may warrant further investigation by the nurse. A synthetic cast should be dry, stiff, and rough. For soiling, the patient can rinse the cast in warm water and dry thoroughly.

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17. The nurse plans care for a patient who has just received a prescription for a leg brace and

crutches. Which of the following is the nurse’s priority in the patient’s plan of care? a. Assisting the patient to a supine position to apply the leg brace b. Asking which device the patient prefers and uses most often c. Determining patient experience with a leg brace and crutches d. Assessing how the leg brace affects ambulation with crutches ANS: C

The most important nursing intervention is to establish baseline data on patient knowledge and experience with the brace aNnU dR crSuI tcN heGsTbB ec.auCsO eM this determines the teaching, assessments, preparation, and collaboration that the nurse plans and provides. The baseline data help the nurse to identify knowledge gaps, prevent complications, and provide effective care. When this is completed, the nurse applies the leg brace properly by positioning the patient in a supine position. The prescription provides instruction for the use of a leg brace with crutches.

After fitting the patient with a brace, the nurse collaborates with physical therapy to teach or reinforce crutch walking with the brace before allowing the patient independent ambulation to provide patient safety and prevent injury.

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18. The parent of a 4-year-old patient with bilateral leg splints calls the office nurse and reports

that the child is “more restless than usual, and I’ve found the splint straps partially loosened.”

Which response by the nurse is most appropriate? a. “Orthotic devices provide needed support.” b. “Manufacturers use flexible materials for comfort of the splints.” c. “Check the skin around the splints.” d. “Bring the child in for us to see either today or tomorrow.”

ANS: D Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Restlessness can indicate pain or discomfort, and, because children grow, the splint might need adjusting. The child’s growth and development necessitate adjusting the splint to accommodate changes in anatomy and increased weight. As the child outgrows the splint, the risks of impaired tissue integrity, patient discomfort, ineffective therapy, and injury increase.

If the child is loosening the splint straps, this may indicate discomfort. The parent is not knowledgeable regarding all aspects to be checked; the child needs to be checked by a medical professional. Manufacturers make splints to withstand daily activity over time; they use sturdy materials such as leather, steel, and strong, molded plastic. Accordingly the nurse teaches the caregivers to observe patient skin for redness and examine the splint for integrity.

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19. The nurse is assisting with the application of a long arm plaster cast. Which action should the

nurse take for this patient? a. Apply an ice pack along the top of the cast. b. Handle the wet cast with the fingertips. c. Maintain the extremity below the heart level. d. Fold the stockinette over the outer edge of the cast.

ANS: D

The nurse folds the stockinette over the outer edge of the cast, secured with an additional layer of casting material, to protect the regional tissue from irritation. Ice bags are placed on both sides of the cast to ensure effective cooling. The nurse handles a wet cast with the palms of the hands. After completing the cast, the nurse positions the extremity above the heart to promote venous drainage from the affected tissue.

N URSINRGETFB: .PCagOeM456

DIF: Cognitive Level: Rememb er OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning

20. A patient with fractures of the femur and pelvis is restless and has a heart rate of 112 and a

respiratory rate of 28. What actions should the nurse take? a. Notify the healthcare provider and check vital signs. b. Restrict physical activity and elevate the head of the bed. c. Reposition the patient and administer pain medication. d. Listen to the lung sounds and give a muscle relaxant.

ANS: A

The patient is experiencing the signs and symptoms of a fat embolus and needs emergency treatment by the physician. The nurse should stay and monitor the patient. This patient already has restricted mobility as a result of the injuries. Elevating the head of the bed may help the respiratory effort, but the first action should be to notify the healthcare provider of the emergency. There are no data to indicate the need to administer either pain medication or a muscle relaxant.

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21. The nurse is instructing nursing assistant personnel (NAP) about caring for a patient with Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

bilateral plaster long leg casts. Which activity can the nurse delegate to NAP? a. Use a warm blow dryer to assist in drying the cast faster.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. Hold the bed linens away from the patient’s cast until it is dry. c. Position the patient’s legs above his or her heart level. d. Teach the patient how to identify potential indicators of infection.

ANS: C

The patient’s legs should be positioned above the level of the patient’s heart. Warm air from a blow dryer dries the cast from the outside, which is counterproductive. The cast must dry from inside to outside. Linens are not placed over the cast until it is completely dry. The nurse retains responsibility for turning a patient with an incompletely dry hip spica cast because the task requires critical thinking and nursing judgment. While turning or repositioning the patient, the nurse must maintain proper bone and cast alignment to allow the cast to dry and provide effective therapy. The nurse instructs the NAP about clinical indicators of infection for a patient in a hip spica cast, including fever and foul odors.

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22. The nurse is preparing for the initial placement of an orthotic device onto the patient’s lower

leg. Which of the following is the priority nursing intervention? a. Instruct the patient how to care for the orthotic device. b. Provide patient teaching before ending the visit. c. Ensure that the orthotic device is free of patient clothing. d. Obtain a baseline observation of the affected skin area.

ANS: D

The most important nursing intervention is to obtain a baseline assessment of the area where the orthotic device will be placed. It is important to accomplish this before regular use of the orthotic because a pressure p o i N n tUpRo tSe nIt N i aG l l yT lBea.dCs Ot oMs k i n breakdown and can result in patient inability to use the device. Providing patient education on maintaining the device occurs before ending the visit, but the first priority should be to establish the baseline assessment before the initial placement.

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23. The nurse is assisting an adolescent female with a Milwaukee back brace for treatment of

scoliosis. Nursing care is correct if the nurse takes which action? a. Has the patient take a Betadine shower before the brace is placed b. Removes any wrinkles from the patient’s thin cotton shirt under the brace c. Asks the patient when her menstrual period is next due d. Instructs the patient on how to loosen the brace for comfort ANS: B

The nurse checks the thin cotton shirt under the brace so there are no wrinkles that could cause skin irritation. The shirt protects the skin from irritation and absorbs moisture. There is no need for a betadine shower before placing the brace. The menstrual cycle can be an annoyance when the brace is in place, but the skin integrity is priority. The brace must remain tight at certain points for it to work properly. The skin will be checked when it is removed daily.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation

24. A patient with Buck’s traction complains of increased pain after the traction is applied and

pain medication is given. After loosening the traction slightly, the nurse assesses the extremity and can find nothing wrong, although the patient is still complaining of pain at a level of 4 on a scale of 0 to 10. What action should the nurse initiate next? a. Notify the healthcare provider. b. Administer additional pain medication. c. Explain that an x-ray film of the leg might be taken. d. Have the patient describe the pain in detail.

ANS: A

Once pain medication is given and the traction is loosened, the healthcare provider must be notified because of the chance of a neurovascular deficit. Administering additional pain medication is inappropriate since it may mask the problem. The need for an x-ray film is up to the healthcare provider to explore with the patient; speculating is inappropriate. If the patient is still experiencing pain, the healthcare provider needs to be called, regardless of the description of the pain.

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25. During assessment of an African-American patient, the nurse notes that the fingernails on the

hand casted in plaster are an ashen-gray color. What information should the nurse collect next? a. Whether the patient is experiencing numbness or tingling in the affected hand b. How pink the fingernails were before the application of the cast OeMdications c. Whether the patient has an N alU leR rgSyItoNlGatTexB. orCm d. The color of the toenail beds for a comparison ANS: A

Numbness and tingling are symptoms that correlate with a decrease in circulation, which can be manifested as an ashen-gray color in this patient. The color of the fingernails before the application of the cast is important to know, but information about the current status is more important. Allergies are checked, but they would not be manifested only on the affected extremity. Toenail beds can alert the nurse if a systemic cardiopulmonary problem is occurring. The comparison would be between the two hands.

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26. The nurse is preparing a patient for discharge after application of a plaster cast. What

information does the nurse include in the patient teaching? a. Report any changes in sensation or mobility. b. Use a cool blow dryer to dry a wet cast. c. Use only soft objects to scratch inside the cast. d. Trim the cast if the skin becomes irritated.

ANS: A Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse instructs the patient to report changes in sensation or inability to move the affected tissues because these clinical indicators are consistent with neurovascular impairment, usually resulting from a compressed or irritated nerve. This potentially results from excessive intracast pressure from bleeding, edema, or compartment syndrome. The patient can facilitate cast drying by using a standard, household fan positioned 45 cm (18 inches) or more from the cast.

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27. The nurse is preparing to help with removal of a long arm plaster cast. What information

should the nurse include in patient preparation for plaster cast removal? a. “Stretch your arm and wrist as soon as the cast is removed.” b. “I’ll get a nail brush to help remove dead cells from your skin.” c. “This is the enzyme wash we’ll use to remove dead skin cells.” d. “The cast saw causes a little discomfort and a burning sensation.”

ANS: C

The nurse instructs the patient to use a cool enzyme wash to facilitate dead cell removal as long as the skin is intact because the skin under a cast becomes dry and flaky. The patient is advised to resume full range of motion gradually to prevent discomfort and patient injury. A nail brush is too rough to use on scaly, dry skin and could cause discomfort. The saw causes no discomfort, although a burning sensation can occur with the removal of a synthetic cast.

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NcUreRaS 28. The patient is complaining of in siI ngNpGaT inBs. evCeO raM l hours after a cast was applied for a severe lower leg injury. What actions should the nurse implement after giving additional pain medication with no relief? a. Call the physician and order a cast saw to the bedside. b. Elevate the leg as high as possible and put ice on the cast. c. Administer half of a dose of additional pain medication and check vital signs. d. Try to distract the patient and have nursing assistive personnel (NAP) stay with him or her.

ANS: A

The patient is experiencing symptoms of compartment syndrome, which is a medical emergency. The physician must be notified, and the cast saw made available because the cast will need to be split (bivalved) so the leg can be assessed. Ice is contraindicated, as is placing the leg high. There is already decreased circulation of the extremity, and nothing should be done to further impair it. The nurse cannot alter the prescribed dose of medication that may be given to the patient without consulting the healthcare provider. Distracting the patient is not a useful response to this situation. The nurse should remain at the patient’s bedside until the emergency situation is addressed.

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

COMPLETION

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 1. The first sign that a neurovascular deficit is developing in a patient who is immobilized in a

traction device after a fracture is

on passive range of motion.

ANS:

pain It is essential to monitor the five Ps (pain, pallor, paralysis, paresthesia, and pulselessness) of neurovascular status because permanent damage results if circulation is not maintained and restored. Pain on passive motion is often the first clinical manifestation when a neurovascular deficit is developing. Promptly report the development of compromised neurovascular status to the patient’s healthcare provider.

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2. The nurse is performing pin site care using evidence-based guidelines. Those guidelines

recommend using

solution to clean the pin sites.

ANS:

chlorhexidine The level of evidence for pin site care is low, but guidelines and reports from an integrative review of the literature provide recommendations for clinical practice (Lagerquist et al., 2012; Timms and Pugh, 2012; Voda, 2011): Perform pin care daily or weekly after the first 48 to 72 hours. Weekly pin care is supported for noninfected pins. Clean pin sites with chlorhexidine 2 mg/mL solution.

DIF: Cognitive Level: Apply REF: Page 452 OBJ: NCLEX: Physiological IntN egUriR tySINTGOTPB : .NCuO rsM ing Process: Implementation

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 18: Urinary Elimination Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. The nurse is preparing to insert an indwelling urinary catheter into a female patient who is

having major open heart surgery and will be in the intensive care unit after surgery. Which statement about the purpose of the catheter by the patient best indicates that teaching by the nurse was effective? a. “An empty bladder always helps prevent bladder infections.” b. “The catheter drains residual urine from a urinary obstruction.” c. “The catheter prevents urinary infections.” d. “The catheter will allow us to monitor your urine output status closely after surgery.”

ANS: D

During acute illness, a patient may require urinary catheterization for close monitoring of urine output or to facilitate bladder emptying when bladder function is compromised. An empty bladder does help prevent bladder infections by decreasing the risk of residual urine; however, a bladder infection is not as immediate a threat to the patient as fluid and electrolyte imbalance. A urinary catheter drains urine from an obstruction, but this is not this patient’s problem. The catheter does not prevent urinary infections.

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NURS IN G TB . C O M

2. The nurse inserts an ind welling u ri n ar y ca th e te r i n t o an adult patient who has been unable to

void. Which assessment finding would the nurse expect? a. The patient complains of burning. b. The urine output exceeds 30 mL/hr. c. The patient develops a fever. d. The urine is yellow and blood tinged.

ANS: B

The nurse expects the catheter to drain more than 30 mL/hr of urine as an indication of adequate urine output because it has been a while since the patient voided. A patient complaint of burning or the development of a fever would be unexpected findings and warrant further assessment. Blood-tinged urine would also be an unexpected finding and warrant further assessment.

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3. The nurse evaluates the effectiveness of the patient’s intermittent urinary catheterization for

residual urine. Which of the following requires follow-up nursing intervention? a. The patient is passing urine in the bathroom. b. The urine is clear yellow and without odor. c. The bladder is nonpalpable above the pubic bone.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf d. The patient complains of frequency and urgency.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: D

Patient complaints of frequency and urgency are consistent with clinical indicators of a bladder infection, which indicates that the intermittent catheterization has been ineffective.

Follow-up nursing interventions include increasing patient fluids to dilute and flush out urinary pathogens and collaborating with the provider for potential alterations to the therapeutic regimen, including urine culture and sensitivity. If the patient passes urine in the bathroom, he or she has enough bladder control to reach the bathroom before urinating, which is consistent with clinical indicators of normal urinary function. Normal urine is clear, yellow, and without strong odors and indicates that intermittent urinary catheterization is effective therapy. A nonpalpable bladder indicates an empty bladder and effective intermittent urinary catheterization.

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4. In which position would the nurse place a female patient when preparing to insert a urinary

catheter? a. Prone b. Supine c. High-Fowler’s d. Dorsal recumbent ANS: D

The nurse assists the female patient to the dorsal recumbent position for insertion of a urinary catheter because this position exposes the perineum adequately to visualize the urinary meatus and maintain aseptic technique during the procedure. Positioning the patient on her stomach, flat in bed, or sitting upright impairs the nurse’s ability to expose the perineum, visualize the NURSINGTB.C urinary meatus, maintain aseptic technique, and drain urine from the bladder.

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5. Which technique should the nurse use to cleanse the perineum of a female patient during

urinary catheter insertion? a. Rinse the perineum with warm antiseptic solution. b. Swab the perineum 3 times from the anus to the urinary meatus. c. Use the nondominant hand to keep the labia spread apart continuously. d. Use the nondominant hand to cleanse from the urinary meatus to the rectum.

ANS: C

The nurse uses the nondominant hand to spread apart the labia and maintain the position until the catheter is in place; once the nurse contaminates the nondominant hand by touching the perineum, he or she cannot use that hand to manipulate sterile equipment. Rinsing the perineum is impractical and not necessary. To prevent infection, the nurse uses the dominant hand to cleanse from the urinary meatus to the rectum in one motion.

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 6. The nurse is changing an external urinary catheter on a male patient. Which observation by

the nurse requires additional attention?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. b. c. d.

The patient urinates at least every 4 hours.

The patient’s urine is dark yellow and clear.

The skin of the penis under the catheter is dusky.

The patient applies the catheter independently.

ANS: C

Regardless of the location, dusky skin is cause for concern because it is a clinical indicator of tissue hypoxia. If the tissue is hypoxic, the perfusion is probably inadequate to meet tissue oxygen demand and increases the risk of skin breakdown. Urinating at least every 4 hours is a desirable outcome. Clear urine is a desirable outcome because it indicates urine that is free of sediment and not infected. The dark yellow color can indicate dehydration. Ability to perform self-care for a urinary catheter depends on the physical abilities and motivation of the patient, but it is generally a desirable outcome.

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7. Discharge teaching for a male patient with an external urinary catheter would include which

of the following instructions? a. Retract the foreskin of the penis before applying the catheter. b. Remove the hair at the base of the penis before applying the catheter. c. Apply a petroleum-based skin barrier to the penis first. d. Press the catheter adhesive to encourage adherence to the penis.

ANS: D

The nurse would instruct the patient to squeeze around the penis gently to firmly secure the adhesive to the penis to prevent leaking. Retracting the foreskin before applying an external catheter and removing the h ai r NatUt R h eSbIa N s eGoTf B th. eC peOnMis are not indicated. Applying a petroleum-based product impairs the ability of the adhesive to adhere to the skin.

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8. Four hours after applying an external urinary catheter, the nurse observes no urine output in

the drainage bag. Which intervention should the nurse implement first? a. Check the catheter tubing for an obstruction. b. Ask the patient if he or she feels the urge to void. c. Notify the provider of inadequate urine output. d. Increase the patient’s fluid intake over the next hour.

ANS: B

Ask the patient if he or she senses the urge to void because it may indicate a full bladder. The patient can also have urinary retention with an urge to void but no urine output. If the patient states that he has no urge to void, the nurse can scan the bladder to evaluate its contents.

Catheter tubing kinks do not affect the flow of urine with an external urinary catheter in the same way they would if an indwelling catheter were used. There could be some wetting of the perineum with leakage if the catheter tubing is kinked. The nurse would not notify the healthcare provider until performing patient assessment. Increasing the patient’s intake can be contraindicated but can be effective to increase urine output.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Analyze

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning

9. The nurse set up the sterile field and is preparing to cleanse a male patient before inserting a

urinary catheter. What step is essential for the nurse to use to facilitate insertion? a. Keep the foreskin over the penis tip. b. Use long strokes down the shaft of the penis. c. Hold the penis at a right angle to the body. d. Hold the cotton balls in the dominant hand.

ANS: C

The nurse uses the nondominant hand to hold the penis at a right angle to the body for cleansing so the dominant hand remains sterile to insert the catheter. The nurse retracts the foreskin during cleansing because the meatus is covered partially by the foreskin; the only method of cleansing the meatus is to retract the foreskin. Cleansing the shaft of the penis is unnecessary. The cotton balls remain on the sterile field until needed by the nurse.

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10. The patient reports a sharp stabbing pain when the nurse inflates the balloon during insertion

of an indwelling urinary catheter. What should the nurse do in response to the patient report of pain? a. Deflate the balloon. b. Remove the catheter. c. Advance the catheter 2 inches. d. Reassure the patient that it will pass.

ANS: A

The nurse deflates the balloon promptly because the balloon inflation precipitated the pain.

The balloon is probably still in the urethra. It had not been inserted far enough into the patient.

It is unnecessary to remove the catheter. After deflating the balloon, the nurse advances the catheter by 2 inches or more before attempting reinflation. The nurse can reassure the patient that the pain should pass and that pain management is available if the sensation persists.

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11. The nurse reviews an order for a continuous bladder irrigation after prostate surgery. Which

action should the nurse take before starting the bladder irrigation? a. Label the irrigation solution with the words for genitourinary (GU) irrigation only. b. Change the irrigation tubing at least once every 12 hours. c. Infuse the irrigation solution at 100 mL/hr for clear urine. d. Ensure that the patient has a triple-lumen urinary catheter.

ANS: D

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse first confirms that the patient has a triple-lumen urinary catheter before beginning the irrigation. This type of catheter is usually placed while the patient is in the operating room.

The nurse labels the irrigation solution properly according to agency policy for patient safety and to prevent inadvertent intravenous infusion. The nurse changes the irrigation tubing according to agency policy; every 12 hours is excessive and is likely to contribute to an infection. The nurse titrates the irrigation solution to maintain clear urine; the rate usually exceeds 100 mL/hr.

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12. The nurse infused a continuous bladder irrigation solution at 250 mL/hr for 12 hours. The

total output amount measured was 3720 mL. What should the nurse record for the patient’s urinary output? a. 550 mL b. 720 mL c. 3000 mL d. 3720 mL ANS: B

The nurse determines the patient’s urine output by subtracting the total volume of irrigation solution infused from the total urinary catheter output because the nurse infused and drained the irrigation solution.

Urinary drainage = 3720 Total of irrigation fluid = (12 hrs  250 mL/hr) = 3000 Actual urine output = 720 mL

N U RSIN G T B . C O M

DIF: Cognitive Level: Compreh en d R E F : P ag e 498 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation 13. The nurse assesses a patient’s suprapubic catheter. Which observation warrants further

investigation by the nurse? a. The catheter does not drain urine continuously. b. The catheter remains in the stoma at all times. c. The patient’s urine is dark yellow and without odor. d. The patient urinates a small volume from the urethra.

ANS: A

The nurse expects the suprapubic urinary catheter to drain urine continuously; if the flow decreases or stops, the nurse suspects an obstruction or adherence of the catheter against the bladder wall. Regardless of the cause, the nurse investigates interrupted flow of urine to prevent infection, tissue trauma, and patient discomfort. The nurse expects the suprapubic catheter to stay in the stoma, the urine to be yellow and odorless, and the patient to urinate a small volume from the urethra.

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14. The nurse determines that the patient’s urinary output from the suprapubic catheter is 150 mL Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

for 8 hours. What does the nurse implement as a follow-up nursing intervention? a. Encourage coughing and deep breathing.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. Clamp the urinary catheter for 30 minutes. c. Contact the healthcare provider for a diuretic. d. Assess the patient’s intake and catheter patency.

ANS: D

Before concluding that the patient’s urinary output is deficient, the nurse completes the assessment to eliminate inadequate intake and catheter obstruction as the potential causes of the low urine output. The nurse expected at least 240 mL of urine in 8 hours. Coughing and deep breathing are ineffective responses for low urine output. Clamping the catheter is wholly counterproductive. The nurse needs to complete the urinary assessment before determining that a diuretic is suitable therapy for the patient; if a diuretic were proper, the patient would exhibit other clinical indicators of fluid volume overload such as crackles, edema, and jugular venous distention.

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15. The nurse assesses the patient’s skin around the suprapubic catheter and observes extremely

reddened skin. Which is the best nursing intervention to promote skin integrity? a. Apply an antiseptic ointment. b. Keep the suprapubic insertion site dry. c. Attach a different bag to the skin. d. Fit the stoma with a tight skin barrier.

ANS: B

The best nursing intervention for reddened skin is to keep the area clean and dry. Reddened skin does not necessarily indicate infection; thus the antiseptic ointment can be contraindicated. The catheter dN raU inRs S inItoNaGbTaB g. anCdOiM s not attached directly to the skin. There is no stoma when a patient has a suprapubic catheter.

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16. The nurse encounters resistance during the insertion of a urinary catheter for a male patient.

Which action should the nurse implement first? a. Hold the catheter against the sphincter. b. Ask the patient to inhale quickly. c. Apply force to insert the catheter. d. Remove the catheter immediately.

ANS: A

The nurse holds the urinary catheter against the sphincter until it relaxes when resistance is initially met during catheterization of a male patient. If the resistance is from prostatic hypertrophy, the nurse can use a catheter with a smaller, curved tip based on institution policy and healthcare provider preference. Asking the patient to inhale quickly is counterproductive because it effectively creates a Valsalva maneuver and stiffens the sphincter muscle. To prevent tissue trauma, the nurse never applies force to insert a urinary catheter. Removing the catheter is premature until holding the tip against the sphincter has been tried to relax the muscle.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF:

Cognitive Level: Analyze

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning

17. The nurse is making patient care assignments for the staff. Which elimination activity can the

nurse delegate to nursing assistive personnel (NAP) for a patient with an indwelling urinary catheter? a. Catheterizing the patient b. Irrigating the catheter c. Obtaining a urine culture d. Providing catheter care ANS: D

The nurse delegates care of an indwelling urinary catheter to the NAP because the NAP is trained to perform this task as part of hygienic care. The nurse catheterizes the patient, irrigates a urinary catheter, and obtains a urine specimen for a culture because each task is a sterile procedure performed by the nurse.

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18. A patient is going to have an indwelling catheter for the next few weeks as a result of

postoperative complications. Which action does the nurse use to prevent the most common complication of an indwelling urinary catheter? a. Maintain slight tension on the tubing. b. Keep the collection bag several inches from the floor. c. Empty the collection bag every 24 hours. d. Clean the catheter from the meatus to the tubing.

ANS: D

Cleansing the indwelling urinary catheter by using circular motions from the urinary meatus to the collection bag tubing decreases the microorganism count on the catheter and prevents a urinary tract infection. The nurse secures the catheter to the patient’s leg to prevent retrograde catheter movement into the bladder, which can introduce potential pathogens into the bladder and increases the risk of a urinary tract infection. The nurse keeps the urinary collection bag below the patient’s hips to facilitate drainage and prevent retrograde flow of urine to the bladder. The collection bag is emptied at least every shift to prevent infection by removing a potential source of bladder contamination.

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19. The nurse notes that 8 hours after removing the patient’s indwelling urinary catheter, the

patient has not voided. Which intervention should the nurse try first to facilitate patient voiding? a. Run a trickle of water in the bathroom. b. Apply a rolling motion over the bladder. c. Ask about voiding difficulties in the past. d. Instruct the patient to run warm water on the perineum.

ANS: C Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse assesses the patient for a history of voiding difficulties, especially after removal of an indwelling catheter, and asks the patient about successful strategies that facilitated voiding.

Patient difficulties often arise from the physical distortion of the urinary meatus and sphincters by the urinary catheter; after the urethra and sphincters return to normal and regional edema improves several hours later, the patient voids. Running water in the bathroom, running warm water over the perineum, and applying gentle pressure to the bladder are suitable techniques to stimulate urination after assessing the patient.

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20. The nurse delegates the application of an external urinary catheter to nursing assistive

personnel (NAP), including application of an external urinary catheter. Which aspect of applying the external catheter must the nurse perform? a. Placing the adhesive from the kit to hold the catheter in place b. Checking the condition of the penis and scrotum before the procedure c. Providing perineal care before catheter placement d. Allowing a space between the tip of the penis and the catheter ANS: B

The nurse assesses the penis and scrotum before the NAP begins the procedure to establish baseline data. The nurse performs assessment tasks because assessing requires nursing judgment and planning skills. He or she delegates using adhesive to hold the catheter in place, providing hygiene, and allowing a space between the tip of the penis and the end of the catheter for urine flow because the NAP is trained to perform these elimination tasks.

REF: Page 473 DIF: Cognitive Level: Apply NURSINGTB.COM OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation 21. A male patient is having difficulty using the urinal in bed. What does the nurse do to facilitate

voiding into the urinal? a. Applies an external urinary catheter b. Assists the patient to the upright position c. Encourages the patient to void every hour d. Instructs the patient to increase his fluid intake ANS: B

The nurse assists the patient into an upright position to facilitate voiding into a urinal because men are accustomed to voiding in a standing position. If sitting upright is ineffective and the patient can be upright without dizziness or weakness, the nurse assists the patient to dangle or to stand for urination into a urinal. Applying an external catheter facilitates containing the urine but not in a urinal. Decreasing or increasing the volume of urine, voiding hourly, or increasing fluid intake, respectively, can be ineffective strategies to facilitate using a urinal in bed if the patient must stand to initiate the flow of urine.

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22. A female patient with a hysterectomy now needs to have her bladder scanned because of Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

difficulty voiding after back surgery. What action should the nurse take to obtain the most accurate scan?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. b. c. d.

Place the scanner head on the symphysis pubis using ultrasound gel.

Set the gender designation on the scanner as “male.”

Place the scanner head above the symphysis pubis without ultrasound gel.

Set the gender designation on the scanner as “female.”

ANS: B

Since the female reproductive organs are absent, the internal structure is similar to that of a male for bladder scanning purposes. The scanner head is placed above the symphysis pubis, not on the bone. Ultrasound gel and the area above the symphysis pubis are used. The female gender designation would be incorrect after a hysterectomy for bladder scanning purposes.

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MULTIPLE RESPONSE 1. The nurse is reviewing the interventions for prevention of urinary catheter infections

(CAUTIs). Which of the following interventions will help prevent infection? (Select all that apply.) a. Maintain a closed system. b. Perform routine perineal hygiene daily. c. Only open the system when necessary. d. Secure the catheter to prevent pulling on the catheter. e. Maintain an unobstructed flow of urine.

ANS: A, B, D, E

Evidence-based interventions to prevent CAUTIs include: NURSINGTB.CO • Use aseptic catheter insertion and sterile equipment.

Secure indwelling catheters to prevent movement and pulling on the • catheter.

• Maintain a closed urinary drainage system.

Maintain an unobstructed flow of urine through the catheter, drainage • tubing, and drainage bag.

• Keep the urinary drainage bag below the level of the bladder at all times.

When emptying the urinary drainage bag, use a separate measuring • receptacle for each patient. Do not let the drainage spigot touch the receptacle.

• Perform routine perineal hygiene daily and after soiling.

Quality improvement/surveillance programs should be in place that alert • providers that a catheter is in place and include regular educational programming about catheter care.

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2. The nurse is providing instructions to the NAP on applying a condom catheter on a male

patient. Which of the following indications should the NAP report to the nurse? (Select all that apply.) a. Patient complains of pain at the site or when voiding Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. Redness or irritation at the site where the condom catheter is applied

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. Skin breakdown of the glans penis or penile shaft d. Urinary incontinence ANS: A, B, C

Complaints of pain and any skin irritation or breakdown should be immediately reported to the nurse. The reason for the condom catheter is for urinary incontinence and therefore would not need to be reported.

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3. The nurse is reviewing the instructions for applying a condom catheter with the NAP. Which

of the following statements indicates an understanding of the procedure? (Select all that apply.) a. “I should shave the pubic hair first.” b. “With my dominant hand, I hold the rolled condom sheath.” c. “I allow 1 to 2 inches of space between the tip of the penis and the end of the condom.” d. “I should not use any additional adhesive tape around the penis.” e. “I should first provide perineal care.”

ANS: B, C, D, E

Perineal care is completed and then the hair is clipped, not shaved. The nondominant hand holds the penis while the dominant hand holds the condom. The securing device supplied by the manufacturer is used. One to two inches of space is left at the tip of the penis and the end of the condom.

DIF: Cognitive Level: Apply NURSINRGETFB : .PC agOeM473 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation COMPLETION 1. A

is a noninvasive device that measures the volume of urine in the bladder by creating an ultrasound image of the bladder from which calculations are made to report urine volumes.

ANS:

bladder scanner The bladder scanner can be used to assess bladder volume whenever inadequate bladder emptying is suspected such as after the removal of indwelling urinary catheters, in the evaluation of new-onset incontinence, when bladder distention is suspected, and to assess voiding after urological surgery.

DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity 2.

REF: Page 475 TOP: Nursing Process: Assessment

is an example of a continuous infusion of a sterile solution into the bladder, usually using a three-way irrigation closed system with a triple-lumen catheter.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS:

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Continuous bladder irrigation CBI is frequently used after genitourinary surgery to keep the bladder clear and free of blood clots or sediment.

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 19: Bowel Elimination and Gastric Intubation Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. The nurse determines a patient requires a fecal impaction removal. Which assessment result

justifies the nurse’s finding? a. The patient exhibits rebound tenderness. b. The patient experiences hard stool that cannot be passed. c. The patient has a history of fecal impaction. d. The patient denies having a bowel movement today.

ANS: B

The nurse determines that the patient who is unable to pass hard stool requires fecal removal after other methods, including suppositories and enemas, have been unsuccessful. Rebound tenderness is a clinical indicator consistent with peritonitis. However, normal pain and tenderness can indicate stool impaction. A patient history of fecal impaction affects prevention strategies for impaction, including exercise, fluids, high-fiber diet, and maintaining a bowel ritual and regular bowel habits. Lack of a bowel movement for a day does not necessarily indicate constipation.

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2. A patient requires digital removal of a fecal impaction. Which action should the nurse perform

before beginning this procedure? a. Administer large-volume tap water enemas until clear. b. Assist the patient into the dorsal recumbent position. c. Check for an order from the healthcare provider. d. Delegate the procedure to nursing assistive personnel (NAP).

ANS: C

The nurse obtains an order from the healthcare provider before implementing fecal impaction removal because it is an invasive procedure and can precipitate unexpected results such as bradycardia. The nurse wants the provider’s validation of the procedure to provide safe and effective nursing care. Other strategies to stimulate a bowel movement, such as suppositories and enemas, will be tried before determining that digital removal of a fecal impaction is needed. For fecal impaction removal, the nurse assists the patient to the side-lying position.

The nurse cannot delegate the procedure to the NAP because it requires the clinical judgment and critical thinking skills of a nurse.

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3. The nurse assesses a patient during digital removal of a fecal impaction. Which patient

assessment finding does the nurse determine to be unexpected? a. Complaints of abdominal cramping b. Large amount of brown, liquid stool Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. Blood pressure 130/86 mm Hg, stable d. Heart monitor showing sinus bradycardia

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: D

Sinus bradycardia is a heart rate less than 60 beats/min and is consistent with clinical indicators for vasovagal stimulation from digital removal of fecal impaction. This heart rate is usually too slow to maintain an adequate cardiac output; thus the patient becomes hypotensive and lightheaded and may lose consciousness. The nurse stops the procedure, assesses patient vital signs and neurological status, and calls for help in anticipation of the need for emergency interventions. Usually bradycardia from vasovagal stimulation resolves spontaneously; however, the nurse also notifies the provider to deliver safe and effective nursing care. The nurse expects abdominal cramping; he or she instructs the patient to focus on slow, even breathing and proceeds with removal slowly and gently to minimize cramping. The patient can pass a large amount of stool after some or the entire impacted stool is removed because fecal matter frequently accumulates behind the impaction in the colon. Stable blood pressure is a highly desirable finding.

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4. A home care patient has a history of fecal impaction. Which intervention does the nurse

instruct the home health aide to implement to prevent another fecal impaction? a. Provide the patient with low-residue foods. b. Notify the provider of patient abdominal pain. c. Administer a cleansing enema every 3 days. d. Encourage and assist the patient to take additional fluids daily.

ANS: D

The nurse instructs the home health aide to assist the patient with increased daily fluids to facilitate bowel passage througN hU thReScoIlN onGtT oBp. reC veOnM t a fecal impaction. The nurse instructs the aide to encourage frequent sips of water and help the patient avoid dehydrating liquids with high-caffeine content. The aide should provide high-fiber foods to increase the stool bulk and facilitate stool passage through the colon. He or she should report abdominal pain, but abdominal pain is not an indicator of fecal impaction. The nurse avoids instructing the aide to administer a cleansing enema to the patient on a regular basis because frequent exogenous methods of stimulating bowel movements tend to encourage patient dependency on these measures for regular bowel movements.

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5. The nurse implements the teaching plan for a patient with chronic constipation. Which of the

following outcomes indicates patient teaching has been effective? a. The patient passes a small liquid stool daily. b. The patient has a firm stool every fourth day. c. The patient reports less frequent abdominal cramping. d. The patient describes methods to prevent constipation.

ANS: D

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

If the patient is able to describe three prevention strategies for constipation, the teaching plan has been effective. Patients can have a small liquid stool and still be experiencing fecal impaction. The patient who has a firm stool every fourth day or experiences abdominal cramping has clinical indicators consistent with chronic constipation. In these instances the patient should be reevaluated for understanding, and additional teaching should be implemented.

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6. The nurse performs digital removal of feces for a patient. Which patient diagnosis cues the

nurse to assess the patient more frequently than usual during the procedure? a. Abdominal pain b. Atrial fibrillation c. Urinary infection d. Diabetes mellitus ANS: B

The nurse assesses the patient who has atrial fibrillation more frequently during digital removal of a fecal impaction because the patient has a serious cardiac arrhythmia. Al-though most patients with atrial fibrillation have ventricular response rates greater than 100 beats/min, most also have heart disease. The nurse scrutinizes the patient keenly during the procedure, taking frequent blood pressure and heart rate measurements, because impaction removal can cause a vasovagal response and slow the heart rate. The patient with heart disease is more likely to be unable to compensate for the changing heart rate. The fecal impaction is a likely cause of the abdominal pain; however, a patient with abdominal pain is assessed thoroughly before the p ro c e d u rNe Ui sRpSe rIfoNr G mTedBt.o CenOsMu r e that the patient’s condition is suitable for impaction removal. Urinary infection should not contraindicate impaction removal or cause difficulty during the procedure. The patient with diabetes mellitus is assessed before the procedure to avoid a glycemic crisis during removal of the impaction.

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7. The nurse performs digital removal of a fecal impaction for a patient with atrial fibrillation

and heart failure. Which is the most serious unexpected outcome that the nurse assesses during the procedure? a. Rectal bleeding b. Perianal redness c. Liquid stool leakage after removal of the impaction d. Abdominal cramping ANS: A

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Patients with atrial fibrillation and heart failure are usually on an anticoagulant to prevent formation of clots; therefore, the most serious unexpected finding during impaction removal is patient rectal bleeding. Rectal bleeding from the patient on anticoagulation is very difficult to control because of the anatomical location and the increased bleeding time of the patient’s blood. The nurse should stop the procedure, keep the patient’s head low as long as the patient tolerates the position, and notify the provider. Perianal redness can indicate regional irritation or future skin breakdown, and the nurse should plan care to restore the perianal tissue integrity; however, this is not more important than responding to the bleeding. Liquid stool leakage after removal of the impaction can indicate ineffective removal. The nurse should reassess the patient for continuing impaction and increase fluids, fiber, and activity level if possible. Abdominal cramping cues the nurse to stop removal of the impaction and allow the cramping to subside before continuing with the procedure.

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8. A patient is weak, has diarrhea, and is refusing to use the bedpan but is on bed rest and unable

to get out of bed. Which is the best nursing intervention to maintain patient dignity? a. Keep the bedpan out of the patient’s sight until it is needed. b. Reassure the patient that most people use the bedpan willingly. c. Instruct the patient that the only alternative for elimination is to use the bedpan. d. Explain to the patient how the nurse ensures privacy and safety when the patient is using the bedpan.

ANS: D

The nurse increases the likelihood of the patient using the bedpan by explaining how the he or she ensures safety and privacy N wU hiRleStI heNpGaT tieBn. tC u sOe sM i t . The nurse places the call bell and other items that the patient needs or wants within easy reach, covers the patient sufficiently for privacy and warmth, pulls the privacy curtain, and prevents other people from entering the room while the patient sits on the bedpan. Telling the patient that is the only alternative is not really helpful. Hiding the bedpan is deceitful and defeats the purpose of placing it at the bedside if the patient has a sudden stool. Comparing the patient to other patients to induce cooperation shames the patient and is improper; in addition, it denies the patient the right to information and informed consent.

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9. A patient in skeletal traction for a fractured pelvis needs to use the bedpan. Which

intervention should the nurse use to prevent complications? a. Logroll the patient and maintain skeletal traction. b. Place a bedpan under the patient while the hips are lifted. c. Remove weights on the traction and turn the patient. d. Warm the bedpan before placing it under the patient.

ANS: B

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The patient has a high risk for skin breakdown because he or she must remain on the back, increasing the risk of tissue hypoxia from pressure and bed rest. The nurse instructs the patient to pull up on the overbed trapeze to lift the lower torso and create a space for inserting the bedpan, keeping the hips and spine in alignment without disrupting the integrity of the traction. This helps to prevent complications of elimination by facilitating use of the bedpan, containing the stool, and preventing exposure of the perineum to the stool. If the patient is unable to help, several staff members lift him or her so the skin is not harmed. The nurse avoids logrolling the patient with a fractured pelvis to maintain alignment of the bone fragments established by the skeletal traction. The nurse wants to keep the bone fragments in alignment because movement of the fragments can extend the regional soft tissue injury and because it promotes healing. The weights are maintained on the pelvic traction to maintain alignment of the bone fragments. Warming the bedpan is a courtesy; however, the primary concerns are to maintain alignment of the bone fragments during elimination and to use a fracture bedpan to facilitate elimination.

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10. The nurse prepares to insert a nasogastric (NG) tube into a patient. Which explanation does

the nurse give to the patient to explain the use of the NG tube? a. An NG tube eases distention and nausea. b. The small, thin tube lubricates the stomach. c. It causes peristalsis to return more quickly. d. It prevents vomiting from ever occurring.

ANS: A

The nurse explains to the p a t i e nNt Ut hRa S t tI heNN GG TBtu.bCe Oremoves gastric contents to decompress the stomach, relieving nausea and distention. The tube gives the gastrointestinal tract a chance to rest before oral nutrition resumes. The tube is not small, nor thin, nor does it lubricate the stomach. The NG tube does not stimulate peristalsis. It only removes gases and fluid.

Vomiting is prevented only if the tube is properly placed and functioning.

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11. The patient is alert and cooperative for insertion of a nasogastric (NG) tube. In which position

should the nurse place the patient for the procedure? a. Sitting upright but leaning back slightly b. In left lateral Sims’ position with the head elevated c. Leaning forward on the overbed table d. Any position that is comfortable ANS: A

The nurse instructs the patient to sit upright and lean back slightly to facilitate passage of the NG tube because, if the patient starts to cough and gag during the insertion, he or she will be in the optimum position already. The nurse avoids instructing the patient to assume reclining and left lateral positions because they increase the risk of patient aspiration during the procedure. The nurse instructs the patient to assume the proper position for the procedure because he or she is responsible for the outcome and for facilitating passage of the tube.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF:

Cognitive Level: Comprehend

REF: Page 523

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation

12. During the insertion of the nasogastric (NG) tube into a patient’s left nares, the nurse meets

strong resistance. What should the nurse have done to minimize the chance that this problem would occur? a. Use a small-diameter tube. b. Apply lubricant to the NG tube. c. Instruct the patient to bear down. d. Assess the patency of both nostrils.

ANS: D

To prevent tissue trauma and minimize patient discomfort during NG tube insertion, the nurse assesses the patency of both nares before insertion. This helps the nurse determine which naris is more patent and the best naris to use for the initial attempt. If the prescription calls for an NG tube, a soft, pliable gastric tube is an unsuitable substitute because a small tube does not allow aspiration of gastric contents. If the nares are obstructed, additional lubricant cannot overcome the obstruction and can cause significant patient trauma if the nurse attempts an insertion. The nurse avoids instructing the patient to bear down during NG tube insertion because the Valsalva maneuver engorges tissue and is more likely to impair passage of the tube.

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13. The nurse is inserting a nasogastric (NG) tube and assessing the patient during the procedure.

Which assessment finding indicates a potentially serious problem? a. Restlessness b. Inability to speak c. Nasal pressure d. Mouth breathing ANS: B

If the patient is unable to speak after NG tube insertion, the nurse can visualize the tube coiled up behind the pharynx instead of passing into the esophagus. The nurse removes the tube quickly because this also means that the tube is in the trachea; it should be in the esophagus.

Patient restlessness and fidgeting should diminish after NG tube placement, especially if the tube helps to relieve nausea and abdominal distention. The nurse continues to monitor the patient for compliance with therapy to ensure that the tube remains in place. The patient is expected to feel nasal pressure after tube placement; however, the pressure should dissipate with time as the patient adjusts to it. Patients often breathe through the mouth after NG tube placement initially until adjusting to the tube in the nose.

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14. The nurse inserts a nasogastric (NG) tube to the measured length. Which method is the best

way to confirm placement of the NG tube without an x-ray film? a. Measure the pH of the gastric aspirate. b. Ask the patient if the tube is comfortable.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. Instill air and listen over the stomach. d. Advance the tube past the measured length.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: A

After inserting the NG tube to the measured length, the nurse asks the patient to speak, visualizes the tube in the posterior oropharynx, and analyzes the gastric aspirate for pH. If the tube is in the esophagus, the patient should be able to speak, the tube should be aligned with the esophagus, and the pH should be less than 4.0. The NG tube is usually uncomfortable initially. The nurse avoids instilling air into the tube as a method of confirming placement because the tube can be in the lungs. Air injected into the stomach increases patient discomfort and gastric distention. The tube is advanced after initial placement assessments when confirmation indicates that it is not in the trachea but potentially has not reached the stomach.

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15. The patient’s nasogastric (NG) tube drains approximately 400 mL/day of yellow-green

drainage. When the patient begins to complain of nausea, which intervention should the nurse implement first? a. Irrigate the tube with 50 mL of water. b. Assess the patency of the NG tube. c. Replace the NG tube with a much larger tube. d. Elevate the patient’s head and reassess.

ANS: B

The nurse should assess NG tube patency and drainage from the last few hours to gather additional information about the patient’s nausea. If the NG tube drains 400 mL/day, it should drain 15 to 20 mL/hr; thus the nurse can observe for drainage. The nurse also assesses for bowel sounds and abdominal dN isU teR ntS ioInNbG ecTaB us. eC thOeMabsence of bowel sounds with abdominal distention indicates impaired peristalsis. The nurse irrigates the NG tube after confirming its placement. Tube irrigation helps to prevent accumulated debris that increases the risk of tube occlusion. The nurse avoids relieving the patient’s problem with a larger-gauge NG tube; he or she inserts a properly sized tube in the patient. Raising the head of the bed is a reasonable response to help facilitate gastric emptying; however, because the patient has an NG tube, the nurse should verify tube placement first to avoid potential aspiration of gastric contents.

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16. The nurse is providing routine care for a patient with a nasogastric (NG) tube. Care by the

nurse is correct if which technique is used? a. Alternates NG tube placement between the nares daily b. Provides patient oral care daily and lubricant to the lips c. Keeps the head of the bed flat with the tube in place d. Prevents pressure on the nasal tissue ANS: D

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse secures the NG tube in place by anchoring it without pressure on the tip of the nares so pressure points do not develop. The nurse avoids alternating NG tube placement daily because the risk outweighs the benefit. The nurse changes tube placement if it is indicated. He or she provides oral care every 2 to 3 hours to maintain moist, intact oral mucosa and help to prevent patient infection. The head of the bed is elevated to prevent aspiration and minimize irritation from swallowing since the tube is irritating.

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17. The nurse prepares to irrigate a patient’s nasogastric (NG) tube after a colon resection. Which

intervention does the nurse implement to irrigate the NG tube? a. Observe sterile technique for each irrigation. b. Inject 50 mL of warm tap water into the tube. c. Gently instill 30 mL of normal saline solution. d. Watch nursing assistive personnel (NAP) irrigate the NG tube.

ANS: C

The nurse instills normal saline solution to irrigate the NG tube to maintain fluid and electrolyte balance and minimize electrolyte depletion from hypotonic fluids. The nurse uses clean technique for irrigating because the patient’s surgical site is farther down the gastrointestinal tract; however, he or she uses sterile irrigating fluid for upper gastrointestinal surgery. Water is usually acceptable for NG tube irrigation and can be a better solution to remove debris from within the tube because it is hypotonic. Irrigating the NG tube is a nursing task that the nurse cannot delegate because it requires clinical judgment and critical thinking skills.

NURSINRGETFB .COM : Page 527

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TOP: Nursing Process: Implementation

18. The nurse records a patient’s intake and output for an 8-hour period and notes nasogastric

(NG) tube irrigation with 50 mL of normal saline solution every 4 hours and lactulose syrup, 30 mL, instilled through the NG tube with 30 mL of normal saline solution. Which total should the nurse record as the patient’s intake over 8 hours? a. 30 mL b. 160 mL c. 110 mL d. 210 mL ANS: B

The patient’s 8-hour intake is 160 mL, obtained by adding 50 mL of saline  2, 30 mL of lactulose, and 30 mL of saline to equal 160 mL. DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 527 TOP: Nursing Process: Implementation

19. The nurse is caring for four patients. Which patient’s assessment information supports the

nurse’s decision to remove the nasogastric (NG) tube after the order by the healthcare provider is completed?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. Restless, confused, without bowel sounds b. Difficulty swallowing from left-sided stroke

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. Not passing gas with lack of appetite d. Abdomen slightly rounded with incisional pain ANS: D

The patient with a slightly rounded abdomen and incisional pain should have the NG tube removed because a rounded abdomen does not carry the risks of distention and incisional pain is a factor that does not interfere with NG tube removal. The nurse manages the patient’s pain with analgesic, keeping in mind that opioids usually lead to constipation. The restless patient and the patient with dysphagia are at high risk for aspiration because the patient potentially cannot protect the airway and needs the NG tube to help prevent aspiration of gastric contents.

The patient who is not passing gas and is experiencing anorexia is not a suitable candidate for NG tube removal because lack of intestinal gas indicates peristaltic impairment. The anorexia is a logical sequela of impaired peristalsis because patients lose their appetites with gastric paresis.

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20. During preparation for removal of a nasogastric (NG) tube, the patient becomes anxious.

Which action should the nurse take to reassure the patient before removing the NG tube? a. Grasp the tube and remove it quickly. b. Medicate the patient with an analgesic. c. Tell the patient this procedure is painless. d. Inform the patient that it only takes a few seconds.

ANS: D

The nurse teaches the patient that the procedure takes a few seconds and usually causes little discomfort. He or she can also N mU enRtiSoI nN thGatTtB is. suCesO, M a warm face cloth, and a warm beverage are provided after the procedure for patient comfort. The nurse encourages the patient to blow his or her nose after removing the tube. The nurse removes the tube in a smooth and steady motion and avoids medicating the patient unless it is indicated; removing an NG tube generally is not an indication for analgesia. The nurse avoids telling the patient that the procedure is painless because he or she cannot guarantee it and avoids making false promises.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

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21. A right-handed nurse needs to remove the patient’s nasogastric (NG) tube. Which intervention

maintains patient safety during removal of the NG tube? a. Leaving the suction on the low setting b. Clamping and then pulling out the tube c. Standing on the patient’s left side d. Asking the patient to inhale deeply ANS: B

The nurse clamps the NG tube and pulls it out smoothly and steadily, clamps the tube to prevent aspiration of drainage, and helps to prevent aspiration by instructing the patient to hold his or her breath during removal. Deep inhalation can increase the risk for aspiration if it is ill timed. The nurse turns off the suction during the procedure to avoid tissue trauma and Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

decreasing the patient’s oxygenation. The right-handed nurse stands on the patient’s right side to remove the NG tube; this is not a safety maneuver but is for the nurse’s convenience.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

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22. The nurse is preparing to insert a nasogastric (NG) tube. Which techniques should the nurse

use to measure the length of an NG tube before gastric intubation? a. Measure and mark a point 72 cm (30 inches) from the end. b. Measure from the nose to the middle of the sternum. c. Measure from the nose to the ear to the patient’s navel. d. Measure from the nose to the earlobe to the xiphoid process.

ANS: D

The nurse measures the patient using the traditional method of measuring from the patient’s nose to the ear to the xiphoid process at the bottom of the sternum. A standard 72-cm (30-inch) length for the NG tube fits some patients and not others; thus this method cannot suitably measure all patients. Measuring to the middle of the sternum results in a short tube, especially since the ear is not involved in the measurement. Measuring to the umbilicus results in an overly long tube.

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23. During insertion of a nasogastric (NG) tube, the patient begins to cough and gag. Which

intervention should the nurse implement for the patient’s benefit? a. Withdraw the tube slightly and ask the patient to swallow. b. Stop the procedure, anchor the tube, and request an x-ray film. c. Tell the patient that the gagging will pass, and advance the tube. d. Remove the tube and allowNthUeRpSatIieNnG t tToBre.gC aiO n Mcomposure.

ANS: A

Coughing and gagging during NG tube insertion are expected; thus the nurse is prepared to manage the patient’s distress. The nurse withdraws the NG tube slightly, provides water, and asks the patient to sip water or swallow to facilitate passage of the tube. This benefits the patient by implementing the prescription. The nurse avoids leaving the NG tube in the area that is causing gagging and coughing because he or she wants to help the patient avoid these as much as possible and complete the procedure. To display caring and concern, the nurse avoids just commenting that the gagging will pass and provides meaningful, facilitative instructions. He or she avoids removing the tube because the patient will have to feel the burning sensation of NG tube passage through the nose.

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24. A patient’s nasogastric tube needs to be irrigated. Which action does the nurse implement first

to prevent complications? a. Introduces 30 mL of sterile fluid b. Verifies the placement of the tube c. Aspirates gastric contents d. Positions the patient on the left side Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: B

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse verifies the nasogastric placement before instilling anything into the tube to prevent fluid instillation into the lungs. Instilling saline solution can help prevent depletion of electrolytes because it is an isotonic fluid; however, the nurse does not implement this before verifying tube placement. The nurse can aspirate the irrigation fluid to prevent fluid volume excess, when the patient is on a fluid restriction, or during the initial insertion. Positioning the patient on the left side can help to prevent aspiration; however, the nurse should verify tube placement before beginning the irrigation.

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COMPLETION 1. A

device is a useful intervention for patients with severe fecal incontinence, such as those with Clostridium difficile–associated diarrhea.

ANS:

fecal containment Fecal containment devices are an effective way to prevent skin damage due to moisture and enzyme action on perianal tissues.

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2. When considering the application of a fecal containment device, it is important to assess the

patient for

allergies.

ANS:

latex Assess patient for allergy to latex, as many containment devices contain latex.

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 20: Ostomy Care Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. The patient notices that the newly formed ileostomy stoma is pinkish red and slightly puffy.

Which information should the nurse include during patient teaching? a. This is what a new healthy stoma looks like. b. Any bleeding indicates that a problem is present. c. Healthy stomas are usually pale pink and flat. d. There should be very little drainage from the stoma.

ANS: A

The nurse instructs the patient to expect a healthy stoma to be pinkish red, indicating adequate oxygenated blood flow, and slightly puffy because it is new. Since the stoma is highly vascular, there may be a little blood. A pale pink stoma indicates decreased blood flow. The stoma should be raised. New stomas drain and are pouched immediately after being created.

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2. A patient with an ascending colostomy made as a result of abdominal trauma 4 days ago

closes his eyes during stoma care. What patient outcome is most important for the nurse to help the patient achieve? a. The patient needs no assistance to perform this procedure within a few days. b. The patient will ask questions about what clothing he can wear before discharge.

NURSINGTB.C c. The patient touches the stoma while looking at it within the next 2 days. d. The patient’s family learns how to pouch his stoma within 1 week.

ANS: C

Patients usually need time to adjust to an abrupt body image change and a change in bodily function. Looking at the stoma and touching it would indicate the beginning of adapting to the changes. The patient needs to be able to be independent eventually in caring for his ostomy, but it is not expected that he would be caring for the stoma within a few days. The patient needs to talk about what type of clothing will work with the stoma well before discharge, but adjusting to the change in his body must come first.

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3. The nurse is teaching the patient how to size the skin barrier around the stoma. Which

instructions does the nurse include? a. Use the measurement guide for a proper fit. b. Extend the skin barrier to cover the incisional area. c. Make a wick from toilet tissue before changing the skin barrier. d. Trim the skin barrier to fit slightly over the stoma margin.

ANS: A Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse instructs a patient to measure the stoma with the measurement template so the stoma will have enough room to fit and to ensure that there is no excessive pressure on the stoma to impair its blood flow. The nurse instructs the patient to avoid covering the incisional area because it is unnecessary and can interfere with healing if the barrier covers a new surgical incision. Toilet tissue wicks can leave residue on the stoma. If a wick is made to absorb drainage, it should be made using gauze. The nurse avoids extending the skin barrier over the stoma to maintain adequate blood flow to the tissue.

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4. The nurse instructs a patient about home colostomy care. What information does the nurse

include in patient teaching about caring for the pouch? a. Empty the pouch at least every 4 hours around the clock. b. Change the pouch every 3 to 7 days. c. Empty the pouch when it is at least three-fourths full. d. Change the pouch every other day.

ANS: B

The nurse instructs the patient to change the pouch every 3 to 7 days unless it begins to leak, in which case the patient should change it earlier. The nurse encourages the patient to use the pouch as long as possible, within reason, because ostomy supplies are costly. The pouch is emptied when it is one-half to two-thirds full to prevent it from pulling away from the body. It can be emptied before going to bed and when the patient awakens. The nurse encourages the patient to empty the pouch before it is two-thirds full because a pouch filled to this level is very heavy and more likely to leak.

NURSINRGETFB .COM : Page 535

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TOP: Nursing Process: Implementation

5. The nurse evaluates the effluent from the patient’s new ileostomy. What does the nurse expect

the effluent to look like immediately after surgery? a. Formed stool b. Stool that is like thick liquid c. Watery stool d. Semi-formed stool ANS: C

Stool from an ileostomy can range from thin to thick liquid. Since no food is present, the effluent would be watery. Formed and semi-formed stool is more consistent with colostomy stool. The normal ileostomy stool when food is present is the consistency of a thickened liquid because there is a lot of water in the effluent since most water absorption occurs in the large intestine.

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6. The nurse cares for a female Asian patient on the fourth postoperative day after an ileostomy.

The patient tells the nurse that she doesn’t think she can cope and refuses to look at the Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

ileostomy. What approach by the nurse would be most helpful in this situation? a. Explore with the patient exactly what her concerns are.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. Tell her when she can start wearing regular clothing. c. Tell the patient that most patients have these feelings. d. Ensure that only female caregivers are assigned to her.

ANS: A

The nurse needs to find out the patient’s deepest concerns and find support for her. Assuring the patient that others have felt the same way ignores her feelings and concerns. A discussion about appropriate clothing does not address the patient’s deeper concerns. It is essential that only a female caregiver be assigned to this patient, but this alone will not help her adapt to the change in her body.

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7. The home health nurse pouches an enterostomy for a patient with serious financial constraints.

What should the nurse recommend to the patient about his ostomy care? a. Use soap and warm water for peristomal cleansing. b. Leave the pouch in place for 3 to 7 days. c. Place several pin holes in the pouch for flatus to escape. d. Use a firm pouching system on a round, hard abdomen.

ANS: B

A pouch is expected to last 3 to 7 days and does not need to be changed more frequently.

Allowing the pouch to remain in place as long as possible saves on the cost of supplies. The nurse helps the patient find community resources for assistance in procuring needed supplies.

The nurse avoids using soap for peristomal cleansing because it can leave a residue on the skin, which can impair the protective properties of the skin barrier, leading to skin breakdown.

Punching holes in the pouch shN ouUlR dS beIaNvG oiTdB ed.bCeO caMuse it allows intestinal gas to drift out of the pouch. The patient is likely to notice the odor and change the pouch to reduce it, incurring unnecessary expense with extra pouch changes. A firm, round abdomen requires a softer, more flexible pouch system to secure the skin barrier.

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8. The patient’s urinary output from his urostomy is 150 mL in the last 4 hours. What action

should the nurse take? a. Document the amount. b. Notify the physician. c. Encourage more fluids. d. Check the skin turgor.

ANS: A

The amount is above the 30 mL/hr minimum for urinary output and is normal. None of the other options is necessary in this situation.

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 9. A patient is hesitant to look at his stoma 2 days after colostomy surgery. Which is the best

response by the nurse to the patient? a. “I see that you don’t want to look at the stoma, but it looks good for a new

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

colostomy.” b. “I’ll teach stoma care to each family member before you leave the hospital.” c. “I’ll explain everything I do in great detail in case you want to know.” d. “You know you must look at it eventually, so let’s look together now.”

ANS: A

The nurse reflects the observation of the patient but also gives him some factual information.

This approach does not force the patient to look at the stoma. Explaining everything in great detail can overwhelm a patient who has had a major change in his body and lifestyle. Telling a patient that he must do something is too forceful and could make him uneasy. The nurse will teach ostomy care to persons who are willing and able to help the patient.

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10. A patient has a new incontinent urostomy because of bladder cancer. The patient asks how he

will manage “all of this urine” at night. Which response by the nurse is best? a. “You’ll get up and empty the bag whenever you wake up at night.” b. “We give you a larger pouch to wear at night to hold the extra urine.” c. “We’ll attach a large bedside drainage bag to the outlet of the pouch.” d. “It’s really nothing to worry about until you start eating regular meals.”

ANS: C

A bedside drainage bag is attached to the pouch outlet, which is opened during the night to allow the urine to drain. It is closed and disconnected if the patient will be up. With this attachment, the patient won’t have to empty the smaller bag overnight. A larger pouch would become heavy and could pull away from the body at night. Urine will begin to flow immediately; thus, telling the pN atU ieRnS t nIoN tG toTwBo. rrC yO isMinaccurate and ignores the question.

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11. The nurse notices that the patient’s stoma is darker than before, purplish in color, and dry. The

patient has been taking care of the ostomy independently. What action should the nurse take initially? a. Document the findings. b. Ask how the patient is measuring the stoma. c. Call the healthcare provider. d. Rub the stoma to see if it bleeds.

ANS: B

The first action is to find out from the patient the technique used for determining the size of the opening for the stoma. If it is too tight, the blood supply to the stoma could be decreased.

Information needs to be obtained before documenting or notifying anyone else. Rubbing the stoma may cause injury. Since the stoma should be highly vascular, slight bleeding might be seen when it is cleaned.

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

12. A patient with a urinary diversion requires a sterile urine specimen for culture and sensitivity.

Which action should the nurse take to obtain the sterile specimen?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. b. c. d.

Have the patient void into a sterile cup after being cleaned.

Collect the specimen from a new urine pouch.

Insert a sterile catheter into the urinary stoma.

Let urine drip from the stoma into a sterile specimen cup.

ANS: C

The nurse must catheterize the urinary diversion to obtain a sterile urine sample. A patient with a urinary diversion cannot void. A new urine pouch is clean, not sterile. Letting urine drip from the stoma into a sterile specimen cup does not yield a sterile specimen. The patient’s skin is not sterile, and the urine could irritate the skin.

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MULTIPLE RESPONSE 1. The nurse is educating a patient about care of a stoma after discharge. Which of the following

statements indicate a good level of understanding? (Select all that apply.) a. “I should apply gentle pressure with my hand over the skin barrier to facilitate adherence.” b. “I should also use a skin prep such as a paste or adhesive first.” c. “I can get a pouch that absorbs gas odors.” d. “I need to change the pouch every 3 to 7 days.”

ANS: A, C, D

The current trend is to apply a pouch to clean, dry skin without other skin preparations, paste, or adhesives unless a patient has a specific problem keeping a pouch intact. The adhesives on NURSINGTB.CO the skin barriers are pressure and heat sensitive; thus have the patient apply gentle pressure with the hand over the skin barrier for several minutes to facilitate the adherence of the barrier to the skin. Some pouches have effective gas filters that absorb odors and allow for flatus to escape slowly from the pouch through a charcoal filter. Pouches should be changed every 3 to 7 days.

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2. You are the home care nurse visiting a patient who is recently discharged home with an

ostomy. Which of the following statements requires you to provide some additional teaching?

(Select all that apply.) a. “I have been buying sterile gloves to use when changing my pouch.” b. “I have been covering the pouch with saran wrap when I shower.” c. “I empty the pouch directly into the toilet.” d. “I keep the new pouches in the bathroom linen closet.”

ANS: A, B

The home care nurses should evaluate the patient’s home toileting facilities and ability to position self to empty the pouch directly into the toilet. The patient may shower without covering the pouch. Ostomy care does not require any sterile supplies; however, family caregivers should wear gloves to avoid direct contact with stool. Patients should avoid placing Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

pouches in extremely hot or cold locations because temperature affects barrier and adhesive materials.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 533| Page 534| Page 538 TOP: Nursing Process: Assessment

COMPLETION 1. A

is surgically created by transplanting the ureters into a closed-off portion of the intestinal ileum.

ANS:

urostomy A urostomy or ileal conduit is surgically created by transplanting the ureters into a closed-off portion of the intestinal ileum. One end of the conduit is sutured closed, and the ureters are implanted through the mucosa. The other end is brought out on the abdominal wall, and a stoma is formed for urine to exit the body. This ostomy is permanent.

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2. Feces and urine can flow through a segment of the colon or small intestine and out through the

opening (called a stoma) on the abdomen. The output from the stoma is called the ANS:

effluent Fecal effluent is watery-to-thick liquid and contains some digestive enzymes.

DIF: Cognitive Level: RemembN e rURSINRGETFB : .PC agOeM532 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 21: Preparation for Safe Medication Administration Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. A patient received a drug that caused an unpredictable and unusual effect. Which term does

the nurse use to describe this effect? a. Toxic b. Allergic c. Therapeutic d. Idiosyncratic ANS: D

An unpredictable overreaction or underreaction to a medication is an idosyncratic reaction.

Toxic medication effects occur with prolonged therapy, excessive dosing, or impaired metabolism or systemic accumulation in the patient. They are adverse effects with the potential to cause patient injury and death. Allergic reactions are unpredictable, unless the patient has a history of a medication allergy, and result from an immunological patient response to the medication involving antibody formation. A therapeutic response is a desirable or intended patient response.

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2. The nurse administers sulfamethoxazole and trimethoprim (Bactrim) for a desirable patient

response derived from the combination of agents. Which type of medication effect does the nurse anticipate? a. Tolerance b. Synergistic c. Dependence d. Subtherapeutic ANS: B

The nurse anticipates a synergistic effect because the two antibiotics, sulfamethoxazole and trimethoprim, work better in combination than either agent works alone. Drug tolerance means that a larger dose of medication is needed to produce the same therapeutic effect over time. Drug dependence is psychological or physical. The patient takes the medication for an effect other than the therapeutic effect, resulting in psychological dependence. Physical dependence involves physiological adaptation to the medication that results in severe adverse effects if withdrawn abruptly. A subtherapeutic effect is less than therapeutic; the therapy treats the disorder inadequately.

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3. A male patient looks at the medication in the cup and tells the nurse that he does not take one

of the tablets. Which action should the nurse take next? a. Tell the patient that the medications are correct.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. Recheck the medication and the medication order. c. Call the pharmacy to bring the correct medication.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf d. Remove the medication and document the incident.

ANS: B

A safe nursing intervention is to recheck both the medication and the order because the drug in question may be a new prescription, a new strength of the same medication, or a different generic form of the same medication. Regardless of the cause, the problem needs clarification.

Telling the patient that the medications are correct is premature and misleading and denies the patient the right to information. The nurse does not know if the medications are correct yet.

After checking the medications against the medication administration record (MAR) and the original prescriptions, he or she can call the pharmacy for help. The nurse removes the entire cup of medications and rechecks all of them. Documenting the incident is premature because the nurse needs to complete the investigation first.

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4. The nurse admits a patient who has an acute kidney infection but refuses to take any

medication. Which is the best initial nursing intervention to implement the therapeutic regimen? a. Notify the healthcare provider of the situation. b. Inform the patient about the risk of renal failure. c. Talk with the patient about taking the antibiotics. d. Disguise the medications so the patient takes them.

ANS: C

The basis of the patient’s refusal is unknown; discussing the situation with the patient provides the nurse with an opportunity to clarify misunderstandings, provide information, and gather valuable patient data to N plU anRnSuI rsN inGgTcB ar. e.CNOoMtifying the healthcare provider is premature. The nurse takes care of the situation initially by educating the patient.

Emphasizing the risk of renal failure may be interpreted as an indirect threat by the patient.

The patient has the right to refuse taking the medication, and disguising the medication is neither indicated nor appropriate.

DIF: Cognitive Level: Analyze REF: Page 549 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation 5. The nurse discharges a patient from the ambulatory surgical center with a prescription for an

opioid analgesic. The patient can take the medication every 4 to 6 hours as needed for pain.

What does the nurse include in patient teaching about the prescription before discharging the patient? a. Take the medication for severe pain. b. Use the medication to facilitate healing. c. Wait 4 to 6 hours before taking the next dose. d. Take every 4 to 6 hours until the bottle is empty.

ANS: C

The nurse instructs the patient to wait 4 to 6 hours between doses avoid serious effects of opioid analgesics, including respiratory depression. The nurse encourages the patient to take an analgesic when the pain is mild because the medication will be more effective. Opioids Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

have little to do with healing; however, if the patient has a thoracotomy or an abdominal incision, opioid analgesia is usually needed to facilitate coughing and deep breathing.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

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6. The nurse administers a patient’s medication; within 30 minutes the patient has bilateral

wheezing and large red blotches on the face and is anxious and dizzy. Which should the nurse implement? a. Encourage the patient to drink plenty of fluids. b. Direct a colleague to contact the provider stat. c. Check the medication administration record (MAR) for an antihistamine as needed. d. Document potential patient allergy to medication.

ANS: B

The patient has clinical indicators of a moderate-to-severe hypersensitivity reaction, most likely related to the medication. The wheezing increases the risk of impairing the patient’s airway, and the blood pressure can be low already, as evidenced by patient dizziness. The nurse should stay with the patient and wait for emergency equipment, supplies, and personnel to assist. In the meantime he or she should plan to support the patient’s airway, breathing, and circulation. Hydrating the patient will not flush the allergic reaction from him or her because it is under way; besides, drinking fluid increases the risk of aspiration of gastric contents or choking. An antihistamine potentially helps to reverse some of the allergic effects; however, the nurse should not leave the patient. The nurse documents the events after the patient is stable.

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7. The provider prescribes aluminum hydroxide gel 2 ounces. The nurse has aluminum

hydroxide in 30-mL containers in the patient’s medication drawer. How many containers does the nurse administer to the patient? a. 1 b. 2 c. 1/2 d. 1 1/2 ANS: B

The nurse administers two containers at 30 mL per container because 1 ounce = 30 mL. The prescription calls for aluminum hydroxide 60 mL; thus, to administer 60 mL, the nurse needs two containers.

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8. A patient has been given high doses of an opioid medication for severe pain. Which

assessment data indicate the most toxic effect of a medication? a. Nausea and vomiting b. Respiratory depression c. Erythema and skin rash d. Bloating and constipation Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: B

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Respiratory depression is an undesirable and potentially fatal effect of medication that occurs with prolonged therapy, excessive dosing, impaired metabolism, or systemic accumulation in the patient. Respiratory depression can quickly deteriorate into respiratory failure, tissue damage, and death without airway and respiratory support. Nausea and vomiting can be clinical indicators of a toxic effect; however, they lack the same fatal potential as respiratory depression. The reddened skin rash is consistent with a hypersensitivity reaction. Bloating and constipation are most likely adverse effects of medication with a very low risk of fatality.

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9. The nurse prepares to administer a parenteral medication. Which route of administration does

the nurse use for the medication? a. Oral b. Topical c. Sublingual d. Intramuscular ANS: D

Parenteral medications are always injected into a vessel or tissue; thus intramuscular administration is suitable. The other routes are suitable for nonparenteral medications.

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10. An older adult who lives alone takes three different white, flat, unscored medications every

day. He has trouble remembering if he has taken the correct pill at the correct time. What strategy would best help this paNtiU enRtSmIaN inG taT inBi. ndCeO peMndence and safety in taking his medications? a. Place a piece of different colored tape on each pill bottle to differentiate the medication. b. Take the medications out of the bottles and place them in a pill holder. c. Have a neighbor give the patient his pills once each day. d. Ask the patient how he wants to identify the medications.

ANS: A

Color coding the pill bottles has the most likelihood of success. It’s essential to keep the medications in their original containers for safety. A system could be set up with the patient to make clear which medications he needs to take at what time. Placing the similar-looking pills in to a pill container could cause more confusion for the patient. Their identities need to be maintained for correct scheduling. Having someone administer the medications reduces the patient’s independence and could become burdensome. Since the patient has not been able to manage his medications to date, an open-ended question about how he wants to identify his medications may be confusing. Suggesting a plan allows the patient to recognize a solution and agree to see if it works.

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 11. Which schedule would the nurse select to achieve a therapeutic level if the medication is

prescribed for administration 4 times a day?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. b. c. d.

8 AM, 10 AM, 2 PM, and 8 PM 10 AM, 2 PM, 6 PM, and 8 PM 10 AM, noon, 4 PM, and 6 PM 8 AM, 2 PM, 8 PM, and 2 AM

ANS: D

The nurse administers medications 4 times a day by evenly spacing out the medications over a 24-hour period so a steady, therapeutic blood level can be achieved.

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12. The patient is to receive 750 mg of a medication. The pharmacy sent 500-mg scored tablets.

How many tablets does the nurse administer? a. 1/2 b. 1 c. 2 d. 1 1/2 ANS: D

The nurse administers 1 1/2 tablets = 500 mg + 250 mg = 750 mg. The nurse calculates the dosage with a proportion equation.

Cross-multiply and divide: 1  750 = 500x Solve for x: 750 ÷ 500 = 1 1/2 tablets DIF: Cognitive Level: RemembN e rURSINRGETFB : .PC agOeM547-548 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation 13. The dose ordered for the patient is 37.5 mg intramuscularly (IM). How many milliliters of the

medication should the nurse administer from a 100-mg/2-mL syringe? a. 0.5 b. 0.75 c. 1.0 d. 1.5 ANS: B

The nurse administers 0.75 mL of a 2-mL syringe containing 100 mg and uses a proportion equation to calculate the dosage.

Cross-multiply and divide: 37.5  2 = 100x Solve for x: 75 ÷ 100 = 0.75 mL DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

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14. The nurse needs to administer 1000 mcg of a medication and has 1-mg tablets. How many

tablets does the nurse administer?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. 1

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. 2 c. 3 d. 4 ANS: A

The nurse administers 1 tablet, because 1 mg = 1000 mcg.

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15. The nurse needs to administer 2 tsp of a medication to the patient. How much of the

medication should the nurse administer? a. 5 mL b. 10 mL c. 15 mL d. 20 mL ANS: B

1 tsp = 5 mL; 2  5 mL = 10 mL. DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

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16. The nurse needs to administer a medication to a toddler who weighs 20 kg. The dosage is 50

mg/kg/day in divided doses, and the medication is available as an elixir at 25 mg/mL. How many milliliters of medication should the nurse administer at each scheduled dose? a. 2 b. 20 c. 8 d. 80 ANS: B

First calculate the daily dose in milligrams per day.

Then calculate how many milliliters of elixir to administer daily.

Finally calculate the dosage at each scheduled time with two doses/day.

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17. The nurse is reviewing concepts of safe medication preparation and administration with a

group of nursing students. Which statement should the nurse include during the review? a. Use sterile technique for most nonparenteral medications.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. Administer the medication prepared by the medication nurse. c. Leave the medication on the meal tray for the patient to take.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf d. Verify medication dosage is within a safe dosage range.

ANS: D

The students should be reminded to verify medication calculations to ensure that the math is correct. Calculate medication doses accurately and use appropriate measuring devices. Verify that the dose prescribed is within a safe dosage range and is appropriate for the patient. Clean technique is used for nonparenteral medication. Nurses should avoid administering medication prepared by another nurse. They should also avoid leaving medication at the bedside or on the meal tray because the nurse will not witness the medication administration and cannot document the time that the medication was taken. In addition, the patient can spill the medication, dispose of it, or leave it on the tray.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

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18. The nurse is preparing to administer a controlled substance. Which action must the nurse take

first if controlled medication is discarded? a. Count the amount of medication daily. b. Document the amount wasted. c. Have a nurse witness the wasting of the drug. d. Administer the unused portion on another patient.

ANS: C

The nurse discards the unused portion of the patient’s controlled substance medication and has another nurse witness the event; then both nurses document the transaction. The nurse follows agency policy about discarding controlled substances. Controlled substances are counted and verified at a frequency determined by regulatory agencies and the institution to prevent unauthorized administration. DN ocUuRmSeI ntN inG gTthBe.aC mO ouMnt wasted occurs after the waste has been discarded and witnessed by another nurse. Unused portions of the patient’s medication may not be administered to another patient, even if they are kept sterile.

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19. The nurse is having difficulty reading a medication order. Which is the best action for the

nurse to take to prevent a medication error? a. Clarify the order with the healthcare provider who wrote it. b. Talk with the pharmacist who knows what is usually ordered. c. Ask a nurse who knows the healthcare provider to read it. d. Have a nurse interpret the written medication order.

ANS: A

To prevent patient injury and decrease nursing liability, the nurse clarifies illegible prescriptions and handwriting with the healthcare provider who wrote it. Asking the pharmacist about what is usually ordered does not reflect what may be in the current order.

Changes may have been requested. Asking another nurse to try to read the order doesn’t eliminate the chance of error.

DIF:

Cognitive Level: Analyze

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 20. A prescription reads, “Aspirin 325 mg 2 tablets orally for pain.” What action should the nurse

take when the patient has pain? a. Add “by mouth” to the prescription for clarification. b. Clarify the administration frequency and whether the medication should be prn or standing. c. Clarify the dose per tablet with the pharmacist. d. Administer the dose whenever the patient requests it.

ANS: B

The nurse speaks with the provider to clarify the frequency of administering aspirin. Aspirin is generally prescribed once daily or every 4 to 6 hours with a prn designation. The nurse does not alter the prescription unless instructed by the provider, and the order already states orally.

The prescriber is the person with whom the nurse must clarify the order. Aspirin is not administered whenever the patient requests it. It has a frequency of administration.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 542 TOP: Nursing Process: Planning

21. The nurse administers oral medications according to the unit dose system. Which technique

should the nurse use for administering the medications? a. Prepare the medications for several patients at the same time. b. Remove the medication from the package and take it to the patient’s room. c. Compare the packaged medication with the healthcare provider’s prescription. d. Take the prescribed dose into the patient’s room in the packaging.

ANS: D

The nurse brings the medication to the patient in the original packaging, provides explanations and information to the patient, N anUdRoS peInNs G thTeBp. acCkO agMe at the bedside. This helps maintain safety, provides reassurance to the patient that the correct medication is being administered, and limits waste. This policy lowers the risk of contaminating the medication on the way to the patient’s room, provides a second opportunity to read the label on the medication, and facilitates patient teaching. The nurse prepares medication for one patient at a time to avoid confusion. Medication remains in the original packaging until the nurse is at the bedside. The medication administration record is compared to the provider’s original prescription.

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REF: Page 543 TOP: Nursing Process: Implementation

MULTIPLE RESPONSE 1. The nurse is working with a group of students and asks them to list the common causes of

medication errors. Which of the following are among the common causes of medication errors? (Select all that apply.) a. Distractions b. Illegible handwriting c. Drug product nomenclature d. Labeling errors e. Medication unavailable Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf f.

Excessive workload

ANS: A, B, C, D, E, F

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Medication safety is a priority goal for safe nursing practice. It begins by having a thorough understanding of the medications you administer and whether patients have any drug allergies.

Then it is important for you to follow safe preparation and administration standards, which are part of the six rights of medication administration. There are many causes of medication errors, including distractions, illegible handwriting, drug product nomenclature, labeling errors, medication unavailable, and excessive workload.

DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 542 TOP: Nursing Process: Implementation

2. The nurse is explaining pharmacokinetic effects to a new nurse working on the unit. Which of

the following statements alerts the nurse that a good level of understanding has been achieved? (Select all that apply.) a. “The trough is the lowest level.” b. “The peak is the highest level.” c. “With IV administration, the serum level falls more slowly.” d. “Toxic concentration is when toxic effects occur.” e. “Peak levels always occur in 30 minutes.”

ANS: A, B, D

Pharmacokinetics affects how much of a drug dose reaches the site of action. The goal in administering a medication is to achieve a constant blood level within a safe therapeutic range. The toxic concentration is the level at which toxic effects occur. When a medication is administered repeatedly, its serum level fluctuates between doses. The highest level is called the peak concentration and the lowest level is the trough concentration. After peaking, the serum concentration falls progressively. With intravenous (IV) infusions, the peak concentration occurs quickly, bNuU t tR heSsIeN ruGmTlB ev.eC l aOlsMo begins to fall immediately. Each medication reaches its peak at different times.

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3. The nurse is describing the role of the pharmacist in medication administration. Which of the

following are correct? (Select all that apply.) a. Assess the medication plan. b. Review the orders for accuracy and validity. c. Prepare the correct medication. d. Deliver them to the nursing unit. e. Independently adjust incorrect medication errors.

ANS: A, B, C, D

Pharmacists assess the medication plan and ensure that orders are valid. The pharmacist is then responsible for preparing the correct medications and delivering them to the nursing unit where they are stocked in a medication administration station. If there are errors, the pharmacist consults with the healthcare provider who wrote the order to have those errors corrected.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 542 TOP: Nursing Process: Implementation

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

COMPLETION

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 1. As a part of the American Recovery and Reinvestment Act of 2009, the Health Information

Technology for Economic and Clinical Health (HITECH) was developed. One of the requirements of HITECH is the implementation of a system.

ANS:

computerized provider order entry A CPOE system in one in which clinicians directly enter medication orders (and, increasingly, tests and procedures) into a computer system, which then transmits the order directly to the pharmacy.

DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity 2.

REF: Page 538 TOP: Nursing Process: Implementation

is the study of how drugs enter the body (absorption), reach the site of action (distribution), are metabolized, and are excreted from the body.

ANS: Pharmacokinetics DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 538 TOP: Nursing Process: Implementation

are unintended, undesirable, and often unpredictable.

3.

ANS:

Adverse drug events Some adverse reactions occur iN mUmReS diI atN elG y,TwBh.eC reO asMothers often take weeks or months to develop. Early clinical recognition of ADEs is the first important step in identification. ADEs range from mild (e.g., rashes or photosensitivity to light) to severe (fatal anaphylaxis). Prompt recognition and reporting of ADEs prevents serious injury to patients.

DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 540 TOP: Nursing Process: Implementation

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 22: Administration of Nonparenteral Medications Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. The healthcare provider prescribes a sublingual medication, and the pharmacy sends an oral

form. Which action should the nurse implement? a. Administer the identical drug orally. b. Call the pharmacy for the correct formulation. c. Withhold the drug and notify the provider. d. Calculate the oral equivalent dose for the patient.

ANS: B

The nurse can administer the sublingual medication in sublingual form only; changing the route of administration is practicing medicine and is outside the scope of practice for the nurse. The nurse cannot administer the oral medication, even if it is the identical drug, because it is the wrong route and violates a patient medication right. Withholding the medication until the provider is notified is risky and unnecessary because the nurse can ask the pharmacy to send the correct form of the medication. If the pharmacy does not carry the prescribed form, the nurse should contact the provider. Many medications come in several forms; thus determining an equivalent dose of a medication in another form is possible; however, the nurse needs a prescription for both forms of the medication to administer the oral form.

DIF: Cognitive Level: Apply REF: Page 564 OBJ: NCLEX: Physiological IntN egUriR tySINTGOTPB : .NCuO rsM ing Process: Planning 2. An alert and oriented patient is to receive oral medication. Which does the nurse implement to

administer the prescribed medication? a. Evaluates the patient’s ability to take the medications unassisted b. Leaves the medications on the breakfast tray for the patient to take later c. Asks the patient if she wants to hold the medications in her hand d. Holds the medicine cup to the patient’s lips and tips it into the mouth ANS: C

Patients can participate in medication administration by holding the medication in the cup or hand before placing it in the mouth. The nurse already knows that this patient is alert. If the provider allows the patient to self-medicate in the hospital, the nurse supervises the activity and ensures patient self-administration of the medications on time. The nurse never leaves medication on the breakfast tray for many reasons. He or she needs to verify that the patient has taken the medication so that correct documentation may occur. Holding the cup for the patient is unnecessary and potentially insulting to the patient.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 562 TOP: Nursing Process: Implementation

3. The nurse approaches a group of patients, one of whom is to receive a dose of medication.

Which is the best method for the nurse to identify the patient needing the medication?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. Question the entire group by calling for the specific patient. b. Request that the other patients identify the patient.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. Ask the patients who is scheduled to receive medications now. d. Compare the patients’ identification bracelets with the specific medication

administration record (MAR) and ask the patient to state his name.

ANS: D

To identify the patient needing the medication, the nurse checks the patient identification bracelet and asks the patient to state his name. The nurse then compares the spelling of the name and the medical record number on the bracelet to the MAR. The nurse does not rely on other individuals to identify the patient for the medication administration to avoid the risk of misidentification. The use of at least two identifiers is the only approved method of identifying a correct patient.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

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4. The nurse needs to document a medication that has just been administered. Which technique

should the nurse use to document medication administration? a. Document the medication immediately before administration. b. Record the time administered and the nurse’s name immediately after administration. c. Record medication administration time, route, and dose at the end of the shift. d. Delegate recording administration time and the nurse’s name in the medication administration record (MAR).

ANS: B

The nurse records his or her name and administration time immediately after medication administration to maintain an up-to-date, accurate patient medical record. Documentation is not done before administ ratio n Nb U ecRauSsIe NthGe TacBti.vC it yO hMas not yet happened. It is risky to document at the end of the shift because the chance of a documentation omission or error increases with the amount of time that passes. Correct documentation is one of the six rights of medication administration. Documentation of medication administration may never be delegated.

DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 564 TOP: Nursing Process: Planning

5. The nurse instructs the patient about applying a transdermal patch. Which should the nurse

include in patient teaching? a. Choose a site with moderate exposure to the sun. b. Remove the old patch before applying a new patch. c. Put the new patch at the same site to promote even absorption. d. Apply a warm compress to the site before application.

ANS: B

To prevent overdoses and tolerance to patches, the nurse instructs the patient to remove the old patch, cleanse the site, and apply the next patch to a different place. Sun exposure can promote medication degradation and increase the absorption rate. The nurse avoids instructing the patient to apply a warm compress to prevent rapid medication absorption that potentially can lead to overdose.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF:

Cognitive Level: Comprehend

REF: Page 572

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation

6. The nurse prepares to administer artificial tears to the patient’s eyes twice daily. Which should

the nurse implement when administering the patient’s eyedrops? a. Dispense the eyedrops to the inner corner of each eye. b. Call the provider for clarification of this order. c. Check the patient identifiers before administration. d. Determine the patient’s history of taking this medication.

ANS: C

The nurse verifies patient identifiers before administering medication, regardless of the route.

He or she avoids dispensing eyedrops to the inner corner of the eye to avoid irritating the cornea. In addition, this is the location of the inner canthus; if administered at the inner canthus, the medication can drain rapidly, losing the therapeutic effect, and increase the risk of systemic effects. Calling the provider and checking the patient history are not indicated.

DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 576 TOP: Nursing Process: Planning

7. The patient complains of blurred vision after the instillation of eyedrops. What action should

the nurse implement first? a. Withhold the patient’s ophthalmic drops. b. Warm the eyedrops for subsequent doses. c. Notify the ophthalmologist of the findings. d. Ask the patient questions to clarify what is meant by “blurred.”

ANS: D

The nurse questions the p at i en tNf U o rRaSddIi N t i oGnTalBi . n fCo rOmMat i on before determining the scope of his or her complaint because blurred vision can be either an adverse effect of the medication or expected because of the type of medication being instilled. The nurse gathers additional information before deciding to withhold the eyedrops. The nurse avoids warming eyedrops because it can increase the absorption rate and patient discomfort. Notifying the provider is not indicated.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

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8. A patient’s family member tells the nurse that she is afraid of hurting the patient when giving

the eardrops since she hasn’t seen it done. Which action should the nurse take first? a. Observe caregiver administration of eardrops. b. Provide a demonstration of eardrop instillation. c. State that eardrop instillations do not injure ears. d. Agree that instillation of eardrops is challenging.

ANS: B

The nurse needs to demonstrate the procedure with a clear explanation based on what the family member is stating. An opportunity for a return demonstration must be provided, with the nurse supporting the family member and coaching as needed. The risk for patient injury is low for eardrops, but it exists. Instilling eardrops is a simple skill; however, when the Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

caregiver expresses concern about medication administration, the duty the nurse owes to the patient is to provide encouragement and teaching to prevent patient injury.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

REF: Page 556 TOP: Nursing Process: Planning

9. The nurse is preparing to administer eardrops to a 5-year-old child. Nursing care is

appropriate if which technique is used by the nurse? a. Warm the eardrops in a microwave oven on low. b. Pull the auricle upward and outward. c. Apply eardrops to a cotton ball and insert them in the affected ear. d. Instruct the child to lie with the affected ear on a warm compress.

ANS: B

The nurse pulls the patient’s pinna upward and outward to provide access to deeper ear structures for a patient over the age of 3 years. Eardrops are never warmed in a microwave oven because of the risk of overheating the medication; microwave heating potentially leads to patient burns or decreased effectiveness of the eardrops. If cotton balls are used with eardrops, they are nonmedicated and inserted into the ear canal gently for a brief period of time after the drops have been instilled. The eardrops would drain out of the ear quickly if the patient lies on a warm compress with the affected ear down.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

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10. A patient with chronic obstructive pulmonary disease uses a metered-dose inhaler (MDI).

Which information does the nurse give the patient to ensure he receives the maximum benefit of the glucocorticoids administered by an MDI? a. Administer two puffs of medication in rapid succession. b. Maintain a firm seal with liN psUaRroSuInN dG thT eB m.oC utO hpMiece of the inhaler. c. Dispense the glucocorticoids 30 seconds after a bronchodilator. d. Instruct the patient to press the MDI after breathing in and out deeply.

ANS: B

The nurse instructs the patient to maintain a firm seal around the mouthpiece of the MDI to facilitate dispensing medication into the lungs so the patient benefits from a full dose of the medication undiluted by room air. The nurse also instructs the patient to take a bronchodilator before any subsequent medications administered by an MDI such as glucocorticoids. An MDI delivers medication by inhalation and does not lend itself to delivering two puffs in rapid succession because a short wait is usually required for the medication to reach deeper parts of the lung. Not only is it difficult to activate the MDI quickly, but the patient may not have the ventilatory capacity to quickly inhale two puffs. When administering glucocorticoids after a bronchodilator, the nurse waits 5 minutes to give the bronchodilator time to work and then administers the second agent. To use an MDI, the nurse instructs the patient to exhale and then inhale slowly and deeply to drive the inhalation medication into the lungs.

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11. The nurse needs to administer a rectal suppository to a patient to treat constipation. Which

action may the nurse delegate to the nursing assistive personnel (NAP)? a. Inserting the suppository into patient’s rectum Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. Notifying the patient’s healthcare provider of the suppository results

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. Documenting the administration of a suppository after insertion d. Informing the nurse of the bowel movement ANS: D

The nurse instructs the NAP to report the results of the suppository, which in this case would be the expulsion of feces. Administration of medication is the nurse’s responsibility. The healthcare provider will learn the results of the suppository by reading the nurse’s documentation or when making rounds unless other instructions were given. Documentation of the medication administration is the nurse’s responsibility.

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REF: Page 592 TOP: Nursing Process: Planning

12. The nurse prepares to administer acetaminophen (Tylenol) 650 mg rectally. Which does the

nurse implement to administer the suppository properly? a. Assists the patient to right lateral position and flexes the left leg b. Performs a preadministration digital rectal examination c. Washes hands and applies sterile gloves before the procedure d. Inserts the suppository 10 cm (4 inches) into the patient’s rectum ANS: D

The nurse inserts the suppository about 10 cm (4 inches) into the patient’s rectum to clear the rectal sphincters because the sphincters help to keep the medication in the patient’s rectum.

The nurse assists the patient into the left lateral position to take advantage of the normal anatomy of the descending colon. This curvature in the colon helps to sequester the medication, contain it in the patient, and increase its effectiveness. The nurse avoids performing a digital examination before inserting a suppository because it is not indicated.

Washing hands is always a reasNoU naRbS leInNuG rsT inB g. acCtiOoM n. Clean gloves are sufficient for this procedure because the nurse wants to avoid contamination from the rectum.

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13. The nurse administers a vaginal suppository. What information should the nurse include in

patient teaching about postadministration care? a. Use a tampon to hold the suppository in place. b. Place a perineal pad in her underpants when getting up. c. Expect a moderate localized burning and itching. d. Remain in the semi-Fowler’s position for 2 hours.

ANS: B

The nurse instructs the patient to place a perineal pad in her underpants because there will be a small amount of vaginal drainage after insertion of a suppository as the suppository melts. The nurse instructs the patient to avoid tampon use during the use of vaginal suppositories because the tampon absorbs the liquid, which decreases the effectiveness of the suppository. Burning and itching after administration of a vaginal suppository are unexpected. Remaining in semi-Fowler’s position after vaginal suppository insertion is unnecessary but is better for retaining the vaginal medication than standing. It is not as effective as remaining in the supine position where gravity has no effect on the absorption rate.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF:

Cognitive Level: Apply

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation

14. The nurse is preparing a liquid medication. Which technique should the nurse use to ensure an

accurate dose? a. Place the medicine cup on the counter while standing over the cup to pour. b. Use a syringe to transfer the medication into the medicine cup. c. Pour the medication with the label on the bottle facing away from the nurse’s hand. d. Pour the dose so the scale is even with the fluid level at the base of the meniscus.

ANS: D

The nurse pours liquid medication into the medicine cup for accurate dispensing and lines up the meniscus to a predetermined line on the cup. The meniscus is the true level of a liquid medication because surface tension draws liquid up the sides of the medicine cup, distorting the level. The nurse stoops to eye level of the cup so his or her eyes are parallel to the medicine cup. He or she avoids using a syringe to transfer liquid from the container to a cup because it risks a medication error if the syringe is injected accidentally. In addition, the nurse risks contaminating the liquid medication, wasting time, and wasting a syringe. The label faces the nurse’s palm while pouring liquid medication to prevent spillage over the label.

DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

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15. The nurse prepares medication for a patient 1 hour after admission. What information about

the patient is the nurse’s priority assessment before the initial administration of medication? a. The diet history b. Any drug tolerance c. Any allergy history d. The surgical history ANS: C

To prevent patient injury, the nurse interviews the patient about allergies, including food and medication, before administering any medication. If the patient admits to drug or food allergies, the nurse probes him or her for additional information about the allergy to determine the nature of the reaction. Diet history is a reasonable assessment because malnutrition increases the risk of patient injury from medications that are protein bound and can increase the risk of complications from nutritionally related problems. Drug tolerance is a reasonable assessment if the patient is receiving pain medication or another agent to which he or she potentially develops tolerance. Surgical history is the lowest-priority assessment for this patient; however, the nurse gathers information about the patient’s surgical history for the admission assessment to complete the patient profile.

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16. The nurse is helping a dyspneic older adult with severe arthritis of the hands and feet to use a

nebulizer for respiratory medications. Nursing care would be correct if the nurse takes which action during the medication administration? a. Instructs the patient to hold the mouthpiece with the hands b. Uses a mask to deliver the ordered medication Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. Places the patient in a supine position for the treatment d. Has the patient drink some fluid before the treatment

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: B

Using a face mask does not require the patient to remember to hold the mouthpiece correctly and would be appropriate for this patient. The patient may be unable to hold the mouthpiece correctly because of the weakness and arthritis of the hands. Patients receiving respiratory treatments should be upright when possible. Patients who are dyspneic need to breathe rather than take in fluids, which alters their breathing pattern. The dyspnea can also cause aspirations if fluids are taken.

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17. The nurse needs to administer enteric-coated aspirin (Ecotrin) to the patient. The available

aspirin is in a stock container on the unit because the pharmacy does not carry enteric-coated aspirin. Which is the best nursing approach for this situation? a. Pour tablets from stock without touching them. b. Withhold the medication and notify the healthcare provider. c. Crush the tablets and mix the powder in pudding. d. Pour aspirin tablets from a stock supply.

ANS: B

The best choice for the nurse is to withhold the medication and notify the provider that enteric-coated aspirin (Ecotrin) is not available. The purpose of administering enteric-coated aspirin is to decrease gastric upset and complications; thus uncoated aspirin is an unsuitable substitute. The nurse needs another order to administer nonenteric-coated aspirin. The nurse pours tablets from any stock container without touching them to maintain infection control. If enteric-coated aspirin is crushed, the tablet loses its protective coating and increases the risk of patient injury and gastric disN trU esRs.SAIsN piGriT nB is.nC otOtM he same medication as enteric-coated aspirin and thus cannot be administered to the patient.

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18. The patient is to receive a buccal medication. Which information does the nurse include in

patient teaching? a. Hold the medication under the tongue. b. Chew the medication before swallowing. c. Swallow the medication after 30 seconds. d. Hold the medication between the cheek and gums until it dissolves.

ANS: D

For proper administration of buccal medication, the nurse instructs the patient to hold the medication between the cheek and gums until it has dissolved. Medication administered under the tongue is delivered sublingually. The nurse instructs the patient to chew a chewable tablet.

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19. The nurse prepares to administer cyclosporine (Restasis) eyedrops to a patient with dry eyes.

Which of the following actions should the nurse implement before instilling the eyedrops?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. Apply mild pressure on the entire eye. b. Apply the eye ointment along inner edge of lower eyelid.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. Remove any periorbital crusting with a warm face cloth. d. Wipe away any crusting from the outer to the inner canthus.

ANS: C

Patients with dry eyes frequently awaken with encrusted eyes. Before instilling any eyedrops, the nurse cleanses the periorbital area with a warm face cloth to remove the debris gently. The nurse can apply pressure to the inner corner of the eye after instillation to decrease systemic absorption of the medication but should not apply pressure over the entire eye. Eyedrops, not ointment, have been ordered. The nurse wipes the eyes from inner to outer canthus.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 577 TOP: Nursing Process: Planning

20. The nurse teaches the patient how to administer eye ointment. Instruction by the nurse has

been correct if the patient demonstrates which technique? a. Moistens the finger with sterile saline b. Places a thin ribbon of ointment along the conjunctiva c. Rubs the medication briskly after application d. Looks downward before application of the ointment ANS: B

A thin ribbon of ointment is placed evenly along the inner edge of the lower eyelid on the conjunctiva from the inner to the outer canthus. The finger can be moistened if applying an intraocular disk, not eye ointment. The patient can rub the lid lightly after the medication is applied as long as rubbing is not contraindicated. The patient needs to look up to move the sensitive cornea away from the conjunctival sac to reduce the blink reflex during application of the ointment.

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REF: Page 578 TOP: Nursing Process: Implementation

21. The patient has a scored white tablet, a capsule, buccal medication, and an enteric-coated

tablet. Which medication should the nurse administer last? a. The scored white tablet b. The capsule c. The buccal medication d. The enteric-coated tablet ANS: C

The buccal medication must be able to dissolve between the cheek and the gums to provide the correct absorption. Any liquid must be postponed until the buccal medication has dissolved. For therapuetic effect, it makes no difference in which order the other medications are given. They will be absorbed in the areas of the body where expected.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

REF: Page 561-563 TOP: Nursing Process: Implementation

22. The nurse plans care for the patient who has asthma and receives albuterol nebulizer therapy.

The patient’s respiratory rate is 34 breaths per minute, and breath sounds reveal wheezing Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

throughout both lung fields. Which outcome is the nurse’s priority for this patient within 24 hours? a. The patient self-administers the medication using the nebulizer.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. The patient correctly describes the use of a small-volume nebulizer. c. The patient recites side effects and clinical indicators to report. d. The patient’s respiratory rate falls to an acceptble level.

ANS: D

Airway and breathing are usually at the top of patient priorities; thus the nurse works to improve the patient’s respiratory status first. Self-administration is contraindicated for the patient during an acute episode. Describing the use of a nebulizer and verbalizing information are indicated before discharge and not during an acute episode.

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REF: Page 589 TOP: Nursing Process: Planning

23. The nurse is teaching a patient how to calculate how long the metered-dose inhaler (MDI)

canister can be used. If the canister contains 200 puffs and the patient administers 2 puffs 3 times each day, how long will the canister last? a. 33 days b. 34 days c. 66 days d. 100 days ANS: A

Two puffs  3 times daily = 6 puffs per day; 200 puffs/6 puffs per day = 33.3 days; therefore, the canister will last 33 days with correct medication administration. If the canister lasted 34 days, there would not be enough for the final entire day. Sixty-six days and 100 days are incorrect calculations of the problem.

DIF: Cognitive Level: Apply NURSINRGETFB : .PC agOeM586 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning 24. The nurse is preparing to administer eardrops to a 28-month-old child. Nursing care is

appropriate if which technique is used by the nurse? a. Warm the eardrops in a microwave oven on low. b. Pull the pinna down and straight back. c. Apply the eardrops to a cotton ball and insert in the affected ear. d. Instruct the child to lie with the affected ear on a warm compress.

ANS: B

The nurse pulls the patient’s pinna down and straight back to facilitate the medication reaching the inner ear. Eardrops are never warmed in a microwave oven because of the risk of overheating the medication; microwave heating potentially leads to patient burns or decreased effectiveness of the eardrops. If cotton balls are used with eardrops, they are nonmedicated and inserted into the ear canal gently for a brief period of time after the drops have been instilled. The eardrops would drain out of the ear quickly if the patient lies on a warm compress with the affected ear down.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 579 TOP: Nursing Process: Implementation

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 25. A patient is to receive three medications via an enteral feeding tube. What action by the nurse

best contributes to maintaining the patency of the tube?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. b. c. d.

Pouring the medications slowly into the tube Checking the gastric residual volume before feeding Elevating the head of the bed at least 45 degrees Flushing the tube between medications and after the last one

ANS: D

Flushing the tube with water helps it to remain patent by rinsing away any of the residual medication left in it. Pouring the medications into the tube slowly does nothing for patency.

Checking the gastric residual volume identifies only how the stomach is emptying. Elevating the head of the bed helps to prevent aspiration, not tube clogging.

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REF: Page 567-568 TOP: Nursing Process: Assessment

26. The nurse is caring for a patient with an enteral feeding tube. During assessment, the nurse

finds that the patient’s oxygen saturation level has dropped significantly and the respiratory rate and effort have increased. What action should the nurse take first? a. Stop any infusion of fluids or medications through the feeding tube. b. Assess all of the patient’s vital signs. c. Notify the healthcare provider. d. Reposition the patient.

ANS: A

The patient is exhibiting signs of aspiration, and feeding and medications through the tube must be stopped first. This is done quickly; if not done, none of the other actions will be effective. It’s essential that the nurse goes to the source of the problem. The vital signs can be checked after the tube feeding has been stopped and the patient repositioned for better airway clearance. The healthcare proviNdU erRcS anIbNeGnT otBif. ieC dOaM fter the nurse has intervened by turning off the tube feeding, repositioning the patient for optimal airway clearance, and taking vital signs.

Repositioning the patient is important; but, if the pump is left on, more fluid will be instilled into an already stressed patient.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

REF: Page 569 TOP: Nursing Process: Planning

MULTIPLE RESPONSE 1. The nurse is preparing medications for a patient who cannot swallow pills. Nursing care

would be correct if the nurse determines which of the following medications cannot be crushed? (Select all that apply.) a. Capsule b. Scored tablet c. Enteric-coated tablet d. Buccal tablet ANS: A, C, D

Capsules and enteric-coated tablets are not crushed because the coating of these drugs protects the stomach from irritation or protects the drug from destruction by stomach acids. The buccal tablet needs to dissolve or remain in the mouth for proper absorption. The nurse can crush the Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

scored tablet because the medication absorption will not be altered.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

REF: Page 557 TOP: Nursing Process: Planning

COMPLETION 1. A

medication is one that is applied directly to skin, mucous membranes, or tissue

membranes.

ANS: topical DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 569 TOP: Nursing Process: Implementation

2. When applying transdermal patches, the nurse must

the application site to reduce the

incidence of a localized skin reaction.

ANS: rotate DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 572-573 TOP: Nursing Process: Implementation

3. The instillation of ophthalmic beta blockers can cause

and

because

of their rapid absorption.

ANS:

bradycardia, hypotension hypotension, bradycardia When drug concentrations are high, systemic effects can occur. For example, bradycardia and hypotension may occur after instillation of ophthalmic beta blockers such as timolol (Timoptic).

DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 589 TOP: Nursing Process: Implementation

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 23: Administration of Parenteral Medications Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. The nurse is teaching a patient to self-administer subcutaneous heparin at home. What does

the nurse include in patient teaching? a. Use a 22-gauge, 1-inch needle for the heparin injections. b. Change needles after withdrawing the heparin from the vial. c. Instruct the patient and family to recap all needles used at home. d. Pinch a large area of skin and inject heparin into the center of the skin fold.

ANS: D

The nurse instructs the patient to grab a large pinch of skin and inject the heparin into the center of the skin fold at a 90-degree angle to deposit the medication into subcutaneous tissue.

A 22-gauge needle is too large for a subcutaneous injection; a 25- or 27-gauge needle is a better choice because a finer needle creates a smaller hole. As a result, the medication tends to remain in the subcutaneous space, the patient is more comfortable, and the skin develops scar tissue more slowly. Changing needles is not necessary. Needles are never recapped; the patient at home should obtain a sharps container or use an impenetrable container to hold used needles. The patient should label the container to prevent injury to others.

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REF: Page 610-611| Page 613 TOP: Nursing Process: Implementation

2. The nurse prepares to administer 2.2 mL of an oil-based medication intramuscularly to a male

patient who is 5 feet 10 inches tall and weighs 165 pounds. Which needle and syringe combination should the nurse choose to administer the injection? a. 20-gauge, 1 1/2-inch needle on a 3-mL syringe b. 21-gauge, 1 1/2-inch needle on a 5-mL syringe c. 23-gauge, 1-inch needle on a 3-mL syringe d. 25-gauge, 1-inch needle on a 5-mL syringe ANS: A

The patient is well proportioned; because the medication is a thick solution requiring a deep intramuscular (IM) injection, the nurse chooses a slightly larger gauge needle, 20-gauge, which is 1 1/2 inches long, to accommodate the thick medication and to reach deep within the muscle. A 21-gauge needle is appropriate, but the syringe is too large. A 23-gauge needle is too small, and the oil would not be able to get through the lumen. A 25-gauge, 1-inch needle is far too narrow and short for an IM injection.

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REF: Page 614-615 TOP: Nursing Process: Planning

3. A patient is admitted to the emergency department after a motor vehicle accident. The nurse

sustains an accidental needlestick injury while performing a venipuncture on the patient. What is the nurse’s priority? a. Determine whether the needle was sterile.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. Follow agency policy for employee injuries. c. Inform the provider to screen the patient for antibodies.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf d. Obtain patient history of communicable diseases.

ANS: B

The nurse’s priority after a needlestick injury is obtaining immediate treatment as outlined in agency policy. He or she needs baseline testing and, depending on the patient’s history and test results, administration of preventive treatments. The needle cannot be sterile after a venipuncture. The nurse’s priority is his or her own safety and receiving prompt treatment; informing the provider and gathering subjective data are secondary in importance.

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REF: Page 599, Box 23-1 TOP: Nursing Process: Assessment

4. When administering an intramuscular (IM) injection, the nurse obtains blood during

aspiration. What action by the nurse is appropriate? a. Wait 30 minutes before giving the ordered medication. b. Notify the healthcare provider of the situation. c. Continue to administer the ordered medication. d. Stop the administration and discard the syringe.

ANS: D

The injection is stopped, the needle is withdrawn, and the filled syringe is discarded. A new dose of medication is prepared in a new syringe with a new needle for the patient. Waiting 30 minutes is not necessary because the medication is due and can be given as soon as a new syringe is prepared. Notifying the healthcare provider is unnecessary. Continuing with the injection is dangerous because the medication could be given intravenously instead of intramuscularly.

DIF: Cognitive Level: ComprehN enUdRSINRGETFB : .PC agOeM619 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning 5. The nurse is teaching a patient to self-administer insulin. The patient is 5 feet tall and weighs

197 pounds. Which of the following does the nurse include in patient teaching? a. Insert the needle into abdominal tissue at a 90-degree angle. b. Include an air space when drawing up the prescribed dose. c. Aspirate before injecting to ensure that the needle is not in a vessel. d. Instruct the patient to use an insulin syringe with a 1-inch needle.

ANS: A

The nurse instructs the patient to insert the needle at a 90-degree angle to inject insulin into subcutaneous tissue because the patient is obese and likely to have excessive abdominal adipose tissue. The 5/8-inch needle is long enough to reach subcutaneous tissue for proper administration of insulin but not long enough to reach muscle. The nurse instructs the patient to remove all air bubbles from the syringe before administering the insulin. Aspiration is unnecessary for subcutaneous injections because the tissue is avascular. A 1-inch needle is unnecessary because a 5/8-inch needle reaches the same subcutaneous tissue in this patient as a 1-inch needle.

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REF: Page 609-610 TOP: Nursing Process: Implementation

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

6. The nurse instructs a patient with diabetes mellitus about subcutaneous insulin administration.

What does the nurse include in patient teaching?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. b. c. d.

Remember that NPH insulin peaks within 15 minutes.

Prepare for hyperglycemia 2 hours after taking insulin.

Keep insulin refrigerated after administering the first dose.

Eat right after taking regular insulin to avoid hypoglycemia.

ANS: D

Regular insulin peaks 15 to 30 minutes after subcutaneous administration; thus the patient needs to eat right after administering the insulin to prevent a hypoglycemic emergency. Once it is administered, the insulin begins to drive glucose into the cells, resulting in a lower blood sugar; thus, if the patient does not eat to sustain the blood sugar, he or she becomes hypoglycemic. NPH, intermediate-acting insulin, peaks 2 to 6 hours after subcutaneous administration. Because insulin drives glucose into the cells, the blood sugar is more likely to drop than to increase after insulin administration. The nurse teaches the patient to store insulin at room temperature as long as the patient is the only person using the insulin vial.

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REF: Page 610 TOP: Nursing Process: Implementation

7. The nurse’s outcome for the patient is, “Patient self-administers subcutaneous heparin before

discharge.” What does the nurse include in patient teaching? a. Expect large areas of bruising around the injection site. b. Promote heparin absorption by massaging the injection site. c. Choose one large area for consistent heparin absorption. d. Inject heparin into the abdomen but avoid the umbilical area.

ANS: D

The nurse instructs the patient to inject heparin into the abdomen and avoid the area around the umbilicus because it is surrN ouUnR deSdIbNyGdT enBs. eC tisOsuMe that delays absorption. The nurse instructs the patient to expect small areas of bruising around the injection site; to avoid massaging the site because it increases absorption and promotes bruising; and to choose various sites, reminding the patient that bruising occurs and the patient may want to keep the areas covered.

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8. The nurse is caring for a 14-year-old patient with diabetes mellitus who does not want to

self-administer insulin because it is too painful. Which information should the nurse use in response to the patient’s concern? a. Adolescents are usually enthusiastic about self-care. b. Insulin mixed with a local anesthetic decreases pain. c. The healthcare provider orders oral insulin for patients with pain. d. There are techniques that will minimize the pain of the injection, though not eliminate it.

ANS: D

Insulin injections are likely to cause mild pain but there are techniques that may be taught to the patient to minimize the pain. The pain will not be eliminated, and this information needs to be shared with the patient. Initially many adolescents are unenthusiastic participants in Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

insulin self-administration. The nurse avoids mixing insulin with a local anesthetic because the benefit does not outweigh the risk. Oral insulin is not available.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 610| Page 612-613| Page 619 TOP: Nursing Process: Planning

9. The nurse is reviewing the records of four patients on heparin therapy. Which patient does the

nurse determine has the highest risk for a bleeding disorder during heparin therapy? a. A 10-year-old patient with an acute viral infection b. A female patient who gave birth more than 6 weeks ago c. A patient who takes a nonsteroidal antiinflammatory drug d. A 60-year-old patient with kidney stones ANS: C

The patient who takes a nonsteroidal antiinflammatory drug has the highest risk of a bleeding disorder complicating heparin therapy because this classification of medication has known risk factors for bleeding, especially gastrointestinal bleeding. The patient who gave birth more than 6 weeks ago probably has the second highest risk. After 6 weeks’ postpartum, involution is usually complete; thus hemorrhaging from the uterus is unlikely. The patients with the acute viral infection and kidney stones have a lower risk of bleeding while on heparin.

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10. The nurse prepares to administer a 3-mL intramuscular (IM) injection of an antibiotic to an

85-year-old patient. What action does the nurse take to administer the medication correctly? a. Prepares the patient for a subcutaneous injection b. Divides the injection into two separate syringes c. Positions the patient for injection in the dorsogluteal area Muscle d. Avoids aspirating when injN ecUtiR ngSiIn NthGeTdB el. toCidOm ANS: B

Older adults may have decreased muscle mass and can tolerate up to 2 mL of an injection; thus the nurse divides the dosage into two separate IM injections to promote patient comfort and prevent tissue damage. A 3-mL injection contraindicates use of the subcutaneous route; subcutaneous injections range from 0.5 to1 mL in volume. The nurse avoids the dorsogluteal area because of the risk of injury to the sciatic nerve and aspirates during IM injections, regardless of the location.

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11. The nurse prepares an IM injection to administer a medication available in a glass ampule.

Which step does the nurse take to administer the injection properly? a. Labels the ampule with date and time of the first dose b. Ensures that the cartridge is fully seated into the syringe c. Cleans the rubber top carefully before inserting the needle d. Uses a filter needle to withdraw the contents of the ampule ANS: D

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

An ampule is a glass container for a single dose of medication. The nurse protects the hands to break open the ampule and removes its contents with a syringe and filter needle to prevent aspiration of glass fragments. The nurse removes the filter needle and replaces it with a regular needle before administering the medication to the patient. Ampules are not amenable to reuse because they are open to air and thus contamination. The nurse opens an ampule and withdraws the contents into a syringe; a cartridge of medication is a prefilled syringe used with a reusable injection device. Ampules do not have rubber tops.

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12. The nurse prepares to administer an irritating medication by the Z-track technique. Which

technique does the nurse use to administer this intramuscular (IM) injection properly? a. Inserts the needle and pulls the skin laterally before injecting the medication b. Has the patient lie in a supine position to prevent medication leakage c. Waits 10 seconds and releases the skin before withdrawing the syringe d. Pulls the patient’s skin laterally before inserting the needle ANS: D

The nurse pulls the patient’s skin to the side before inserting the needle using the Z-track technique to prepare the seal for the medication after injection. When the skin is released after the needle is withdrawn, it assumes its original place and helps to contain the medication. The nurse retracts the patient’s skin and inserts the needle. Supine positioning does not prevent medication leakage. The nurse waits 10 seconds but withdraws the needle and then releases the skin.

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REF: Page 615 TOP: Nursing Process: Implementation

13. A toddler is to receive an intramuscular injection. What action can the nurse take to make the

injection less traumatic? a. Have the parents hold the toddler down during the injection. b. Collaborate with the healthcare provider about what to do. c. Encourage the toddler to move the leg after the injection. d. Obtain an order for EMLA cream or vapo-coolant spray.

ANS: D

Use of EMLA cream on the injection site l hour before the injection or vapo-coolant spray just before the injection decreases the pain. The parents should support the child during the injection, not help to hold him or her down during a painful procedure. The nurse should know what to do and does not need to ask the healthcare provider. Moving the leg after the injection helps to disperse the medication but does nothing about the trauma of the injection.

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14. The nurse is providing teaching for a patient who needs an intradermal test for tuberculosis.

What information should the nurse include? a. Check with the healthcare provider in 2 hours for test results.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. Relaxation helps make this type of injection painless. c. A total of 0.1 mL of solution will be injected into the muscle.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf d. The test must be read in 48 to 72 hours.

ANS: D

The time period for reading the results of the tuberculin skin test is within 48 to 72 hours after it has been done. The nurse or provider reads the test results 48 to 72 hours after the injection.

Relaxation doesn’t make a difference since the procedure involves a minor skin prick and generally causes a mild transient pain. The nurse injects 0.1 L of solution but not into the muscle.

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15. The nurse is instructing a nursing student in proper technique for an intradermal injection.

Which does the nurse use to evaluate proper technique for a tuberculin skin test after injecting the solution? a. The nurse palpates a deep, firm pocket of the test solution. b. The nurse observes a nearly clear bubble slightly under the skin. c. A small trickle of blood appears at the puncture site within minutes. d. A 2-cm (3/4-inch) pink, flattened area develops at the injection site within 1 hour.

ANS: B

The nurse observes a small bubble (bleb) just under the surface of the skin on needle withdrawal after a properly administered tuberculin skin test; an intradermal injection deposits medication below the skin but above subcutaneous tissue. The wheal is practically clear, denoting that the medication is in an avascular area. The pocket of test solution is relatively soft and superficial. Blood should not trickle from the injection site; if it does, the injection is potentially too deep. Within 1 hour, most intradermal tests are completely absorbed unless the patient has a reaction to the f l u N i d U, aRsSwIitN h GalTleBrg.yCtO esM ting or a positive tuberculin skin test.

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REF: Page 623 TOP: Nursing Process: Evaluation

16. The nurse evaluates the tuberculosis skin test results for a patient who recently emigrated

from Southeast Asia. Which result is consistent with the presence of tuberculosis antibodies in the patient’s system if the nurse reads the test 72 hours after injection? a. The injection site is an 11-mm red, warm, swollen area. b. The skin around the injection site is black, dry, and scaly. c. The nurse palpates a hard, dense, raised area 14 mm across. d. According to the patient, the skin around the injection site feels cool.

ANS: C

A tuberculin skin test indicating the presence of antibodies results in a palpable, indurated area at the injection site greater than 10 mm in diameter for a recent immigrant from Southeast Asia because many immigrants from that area are exposed to tuberculosis. In addition, tuberculosis immunizations are common in Southeast Asia; if a patient is tested after receiving the tuberculosis vaccine, the intradermal skin test will always be positive. Patients with no known risk factors have a positive test with a 15-mm induration, and an immunocompromised patient has a positive test with a 5-mm induration. This site is suspicious, but if it is not indurated, it does not indicate a positive result. Black, dry, scaly skin is consistent with Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

necrotic tissue. A cool sensation around the injection site after a tuberculin skin test is an unusual finding.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 623 TOP: Nursing Process: Evaluation

17. The nurse prepares an insulin injection for the patient who has diabetes mellitus. Which does

the nurse implement for correct insulin administration? a. Gives regular insulin within 15 to 30 minutes of meals b. Injects insulin just removed from the refrigerator c. Examines vials of NPH insulin for abnormal cloudiness d. Administers NPH insulin for sliding-scale insulin dosing ANS: A

The nurse administers regular insulin subcutaneously within 15 to 30 minutes of the patient’s meal because it starts to work in 30 minutes to 1 hour; thus the patient eats around the same time as the insulin administration to avoid severe hyperglycemia, which occurs if the patient eats and does not take insulin, or hypoglycemia, which occurs if the patient does not eat and takes insulin. Although insulin generally is stored in a refrigerator to prevent decomposition, it needs to be at room temperature when administered. The nurse can draw up the dose and have it checked; then it will be time to administer it. NPH insulin has a cloudy appearance. Regular insulin is used for sliding-scale insulin and as needed insulin.

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18. The nurse evaluates the patient’s ability to self-administer a subcutaneous injection of the

anticoagulant enoxaparin (Lovenox). What action by the patient indicates a need for additional patient teaching? a. Insert the needle at a 45- toN9U 0-RdS egIreNeGaT ngBl. e.COM b. Massage the area after performing the injection. c. Administer the injection without aspirating. d. Inject at least 7.6 cm (3 inches) from the umbilicus.

ANS: B

The nurse wants the patient to avoid massaging the injection site after administering enoxaparin to prevent the formation of large hematomas and decrease the risk of additional bleeding and tissue damage. The nurse instructs the patient to inject the enoxaparin and withdraw the needle without massaging the site afterward. If the patient massages the area to dispel pain or discomfort, he or she reports this to the nurse or provider because it is an unusual finding. The patient demonstrates proper injection technique with injections at 45 to 90 degrees, avoiding aspiration and injecting at least 2 inches away from the umbilicus.

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REF: Page 613 TOP: Nursing Process: Evaluation

19. The patient wants to receive insulin by continuous subcutaneous injection (CSCI). Which

injection site does the nurse suggest for the patient? a. The upper arm b. The upper chest c. The lower abdomen d. The thigh Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: C

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse instructs the patient to use the tissue in the lower abdomen, which has sufficient subcutaneous tissue and where insulin is most consistently absorbed. The upper arm and thigh are potential sites, but since most patients are active, the needle could become displaced with normal activity. The upper chest does not have as much subcutaneous tissue as the abdomen.

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REF: Page 635 TOP: Nursing Process: Planning

20. Which technique does the nurse use to administer a parenteral medication properly? a. Inserts the needle with the bevel facing downward b. Pushes the needle through the patient’s tissue slowly c. Applies sterile technique to draw up the medication d. Uses a 16- or 18-gauge needle with aqueous solutions ANS: C

The nurse uses sterile technique while drawing up the medication and for needle changes to prevent the introduction of pathogens to the patient and increased risk of infection. The hub and the inside of the syringe are sterile, as is the needle. The nurse attaches a sterile needle with the cap firmly in place to the syringe without contaminating the hub of the syringe. The nurse removes the cap without contaminating the needle to inject the medication. The bevel remains up for an injection. The nurse quickly inserts the needle into the patient to minimize the pain. Sixteen-gauge needles are not used for injections into soft tissue; oil-based, viscous solutions require an 18- to 25-gauge needle.

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NiGnT 21. Which angle should the nurse uNsU eR toSaI dm istBe. r aCnOinMt r am u s cu l a r (IM) injection for a patient who is 5 feet 6 inches tall and weighs 140 pounds? a. 15 degrees b. 45 degrees c. 60 degrees d. 90 degrees ANS: D

The nurse administers an IM injection at a 90-degree angle to the surface to ensure injecting the medication into the muscle. An angle less than 90 degrees increases the risk of injecting the medication into subcutaneous tissue.

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REF: Page 615 TOP: Nursing Process: Planning

22. The nurse administers intradermal injections for allergy testing. Which is the best technique

for the nurse to use for skin testing? a. Select a 22-gauge needle. b. Inject at a 45-degree angle. c. Choose the back for the first test. d. Inject below the antecubital space.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: D

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse chooses a clear site without bruises, inflammation, edema, or other factors that potentially impair absorption. Three to four fingerbreadths below the antecubital space or 1 handwidth above the wrist are suitable sites. The nurse can use both arms if more extensive testing is indicated because each forearm can manage 12 to 20 tests. A 22-gauge needle is too large. The nurse injects at a 5- to 15-degree angle. The back is a suitable testing site, but the forearms are better because they are accessed more easily and visible.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

REF: Page 620| Page 622 TOP: Nursing Process: Implementation

23. The nurse instructs a patient’s partner to administer subcutaneous regular Humulin insulin.

What information should the nurse include in the partner’s teaching? a. Select a 25-gauge, 5/8-inch needle. b. Massage the site after the injection. c. Always insert the needle at a 90-degree angle. d. Use a different injection site each time.

ANS: A

To ensure subcutaneous delivery of the insulin, the nurse instructs the partner to use a 25-gauge, 5/8-inch needle and to insert the needle at a 45- to 90-degree angle into the elevated skin area. The nurse instructs the partner to avoid massaging the injection site. The needle is inserted at a 45- to 90-degree angle, depending on the site and the amount of subcutaneous tissue present. Rotating sites is unnecessary with Humulin insulin because antibodies are much less likely to form and cause hypertrophy of tissue.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 620 TOP: Nursing Process: Implementation

24. The nurse is preparing to administer the anticoagulant enoxaparin (Lovenox) subcutaneously.

Which injection site is most appropriate for the nurse to use? a. Thighs b. Deltoid area c. Sides of abdomen d. Ventrogluteal area ANS: C

The sides of the abdomen are the preferred injection sites for enoxaparin to minimize bruising and discomfort. There are no major blood vessels or nerves in these areas. The nurse avoids injecting enoxaparin into the thighs because it potentially increases hematoma formation and discomfort from physical activity. The nurse avoids injecting enoxaparin into the deltoid region because it is likely to be more visible; in addition, patient activity can increase the risk of hematomas and discomfort. The nurse avoids the ventrogluteal site because injecting there potentially increases discomfort when the patient is trying to rest.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 609| Page 610 TOP: Nursing Process: Assessment

25. The nurse needs to administer an intramuscular (IM) injection to a patient who is 7 months

old. Which is the best site for the nurse to use for the injection?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. Deltoid b. Dorsogluteal

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. Ventrogluteal d. Vastus lateralis ANS: D

The preferred IM injection site for patients under the age of 12 months is the vastus lateralis muscle because it is a relatively large muscle mass without major nerves and blood vessels, has a consistent layer of fat, and has a good safety record. The deltoid is suitable for well-developed children and adolescents with use of a 5/8-inch needle. The dorsogluteal site is contraindicated because of the major anatomical structures that it contains. The ventrogluteal site is a safe site for injections in all age-groups; however, the vastus lateralis is the preferred site for infants.

DIF: Cognitive Level: Comprehension OBJ: NCLEX: Physiological Integrity

REF: Page 615 TOP: Nursing Process: Planning

26. The nurse is preparing to give an injection in the ventrogluteal injection site. Which pair of

anatomical landmarks does the nurse use for this site? a. Greater trochanter and knee b. Acromion process and axilla c. Anterior superior iliac spine and iliac crest d. Posterior superior iliac spine and iliac crest ANS: C

To locate the ventrogluteal muscle with the patient on the left side, the nurse palpates the head of the femur and the anterior superior iliac spine with the left hand. Place the heel of the right hand on the greater trochanter, with the thumb pointing to the groin and the index finger toward the anterior superior iliac spine. Extend the middle finger back to the iliac crest toward the buttocks, creating a V betwN eeUnRthSeIiN ndGeT xB fi. ngCeO rM a n d the middle finger; the injection site is deep in the middle of this V. The remaining anatomical landmarks are used with other sites, not the ventrogluteal.

DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 615-616 TOP: Nursing Process: Implementation

27. The nurse is preparing to give a patient a medication via a piggyback infusion. What is the

safest action for the nurse to take? a. Fill the tubing with medication before connecting it to the Y-port. b. Obtain a second intravenous (IV) site where the infusion will be administered. c. Ask the patient his or her preference about starting a new IV line. d. Consult with the healthcare provider to obtain the best approach.

ANS: A

Preventing air bubbles, which can cause an air embolus, is essential before attaching the the secondary infusion to the primary infusion line. There is no need to start a second IV site unless the medication is incompatible with what is running or if blood or blood products are infusing. The patient doesn’t have the knowledge about what approach is best. The nurse should know what to do in this situation.

DIF:

Cognitive Level: Remember

REF: Page 632

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf MATCHING

The nurse prepares to initiate a continuous subcutaneous injection (CSCI). Match the steps of the nursing interventions. a. Insert the needle at 45- to 90-degree angle. b. Connect the tubing of the needle to the tubing of the pump. c. Cleanse the site with alcohol and chlorhexidine. d. Apply occlusive dressing over the insertion site.

1.

2.

3.

4.

Step 1 Step 2 Step 3 Step 4

1. ANS: C DIF: Cognitive Level: Remember REF: Page 636-637 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation MSC: After selecting a suitable site, the nurse prepares the skin with alcohol and chlorhexidine to reduce the risk of infection. The nurse then allows the cleansing agents to dry by letting them evaporate and doesn’t try to speed up the process. The nurse inserts a butterfly needle at a 45-degree angle or a prepackaged needle at 90 degrees according to the manufacturer’s directions. The nurse covers the insertion site with a transparent occlusive dressing so he or she can assess the site as often as necessary for infection or other complications. Finally the nurse connects the tubing from the needle and the pump to initiate the infusion.

2. ANS: A DIF: Cognitive Level: Remember REF: Page 636-637 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation MSC: After selecting a suitable site, the nurse prepares the skin with alcohol and chlorhexidine to reduce the risk of infection. The nurse then allows the cleansing agents to dry by letting them evaporate and doesn’t try to speedNuUpR thS eI prN ocGeT ssB . T.hC eO nuMrse inserts a butterfly needle at a 45-degree angle or a prepackaged needle at 90 degrees according to the manufacturer’s directions. The nurse covers the insertion site with a transparent occlusive dressing so he or she can assess the site as often as necessary for infection or other complications. Finally the nurse connects the tubing from the needle and the pump to initiate the infusion.

3. ANS: D DIF: Cognitive Level: Remember REF: Page 636-637 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation MSC: After selecting a suitable site, the nurse prepares the skin with alcohol and chlorhexidine to reduce the risk of infection. The nurse then allows the cleansing agents to dry by letting them evaporate and doesn’t try to speed up the process. The nurse inserts a butterfly needle at a 45-degree angle or a prepackaged needle at 90 degrees according to the manufacturer’s directions. The nurse covers the insertion site with a transparent occlusive dressing so he or she can assess the site as often as necessary for infection or other complications. Finally the nurse connects the tubing from the needle and the pump to initiate the infusion.

4. ANS: B DIF: Cognitive Level: Remember REF: Page 636-637 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation MSC: After selecting a suitable site, the nurse prepares the skin with alcohol and chlorhexidine to reduce the risk of infection. The nurse then allows the cleansing agents to dry by letting them evaporate and doesn’t try to speed up the process. The nurse inserts a butterfly needle at a 45-degree angle or a prepackaged needle at 90 degrees according to the manufacturer’s directions. The nurse covers the insertion site with a transparent occlusive dressing so he or she can assess the site as often as necessary for infection or other complications. Finally the nurse connects the tubing from the needle and the pump to initiate the infusion.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse instructs the patient on mixing NPH and regular insulin in the same syringe. Match the steps in order that the patient should follow to ensure accurate dosing. a. Withdraw the NPH insulin. b. Withdraw the regular insulin. c. Remove bubbles from regular insulin. d. Inject air equal to the NPH insulin volume into the vial. e. Inject air equal to the regular insulin volume into the vial.

5.

6.

7.

8.

9.

Step 1 Step 2 Step 3 Step 4 Step 5

5. ANS: D DIF: Cognitive Level: Apply REF: Page 606-607 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning MSC: The first step when mixing NPH and regular insulin is to aspirate air into the syringe. The air is equal to the volume of NPH insulin needed. Inject the air into the NPH vial, and avoid removing NPH insulin at this time. Injecting the air prepares the vial to dispense the correct volume of NPH insulin by displacement. The regular insulin is then withdrawn. Any bubbles in the regular insulin must be removed at this time. The NPH insulin is withdrawn after the regular insulin dose has been checked for accuracy and absence of a bubble.

6. ANS: E DIF: Cognitive Level: Apply REF: Page 606-607 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning MSC: The first step when mixing NPH and regular insulin is to aspirate air into the syringe. The air is equal to the volume of NPH insulin needed. Inject the air into the NPH vial, and avoid removing NPH insulin at this time. Injecting the air prepares the vial to dispense the correct volume of NPH insulin by displacement. The regular in s u l i n Ni sUt hReS nI wN ithGdT raB w. n.CAO nyMbubbles in the regular insulin must be removed at this time. The NPH insulin is withdrawn after the regular insulin dose has been checked for accuracy and absence of a bubble.

7. ANS: B DIF: Cognitive Level: Apply REF: Page 606-607 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning MSC: The first step when mixing NPH and regular insulin is to aspirate air into the syringe. The air is equal to the volume of NPH insulin needed. Inject the air into the NPH vial, and avoid removing NPH insulin at this time. Injecting the air prepares the vial to dispense the correct volume of NPH insulin by displacement. The regular insulin is then withdrawn. Any bubbles in the regular insulin must be removed at this time. The NPH insulin is withdrawn after the regular insulin dose has been checked for accuracy and absence of a bubble.

8. ANS: C DIF: Cognitive Level: Apply REF: Page 606-607 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning MSC: The first step when mixing NPH and regular insulin is to aspirate air into the syringe. The air is equal to the volume of NPH insulin needed. Inject the air into the NPH vial, and avoid removing NPH insulin at this time. Injecting the air prepares the vial to dispense the correct volume of NPH insulin by displacement. The regular insulin is then withdrawn. Any bubbles in the regular insulin must be removed at this time. The NPH insulin is withdrawn after the regular insulin dose has been checked for accuracy and absence of a bubble.

9. ANS: A DIF: Cognitive Level: Apply REF: Page 606-607 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 24: Wound Care and Irrigation Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. The nurse assesses several preoperative patients for potential postoperative referrals to the

wound care team. Which patient assessment does the nurse use to identify the patient who is least likely to have delayed postoperative wound healing? a. Eight weeks postpartum from live vaginal birth in for tubal ligation b. Older than 70 years, coronary artery disease, and hypertension c. Six-week course of chemotherapy for a cancerous tumor d. Chronic obstructive lung disease on long-term prednisone therapy ANS: A

The patient with the lowest risk of delayed wound healing is the patient scheduled for a tubal ligation because she is likely to be 40 years old or younger, decreasing the risk for chronic disease. She is likely to have generally good health as evidenced by a live vaginal birth. The older patient with coronary artery disease and hypertension has atherosclerotic lesions in the heart aggravated by high blood pressure. The patient is likely to have atherosclerotic lesions in other vessels because atherosclerosis is a nonselective disease; thus the patient is at risk for delayed healing because of the potential for impaired tissue perfusion. Radiation therapy increases the risk of postradiation scarring and fibrosis which increases the risk of delayed healing. The patient taking prednisone is at high risk for delayed healing because glucocorticoids suppress inflammation and the immune system.

DIF: Cognitive Level: Analyze NURSINRGETFB : .PCa gOe M6 4 3 | Page 645-646 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Evaluation 2. The nurse assesses a patient with a surgical incision. What is an expected patient outcome on

the fourth postoperative day? a. The tympanic temperature is 39.5° C at 8 AM and noon. b. The incision is slightly reddened and swollen without drainage. c. The skin is spongy and warm around the incision. d. The patient’s pain has been increasing gradually.

ANS: B

By the fourth postoperative day the patient’s surgical incision is expected to have slight redness and swelling but no drainage, indicating a physiological, expected, inflammatory response to tissue injury. Tympanic temperature of 39.5° C is febrile and warrants further investigation to rule out infection. Spongy, warm skin around the wound area can indicate infection and requires follow-up. Increasing pain can indicate that the wound status is deteriorating and needs to be assessed.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 643 TOP: Nursing Process: Evaluation

3. The nurse prepares to assess the patient’s wound after removing the dressing. Which does the

nurse implement to promote infection control?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. Scrubs the drain insertion site in a back-and-forth manner b. Cleans the incision from wound edges toward the center

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. Applies clean gloves after removing the old dressing; inspects the wound d. Dons sterile gloves, removes the dressing, and inspects the wound ANS: C

First the nurse applies clean gloves, and then removes soiled dressings and examines dressings for quality of drainage (color, consistency), presence of odor, and quantity of drainage (note if dressings were saturated, slightly moist, or had no drainage). The nurse discards dressings in a waterproof biohazard bag, removes and discards gloves, performs hand hygiene, and applies clean gloves. Then the nurse inspects the wound and determines the type of wound healing (e.g., primary or secondary intention). The wound is cleansed from the cleanest to the dirtiest area to avoid contamination of the cleaner area. The nurse does not need to put on sterile gloves to remove the dressing but does need to change gloves before inspecting the wound.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 645 TOP: Nursing Process: Implementation

4. The nurse teaches a patient about self-care of two Jackson-Pratt drains after breast surgery.

What does the nurse include in patient teaching? a. Empty the drain every 2 hours and measure the contents. b. Maintain a small, steady amount of tension on the drain tubing. c. Record the amount removed from each drain separately. d. Keep the collection end of the drain lower than the patient’s waist.

ANS: C

Since the patient has two Jackson-Pratt drains, the amount removed from each drain should be recorded separately to allow the healthcare provider to know their effectiveness and when TB they can be removed. The bulbNsU hoRuS ldIbNeGem pt. ieC dO wMhen it is approximately two-thirds full, and a household device should be used to measure the contents as precisely as possible. The nurse instructs the patient to avoid putting tension on the tubing and to keep the bulb below the insertion site. Waist level is probably as low as the tubing can reach and still allow slack in the tubing.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 649| Page 652 TOP: Nursing Process: Implementation

5. The nurse teaches a patient about Steri-Strips after suture removal. What information does the

nurse include in patient teaching? a. They provide a skin barrier. b. They provide gentle support. c. They prevent scarring of the wound. d. They collect additional drainage.

ANS: B

Steri-Strips provide continued support to the incision after sutures or staples are removed. The nurse instructs the patient to expect the Steri-Strips to curl up and eventually fall off the skin and instructs the patient not to remove them. Steri-Strips do not provide a barrier since they are not applied continuously along the incision. The method of skin closure, site, and patient status determine the level of scarring. Steri-Strips are able to absorb only a few drops of Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

drainage.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 653| Page 655 TOP: Nursing Process: Implementation

6. The nurse notes evisceration of the patient’s abdominal incision. Which nursing intervention

is the priority before collaborating with the surgeon? a. Reinforce the wound with a dry sterile dressing. b. Use Steri-Strips to approximate the wound edges. c. Ask the patient whether coughing or activity is the cause. d. Cover the area with saline solution–moistened sterile towels.

ANS: D

Wound evisceration means that internal organs protrude from the incision; thus the risk of infection is high if the area is exposed. The nurse obtains sterile towels, gloves, and saline solution; moistens the towels; and covers the area. If the patient is stable, the nurse instructs the patient to remain in place and wait for additional instructions. Dry dressings are avoided because the dressing absorbs moisture from the protruding tissue, increasing the risk of infection or tissue damage. Applying Steri-Strips to a wound evisceration is inadequate because excessive pressure pushed the organs through a weakness in the incision. The nurse’s priority is to prevent infection and tissue damage; identifying the events leading up to the evisceration can wait.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

REF: Page 656 TOP: Nursing Process: Planning

7. The nurse performs a dressing change for a patient with a negative-pressure wound therapy

device. Which step does the nurse implement to facilitate wound healing? a. Cuts the foam smaller than wound edges b. Uses black foam to preventNgU raRnS ulI atN ioGnTtiB ss.uC eO froMm forming c. Determines if the patient needs pain medication before beginning the procedure d. Checks the dressing to ensure that the negative-pressure wound therapy tubes are functioning ANS: D

The nurse checks the dressing and tubing placement frequently to prevent new skin breakdown and aggravation of impaired tissue. The foam is cut to fit the entire wound bed, including tunnels and undermined areas, because the therapy cannot facilitate wound healing if it cannot reach the damaged tissue. Black foam is used to assist in granulation tissue formation. Pain medication might be needed, but it does not affect wound healing unless the nurse can’t manipulate the wound enough for a proper fit.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 657 TOP: Nursing Process: Implement

8. The nurse applies Steri-Strips to the patient’s surgical site after suture removal. During patient

teaching, what does the nurse instruct the patient to avoid doing? a. Limit heavy lifting activities. b. Ambulate several times a day. c. Soak in the bathtub for relaxation. d. Use a pillow to support incision.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: C

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse instructs the patient to avoid soaking in the bathtub. Soaking in water decreases the longevity of the Steri-Strips. The nurse instructs the patient to avoid heavy lifting completely to prevent exposing the new incision to excessive pressure. If the incision separates or eviscerates, the patient’s risk of infection and complications increases. The nurse encourages the patient to ambulate several times a day to prevent deconditioning, thromboembolic events, pneumonia, and constipation. The patient is also instructed to support the incision with a pillow for turning, coughing, deep breathing, and other activities as necessary.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 653| Page 655 TOP: Nursing Process: Implementation

9. The nurse evaluates the surgical incision before removing the patient’s staples. What

assessment finding would suggest staple removal is contraindicated for now? a. The area could have an increased risk of visible scarring. b. There is a small open area along the incision. c. The site is without drainage or erythema. d. The patient is quite anxious about the staple removal.

ANS: B

The nurse avoids removing staples from an incision with an open area because this indicates the incision has delayed healing. If the nurse removes the staples too soon, the risk of infection increases from wound dehiscence or evisceration. The method of wound closure, healing progression, and patient nutritional status determines scarring; staple removal generally has no effect on scarring. A surgical incision without drainage or redness has clinical indicators consistent with a healing wound. Patients are frequently anxious about procedures perceived as potentially painful; thus the nurse instructs the patient to expect a stinging sensation.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 653 TOP: Nursing Process: Evaluation

10. The nurse prepares to remove the patient’s sutures and staples. Which step should the nurse

implement before proceeding with the removal? a. Assess the type of suture material used. b. Snip off both ends of the suture material. c. Cleanse crusting with hydrogen peroxide. d. Plan staple removal for postoperative day 5.

ANS: A

The nurse determines the type of material used for wound closure before removing the staples or sutures for efficient time management and proper preparation for removal. To avoid patient exposure, discomfort, and dissatisfaction, the nurse avoids starting the procedures without suitable supplies. The nurse avoids snipping off both ends of the suture material to keep the sutures visible at all times, ensuring that he or she always has an end to grasp for removal.

Hydrogen peroxide is avoided for wound care or removal of staples or sutures because it is too harsh for topical use. Generally postoperative day 5 is too early for staple removal; staples are more typically removed on days 7 to 10.

DIF:

Cognitive Level: Analyze

REF: Page 652-653

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 11. A patient has an abdominal wound with a Hemovac drain in place. Which technique should

the nurse implement to maintain optimal suction in the drain? a. Replace the Hemovac drain when full. b. Attach the tubing to the patient’s gown. c. Compress the Hemovac on a flat surface after emptying. d. Apply high continual suction to the Hemovac plug.

ANS: C

To maintain the gentle suction designed into the Hemovac drainage system, the nurse empties the drainage into a measuring cup; compresses the Hemovac on a firm, flat surface; and reinserts the plug into its opening on the Hemovac. The Hemovac is an integral unit, and the surgeon places the drain in surgery. After surgery the unit is removable but not replaceable.

The Hemovac container is attached to the patient’s gown for activity. If the nurse attaches the tubing to the gown, the weight of the Hemovac creates excessive tension on the tubing and increases the risk of accidental removal. Suction is never applied to a Hemovac without a specific order for the amount and type of suction.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 650 TOP: Nursing Process: Implementation

12. The nurse assesses a patient’s wound and notices leakage at the edge of the transparent film of

the negative-pressure wound therapy. Which should the nurse implement to promote wound healing and prevent infection? a. Apply another layer of transparent film. b. Change the patient’s negative-pressure wound therapy dressing. c. Patch the leaks with an adhesive dressing. d. Contain leakage with a largN eU ARBS DIdNreGsT sinBg.. COM ANS: B

The nurse replaces the patient’s entire negative-pressure wound therapy dressing because it cannot establish negative wound pressure unless it is airtight. A leaking dressing provides an entry for pathogens. In addition, a leak in the dressing means that the negative pressure pulls room air currents over the wound bed, potentially contaminating the site. Adding another layer of transparent film could trap contaminants in the dressing, increasing the risk of infection. Adhesive dressing is avoided because it can irritate the skin and is too porous for establishing negative pressure. Likewise, an ABD pad is too porous to allow negative pressure to be reestablished.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 657 TOP: Nursing Process: Planning

13. The nurse is performing a wound assessment after removing the soiled dressing. What finding

would indicate a problem requiring additional assessment? a. An incisional ridge continues to be present. b. The patient experiences less discomfort. c. There is a lack of new drainage. d. The patient states, “My wound smells funny.”

ANS: D Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse would need to evaluate the wound for clinical indicators for infection since an odd smell may indicate a developing infection. A wound culture may be required. Ridge formation, decreased discomfort, and lack of drainage are consistent with clinical indicators of a healing surgical incision without infection.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 645 TOP: Nursing Process: Assessment

14. The nurse prepares to apply a dressing for a patient who has a full-thickness wound with

moderate exudate and necrosis. Which is the best nursing intervention to help the patient achieve an expected long-term outcome for this wound? a. Assess the wound for sinus tracts and tunneling. b. Maintain oxygenation with supplemental oxygen. c. Pack the wound lightly with a wet-to-dry dressing. d. Provide a well-balanced diet with high-quality protein.

ANS: D

Improving the patient’s nutrition is imperative for wound healing. A well-balanced diet with high-quality protein is required to maintain an adequate supply of substrate for wound healing. Initially the nurse performs wound care to remove exudate and necrotic tissue; during this time good nutrition is important to begin tissue repair. After this the purpose of the dressing changes is to promote granulation tissue, tissue growth, and wound closure.

Assessing the wound for sinus tracts and tunneling is most important at the beginning of wound care to provide a comprehensive plan. The importance of this assessment diminishes over time as the wound granulates and decreases in size. However, the nurse continues to assess the wound frequently, evaluate care, and plan suitable nursing care and dressing changes to suit the phase of heaNliUnR g.SInIiN tiaGllTyBth.eCpO atM ient needs supplemental oxygen to facilitate wound healing because regional tissue perfusion and oxygenation are inadequate to sustain cell metabolism and promote tissue growth and repair. The need for supplemental oxygen for healing should diminish as healing progresses and a new vascular bed forms that delivers adequate oxygen to the region. The nurse should not pack the wound using a wet-to-dry dressing after eliminating the exudate and necrotic tissue because a wet-to-dry dressing is nonselective débridement and risks damaging granulation tissue in the wound bed.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

REF: Page 643, Box 24-1 TOP: Nursing Process: Planning

15. The nurse assigns patient care to nursing assistive personnel (NAP). Which wound care task

should the nurse assign to NAP? a. Applying a hydrocolloid dressing b. Assessing the dimensions of the wound c. Reporting visible drainage on dressing d. Changing the first postoperative dressing ANS: C

The nurse assigns reporting visible drainage on the dressing to the NAP because the NAP is trained to perform that wound care task. The remaining wound care tasks require critical thinking and nursing judgment, assessment, and evaluation skills that the nurse cannot delegate because he or she owes these duties to the patient. In addition, the nurse avoids Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

delegating the first postoperative dressing change because it is a sterile procedure requiring the same nursing skills and judgment.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 645 TOP: Nursing Process: Planning

16. The nurse needs to apply a dry sterile dressing. Which should the nurse implement first? a. Inspect the appearance of the wound. b. Remove excess moisture from the wound. c. Cleanse the wound with sterile saline solution. d. Prepare the sterile field for supplies.

ANS: A

After removing the old dressing, the nurse assesses the wound for color, size, depth, drainage, and edema and compares the findings with baseline data. The nurse uses the conclusions from the assessment to plan follow-up nursing care. After the assessment the nurse creates the sterile field to maintain the integrity of sterile supplies in preparation for the dressing change.

He or she then cleanses the wound using sterile saline or an antiseptic swab and blots the excess moisture to reduce the risk of infection.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 645 TOP: Nursing Process: Planning

17. While cleaning a wound, the nurse determines that undermining is at the top of the wound.

Which documentation of the wound by the nurse is best? a. Dark pink wound with undermining at 2 o’clock b. Wound clean and without odor with slight undermining toward patient’s head c. See photograph of wound taken today d. Pale pink wound 2 cm  3 cm  2 cm deep with undermining at 12 o’clock ANS: D

The best documentation is “Pale pink wound 2 cm  3 cm  2 cm deep with undermining at 12 o’clock.” This entry contains the size, color, and location of the undermining of the wound.

The other entries omit key information. Although a photo may be useful, the documentation contains no description of the wound itself.

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18. The nurse is preparing to remove the skin staples from an older adult’s incision. Which action

should the nurse take to prevent a complication as a result of age and its effect on healing? a. Be prepared to use skin glue on the edges of the wound. b. Have Steri-Strips ready to use after the staples are removed. c. Increase the amount of protein in the patient’s diet. d. Assess the skin edges before the patient is discharged.

ANS: B

Steri-Strips can help support tissues after the staples are removed. Skin glue can be irritating to older tissue. Increased protein aids skin health, but the need is immediate, and additional protein won’t help right now. The skin edges should be assessed frequently during the remainder of the patient’s hospitalization.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 19. The nurse is irrigating a wound with a wide opening. What equipment would be appropriate

for the nurse to use? a. A 10-mL syringe with a 20-gauge needle b. A 35-mL syringe with a 19-gauge angiocatheter c. A 50-mL syringe with a 27-gauge needle d. A 60-mL syringe with a 24-gauge angiocatheter ANS: B

The 19-gauge catheter lumen and the volume of the syringe provide the ideal pressure for cleaning the wound and removing debris. A 1-mL syringe is too small. The 20-gauge needle is similar to the size of the angiocatheter and could be used. A 27-gauge needle and a 24-gauge angiocatheter are both too small.

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20. The nurse is preparing to perform a wound irrigation on a 7-year-old child who is

uncooperative. Which of the following will be the most helpful in alleviating the child’s fear? a. Restrain the child because no explanations will help. b. Have the parents leave the room. c. Describe the wound irrigation in detail. d. Use a doll to show the child how you will irrigate the wound.

ANS: D

Some pediatric patients may become frightened and may verbally or physically attempt to prevent the wound irrigation. Describing the wound irrigation using a doll may help to alleviate the fear. When p o s s i b N l eU , iR ncSluIdNeGpT arB en.tsCiO nMthe procedure.

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21. The nurse is caring for a patient who has a Jackson-Pratt drain in place on postoperative day

1. The NAP reports there is no drainage and the patient is complaining of pain at the site.

What should the nurse do first? a. Notify the healthcare provider. b. Inspect the area around the drain. c. Ask the patient to rate his or her pain level. d. Administer pain medication.

ANS: B

It is important to compare amount and characteristics of drainage with what is expected to determine patency of tubing and functioning of the drainage evacuator. You would expect some drainage on postoperative day 1, so the nurse should inspect for drainage around the tubing, which may indicate lack of vacuum or obstruction of the drainage system and then notify the healthcare provider if there is an obstruction. The nurse should reestablish a seal and see if there is drainage that comes out. Rating the patient’s pain and giving pain medications would be done after the drain is managed.

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf MULTIPLE RESPONSE 1. The nursing student is listing the phases of full-thickness wound healing to the nursing

mentor. Which of the following phases she lists indicate she needs further education? (Select all that apply.) a. Inflammatory phase b. Hemostasis c. Primary intention d. Proliferation e. Remodeling f. Secondary intention ANS: C, F

Wound healing occurs in four stages. (1) Hemostasis: Blood vessels constrict; clotting factors activate coagulation to stop bleeding. Clot formation seals disrupted vessels so blood loss is controlled and acts as a temporary bacterial barrier. Growth factors are released, which attract cells needed to begin tissue repair. (2) Inflammatory phase: Vasodilation occurs, allowing plasma and blood cells to leak into the wound, noted as edema, erythema, and exudate.

Leukocytes (WBCs) arrive in the wound to begin cleanup. Macrophages appear and regulate the wound repair. (3) Proliferation/rebuilding phase: New capillaries are created, restoring the delivery of oxygen and nutrients to the wound bed. At the same time new granulation tissue is formed. Collagen is synthesized and begins to provide strength and structural integrity to a wound. Contraction reduces the size of the wound. Epithelial resurfacing (the construction of new epidermis) begins to cover the wound. (4) Maturation/remodeling phase: Collagen is remodeled to become stronger and provide tensile strength to the wound. Outer appearance in an uncomplicated wound will bNeUthRaS t oIfNaGwTeB ll-.hC eaOleMd scar. Healing by primary intention occurs when the wound edges of a clean surgical incision remain close together. Wounds left open and allowed to heal by scar formation are classified as healing by secondary intention.

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2. The nurse is assessing a wound that is healing by secondary intention. Which of the following

assessments are important to address? (Select all that apply.) a. Wound dimensions b. Tissue type c. Wound edges d. Periwound skin e. Pain f. Undermining ANS: A, B, C, D, E, F

When assessing a wound that is healing by secondary intention (e.g., pressure ulcer or contaminated surgical or traumatic wound), it is important to assess the anatomical location of the wound, the wound dimensions, undermining, the extent of tissue loss, the tissue type, the presence of exudate, the wound edges, and the periwound skin.

DIF: Cognitive Level: Apply REF: Page 645 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 3. The nurse is preparing to use high-pressure pulsatile lavage to irrigate a necrotic wound.

Which of the following statements indicate a need for further education on this type of irrigation? (Select all that apply.) a. “I can set the psi between 15 and 17.” b. “I should never use this on exposed blood vessels.” c. “It is okay to use this on skin grafts.” d. “I should not use this on exposed muscles or tendon.” e. “I should never use this on patients with a coagulation disorder.”

ANS: A, C, E

Pulsatile high-pressure lavage is often the irrigation of choice for necrotic wounds. Pressure settings should be set per provider order (usually between 4 and 15 psi) and should not be used on skin grafts, exposed blood vessels, muscle, tendon, or bone. Use with caution if the patient has coagulation disorder or is on anticoagulants.

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COMPLETION 1. A

wound is a loss of the epidermis and superficial dermal layers and

heals by regeneration.

ANS:

partial-thickness partial thickness DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

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2. A

wound is a total loss of epidermis and dermis and in some cases is as deep as the muscle layer or bone; it heals by scar formation.

ANS:

full-thickness full thickness In a full-thickness wound, healing occurs in four phases.

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 25: Pressure Ulcers Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. The nurse is caring for a patient with a small chronic pressure ulcer on the ankle. Which

activity can the nurse delegate to nursing assistive personnel (NAP)? a. Measure the wound for length, width, and depth. b. Reposition the patient at least every 2 hours. c. Ask the patient to rate the pain during the dressing change. d. Examine the wound bed for the type and amount of tissue.

ANS: B

The nurse delegates patient repositioning to the NAP after the dressing change because the NAP is trained to perform this patient care activity. The nurse assesses the wound for type and amount of tissue in the wound bed, measures the wound, and assesses patient pain control because assessment is a major nursing responsibility.

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2. The nurse admits the patient to the surgical unit and determines that the patient’s Braden scale

score is 18. Which does the nurse include in the patient’s initial plan of care? a. Using moisturizing lotion to massage the sacrum b. Assisting the patient to turn and reposition every 4 hours c. Keeping the skin clean and dry with frequent bathing NURSINGTB.C d. Maintaining the head of the bed at approximately 30 degrees ANS: D

The nurse elevates the head of the bed to 30 degrees or less to reduce shear forces. If the patient sits in the Fowler’s or semi-Fowler’s position, the lower back and buttocks receive excessive force from the his or her weight pressing into the mattress, which can increase the risk of skin breakdown. Moisturizing lotion applied to areas at risk for friction is indicated for any patient in bed. The nurse avoids massaging the skin over bony prominences such as the sacrum because the tissue lacks supportive structures such as muscle and fat to distribute pressure over a large surface and provide oxygenated blood. Al-though the patient has a slight risk for skin breakdown, repositioning and turning every 4 hours is inadequate to maintain adequate tissue oxygenation. Excessive bathing increases the risk of skin breakdown by stripping the skin of essential oils and moisture. The skin may be kept clean and dry with daily and as-needed bathing using mild soap or commercial bathing products.

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3. Patients with a dry wound base have a better chance of wound healing if certain approaches

are used. Nursing care would be correctly focused on the maximum outcome if which interventions were used? a. Using dry gauze dressings and a liquid antimicrobial into the wound Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. Optimal nutritional support and the use of hydrogel dressings c. Bathing frequently with soap and the use of transparent film dressings

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf d. Using nonstick pads and enzymatic débriding agents ANS: B

Nutritional support and the use of hydrogel dressings have been found to bring moisture to a dry wound base. Gauze dressings absorb moisture, which is contraindicated, and a liquid antimicrobial is not indicated. Daily bathing with a mild soap is sufficient to keep the area clean. Transparent film dressings are used on partial-thickness wounds with minimal drainage.

Nonstick pads are suitable for abrasions so the dressing does not adhere to the wound.

Enzymatic débriding agents promote removal of dead tissue.

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4. The nurse assesses a patient with a pressure ulcer. Which assessment datum does the nurse

use to support the identification of a stage III pressure ulcer? a. Nonblanching and reddened areas of intact skin b. Extensive destruction of the skin and muscle c. Full-thickness skin loss from the surface down to the bone d. Full-thickness skin loss from the surface down to the fascia ANS: D

A stage III ulcer involves damage or necrosis of subcutaneous tissue extending down to, but not through, the fascia. A nonblanching area of reddened skin is a stage I pressure ulcer. Stage IV pressure ulcers are full-thickness ulcers involving extensive tissue destruction and necrosis of subcutaneous tissue, fascia, muscle, and bone.

DIF: Cognitive Level: Remember REF: Page 667 OBJ: NCLEX: Physiological IntN egUriR tySINTGOTPB : .NCuO rsM ing Process: Assessment 5. The nurse assesses a patient using the Braden scale. A patient having a majority of which

number indicates being at great risk for pressure sores? a. 1 b. 2 c. 3 d. 4 ANS: A

A score of 1 out of 3 or 4 signifies that the patient is at risk of having a specific problem such as sensory perception, moisture, activity, mobility, nutrition, or friction and shear. A 4 is the highest score possible and indicates no problem in that category. Scores of 2 and 3 aren’t as low and aren’t as critical.

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6. The nurse is caring for four patients at risk for impaired skin integrity. Which patient requires

the most frequent assessment and possible intervention? a. A malnourished, homeless patient with a nasogastric tube who is bedridden b. A college football player with bilateral long leg casts after a motorcycle accident Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. An elderly female ambulating after hip replacement surgery d. A school-age child recovering from a tonsillectomy and adenoidectomy

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: A

The homeless patient has four major factors that can contribute to skin breakdown: poor nutrition, being homeless, being bedridden, and having a nasogastric tube. The edges of the casts on the football player need to be watched for irritation, but he is at low risk for skin breakdown because of his youth, nutritional status, and activity level. The elderly female after hip replacement surgery would be at risk for skin breakdown at the site of the surgery. Her age would also be a factor because of the decrease of tissue under the skin. The school-age child has no risk factors for skin breakdown.

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7. The nurse is assessing a newly admitted patient with a pressure ulcer on the hip. Which

clinical indicator does the nurse use to assess a stage II pressure ulcer? a. Deep, open crater b. Persistent redness c. Boggy consistency d. Superficial blistering ANS: D

A stage II pressure ulcer is a superficial, partial-thickness skin loss presenting as an abrasion, blister, or shallow crater. A deep crater is consistent with clinical indicators for a stage III or stage IV ulcer. Persistent redness and a boggy or firm consistency are characteristics of a stage I pressure ulcer.

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8. The nurse uses the Braden scale to assess the patient’s pressure ulcer risk. Which patient score

mandates that the nurse implement aggressive prevention measures because of being at high risk for skin breakdown? a. Less than 9 b. 15 to 18 c. 19 d. 23 ANS: A

A Braden scale score less than 9 indicates that the patient has a very high risk for development of a pressure ulcer. These scores are indicative of a patient who has impaired sensation, very frequent exposure to moisture, moderate-to-severe activity impairment, and inadequate nutrition. Braden scale scores 13 and 14 indicate a moderate risk, scores 15 to 18 indicate a mild risk, and a score above 19 includes patients with the lowest risk for development of pressure ulcers. A patient with a score of 23 has no risk of skin breakdown.

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9. The patient is at risk for development of a pressure ulcer. Which problem related to the

patient’s iron-deficiency anemia and smoking habit supports the nurse’s decision to address Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

the anemia for prevention of a pressure ulcer? a. Decreased tissue perfusion

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. Decreased mobility impairment c. Increased skin moisture d. Increased level of consciousness ANS: A

Iron-deficiency anemia and smoking lead to decreased oxygen-carrying capacity of the blood, which increases the risk of cell death. Restoring iron levels improves the oxygen-carrying capacity of the patient’s blood by supplying adequate oxygen for cell metabolism and energy production. Decreased mobility impairment and increased level of consciousness would be desired outcomes and are not problems related to iron-deficiency anemia. Increased skin moisture most often occurs from fecal or urinary incontinence, not anemia.

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10. The patient has a clean partial-thickness wound. Which dressing material should the nurse

choose for dressing this ulcer? a. Strip packing b. Nonstick pads c. Transparent film d. Alginate dressings ANS: C

Transparent film is a suitable dressing for the clean partial-thickness wound with minimal exudate. Strip packing and alginate dressings are unsuitable for a stage II ulcer because the ulcer does not involve a deep crater suitable for filling with strip packing or alginate for absorption of moderate-to-heavy exudate. Nonstick pads are suitable for abrasions to keep the dressing from adhering to the wNoUuR ndS. DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

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11. The nurse assesses the patient’s pressure ulcer and notes tissue maceration around the wound.

Which action does the nurse take to address this issue? a. Eliminates dead space b. Uses a skin barrier c. Applies a foam dressing d. Obtains a wound culture ANS: B

Macerated skin around a wound is consistent with tissue exposure to irritating agents or moisture. The nurse cleanses the area gently and applies a moisture barrier to protect the skin.

Although skin needs moisture and a moist environment facilitates wound healing, frequent exposure to moisture or other agents that strip the skin of surface protection increases the risk of skin breakdown. Examples of such agents would be urine or feces, especially diarrhea.

Macerated skin has no dead space. Moderate-to-heavy exudate is an indication for a foam dressing. A wound culture is not indicated because macerated tissue is not necessarily infected.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 12. The patient’s pressure ulcer needs packing and has a moderate-to-heavy amount of drainage.

Which type of dressing should the wound care nurse use on the ulcer? a. Foam b. Hydrogel c. Impregnated gauze d. Alginate ANS: D

An alginate dressing can both absorb various amounts of drainage and be packed into the defect to fill the wound. Foam dressings are suitable for moderate-to-heavy amounts of wound drainage but are not used for packing. A hydrogel dressing is unsuitable for a wound with heavy drainage because it is designed to maintain a moist environment for the wound bed.

Impregnated gauze dressings are used for débridement.

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13. A patient with darkly pigmented skin is on bed rest and is being assessed for a possible stage I

pressure ulcer. What datum about the area of concern will best help the nurse determine the correct staging assessment? a. The skin will be slightly broken. b. The skin color is darker than surrounding tissues. c. The tissue is the same temperature as surrounding tissues. d. The skin blanches easily.

ANS: B

Early detection of pressure ulcers for a patient with dark skin is problematic because initial skin changes are difficult to disNtiU ngRuS isI h.NCGhTarBa. ctC erO isM tics of impaired skin integrity for patients with dark skin include changes in skin color, especially skin darkening or areas of purplish or bluish tones as cells begin to exhibit clinical indications of hypoxia. If the skin is already broken, the patient is not “at risk” but rather has a skin integrity issue. The tissue can be warmer or cooler than adjacent tissue. Blanching may not be visible in a person with darkly pigmented skin.

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14. The patient requires prone positioning for a severe respiratory condition. Which areas are at

risk for developing a pressure ulcer and require pillow bridging as a prevention strategy? a. Ears and toes b. Nose and elbows c. Occipital area and knees d. Sacrum and coccyx ANS: A

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

In the prone position, the nurse positions the patient face down on the bed with the head turned to the side or with a special face pillow that has a hollow center. Because of the severe respiratory problem, the nurse most likely positions the patient with the head to the side to provide easy access to the endotracheal tube and the patient’s airway for suctioning. This positioning exposes the dependent ear and the toes of both feet to an increased risk of pressure ulcers from concentrated pressure on a small area; therefore the nurse supports these areas with padding or pillows to distribute the weight over a larger surface evenly. The nose is not at risk with the head turned to the side, and pressure on the elbows is distributed along the length of the ulnar and radial bones. The sacrum and coccyx are not in contact with a hard surface when the patient is prone. The back of the head is in an independent position with the patient in the prone position with the head facing down or to the side, but prone positioning exposes the anterior aspect of the knees to excessive pressure and requires padding to prevent a pressure ulcer.

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15. A patient has a slight skin breakdown in the perianal area from incontinent stools. For which

combination of therapies should the nurse obtain an order? a. Diapers and a moisture barrier ointment b. Hydrogen peroxide and povidone-iodine c. Fecal incontinence bag and a protective barrier paste d. Alginate and transparent film dressings ANS: C

Application of a fecal incontinence bag minimizes the amount of fecal matter that will touch the skin. Applying the protectivNeUbRarSriIerNpGaT steB t.oCthOeMperineum and surrounding skin after each incontinent episode helps to heal the denuded skin and protect surrounding skin. Diapers keep moisture against the skin, and the moisture barrier ointment is used on intact skin only.

Hydrogen peroxide can cause additional tissue damage on broken skin, and povidone-iodine has been found to be ineffective for wound care because it is associated with increased rates of infection. Alginate and transparent film dressings would not be appropriate. Alginate dressings absorb large amounts of exudate in heavily draining wounds, which is not the situation here, and the transparent film dressing would neither protect the skin area nor help it heal.

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16. The nurse assesses the patient’s pressure ulcer after 2 weeks of ambulatory wound care and

observes pink tissue at the base of the wound. Which should the nurse implement? a. Refer the patient to a dietitian to improve nutrition. b. Alter the wound care to include a débriding agent. c. Collaborate with the healthcare provider for wound culture. d. Recommend a hydrocolloid wound dressing.

ANS: D

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Pink tissue in the wound base is consistent with clinical indicators of granulation tissue; thus the nurse recommends using a hydrocolloid dressing to maintain a moist environment and protect the wound base because a moist environment facilitates healing. The appearance of granulation tissue indicates that the patient’s wound is healing. Unless the patient requests nutritional counseling, it is not indicated. The wound does not contain cellular debris or necrotic tissue; thus débridement is not indicated. The wound does not have clinical indicators of infection, which would include exudate and foul odor.

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17. The nurse is positioning a patient at risk for development of a pressure ulcer. Which potential

pressure point(s) does the nurse relieve by assisting the patient to a side-lying position? a. Symphysis pubis b. Ischial tuberosities c. Greater trochanters d. Occipital prominence ANS: D

The nurse positions the patient in the lateral position to prevent pressure on the back of the patient’s head. Pressure can develop over bony prominences when a patient is allowed to remain in one position too long. The patient exerts pressure on the symphysis pubis in the prone position. The nurse assists the patient to the supine position to avoid pressure on the ischial tuberosities and the greater trochanters.

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18. The nurse observes a thick, tannish-brown covering over a large wound and needs to stage the

wound. What action by the nurse is most appropriate? a. Removing this covering with a sterile forceps and scissors b. Filling the base of the patient’s ulcer with a silicone lotion c. Placing a hydrocolloid dressing directly over the tannish-brown covering d. Deferring staging until the tannish-brown covering has been removed ANS: D

The tannish-brown covering is eschar, which has formed as a result of the severe tissue injury.

Until the base of the wound can be seen, the true depth and therefore the stage cannot be determined. Eschar is not simply removed; often it is scored, and a solution is put on it to soften it so it can be removed. When the eschar is removed, sterile instruments are used because removing it exposes fresh tissue. If the nurse applies the dressing over eschar, the dressing effectively seals the necrotic tissue onto the wound bed. Silicone lotion is contraindicated for use in a large crater. A hydrocolloid dressing creates its own seal and cannot be used until the eschar has been removed.

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19. One outcome for a patient on bed rest is that the patient has intact skin within 2 weeks. Which Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

rationale pertaining to the patient best justifies the suggestion by the nurse to use a support surface or special mattress?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. b. c. d.

It eliminates pain and discomfort.

It prevents joint contractures.

It eliminates the need for turning.

It reduces risks of immobility.

ANS: D

The nurse recommends a support surface or special mattress for the patient to reduce the risks associated with immobility (i.e., impaired skin integrity) by reducing or relieving pressure on the patient’s skin, especially at the bony prominences. Support surfaces or special mattresses do not eliminate pain and discomfort. Contractures are prevented with range of motion, physical therapy, and splints. The nurse continues to turn and reposition the patient on a support surface as part of care.

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20. The patient’s sacrum has nonblanching redness on Monday. On Wednesday the nurse

determines that the pressure ulcer on the patient’s sacrum is stage II despite skin care, including an air-filled mattress overlay. Which is the best nursing intervention to implement? a. Document the extreme progression of the patient’s pressure ulcer. b. Collaborate with the healthcare provider for physical therapy. c. Reassess the patient’s need for a different support surface or bed. d. Increase the frequency of bathing and linen changes as needed.

ANS: C

The patient’s pressure ulcer is deteriorating. This means that the current skin care plan is unsuccessful and needs reevaluation; thus the nurse should assess the patient for a different NeGnT support surface. He or she shouNldUdRoScuIm t tB h. e pCaOt i Me n t ’ s skin assessment, but the best response to the patient’s deterioration is to reassess the skin care plan and amend it. Nursing collaboration for physical therapy is a reasonable response and potentially benefits the patient on a support surface, especially if the patient is on bed rest; however, the nurse needs to first assess the patient to determine whether physical therapy is indicated for the patient. He or she provides bathing for a patient with a pressure ulcer on a routine and as-needed basis but avoids planning frequent baths and linen changes as therapy because excessive bathing strips the skin of essential moisture and surface oils.

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MULTIPLE RESPONSE 1. The nurse is planning care for her patients and is concerned about skin breakdown and

delayed wound healing. Which of the following patients are likely to be at a higher risk for wound healing should they develop a pressure ulcer? (Select all that apply.) a. An elderly female patient with mobility issues b. A young diabetic patient in traction and on bed rest c. A teenager receiving chemotherapy d. An elderly man with stage IV congestive heart failure Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf e. A middle-aged woman with lupus who is having back surgery but is ambulatory ANS: A, B, C, D

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Risk factors that delay wound healing include age (older adults have a diminished inflammatory response), obesity, diabetes, compromised circulation, malnutrition, immunosuppressive therapy, chemotherapy, and high levels of stress. An elderly female is at risk due to her age even though she is mobile; a diabetic is at risk especially if in traction; the teenager on chemotherapy is at risk due to the chemotherapy, which can also affect nutrition status. The elderly man has two risk factors: his age and circulatory status. The woman with lupus may not be on immunosuppressive therapy and has no age-related risk factors.

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2. The nurse is concerned about device-related pressure ulcers in her patients. Which of the

following interventions should she take?(Select all that apply.) a. Perform frequent skin assessment under devices and tubes. b. Assess for edema in the skin underlying a tube. c. Rotate tubes to different positions to relieve pressure. d. Implement pressure ulcer care bundles. e. Do not remove the adhesive tape until it is time to remove the device.

ANS: A, B, C, D

Medical devices known to contribute to pressure ulcers include nasogastric tubes, endotracheal tubes, Foley catheters, and other plastic, rubber, or silicone tubes. It is thought that the device-related pressure ulcer may occur because of poor fixation or positioning of the equipment. To prevent breakdown, the following should be done: 1. Frequently perform skin assessment around and under devices and tubes. Frequently assess for edema in the skin underlying a tube or other medical device.

2. Remove adhesive tape a n Nd U asRseSsI sN unGdT erBly.inCgOsM kin; determine if another type of tape is needed.

3. Rotate tubes to different positions to decrease pressure in the area where the tube is in contact with the skin. For example, endotracheal (ET) tubes can be moved from one side of the mouth to the other.

4. Double-check and determine that the tube or device is properly positioned and has proper fixation to decrease unnecessary tube movement and skin damage.

5. Implement care bundle for pressure ulcer prevention.

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REF: Page 675 TOP: Nursing Process: Planning

3. The nurse is delegating care related to her patients to the NAP. Which of the following

indicates the nurse is appropriately delegating tasks related to pressure ulcer care? (Select all that apply.) a. The nurse asks the NAP to report any redness in the patient’s skin. b. The nurse explains to the NAP that the patient will need to be repositioned every 2 hours. c. The nurse asks the NAP to assess the patient’s risk factors for skin breakdown. d. The nurse explains to the NAP which positions the patient should be repositioned in. e. The nurse asks the NAP to record the patient’s nutritional intake.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: A, B, D, E

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The skill of pressure ulcer risk assessment may not be delegated to nursing assistive personnel (NAP). Instruct the NAP about the following: 1. Explaining frequency of position changes and specific positions individualized for the patient 2. Reviewing need to report to you any redness or break in the patient’s skin or any abrasion from adhesives, tubes, assistive devices, or other medical devices 3. Recording the patient’s nutritional intake is important as malnutrition delays wound healing.

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REF: Page 675 TOP: Nursing Process: Planning

COMPLETION 1. Poor

decreases the patient’s ability to feel the sensation of pressure or

discomfort.

ANS:

sensory perception Immobility and inactivity reduce the patient’s ability or desire to independently change position. Poor sensory perception decreases the patient’s ability to feel the sensation of pressure or discomfort.

DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 671 TOP: Nursing Process: Assessment

2. The rubbing of the tissue a g a i nNs t Ua Rs S u rIf aNc eG iTs B ca.llCedOM ; it abrades the top layer of skin

(epidermis), which makes tissue susceptible to pressure injury.

ANS: friction DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 674 TOP: Nursing Process: Assessment

3. A parallel force that stretches tissue and blood vessels is called

.

ANS:

shear Shear is a parallel force that stretches tissue and blood vessels such as when a patient is in a semi-Fowler’s position and slides toward the foot of the bed.

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 26: Dressings, Bandages, and Binders Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. The nurse applies a circumferential gauze dressing to a patient’s amputated leg. Which

method should the nurse use to decrease edema in the extremity? a. Montgomery straps b. An adhesive tape wrap c. A figure-eight wrap d. A circular turns dressing ANS: C

The nurse applies a dressing around the extremity using the figure-eight method to avoid restriction of blood flow and main venous return. This allows the dressing to be anchored by wrapping gauze in alternating directions that ascend and descend with oblique, overlapping turns. The terminal end of the dressing is secured with a short piece of tape, taking care not to restrict blood flow in any manner. Montgomery straps are contraindicated for dressing an extremity because the circumference is usually too small to make them practical. Adhesive tape potentially constricts blood flow to the extremity if it is wrapped tightly over itself in a circumferential manner. Circular turns dressings are used on small parts like fingers or toes, but are too constricting to use on larger body parts.

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REF: Page 703-705 TOP: Nursing Process: Planning

NURSINGTB.COM

2. The nurse assigns patient care to nursing assistive personnel (NAP). Which wound care tasks

should the nurse assign to this staff member? a. Apply the hydrocolloid dressing. b. Assess dimensions of the wound. c. Report visible drainage on the dressing. d. Change the first postoperative dressing.

ANS: C

The nurse assigns reporting visible drainage on the dressing to the NAP because this individual is trained to perform this wound care task. It is essential to review what needs to be looked for and what to report back to the nurse. The remaining wound care tasks require critical thinking and nursing judgment, assessment, and evaluation skills that the nurse cannot delegate because he or she owes these duties to the patient. In addition, the nurse avoids delegating the first postoperative dressing change because it is a sterile procedure requiring the same nursing skills and judgment.

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3. The nurse plans care for the patient’s wound that requires a moist-to-dry dressing. Which

should the nurse use for an expected patient outcome several hours after applying a new dressing?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. The patient states that the dressing feels cold. b. The dressing is dry and intact.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. The dressing has bright red drainage. d. The patient states that the pain level is 8 on a scale of 1 to 10.

ANS: B

The nurse uses a moist-to-dry dressing for wound débridement and exudate collection because cellular debris and exudate in a wound bed delay healing. The nurse expects the dressing to absorb wound drainage and to be dry and intact. The dressing should feel cold as the nurse applies the moist gauze, not later. It should absorb drainage, not cause drainage to increase and penetrate the layers of dressing material. Pain rated as 8 on a scale of 1 to 10 is severe and warrants further investigation by the nurse because a dressing should provide patient comfort.

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REF: Page 691-692 TOP: Nursing Process: Evaluation

4. The wound care nurse prepares to dress the wounds of four patients. Which wound should

receive a transparent film dressing? a. A clean, superficial laceration b. A deep leg ulcer with infection c. A puncture wound with bleeding d. A large laceration over the eyebrow ANS: A

An indication for a transparent film dressing includes a clean, superficial laceration because transparent dressings adhere to wounds and are nonabsorbent. A transparent dressing is contraindicated for a deep ulcer because the dressing is adherent; in addition, a deep ulcer most likely drains exudate or requires débridement, contraindicating the use of the dressing.

The nurse avoids using the transparent dressing for the bleeding puncture wound because he or she first applies a pressure dN reU ssRinSgItoNsGtoTpBt. heCbOleMeding and then dresses the wound with an absorbent dressing to collect subsequent drainage. Because the dressing is adherent, the nurse avoids using a transparent dressing over a large laceration. The laceration is likely to require sutures or Steri-Strips to close the wound; thus the nurse avoids using a dressing that can pull on the fragile wound edges.

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5. The nurse is caring for a patient with a history of chronic respiratory problems who has an

abdominal binder in place. Which should the nurse instruct nursing assistive personnel (NAP) to report as an unexpected outcome? a. The skin around the binder is dry without redness or edema. b. The patient experiences difficulty moving around in bed. c. The patient’s pain level has changed from 8 to 6 on a scale of 1 to 10. d. The respiratory rate has decreased from 17 to 15 breaths per minute.

ANS: B

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The patient’s activity should not be hampered by the binder. The nurse needs to assess the patient’s ability to move in bed before the binder is applied and reassess after the binder has been in place for a short time. The binder may be too tight, and loosening it may be enough to allow more mobility by the patient. Assessing the skin around the binder and evaluating trends in data are nursing tasks requiring nursing assessment skills and nursing judgment and evaluation; thus the nurse avoids delegating skin assessments and data analysis. Determining the patient’s pain level is a nursing function requiring assessment skills. The nurse expects the NAP to report the respiratory rate, even if normal, and the nurse draws conclusions about the data reported.

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6. The nurse delegates applying a binder over the patient’s abdominal incision to nursing

assistive personnel (NAP). Which does the nurse include in the NAP’s instructions? a. Start the binder right under the axilla. b. Place the patient in a semi-Fowler’s position. c. Secure the binder with metal fasteners. d. Remove the old dressing and apply a binder.

ANS: C

The nurse instructs the NAP to secure the binder with metal fasteners, Velcro strips, or safety pins to keep the dressing in place. This prevents the binder from opening accidentally and increasing the risk of patient infection. If the NAP starts right under the axilla, the binder will encase the thorax, potentially impairing the patient’s ability to oxygenate, ventilate, cough, and deep breathe thereby increasing the risk of hypoxia, acidosis, atelectasis, and pneumonia.

The NAP is instructed to p l a c e Nt hUeRpSa tIi eNn tGi Tn B th. eC suOpM ine position to apply the binder because in that position the patient may assist the NAP by rolling from side to side. This allows the NAP to place the fanfolded binder under the patient so it may be drawn around the abdomen. The nurse instructs the NAP to apply the binder after the sterile dressing change is completed to prevent patient infection and protect the wound.

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7. The nurse prepares to perform a dressing change on an ulcerated area. Which principle does

the nurse apply while performing a dressing change? a. The dead space found in an ulcer should be packed tightly. b. The wound should be débrided using multiple dry gauze pads. c. The dressing should absorb exudate without damaging the wound bed. d. The wound bed should be dried to stimulate granular tissue.

ANS: C

The dressing should absorb drainage but, when removed, should not interfere with the healing that has occurred in the wound bed. The dead space in a wound is lightly packed to absorb exudate. The purpose of a dry dressing is protection for wounds with minimal drainage. Dry dressings do not interface with the wound, and débridement uses a wet-to-dry or moist-to-dry dressing. If exudate saturates a dry dressing, the nurse removes and changes it quickly or reinforces it. The nurse keeps the wound bed moist to promote healing, because a moist Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

wound bed stimulates formation of granulation tissue, and keeps the area around the wound dry to keep it clean.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 686-687 TOP: Nursing Process: Evaluation

8. The nurse is preparing to dress an open, shallow wound with a moderate amount of drainage.

Nursing care is correct if the nurse chooses which dressing material? a. Alginate nonwoven b. Adhesive membrane c. Hydrocolloid adhesive d. Foam nonadherent pad ANS: C

Hydrocolloid dressings are the best choice for this wound. They are adhesive dressings composed of gelatin, pectin, and absorbent material suitable for stages I to IV pressure ulcers with minimal-to-moderate exudate. Although hydrocolloid adhesive is a versatile product, the nurse considers its propensity for skin maceration if left in place beyond its recommended time. Alginate dressings are absorbent and indicated for use with partial- and full-thickness wounds that drain moderate-to-heavy amounts of exudate. This dressing is expensive and needs to be changed daily. Transparent film dressing is appropriate for shallow wounds with minimal exudate to protect the wound and promote autolytic débridement. Foam pads are used for partial- and full-thickness wounds that drain moderate-to-heavy amounts of exudate; a secondary dressing is required.

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9. The nurse removes the patient’s hydrocolloid dressing and observes minimal clear, watery

drainage. Which action should NthUe RnS urIseNtG akTeBa. t tChO is Mtime? a. Evaluate for leukocytosis. b. Change to foam dressing. c. Collaborate with the healthcare provider. d. Document serous drainage.

ANS: D

The nurse documents that there is serous drainage after the dressing change to record the wound drainage accurately. Serous drainage is a benign finding. Leukocytosis indicates infection, inflammation, or malignancy. If the patient has leukocytosis, the nurse determines that the wound is probably not the cause because serous drainage is a benign finding and inconsistent with clinical indicators of infection. The nurse uses a dressing indicated for wounds with minimal exudate and does not need to collaborate with the healthcare provider because serous drainage from the wound is consistent with a successful wound care protocol.

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10. The nurse prepares to change the patient’s dressing over a surgical incision without drainage

but palpates a ridge along the suture line. Which dressing should the nurse apply to this wound? a. Foam pad b. Wet-to-dry Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. Transparent film

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf d. Dry sterile gauze ANS: D

The nurse uses a dry sterile gauze dressing over the surgical incision because a nondraining incision with a healing ridge is consistent with clinical indicators of a properly healing surgical incision. The nurse chooses this dressing because the incision needs protection. The surgical incision has no drainage; thus a foam pad dressing is contraindicated because it is intended for use with partial- to full-thickness wounds with moderate-to-heavy drainage. A wet-to-dry dressing is contraindicated for use with a nondraining surgical incision but is indicated for mechanical débridement of wounds. A transparent film dressing is a reasonable choice to protect the wound because the wound may be observed through it; however, the nurse avoids choosing this dressing to cover a surgical incision because removing the dressing pulls on the fragile borders of the incision.

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11. The nurse needs to apply a dry sterile dressing. Which should the nurse implement first? a. Inspect the appearance of the wound. b. Remove excess moisture from the wound. c. Cleanse with sterile saline solution. d. Prepare the sterile field for supplies.

ANS: A

After removing the old dressing, the nurse assesses the wound for color, size, depth, drainage, and edema and compares the findings with baseline data. The nurse takes the conclusions from the assessment to plan follow-up nursing care. After the assessment, the nurse creates the sterile field to maintain t h e Ni nUt eRgSr itIyNoGf T s t eBr. i leCsOuM ppl i es in preparation for the dressing change. He or she cleanses the wound using sterile saline or an antiseptic swab and blots the excess moisture to reduce the risk of infection.

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12. The nurse is caring for a patient who requires a moist-to-dry dressing. Which action by the

nurse is appropriate during the procedure? a. Applies a dry absorbent outer dressing b. Packs flat gauze into the wound bed c. Soaks the wound packing with antiseptic d. Moistens the old dressing before removal ANS: A

The nurse applies a dry secondary dressing over the wound for protection and infection control and to contain the moist packing. He or she squeezes excess moisture from the fine mesh gauze and packs the wound with the gauze compressed from squeezing to facilitate drainage and debris collection. The gauze used for packing is soaked with sterile saline solution or another isotonic solution. To facilitate débridement, the nurse removes the old dressing without dampening it.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 13. The nurse inspects a patient’s surgical incision and notes dehiscence several inches long.

Which is the most important intervention for the nurse to implement? a. Call for assistance. b. Place a sterile moist dressing on the wound. c. Apply direct pressure over the wound dressing. d. Apply a pressure dressing over the open area.

ANS: B

The most important interventions for the nurse to take are to have the patient lie still, place moist sterile dressings over the area and cover it with dry pads, and notify the healthcare provider. The nurse should not put any pressure on the area that has dehisced. A pressure dressing is contraindicated for this type of opening. A pressure dressing would be used over a bleeding wound or puncture area after a procedure.

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14. The nurse assesses the patient’s transparent film dressing and observes white opaque exudate

and reddened and edematous wound edges. Which is the priority intervention for the nurse to implement? a. Record the observation in the patient’s record. b. Remove the white exudate carefully. c. Obtain an order for a wound culture. d. Apply a light absorbent dressing.

ANS: C

The nurse suspects an infected wound because exudate can indicate wound debris from an IeNnGtaTtiB infection. Although all of theseNiU mR plS em on.sCmOaM y be performed, the priority is to start effective treatement for the suspected infection, so the culutre must be obtained as soon as possible. The nurse notifies the healthcare provider so an order can be written for the culture then obtains a wound specimen sample for testing. The nurse must obtain the culture before antimicrobial therapy begins. The wound assessment is recorded after completing wound care and obtaining the culture.

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15. The nurse is applying a gauze bandage to hold a dressing on a patient’s wrist since the patient

is allergic to tape. Which technique would be most appropriate for the nurse to use? a. Montgomery straps b. A 7.6-cm (3-inch) bandage wrapped proximal to distal c. A 2-inch bandage using the spiral wrap technique d. A loosely wrapped elastic bandage using a recurrent turn ANS: C

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse needs to secure the dressing in place using a small bandage because the wrist is small and a spiral wrap covers the area effectively without compression. A Montgomery strap is inappropriate because of its large size and adhesive backing. A 7.6-cm (3-inch) bandage is most commonly used for the adult leg and should be wrapped distal to proximal to promote venous return. An elastic bandage is generally used for simple intermittent compression. The recurrent turn is used to cover uneven body parts such as the head or the residual limb after an amputation.

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16. The nurse is assisting a patient with putting on an abdominal binder. In which position does

the nurse place the patient? a. Semi-Fowler’s b. Supine c. Prone d. High-Fowler’s ANS: B

The nurse positions the patient in supine position with head slightly elevated and knees slightly flexed. None of the other positions would allow the nurse to secure the binder correctly.

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17. The patient started bleeding profusely from a surgical wound on the thigh. Nursing care is

appropriate if the nurse takes wNhU icR hS acItiN onGT toBc. arC eO foMr this patient? a. Assesses the wound for sinus tracts and tunneling b. Applies roller gauze over the gauze pads on the extremity using a figure-eight pattern c. Obtains sterile gauze and sterile gloves d. Has nursing assistive personnel (NAP) apply the pressure dressing ANS: B

Assessing the wound for sinus tracts and tunneling would increase the hemorrahging. Since this is a fresh wound there is no need to do this. The figure-eight pattern of wrapping acts as a pressure dressing, exerting even pressure over the extremity. Assessment has indicated that the patient is hemorrhaging. Pressure needs to be applied to the area to prevent blood loss and patient deterioration. Sterile technique is not the priority at this time. As long as the dressings are clean, they can be applied. The nurse needs only clean gloves. The skill of applying a pressure bandage in an emergent situation should not be delegated to the NAP. If the application requires more than one person, the NAP can assist the nurse as directed.

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18. The wound care nurse prepares wound care supplies. Which patient assessment datum cues

the nurse to provide Montgomery straps to promote wound healing?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. Heavy exudate b. Deep laceration

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. Femoral dressing d. Wound dehiscence ANS: A

The patient with heavy exudate will need repeated dressing changes and Montgomery ties will allow access to the wound while protecting the skin. The repeated removal of an adhesive bandage in this situation could damage the skin. A deep laceration often requires varying amounts of surgical repair after cleansing. After approximating the laceration with sutures or staples, the nurse would apply a dry dressing. A femoral dressing usually covers the crease created by the hip and thigh; thus the area does not lend itself to Montgomery straps. Because of leg movement and the close proximity to the groin, a simple dressing works best. Wound dehiscence requires surgical repair. If tension on the suture line is an issue, the patient can benefit from a binder to support the incision.

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19. The nurse dresses the surgical incision on the patient’s elbow. Which method of securing the

bandage should the nurse use with this patient? a. Spiral b. Circular c. Recurrent d. Figure-eight ANS: D

The nurse uses a figure-eight bandage to cover the patient’s elbow dressing because it involves oblique, overlapping turns of the gauze roll, lending itself to use on a joint. By ToBro.uCsOanMd radial and ulnar bones, the bandage alternating the oblique turns aroNuUnR dS thI eN huGm anchors the dressing and immobilizes the joint. Overlapping, ascending turns of the spiral dressing effectively anchor a dressing to the upper or lower arm separately but do not secure the dressing at the elbow effectively because the dressing anchors at the beginning and the end. Bandage turns overlapping one another are as effective for the elbow as the spiral dressing. The recurrent dressing is most effective on the skull or a stump because the bandage folds back on it to cover the region. The nurse avoids choosing this bandage for an elbow because the bandage needs to cover a center portion of the arm versus the terminal end of an extremity.

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20. The nurse is preparing to change a moist-to-dry dressing on a patient. After correctly

identifying the patient, what is the next most appropriate step for the nurse to perform? a. Assess patient/family’s knowledge of the purpose of the dressing change. b. Assess the dressing for the presence of drainage. c. Ask the patient to rate his or her wound pain. d. Review the order for the type of dressing.

ANS: C Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The first step the nurse should do after identifying the patient is to determine if the patient is having any wound pain. It is important to administer prescribed analgesic as needed 30 minutes before the dressing change because giving pain medication before dressing change achieves peak effect of the drug during the procedure. Assessing the dressing for drainage, reviewing the orders, and assessing the patient’s knowledge are important but can be done after the pain has been assessed and treated so that the pain medication can have time to reach peak effect when the dressing change begins.

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21. The nurse has applied a transparent dressing to facilitate débridement of the pressure ulcer.

How often should the nurse change that dressing? a. Every 6 days b. Every day c. Every 3-4 days d. Every 12 hours ANS: B

Transparent dressings are normally changed every 3 or 4 days or as needed; however, if using the dressing to facilitate autolytic débridement, it should be changed every 24 hours.

DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

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MULTIPLE RESPONSE 1. The nurse is working with a student nurse to provide care to a patient with a pressure ulcer.

The student nurse describes characteristics of an ideal dressing. Which of the following statements indicate the student needs more education? (Select all that apply.) a. The dressing should keep the wound bed dry. b. The dressing can be removed without causing trauma. c. The dressing should conform to the body to allow for movement. d. Cost should not be a consideration.

ANS: A, D

The characteristics of an ideal dressing include a dressing that is able to absorb exudate yet keep the wound bed moist but the surrounding peri-wound area dry and intact, be appropriate for infected wounds, conform to the body for ease of movement, maintain physiological wound environment, and be cost-effective.

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2. The nurse is caring for a patient with a pressure ulcer. The nurse would expect which of the

following outcomes if the patient’s wound is healing? (Select all that apply.) a. Pain intensity is reduced during dressing changes. b. The depth of wound is reduced.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. The amount of exudate increases. d. The amount of necrotic tissue decreases.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: A, B, D

Outcomes of wound healing include a reduction in the volume of exudate and amount of necrotic tissue. In addition, peri-wound erythema resolves, there is a reduction in wound dimensions or depth, and there is a reduction in pain intensity during dressing changes.

DIF: Cognitive Level: Comprehend REF: Page 688| Page 702 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment COMPLETION 1. A highly absorbent nonwoven material that forms a gel when exposed to wound drainage is

called a(n)

dressing.

ANS:

alginate This product is derived from brown seaweed and used for moderate-to-heavy exudating wounds.

DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 685 TOP: Nursing Process: Implementation

2. A

is a fungal or bacteria-embedded slimy matrix of proteins and sugars that adhere to the surface of a wound bed.

ANS:

biofilm These biofilms are known to coNnU trR ibS utI eN toGiT nfBec.tiCoO nsM, especially in chronic wounds. Biofilms contribute to inflammation and an increased production of exudates and slough.

DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 686 TOP: Nursing Process: Implementation

3. A

dressing is contraindicated in ischemic wounds with dry eschar and third-degree burns or wounds that tunnel.

ANS: foam DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 685 TOP: Nursing Process: Implementation

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 27: Intravenous and Vascular Access Therapy Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. After inserting a peripheral intravenous (IV) line into the patient, the nurse provides patient

teaching about the IV insertion site. What information should the nurse give to the patient? a. Expect minor pain at the insertion site. b. Report redness at the insertion site. c. Remain on bed rest with the IV infusion. d. Disconnect IV tubing to change a gown.

ANS: B

The nurse instructs the patient to report redness at the insertion site for early detection of IV complications, including infection and phlebitis. The IV site should cause very little discomfort if the infusion is proceeding without problems. Pain associated with an IV infusion indicates vein irritation from infusing fluid, irritating medication, infiltration, extravasatioin, infection, or phlebitis. Patients with IV infusions are not confined to bed. The nurse instructs the patient to call for help when changing the gown because, if the gown has no snaps at the shoulder, the nurse must feed the IV tubing and bag through the opening of the gown when the gown is changed.

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2. The nurse is trying to access the best insertion site on a patient. Which principle would the

NURSINGTB.CO

nurse use to achieve this goal? a. Avoid using soft, bouncy veins. b. Choose the patient’s best proximal vein. c. Choose a site large enough for adequate blood flow. d. Always use the smallest-gauge intravenous (IV) catheter available.

ANS: C

The site must be large enough to prevent interruption of venous flow while allowing adequate blood flow around the catheter. The nurse chooses a site for venipuncture with soft, bouncy veins because these veins are more easily punctured and stabilized during the insertion. The most distal vein is the best for insertion to maintain the maximum number of potential sites for future use. The smallest-gauge IV catheter suitable for both the therapy and the patient’s vein should be selected.

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3. The healthcare provider’s order reads, “Administer 5% dextrose solution with normal saline

(D5NS) intravenously now.” Which should the nurse implement next? a. Infuse a bolus of D5NS to the patient now. b. Regulate an intravenous (IV) infusion pump at 125 mL/hour. c. Call the healthcare provider to clarify the order.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf d. Perform venipuncture with a butterfly needle.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: C

The only recourse for the nurse is to clarify the order because it is incomplete. It is missing an infusion rate. You would not start an IV or give the IV until you have the infusion rate information.

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4. The healthcare provider prescribes 500 mL of 0.25% normal saline (1/4 NS) intravenously

over 4 hours for the patient. At which rate does the nurse infuse the intravenous (IV) solution into the patient using IV tubing with a drop factor of 15 gtts/mL? a. 125 mL/hr b. 31 mL/min c. 31 gtts/min d. 125 gtts/min ANS: C

500 mL  4 hr

1 hr  15 gtts = 31.25 gtts/min = 31 gtts/min 60 min 1 mL

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5. The prescription for the patient’s intravenous (IV) infusion reads, “100 mL/hr.” The nurse

observes that the patient’s IV line infused 125 mL in addition to the ordered volume after 2 hours. Which is the most important intervention for the nurse to implement? a. Compare weight to baseline data. b. Replace the infusion p u mp NbaUt R te S ri eIsN . GTB.COM c. Assess the patient for respiratory distress. d. Reduce the infusion rate below 75 mL/hr.

ANS: C

The nurse assesses the patient for respiratory distress after an excessive infusion of 125 mL of IV fluid because excess total body fluid often leaks into the pulmonary vascular bed to decrease gas exchange. This may lead to hypoxemia and dyspnea because the patient has difficulty with oxygenation, and there can be enough fluid overload to precipitate heart failure in a patient with heart disease or respiratory failure in a patient with pulmonary disease.

Weighing the patient is a reasonable nursing intervention to differentiate patient weight gain from fluid or caloric intake. Verifying patient safety and well-being is a better choice and is more important than differentiating the weight because the extra fluid can cause dyspnea, desaturation, and heart failure. Checking the infusion pump batteries is a reasonable intervention if the pump operates on battery power. The nurse can reduce the infusion rate to 75 mL/hr after collaborating with the healthcare provider. The nurse cannot change the infusion rate because doing so is equivalent to practicing medicine.

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6. The patient has an intermittent infusion device inserted in the hand. Which strategy should the Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

nurse use related to prevention of dislodging the patient’s intravenous (IV) access? a. Instruct the patient how to protect the IV site.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. Apply a new sterile dressing every day. c. Change the IV tubing at least daily. d. Flush the IV catheter every morning.

ANS: A

The most important prevention strategy for the nurse to implement is to instruct the patient to protect the IV site by reducing trauma, keeping the IV line in sight, and getting out of bed properly. Less manipulation or trauma to the IV site reduces intravenous irritation and maintains a better seal at the skin to prevent the entry of microorganisms. Daily sterile dressing changes are excessive and may increase the risk of infection and impaired skin integrity. Generally the nurse changes the dressing every 3 days and when needed; however, he or she follows agency policy. Daily flushing of the IV access is inadequate to maintain patency. The nurse changes the IV tubing according to agency policy to prevent infection; however, instructing the patient to participate in access care of the IV line is a more comprehensive prevention strategy. IV access devices require flushing at least 3 times a day with normal saline solution.

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7. The nurse observes fine white crystals in the intravenous (IV) tubing that is infusing an

antibiotic. Which action should the nurse take? a. Tell the patient that this is a common occurrence. b. Stop the infusion and notify the healthcare provider. c. Flush the tubing with normal saline solution. d. Attach a 0.22-micrometer inline intravenous (IV) filter.

ANS: B

White crystals in IV tubing indicate precipitation of a substance in the infusion, most likely the medication because it is the solute with the highest concentration. If the crystals enter the patient, they can behave like emboli, occluding tiny vessels, and cause regional irritation. At a minimum, the crystals usually occlude the IV line. The nurse stops the infusion, discards the IV tubing, checks to ensure compatibility of all agents in the infusion, and notifies the healthcare provider. The IV access potentially needs to be changed. The nurse avoids telling the patient that this is a common occurrence because it is a complication of an IV infusion. He or she avoids flushing the tubing because injecting a fluid bolus increases the risk of infusing a crystal into the patient. He or she uses an IV filter when indicated for effective therapy.

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8. The nurse observes that the patient’s left cephalic intravenous (IV) site is cool, swollen, and

mildly tender, although the IV line is infusing at the prescribed rate. Which action should the nurse take first? a. Instruct the patient to elevate his or her arm on two pillows. b. Discontinue the IV infusion and start one in the right arm. c. Apply a warm, moist compress to the IV site. d. Reassess the IV site in 2 hours for any change.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: B

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The patient’s IV site is infiltrated; thus the nurse should discontinue the infusion immediately and start another IV infusion, preferably in the other arm. If the right arm is contraindicated, the nurse chooses a subsequent site that is proximal to the original site to avoid additional irritation of the vein. An infiltrated IV site increases the risk of regional phlebitis. The nurse should collaborate with the healthcare provider to apply a warm, moist compress to facilitate healing and provide comfort once the IV line has been removed. After the nurse discontinues the IV infusion, he or she instructs the patient to elevate the arm to reduce edema because this technique facilitates venous return.

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9. The nurse is explaining to nursing assistive personnel (NAP) how to help maintain the

patient’s intravenous (IV) therapy. What action regarding IV therapy can be delegated to the NAP? a. Adjusting the infusion rate b. Changing the IV dressing c. Reporting patient complaints d. Administering IV antibiotics ANS: C

The nurse delegates very little to the NAP related to IV therapy. The NAP is expected to report patient complaints to the nurse because he or she receives training to perform this task, however the nurse must determine the meaning of the complaint and how to resolve it. The nurse retains responsibility for adjusting the infusion rate, changing the dressing, and administering IV antibiotics because these nursing tasks require critical thinking and nursing judgment.

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10. The nurse feels resistance while trying to flush the intravenous (IV) line with a 5-mL syringe

of normal saline solution before administering a medication by IV bolus. Which should the nurse implement next? a. Use a 3-mL syringe to flush. b. Aspirate the IV line for a blood return. c. Check for causes of resistance. d. Inject the IV medication slowly.

ANS: C

The nurse checks for causes of resistance, such as clamped or kinked tubing. If the IV site is occluded, the nurse discontinues the IV infusion and inserts another IV line in another site.

Using a 3-mL syringe increases the potential pressure delivered by the flush. The smaller the syringe, the higher the pressure exerted on the vein. Blood return is a not a sensitive indicator of IV patency; thus the nurse avoids basing follow-up nursing care on the blood return. He or she avoids injecting the medication to prevent complications.

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 11. The nurse infuses a unit of blood, but after 4 hours the blood infusion is not complete. Which

action should the nurse implement? a. Check the intravenous (IV) access for patency. b. Increase the infusion rate of the blood. c. Discontinue the blood infusion. d. Assess the patient for an ABO mismatch.

ANS: C

The nurse infuses whole blood within a 4-hour time limit; thus, if the infusion is incomplete at the end of 4 hours, the nurse must discontinue it to decrease the risk of adverse transfusion effects because the blood has warmed sufficiently to promote microorganism growth.

Checking the IV access for patency is a reasonable intervention because at the end of 4 hours the IV access is likely to have fibrin deposits or small accumulations that impede infusion rates. Nevertheless the nurse must discontinue the blood infusion because after 4 hours, the blood is not safe to infuse. He or she avoids increasing the infusion rate to complete the transfusion because it increases the risk of fluid volume overload. Although delayed transfusion reactions occur, if a mismatch exists between the blood and the patient, the patient is more likely to manifest reaction within the first few minutes of the transfusion because this is when most transfusion reactions occur.

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12. The nurse prepares to administer blood to the patient. Which is the nurse’s priority action? a. Determining patient history of autologous blood donations b. Assessing patient baseline vital signs before the transfusion c. Confirming the rate of the bNlo usGioTnBw.itChOthMe healthcare provider UoRdSinIfN d. Identifying patient blood type, cross-match, and blood product ANS: D

The most critical intervention to administer blood products safely is to accurately identify patient, blood type, cross-match, and blood product because an identification error potentially leads to devastating adverse effects, including hypersensitivity reactions, renal damage, and death. The nurse follows agency policy throughout the process of blood administration to prevent complications from the administration of blood products. Assessing patient vital signs for baseline data is very important for comparison during the transfusion because the data provide the nurse with a basis of comparison to evaluate patient changes. The patient’s history of blood donations is irrelevant information unless the donations left the patient grossly anemic. The nurse clarifies any orders when a question develops. Most agency policies do not routinely require confirmation of the infusion rate.

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13. The nurse prepares to relocate an intravenous catheter because of signs of infiltration. The

IV was located in the patient’s nondominant hand. Which criterion would be best for the nurse to use when deciding on the location of the new intravenous (IV) site? a. Use a site distal to the original site. b. Place it wherever a vein is suitable.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. Place the new site at a venous bifurcation. d. Continue to use the nondominant extremity.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: B

Since an IV site has infiltrated, it is no longer appropriate to use, even though it is on the nondominant extremity. The nurse must now find a site where the vein is of adequate size, location, and pliability and place the IV catheter there. The most distal site is suitable for an original IV site, but it should not be used if an IV line is being reinserted in the same extremity because of possible infusion difficulty, especially when infiltration is present. The nurse avoids inserting the IV catheter at a bifurcation because he or she exposes two vessels to the risks of IV therapy. Although it is ideal to use the patient’s nondominant hand, it may not be possible if the prior IV infusion has infiltrated. Injury and pain to the patient could occur.

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14. The nurse is caring for a patient with a peripheral intravenous access that is used

intermittently for medications but is not a continuous infusion. Which technique should the nurse use for routine care of this peripheral line? a. Flush with a low concentration of heparin. b. Always change the end cap with each medication dose. c. Change the intravenous (IV) insertion site every day. d. Flush with 0.9% saline solution.

ANS: D

Guidelines for the nursing care and maintenance of IV access devices include regular flushes with normal saline solution to assess for and maintain patency since the line is not used constantly. Heparin flushes are not considered routine but are specifically ordered for use in certain patients. The end cap does not need to be changed with every medication dose unless this is agency policy, but it d o eNs U neReS dI toNbGeTs B w. abCbO edMwith an antiseptic. Routine nursing care of an IV site should prevent phlebitis and infiltration. Changing the IV insertion site daily causes patient discomfort, increases costs, and is contraindicated.

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15. The nurse assesses the patient’s intravenous (IV) insertion site and notes that it is warm, red,

and tender. Which intervention should the nurse implement first? a. Slow the infusion rate. b. Discontinue the IV infusion. c. Apply cool compresses. d. Apply warm compresses.

ANS: B

The nurse must discontinue the IV infusion with a warm, red, and tender appearance because these clinical indicators are consistent with an infection. The nurse also discontinues the IV infusion to decrease the risk of sepsis, tissue loss, and a thromboembolic event. If the site is infected, slowing the infusion rate is unlikely to help. Cool compress application is an improper therapy for the problem. The nurse applies a warm compress after discontinuing the IV line from the inflamed tissue.

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 16. The nurse is preparing to administer blood. What solution is most appropriate for the nurse to

use when priming the blood administration set? a. 0.45 normal saline b. 0.9 normal saline c. D5 0.45 normal saline d. Dextrose 5% in water ANS: B

The only compatible solution for blood administration is normal saline because it is an isotonic solution. The remaining solutions, especially the dextrose solution, can cause problems with blood administration.

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17. The nurse is setting up to administer a unit of blood. Which is the most important nursing

intervention during preparation for this procedure? a. Prepare a normal saline solution. b. Obtain a Y-tubing for administration. c. Provide the patient with information. d. Identify the blood product and patient.

ANS: D

Before administering blood, the nurse checks the identification of the patient and the blood product according to agency policy, which includes several patient identifiers. Accurate identification decreases the risk of patient injury, infection, or death from patient-blood mismatch. The nurse prepares the Y-tubing with normal saline before the blood transfusion is started. He or she takes time toNteUaR chStI heNpGaT tiB en.t C beOfM o re beginning the transfusion. The instruction should include when the nurse should be notified; this instruction is given not to alarm the patient but to make the patient an active participant.

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18. The patient has a peripheral infusion for the administration of antibiotics. Which action is

most effective for the nurse to use to detect an intravenous (IV) therapy–related infection? a. Use clean technique for dressing changes. b. Palpate the insertion site through the dressing. c. Change the IV tubing at 12-hour intervals. d. Routinely apply an antimicrobial to the IV site.

ANS: B

The nurse palpates the insertion site gently through the dressing to detect any infection by checking for tenderness or swelling. Removing the dressing exposes the insertion site to contamination from the nurse’s contact and environment and risk to the tissues. The nurse uses aseptic technique for IV dressing changes. IV tubing changes every 12 hours are excessive and costly. The nurse applies antimicrobial agents to the insertion site according to agency policy.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 19. The nurse assesses the patient’s intravenous (IV) infusion. Which clinical indicator cues the

nurse to take special precautions while infusing IV fluids? a. Poor skin turgor b. Bilateral crackles c. Mild hypotension d. High serum sodium ANS: B

The nurse scrutinizes IV therapy for patients with crackles in the lungs because it is consistent with clinical indicators of fluid overload and pulmonary edema. In fact, crackles consistently indicate fluid of some type in the lungs and are a classic sign of fluid overload. As a result, the nurse administers IV fluids to the patient with heightened scrutiny to avoid administering excess IV fluids. Poor skin turgor, hypernatremia, and hypotension indicate a potential need for additional fluid volume.

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20. The nurse is preparing to insert a peripheral intravenous (IV) line. Which technique should the

nurse implement to prepare for the IV insertion? a. Slap the selected vein gently several times. b. Select a proximal site on the extremity. c. Shave the hair in the area of the insertion site. d. Tie a tourniquet above the selected insertion site.

ANS: D

The nurse applies a tourniquet to the patient’s arm to engorge the vein selected for IV insertion. This facilitates c a t h e tNe rUiRn sSe Ir t iNo G nT beBc. auCsO eM a larger vein is easier to enter without transecting the vein than a small vessel. The nurse avoids tapping and massaging the vein before IV insertion because these actions increase the risks of hematoma formation and vasoconstriction. The most distal site on the extremity suitable for IV therapy is selected, and hair around the potential IV insertion site is clipped not shaved, because shaving increases the risks of impaired skin integrity and infection through microabrasions.

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21. The nurse is trying to get an intravenous (IV) line to last several days. What responsibility

does the nurse have related to the assessment and maintenance of a peripheral IV site? a. Elevating the patient’s arm to maintain the ordered flow b. Padding the IV site for skin protection c. Inspecting the insertion site on a regular schedule d. Changing the site every day at the same time ANS: C

The nurse inspects the insertion site regularly for early detection of inflammation, infection, phlebitis, and leakage to fulfill the duty the nurse owes to the patient for preventing complications. Elevating the patient’s arm is unnecessary. Changing the site daily increases patient risk for infection and trauma. Padding the site obstructs direct observation of the site Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

and prevents early detection of complications; the best method of protecting the IV site is patient education and continuously observing site.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

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22. The nurse assesses the patient’s intravenous (IV) site. Which clinical indicator does the nurse

recognize as being most consistent with phlebitis? a. An elevated heart rate b. Decreased skin temperature c. Erythema along the vein line d. Edema around the insertion site ANS: C

The nurse scrutinizes the IV insertion site for redness along the outline of the vein through the skin. The erythema indicates inflammation of the vein. Tachycardia is consistent as a clinical indicator for infection. Cool skin is consistent with clinical indicators for infiltration. Regional edema is consistent with clinical indicators for inflammation and infection.

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23. The nurse observes bleeding on the dressing of a site where the IV was discontinued. Which

action should the nurse take first? a. Hold pressure on the site. b. Replace the dressing. c. Apply a warm compress. d. Lower the site below the level of the heart.

ANS: A

The nurse needs to hold pressure on the site since it is continuing to bleed after the IV was discontinued. Replacing the dressing will not address the cause. A warm compress causes vasodilation to increase localized blood flow. Lowering the site will increase the bleeding.

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24. A patient in the emergency department needs a blood transfusion of A blood, and none is

available. Nursing care would be correct if the nurse administered blood of which type? a. A+ b. O+ c. O d. AB ANS: C

The nurse can administer O because it doesn’t contain any proteins or substances that the patient doesn’t already have. O+ and A+ nor AB cannot be administered because the presence of the Rh factor would cause a reaction in the patient. Th patient has antibodies to the B antigens found in the AB blood.

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 25. The nurse is administering parenteral nutrition via a central venous access device. Which

outcome would best substantiate the nurse’s assessment that this therapy is effective? a. The patient gains 4 1/2 pounds in 1 week. b. The patient’s blood glucose stays between 130 and 160. c. The patient states, “I’m feeling much stronger today.” d. The patient gains 6 pounds over 12 days.

ANS: D

The patient should gain between 1 and 3 pounds per week on parenteral nutrition. Four and a half pounds is too much of a weight gain in 1 week. The blood glucose level is too high. The patient’s statement is subjective datum and is less accurate than measurable data.

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26. The prescription for the patient’s intravenous (IV) fluid reads, “Infuse 1000 mL over 10

hours.” At which rate does the nurse infuse the IV fluids using IV tubing with a drop factor of 15 gtts/mL? a. 20 gtts/min b. 25 gtts/min c. 30 gtts/min d. 32 gtts/min ANS: B

1000 mL  1 hr  15 gtts = 25 gtts/min 10 hr 60 min 1 mL DIF: Cognitive Level: RemembN erURSINRGETFB : .PC agOeM723 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation 27. A 5-year-old patient has intravenous (IV) fluids prescribed at 40 mL/hr, through microdrip

tubing. Which rate does the nurse use to infuse the patient’s IV fluid? a. 20 gtts/min b. 25 gtts/min c. 40 gtts/min d. 60 gtts/min ANS: C

When the nurse uses microdrip tubing, he or she realizes that the infusion rate in drops per minute equals the hourly rate because the drip factor for this tubing is 60 gtts/mL. DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 723 TOP: Nursing Process: Implementation

28. The order calls for the patient to receive 500 mL of intravenous (IV) fluid over 4 hours, and

the nurse uses IV tubing with a drop factor at 10 gtts/mL. Which rate should the nurse use on an electronic infusion pump for IV fluids to administer this prescription? a. 125 mL/hr b. 500 mL/hr Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. 21 gtts/min d. 32 gtts/min

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: A

The electronic infusion pump administers fluid in milliliters per hour; thus the nurse programs the pump to infuse 125 mL/hr. The nurse obtains the infusion rate by dividing the total volume to be infused by the number of total hours for the infusion: 500 ÷ 4 = 125. If the nurse uses gravity to administer the fluid, he or she should use the roller clamp to limit the drops per minute to 21 gtts/min by using tubing with a drop factor of 10 gtts/mL. DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

REF: Page 723 TOP: Nursing Process: Planning

29. The nurse is preparing to change the intravenous (IV) solution after the current one infuses.

What action is appropriate for the nurse to take to provide for a smooth transition from the empty bag to the new one? a. Hang another bag of the identical IV solution. b. Change the tubing when preparing a new IV bag. c. Allow IV fluid to empty into the upper part of the tubing. d. Obtain the next solution bag approximately 1 hour ahead.

ANS: D

The nurse checks the order and prepares the next bag of IV fluid 1 hour ahead of schedule to have the solution ready for administration. This avoids disruptions in therapy. Hanging the identical IV solution can contradict the prescription. Changing the tubing with each new bag is unnecessary and wasteful. The nurse stops the infusion before air reaches the IV tubing.

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UiRthSaIpNeGriT 30. The nurse is caring for a patienN tw phBe. raC l iOn M t r av e n o u s (IV) line. What should the nurse do during the IV site dressing change to prevent accidental dislodgement of the IV catheter? a. Stabilize the IV catheter until the tape is in place. b. Place folded gauze under the IV catheter hub. c. Wear clean gloves to remove the old dressing. d. Clean in a circular motion away from the site.

ANS: A

To prevent accidental catheter dislodgement, the nurse stabilizes the IV catheter with the nondominant hand until the agency-approved covering is in place during the IV dressing change. The nurse avoids applying traction or bending the catheter to maintain infection control and the integrity of the catheter. The nurse places a folded 2  2–inch gauze pad under the hub to prevent excessive skin pressure from the hub. He or she wears clean gloves to remove the old dressing to prevent self-contamination. The insertion site is cleansed using a circular motion from the center to the exterior of the site to prevent recontamination.

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31. The nurse is preparing to initiate a blood transfusion. Which step of the procedure should the

nurse implement first? a. Begin the infusion at 2 mL/min.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. Establish a single-line infusion. c. Check vital signs in 30 minutes.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf d. Shake the blood gently to mix the preservative.

ANS: A

The nurse initiates infusion of the blood very slowly at 2 mL/min to prevent the infusion of a large volume bolus of potentially incompatible blood. Most transfusion reactions occur during the first 15 minutes of the infusion; thus the nurse continues the slow rate for 15 minutes while closely monitoring the patient for a transfusion reaction. The nurse needs to infuse blood products through a Y-tubing administration set. The nurse evaluates the patient’s vital signs within 5 minutes of starting the infusion for 15 minutes and then every 15 minutes or according to agency policy. The nurse avoids shaking blood products because violent movement damages erythrocytes and increases their hemolysis.

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32. A patient on an anticoagulant is going home and needs his peripheral intravenous (IV) line

removed. Which action is essential for the nurse to take? a. Pull the IV catheter out smoothly but quickly. b. Apply sterile gloves before going to the patient’s bedside. c. Check the most recent clotting studies. d. Apply pressure over the insertion site after removal of the IV line for 5 to 10 minutes.

ANS: D

The patient taking an anticoagulant has a longer bleeding time; thus the nurse applies pressure to the puncture site for 5 to 10 minutes to minimize blood loss and prevent hematoma formation. The nurse removes the catheter slowly to avoid patient injury or damage to the catheter. He or she applies cl e aNn UglRoS v eIs Nb G ecTa uBs.e Ct hOe Md r es s i n g and catheter are contaminated.

Checking the most recent coagulation is helpful, but, regardless of the results, extra pressure should be applied over the insertion site after removal for 5 to 10 minutes.

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33. The nurse administers blood to the patient and observes that the patient has tachycardia, chills,

and lower back pain. Which should the nurse implement first? a. Notify the healthcare provider. b. Notify the blood bank. c. Complete the vital signs. d. Remove the intravenous (IV) tubing.

ANS: D

Once the nurse suspects a transfusion reaction, he or she immediately stops the infusion so the patient receives no additional blood from the current bag and quickly primes different IV tubing with saline solution. He or she uses this to replace the blood tubing but retains the blood and the tubing for the blood bank. He or she completes the vital signs and notifies the healthcare provider and the blood bank. Stopping the infusion is the priority to limit the transfusion reaction as much as possible.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf COMPLETION 1. A

infusion occurs when the flow rate is set at an ordered rate and given over a 24-hour period.

ANS: continuous DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

2.

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is a specialized form of nutritional support in which nutrients are given intravenously (IV) through a CVAD by an infusion pump to patients with significant gastrointestinal (GI) dysfunction.

ANS:

Parenteral nutrition Parenteral nutrition is composed of amino acids, glucose, and lipid as energy sources, with the addition of various electrolytes, minerals, and trace elements, as a means to provide complete or partial nutritional supplementation.

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 28: Preoperative and Postoperative Care Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. The nurse instructs the patient about scheduled surgery involving general anesthesia and about

postoperative care. Which should the nurse include in patient teaching? a. Determine patient preference about pain medication. b. Avoid eating or drinking anything 2 hours before surgery. c. Ask for antianxiety medication in the operating room. d. Follow the rules for beginning to exercise after the incision has healed.

ANS: A

Patients must be asked about their cultural practices and religious beliefs that may alter their family caregiver’s acceptance of necessary education and procedures. It is helpful to assess patient preference for pain medication, before and after surgery. The nurse instructs the patient to avoid food and fluid 6 to 8 hours before the procedure to prevent aspiration of gastric contents. The patient is advised that he will be unconscious in the operating room under general anesthesia. To avoid unnecessary patient upset and distress, the nurse also states that the patient will feel nothing, may remember nothing, and will wake up after the procedure. The surgeon will discuss resumption of exercise with the patient.

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2. The patient is prepared for shoulder surgery and tells the preoperative nurse that the scar will

NURSINGTB.

be invisible after the surgery. Which action should the nurse take at this time? a. Tell the patient that this surgery always leaves a scar. b. Change the operative consent form to reflect what the patient says. c. Inform the surgeon that the patient is not ready for surgery. d. Notify the surgeon of the patient’s statement before medication is given.

ANS: D

The patient’s statement about an invisible scar is inconsistent with shoulder surgery because skin incisions always leave a scar. The inconsistent statement cues the nurse to verify the patient and the procedure on the surgical consent form and then, once patient identity is secure, address the patient’s misunderstanding and ask the surgeon to speak with him or her.

Many procedures leave a nonvisible scar, including vaginal, rectal, and cystoscopic procedures and procedures behind the hairline. The nurse avoids changing the consent form.

The nurse does not know yet whether the patient is ready for surgery; he or she resolves the patient misunderstanding or misidentification first.

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3. The patient’s family has had many surgical experiences with complications. What information

is most important for the nurse to use to understand the patient’s stress in the perioperative period?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. Ask the patient if medications will calm him or her before surgery. b. Identify specific concerns regarding the surgical experience.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. Explain to the patient that stress is easily identified and managed. d. Tell the patient that stress is unrelated to environmental factors.

ANS: B

The patient’s perception of the perioperative experience creates a point of reference for evaluation of the situation. Asking about fears, cultural practices, and religious beliefs allows the nurse to anticipate the patient’s and family caregiver’s priorities and adapt the plan to give appropriate instruction and support. The nurse should get more information so potential concerns can be identified. Anxiolytics can relieve stress quickly by sedating the patient but do nothing to resolve the patient’s stressor. Stressors can be difficult to identify and are usually more difficult to manage. Stress can develop from hereditary and environmental factors.

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4. The nurse interviews a preoperative patient who evades all questions about medications taken

at home. Which is the best response for the nurse to use to facilitate safe, effective nursing care? a. “I feel that you’re uneasy about discussing medications.” b. “Why don’t you want to talk about your medications?” c. “You’re avoiding me; so you must have a big secret.” d. “Don’t you think that it’s important to discuss medications?”

ANS: A

The best response is to validate the nurse’s perception of the patient’s behavior in a nonthreatening manner in order to elicit more information from the patient. The nurse avoids SaIyNmGaTkB asking a “why” question b e c a u Ns eUi R tm e. aC paOtiM ent feel defensive. Stating that the patient is avoiding the question has the potential to be beneficial for interviewing, but concluding that the patient has a secret may be perceived as an accusation, sarcasm, or humor and lacks professionalism. It is unlikely to elicit more information. Asking a question that implies a position that the patient hasn’t advocated (you don’t think medications are important to discuss) is judgmental and unlikely to uncover the patient’s true concerns.

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5. The nurse determines that the patient is at risk for atelectasis caused by pain from back

surgery 3 hours ago. Which is the best goal for the nurse to help the patient achieve? a. The patient’s lungs will be clear when auscultated every 2 hours. b. The nurse will manage the patient’s pain with oral morphine. c. Cool the patient’s elevated temperature with a cooling mat. d. Maintain adequate cardiac output with a positive fluid balance.

ANS: A

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Because of the cut back muscles, the patient is at risk for respiratory problems after surgery due to pain. The outcome reflects the patient’s status and is stated in a manner that can be evaluated. The patient would benefit from intravenous morphine to manage pain because it is easier to control. He or she can receive small, frequent doses for pain instead of a single, large dose that is more likely to result in hypotension. There is no indication for a cooling mattress.

In addition, both of these are nursing interventions. For the patient at risk for alteration in cardiac output, maintaining a positive fluid balance increases the risk of fluid volume overload and can cause heart failure in the patient until the fluid is removed. The term adequate cannot be evaluated.

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6. A nurse admits a patient, who works in dental office, to ambulatory surgery. The patient’s

history includes multiple surgeries over the last 10 years. In addition, when the patient wears antiembolism stockings, a rash develops. Which action should the nurse take initially? a. Use powdered gloves to provide care to this patient. b. Remove latex products from the patient’s room. c. Inform the surgeon about the patient’s hypersensitivity to latex. d. Gather additional information about potential allergies.

ANS: D

The nurse addresses the patient’s potential hypersensitivity to latex directly to develop a comprehensive history of the problem before collaborating with the healthcare provider. If the patient has a hypersensitivity to latex, wearing powdered gloves potentially aggravates the problem because the powder can aerosolize and increase the risk of patient exposure by inhalation. Removing latex supN plUieRsSisIpNreGmTaB tu.reCbOeM cause the nurse needs to complete the patient assessment. The nurse must complete the assessment about the patient’s potential allergies before notifying the surgeon.

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7. The nurse instructs the patient about postoperative coughing and deep-breathing exercises

following abdominal surgery. Which technique should the nurse use to engage the patient in prevention of pneumonia and atelectasis? a. Begin coughing and deep breathing when the patient is ready. b. Take a deep breath, hold it for 10 seconds, and exhale slowly. c. Support the incision when doing these exercises. d. Begin coughing and deep breathing when the patient is wide awake.

ANS: C

The nurse engages the patient in postoperative coughing and deep breathing by instructing him or her to splint the incision similar to when the patient is turning. By holding the incision, the patient stabilizes the edges of the wound and puts less stress on the incision. The nurse does not allow the patient to decide when and if coughing and deep breathing are done. He or she involves the patient actively. Simply taking a deep breath and holding it before exhaling does not clear secretions from the respiratory tract. As soon as the patient begins waking, he or she will be coached by the nurse to cough and deep breathe. Pain medication will help the Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

exercises to be less painful.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

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8. The nurse assesses the patient and determines that he may be at risk for altered peripheral

tissue perfusion. Which activity should the nurse include in patient teaching to prevent decreased perfusion to his extremities while he is on bed rest? a. Avoid any fluids by mouth until the patient begins passing gas. b. Flex and rotate the ankles several times every hour while awake. c. Rest quietly to allow the maximum action of the opioid analgesics. d. Stay positioned on either side with pillows between the legs.

ANS: B

The nurse instructs the patient to perform ankle flexion and rotation to promote venous return from the lower extremities, which helps prevent thromboembolic complications and increases arterial perfusion to provide oxygen for the tissues while the patient is not ambulating. Passing gas has no correlation to decreased perfusion in the patient’s lower extremities. Pain needs to be controlled, but this has little to do with potential impaired tissue perfusion in the lower extremities. Placing pillows between the legs when positioned on the side provides comfort and is a passive method of preventing compression of the lower leg by the upper one. This is not the most effective way of preventing perfusion to the lower extremities.

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9. The nurse plans assignments for the staff in an ambulatory surgery center. Which assignment

can the nurse delegate to nursing assistive personnel (NAP)? a. Bring the preoperative medications prepared by the nurse to the patient.

RaStIoNthGeTpBat.ieCntO. M b. Administer a preoperative eNnU em c. Instruct the patient to arrange for a ride home and a companion after surgery. d. Reinforce preoperative teaching related to the patient’s postoperative diet.

ANS: B

The nurse delegates administering the preoperative enema to the NAP because this individual can be trained to perform this task. Handling medications is a nursing responsibility and cannot be delegated. Patient teaching remains a nursing responsibility because it involves assessment, planning, and evaluation components.

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10. The patient asks why preoperative application of compression stockings has been ordered.

Which response by the nurse is most appropriate? a. “They help to prevent any chance of blood clots after surgery.” b. “They are measured from behind the knee to the heel.” c. “They are connected to a pump that compresses different parts of the leg at different times to help the circulation in your legs after surgery.” d. “They put continual light pressure on your legs to improve venous return after surgery.”

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: D

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The purpose of compression stockings is to promote circulation during periods of immobilization, reducing the risk of an embolism. They cannot prevent any chance of blood clots because blood clots can develop in other body areas for other reasons. The method of measurement doesn’t answer the patient’s question about why they are used. The devices connected to a pump to promote circulation in the lower extremities are called sequential compression devices.

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11. The nurse admits a male patient for ambulatory surgery. The patient tells the nurse that he

skipped breakfast but drank a cup of coffee and some juice. Which does the nurse implement next? a. Asks the patient to estimate the fluid volume b. Instructs the patient to dress and return home c. Notifies the anesthesiologist and surgeon d. Changes or delays surgery for several hours ANS: A

The nurse obtains additional information from the patient before collaborating with the surgical team so he or she can present a complete picture of the patient’s consumption.

Drinking fluids before surgery increases this risk of aspiration of gastric contents. The nurse notifies the surgical team and collaborates with them to decide about rescheduling, delaying, or proceeding with the patient’s procedure. The nurse does not change or delay the surgery independently. This is a collaborative effort within the patient’s surgical team.

DIF: Cognitive Level: Analyze REF: Page 759| Page 762| Page 767| Page 769 NURSINGTB.CO OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment 12. The nurse prepares the patient for surgery to begin in 1 hour, but the pregnancy test included

in the preoperative orders written yesterday is not in the medical record. Which action should the nurse implement first? a. Call the laboratory to determine if they have the pregnancy test results. b. Collaborate with the surgeon. c. Draw a stat pregnancy test. d. Ask the patient if she is pregnant.

ANS: A

The nurse should first find out if the test results are available before doing anything else. If the results cannot be found, the nurse obtains a blood specimen for a stat pregnancy test because the provider ordered one before surgery and the order is still valid. If the results have not been found after the specimen for the pregnancy test is drawn and sent to the lab, the nurse notifies the surgeon about the situation. The nurse avoids sending the patient to surgery on the basis of her verbal report because she may be unaware of a pregnancy or she may be concealing the truth. The aneshesia and other operative medications can do damage to an embryo or a fetus.

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 13. The nurse assesses a patient before hip surgery. Which piece of information is most critical

for the nurse to report to the surgeon before surgery?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. b. c. d.

The patient is complaining of a pounding headache.

There is a bruise on the patient’s left anterior chest.

The patient uses continuous positive airway pressure (CPAP) at home.

The blood pressure is 20 mm Hg higher than baseline.

ANS: C

The nurse reports the use of CPAP since this may indicate that the patient has obstructive sleep apnea, which poses a risk after surgery. The headache could potentially result from anxiety or hypoglycemia. A bruise on the patient’s chest is not near the operative area. The elevated blood pressure could be a result of preoperative anxiety.

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14. The nurse assesses a patient before surgery. Which piece of patient information is most likely

to require follow-up nursing interventions? a. The patient’s father died after surgery last year. b. The patient was exposed to chickenpox 8 weeks ago. c. The serum hemoglobin level is 13.5 g/dL. d. The patient’s weight is 136 pounds; height is 5 feet 6 inches.

ANS: A

A perioperative death of a first-degree relative warrants further investigation by the nurse to determine the details surrounding the death. If the father died from the surgery or anesthesia, the surgical team needs details to determine whether surgery is indicated for this patient. The patient’s risk for developing chickenpox is past. The serum hemoglobin level is fine for surgery. The data indicate a normal weight for the patient’s height.

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15. While being prepared for surgery, the patient tells the nurse that he didn’t take the ordered

antibiotics in preparation for the surgery. What initial action should the nurse take? a. Document what the patient just said. b. Order the missed medication but in a parenteral form. c. Notify the patient’s surgeon. d. Ask the patient why he didn’t take it.

ANS: C

The nurse must alert the surgeon of the patient’s lack of compliance regarding taking the ordered antibiotics so the surgeon can make a decision. The nurse will document what the patient said, but it is more critical to alert the surgeon. The CDC has identified prophylactice antiobiotics, as recommended, to be crucial in preventing surgical site infections. The nurse cannot order a medication, even though the patient said that the surgeon has ordered it, because there is no order available; nor can the nurse change the medication route of administration. Asking a “why” question is nontherapeutic because it puts the patient in a defensive position.

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 16. The nurse is explaining the purpose and procedure regarding informed consent to a nursing

student. What information should be included in the explanation? a. The nurse provides information about the risks and benefits of the procedure. b. Informed consent only describes the details of the surgery itself. c. The nurse verifies it is complete and consistent with patient’s understanding. d. The nurse obtains consent after administration of the preoperative medication.

ANS: C

The nurse’s role is to verify the patient’s signature and verify that it is complete and consistent with the patient’s understanding. The nurse must know the policies of the facility regarding what to do if the patient later states a lack of understanding. The informed consent states what is being done by whom and includes contingency plans, risks, and benefits. The nurse can help the patient understand the information, but the nurse does not provide it. The healthcare provider who performs the procedure provides informed consent and includes details about the procedure. The patient is potentially incompetent after receiving preoperative medication such as sedatives and opioids; thus the nurse verifies that the consent is in order before administering preoperative medication.

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17. The nurse assesses a patient before knee surgery. Which assessment finding reported by the

nurse will most likely require the surgery to be delayed? a. A 10-year history of smoking a pack of cigarettes per day b. A reddened, swollen, and painful calf c. An upper respiratory infection last month d. A low-normal serum hemoN glU obRinSI leN veGl TB.COM ANS: B

Calf pain, tenderness, and swelling are consistent with clinical indicators of a deep vein thrombosis or an infection; thus the surgery most likely will be rescheduled after resolution of these findings. Impaired circulation of the lower extremities would require that the surgery be postponed. Many surgeons refuse to operate electively on patients with a significant smoking history unless they quit smoking for a long period because smoking impairs tissue healing.

The patient should be fully recovered from an uncomplicated upper respiratory infection last month. Low-normal hemoglobin is sufficient to clear the patient for surgery.

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18. The nurse provides instructions about postoperative exercises to the patient who is scheduled

for a laparotomy. What does the nurse include in patient teaching? a. Flex and extend the knees several times every few hours. b. Cough and deep breathe at least once every day. c. Repeat range-of-motion exercises twice. d. Reposition in bed every 4 hours.

ANS: A Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse instructs the patient to exercise each extremity several times to promote blood flow and venous return to prevent deep vein thrombosis formation. Once-daily coughing and deep breathing are inadequate. Performing each exercise twice is inadequate. The patient needs to reposition at least every 2 hours to prevent inadequate tissue perfusion caused by pressure.

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19. The nurse admits the patient to the postanesthesia care unit (PACU) after hand surgery. The

patient is groggy but can respond after receiving conscious sedation and regional anesthesia.

Which action by the nurse is priority? a. Position the head to maintain a patent airway. b. Elevate the affected hand higher than the level of the heart. c. Monitor the circulatory status in the operative hand. d. Measure the core body temperature.

ANS: A

Although the patient did not receive general anesthesia, the nurse’s priority is maintaining the airway because short-acting benzodiazepines and opioids used during conscious sedation potentially depress respirations. If the patient is very lethargic, he or she may have trouble maintaining the airway and require temporary support. After establishing a stable airway, breathing, and circulation, the nurse elevates the hand according to the provider’s preference while assessing it. Monitoring the circulatory status in the hand that was operated on is essential but not a priority. Checking the temperature is important but is not the priority.

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20. The nurse is caring for a patient who had an ovarian cyst removed under general anesthesia 12

hours ago. Which is the most important goal for this patient? a. The patient will cough and deep breathe every hour for 48 hours. b. The patient will have bowel sounds within 24 hours after surgery. c. The patient will exercise the feet and ankles 3 times this shift. d. The patient will ambulate tonight and 3 times tomorrow.

ANS: D

The most important goal for this patient is ambulation because it promotes lung expansion, restoration of peristalsis, peripheral perfusion, venous return, and tissue integrity and thereby decreases atelectasis and prevents pneumonia, constipation, thromboembolic events, skin breakdown, and infection. The patient should not cough and deep breathe every hour. She must be allowed to sleep. Establishing bowel sounds within 24 hours after surgery is an unrealistic goal. If the intestines are emptied before surgery, restoring bowel sounds can take longer than 1 day, and producing a bowel movement often takes 4 to 5 days. Ankle and foot exercises promote perfusion and venous return, which help to prevent circulatory problems, but ambulation is best.

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 21. The nurse is caring for a shivering 66-year-old patient immediately after back surgery under

general anesthesia. Which nursing intervention is most suitable for this patient?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. b. c. d.

Apply warm blankets to stop the shivering.

Administer medication to relax the muscles.

Use a cooling mat to lower the body temperature.

Tell the patient that shivering is to be expected after surgery.

ANS: A

To warm the patient, the nurse applies warm blankets or a warming device to eliminate shivering because shivering consumes massive amounts of oxygen in skeletal muscle. If the patient has a respiratory or cardiovascular problem, shivering potentially aggravates it significantly. Medication is not indicated for shivering unless it becomes unresolved. The nurse applies a cooling mat in the postanesthesia care unit (PACU) to the patient with an elevated body temperature from infection or from malignant hyperthermia to save the patient’s life and vital organs. Shivering is much more common than malignant hyperthermia, which has a very high fatality rate; most patients die from malignant hyperthermia in the operating room. Telling the patient that this is expected does nothing to relieve the shivering.

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22. The nurse is caring for the patient who has stridor 30 minutes after a thyroidectomy. Which

action should the nurse implement? a. Reposition the patient’s head to open the airway. b. Apply a pressure dressing with gauze. c. Turn the patient to the recovery position. d. Apply oxygen at 10 L/min by face mask.

ANS: A

CpOaMired airway, especially after surgery of the A patient with stridor or who isNsUnoRrS inIgNhG asTaB n.im neck, because surgical manipulation of the tissues usually leads to regional postoperative edema. These patients are at high risk for an impaired airway and dysphagia. The nurse can reposition the patient’s head to open the airway; because the patient is in the immediate postoperative period, the nurse stays at the bedside and manually maintains the airway until the patient supports it independently. There are no data that state that the patient displays signs of bleeding; thus he or she does not need a pressure dressing. The recovery position is a reasonable response if this position helps to maintain the airway. The nurse must open the airway before oxygen at any level benefits the patient.

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23. The patient had shoulder surgery 2 hours ago, and the Hemovac drain is filling at a continuous

rate. Which should the nurse do first? a. Notify the surgeon. b. Monitor the Hemovac drainage. c. Irrigate the Hemovac with sterile saline. d. Attach a larger Hemovac drain.

ANS: A Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse calls the surgeon because the amount of drainage varies with a procedure and the nurse needs to know a specific amount for this patient and surgery so the patient can be monitored appropriately. The surgeon may need to take the patient back to surgery if a problem exists. The nurse should continue to monitor the drainage. Because the volume of drainage is large, the more important action is to call the surgeon. Surgical drains are not designed for irrigation. The Hemovac is an integrated unit that includes the drainage container and attached drain that is placed in the surgical site at the conclusion of a procedure; to change a Hemovac, the provider replaces the tubing and container. This is not a nursing function.

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24. The nurse is caring for the patient after general anesthesia. How often does the nurse perform

routine patient assessment and documentation in the postanesthesia care unit (PACU)? a. Every 5 minutes b. Every 5 to 15 minutes c. Every 15 to 30 minutes d. Every 30 minutes to 1 hour ANS: B

The nurse assesses the patient every 5 to 15 minutes in the PACU because he or she is recovering from general anesthesia and suppression of several vital functions, including maintaining an airway, breathing, and the gag reflex. If adverse responses are occurring, a patient could need reassessment every 5 minutes, but usually every 5 to 15 minutes is sufficient. Assessing at intervals of 30 minutes or more is dangerous because complications develop quickly and subtly, leaving the patient exposed to risks for extended periods.

N URSINRGETFB: .PCagOeM775

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TOP: Nursing Process: Assessment

25. At what point in the surgical recovery process does the nurse need to ambulate the

hospitalized patient for the first time? a. At discharge from the postanesthesia care unit (PACU) b. After discharge to home and before complete recovery c. Between induction for surgery and arrival in the PACU d. After discharge from the PACU and before discharge to home ANS: D

Unless the patient is being discharged from ambulatory surgery, the nurse needs to ambulates the patient for the first time on the surgical unit after discharge from the PACU and before discharge to home because postoperative ambulation is critically important to prevent postoperative complications. Unless the patient is discharged to home, he or she remains on bed rest until after the transfer to a surgical unit for extended postoperative care. The patient is likely to be groggy from anesthesia and affected by pain medication, making ambulation dangerous. The nurse owes a duty to the patient to ambulate before discharge to home.

Surgery occurs between induction and arrival in the PACU. DIF: Cognitive Level: Analyze REF: Page 788 OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 26. The patient is coughing up white mucus after having been intubated for surgery. What action

would be most appropriate for the nurse to maintain a patent airway? a. Administer supplemental oxygen. b. Place the patient in a supine position. c. Perform oropharyngeal suctioning. d. Prepare for endotracheal intubation.

ANS: C

In the immediate postoperative period, patients frequently have pulmonary secretions from mechanical ventilation during surgery. The nurse suctions the patient as necessary to help remove the secretions from the airway. Supplemental oxygen is ineffective therapy to clear an airway. The supine position is contraindicated for patients in the immediate postoperative period unless the patient is hypotensive. The nurse avoids preparing for endotracheal intubation unless the patient develops respiratory failure.

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27. After instructing the patient in using the incentive spirometer (IS), the nurse instructs nursing

assistive personnel (NAP) to encourage the patient to use it. What does the nurse provide to the NAP as a rationale for using the IS after surgery? a. It helps to maintains venous return. b. It helps to reexpand the lungs. c. It prevents any type of respiratory infection. d. It decreases the blood pressure.

ANS: B

CiO Using the IS involves inh aling;NaUs R thS eI luNnG gsTfB ill.w thMair, alveoli that collapse in surgery pop open from expansion of the chest wall. In addition, IS promotes airway clearance by stimulating coughing and gas exchange as secretions are removed from the lungs. Inhalation does promote venous return to the heart, but this is not the reason for using an IS with postoperative patients. Incentive spirometry cannot prevent any type of respiratory infection from occurring. Blood pressure can decrease as the patient stabilizes after respiratory secretions are removed, but this is not the reason for using the IS. DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

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28. The nurse wants to detect a paralytic ileus promptly in a patient after a total abdominal

hysterectomy. Which method is best for the nurse to use to assess for this postoperative complication? a. Auscultate the bowel sounds every few hours. b. Palpate the suprapubic region for distention. c. Evaluate the patient’s postoperative appetite. d. Administer stool softeners for prophylaxis.

ANS: A

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Most patients resume bowel function within days of an abdominal procedure, but it potentially takes longer when the patient takes opioid analgesics for pain control. The nurse auscultates bowel sounds every 4 hours, asks the patient whether gas is passing, and palpates the abdomen for distention for early detection of paralytic ileus to prevent a bowel obstruction and patient pain. The suprapubic region is palpated to check for a distended bladder, not a paralytic ileus. The patient’s appetite can be unaffected by a paralytic ileus at first. If an ileus continues, patients usually lose their appetite and begin vomiting after eating. Administering stool softeners is a nursing action, not an assessment technique.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

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29. The nurse assesses the patient on the first postoperative day after major abdominal surgery.

Which is the most important patient outcome that requires follow-up interventions by the nurse? a. The pain level is 2 on a scale of 0 to 10 after an analgesic. b. The patient is voiding an average of 45 mL/hr. c. Bowel sounds are inaudible in all quadrants. d. The patient performs breathing exercises every 6 to 8 hours.

ANS: D

Increasing the frequency of breathing exercises is important because breathing is a vital function. The patient decreases the risk of atelectasis and pneumonia after surgery with frequent coughing, deep breathing, incentive spirometry, and ambulation. A pain level of 2 is within normal limits for a postoperative patient requiring routine postoperative nursing care.

The urine output is normal. Inaudible bowel sounds after major abdominal surgery on the first postoperative day would not beNtU otR alS lyIuNnG exTpB ec.teCdO . TMh e y would require follow-up nursing interventions, but the respiratory system is priority.

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COMPLETION 1. Postoperative pain tends to be undertreated in

.

ANS:

older adults Postoperative pain tends to be undertreated in older adults. Some patients fear “becoming addicted” or minimize pain because they are stoic. Assess for pain and encourage use of nonpharmacological measures such as relaxation and imagery along with pain medications.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

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2. Effective methods for helping children share their feelings about surgery are

and

.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS:

drawing, storytelling

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

storytelling, drawing Assessment of a child’s perceptions of the surgical experience enforces positive experiences and clarifies misconceptions. Drawing and storytelling are effective methods that allow children to share their thoughts and feelings.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

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3. Maintenance of body temperature in infants and children after surgery is a priority because of

their

temperature-control mechanisms.

ANS: immature DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 775 TOP: Nursing Process: Planning

4. The

phase in the care of postoperative patients extends from the time the patient leaves the operating room (OR) to the time of transfer to the nursing unit.

ANS: postanesthesia DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 755 TOP: Nursing Process: Planning

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 29: Emergency Measures for Life Support in the Hospital Setting Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. The nurse is caring for four patients on the intermediate care unit and plans emergency care

for the patients. Which patient is unsuitable for cardiopulmonary resuscitation (CPR)? a. An 88-year-old patient with end-stage lung disease b. The patient with a valid order for a no-code status c. The patient who specifies not to perform chest compressions d. The patient whose family does not want the patient resuscitated ANS: B

The patient who has a valid order to withhold patient resuscitation from the healthcare provider or according to agency policy should not receive CPR if breathing stops, the heart stops beating, or the patient cannot maintain an airway. The nurse communicates the patient’s directive to withhold resuscitative measures to the entire nursing staff because inadvertent CPR can result in legal liability. Unless the patient specifies that CPR is to be withheld, the nurse must institute resuscitative measures as the need arises despite a grim diagnosis or advanced age. A patient who specifies no chest compressions allows the nurse to provide an airway and breathing; thus the nurse implements resuscitative measures except for chest compressions. Unless the patient is incompetent, the family cannot decide his or her code status because it violates the patient’s right to self-determination and to refuse treatment.

DIF: Cognitive Level: Apply REF: Page 782 OBJ: NCLEX: Physiological IntN egUriR tySINTGOTPB : .NCuO rsM ing Process: Assessment 2. The nurse walks into a male patient’s room and finds him on the floor with his eyes closed.

Which should the nurse implement first? a. Initiate cardiac compressions. b. Call for a code from the room. c. Help the patient back into the bed. d. Verify patient unresponsiveness.

ANS: D

The nurse should assess the patient for unresponsiveness by touching him and calling, “Are you okay?” before activating a code. Although unresponsiveness can be caused by many factors, the nurse wants to stimulate the patient and improve breathing first if possible. The nurse avoids initiating chest compressions until assessing for a pulse because chest compressions over a beating heart can precipitate arrhythmias. Until the patient’s status is assessed, a code should not be activated. The nurse should not move the patient until the spine is cleared. The nurse is not aware of why he is on the floor; thus he must be treated as though he has a spinal injury until that possibility is eliminated.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 788 TOP: Nursing Process: Planning

3. The nurse determines that the patient is in cardiac arrest. Which does the nurse delegate to Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

nursing assistive personnel (NAP)? a. Deliver chest compressions.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf b. Help with patient positioning as directed. c. Inform the family about the patient. d. Prepare emergency medications.

ANS: B

The nurse instructs the NAP to help position the patient, including logrolling onto a backboard or other positions for resuscitative measures, because the NAP receives training to perform the task. Agency policy usually dictates nursing responsibilities during a code. Although NAP are trained to perform basic cardiopulmonary resuscitation (CPR) and use the automatic external defibrillator (AED), the nurse is present; thus the nurse delivers chest compressions.

The nurse avoids delegating family communication to the NAP because the nurse has the critical thinking skills and clinical judgment to discuss the patient with the family and provide meaningful information. The nurse retains responsibility for medications during a code because he or she receives training to administer emergency medications properly.

DIF: Cognitive Level: Analyze OBJ: NCLEX: Physiological Integrity

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4. The nurse participates in the patient’s resuscitation. Which patient assessment finding does the

nurse determine to be an undesirable event during cardiopulmonary resuscitation (CPR)? a. Bruising is present over the anterior thorax. b. The abdomen has become distended. c. The patient has an advance directive. d. An airway is in place without gagging.

ANS: B

Abdominal distention is undesirable during CPR because it is consistent with clinical indicators of air in the stomachN, U whRiS chIcNanGT poBte.nC tiO alM ly occur from esophageal intubation with the endotracheal tube or ventilating the patient with an Ambu bag and airway. Because distention increases the risk of patient aspiration or expiration, the resuscitation team investigates the distention, verifies endotracheal tube placement, and inserts a nasogastric tube for decompression. Thoracic bruising from chest compressions is usually unavoidable; however, since the bruises can upset the family, the nurse should discuss them with the family to ensure understanding. The healthcare team welcomes the patient’s advance directive to clarify resuscitative measures promptly. Maintaining an airway without patient gagging is a desirable event during the code because it facilitates patient oxygenation and ventilation.

However, although this allows for breathing, the code team would rather discontinue the airway with spontaneous patient respirations and airway maintenance.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

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5. The nurse determines that the infant is in respiratory arrest from an airway obstruction caused

by a foreign object. Which does the nurse implement to clear the infant’s airway? a. Applies several back slaps followed by chest thrusts b. Aspirates the foreign object with a Yankauer suction tip c. Holds the child upside down and strikes the anterior chest d. Holds the child on his or her side and performs a blind finger sweep Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: A

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The best chance that the nurse has to remove the foreign object from an infant’s airway is to deliver back slaps followed by chest thrusts. This creates bursts of positive pressure in the infant’s airway to loosen and expel the object. The nurse avoids using a Yankauer suction tip because it is probably too big for the infant’s airway and increases the risk of lodging the object more firmly in the airway. Striking the child on the anterior chest is risky because it mimics chest compressions and, for an infant in sinus rhythm, risks causing an arrhythmia.

The American Heart Association does not recommend blind finger sweeps; however if the object is visible, the rescuer can attempt to remove it if it can be removed without lodging the object more firmly in the airway.

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6. The nurse has been performing cardiopulmonary resuscitation (CPR) on an infant. Which

method does the nurse use to determine its effectiveness? a. Waits for the infant to cry after CPR ceases b. Stops chest compressions to feel for a pulse c. Feels for the pulse during chest compressions d. Delivers 30 compressions to each rescue breath ANS: B

The nurse palpates a brachial pulse to evaluate the effectiveness of infant CPR because it is a large, accessible artery easily palpated by a single rescuer. Although the resuscitation efforts are successful, the infant potentially does not cry after CPR. The carotid pulse on an infant is too difficult to palpate during CPR because the infant is so small and because rescue breathing occurs around the same area. The ratio of chest compressions to rescue breaths for two rescuers is 15:2, and for one resNcU ueRrSitIisN3G0T :2B. .COM DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

REF: Page 790 TOP: Nursing Process: Implementation

7. The patient is in cardiac arrest, and the nurse uses the automatic external defibrillator (AED).

Which does the nurse implement to use the AED? a. Places the AED next to the patient, turns on the unit, and follows the prompts b. Receives training in advanced cardiac life support (ACLS) c. Applies a shock in coordination with the chest compressions d. Uses the automatic defibrillator instead of conventional cardiopulmonary resuscitation (CPR) ANS: A

The nurse places the AED next to the patient near the chest or head and then turns on the unit.

The unit has verbal prompts. The AED is user friendly with clear instructions labeled on the gel pads and instructions embedded on the AED unit. An AED user needs to follow directions correctly to use an AED effectively. ACLS training is unnecessary to use an AED. The nurse avoids delivering shocks and chest compressions together to prevent accidental electrocution.

An AED is used along with conventional CPR because the AED does not compress the chest; its only function is analyzing the patient’s electrocardiogram (ECG) and delivering defibrillations.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 8. The patient’s resuscitation lasts 30 minutes. The patient’s electrocardiogram (ECG) shows

ventricular fibrillation, and the patient has no pulse or blood pressure. What does the nurse rely on to determine when this code should end? a. According to the nursing unit policy b. After 30 minutes of unresponsiveness c. When instructed by the healthcare provider to stop d. After futile results from vasoactive drugs ANS: C

The nurse does not usually determine when to stop resuscitative efforts; it is the code leader, usually a healthcare provider, who stops the resuscitative efforts and pronounces the patient dead. Individual nursing units do not establish protocols for determining when to stop resuscitative measures because individual patients have specific needs that a single protocol cannot deliver; each resuscitation deserves the attention of the patient’s healthcare provider to analyze the resuscitation efforts. An unresponsive patient after 30 minutes of resuscitation is not necessarily hopeless; thus time, as the only factor, does not determine whether resuscitation efforts should continue. If the administration of vasoactive drugs proves unsuccessful, the healthcare provider determines the next step.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

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9. The nurse has just called a code and is preparing to perform cardiopulmonary resuscitation

(CPR) on a child. Where does the nurse position the hands for chest compressions? a. Puts both hands over the upper half of the child’s sternum b. Places the heel of one hand on the lower half of the sternum NURSINGTB.C c. Puts the heels of both hands on the lower third of the sternum d. Places two fingers below the left nipple line at the sternum ANS: B

The nurse uses the heel of one hand and places it on the lower half of the sternum to deliver chest compressions to a child to avoid traumatizing the distal sternal edge. Both hands placed on the chest of a child can deliver excessive pressure and risk serious trauma; in addition, the compressions are ineffective if the hand is placed too high on the sternum. Compressing the chest on the lower third of the sternum risks trauma to the distal sternal edge. Two fingers cannot deliver enough pressure to deliver effective chest compressions to a child.

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10. The nurse has been performing cardiopulmonary resuscitation (CPR) on an adult. Which

artery should the nurse check to evaluate the effectiveness of chest compressions? a. Radial b. Carotid c. Brachial d. Temporal ANS: B Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse evaluates the effectiveness of chest compressions during CPR by palpating a carotid pulse because it is a large artery close to the heart. He or she uses an artery proximal to the heart because the chest compressions are unlikely to perfuse the patient’s periphery. The nurse avoids using the radial and brachial arteries because they are distal to the heart. The temporal artery is too small to provide an evaluation of the effectiveness of CPR. DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 790 TOP: Nursing Process: Implementation

11. The nurse and a colleague begin cardiopulmonary resuscitation (CPR) on an adult patient.

Which ratio of chest compressions to rescue breaths should be used? a. 5:1 b. 5:2 c. 10:1 d. 30:2 ANS: D

The latest guidelines issued by the American Heart Association recommend a ratio of chest compressions to rescue breaths of 30:2 to balance the need to circulate blood and oxygenate the adult patient. The remaining options are not suitable for two-person CPR. DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

REF: Page 789 TOP: Nursing Process: Implementation

12. On entering a patient’s room, the nurse determines that the patient is unresponsive. Which

should the nurse implement next? a. Check the carotid or brachial pulse.

T.B.COM b. Activate the emergency resN poUnRseSsIyN stG em c. Perform a jaw thrust to open the airway. d. Deliver rescue breaths and start cardiopulmonary resuscitation (CPR).

ANS: B

The patient’s recovery depends on the restoration of breathing and perfusion; thus the nurse activates the emergency system and then begins chest compressions because patients have a better chance of recovery if defibrillation is initiated within 5 minutes. Rescue breaths are no longer used to begin CPR. The nurse restores the airway, begins chest compressions, and checks the pulse after activating the emergency system because the nurse wants the resuscitation team in attendance as soon as possible. A jaw thrust is a reasonable nursing intervention after activating the emergency alarm to restore the patient’s airway without disturbing the spine.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

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13. The nurse needs to perform chest compressions for a pulseless child. Which depth does the

nurse use for each chest compression? a. One half to 1 inch in depth b. One to 1 1/2 inches in depth c. One fourth to one half the depth of the chest Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf d. One third to one half the depth of the chest ANS: D

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse performs chest compressions on a child by compressing the chest by one third to one half the depth of the child’s chest. This effectively displaces blood from the heart without traumatizing regional tissue.

DIF: Cognitive Level: Remember OBJ: NCLEX: Physiological Integrity

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14. A child has choked on a hotdog while on a picnic and is unable to breathe. What method

should the nurse use to try to clear the airway? a. Use abdominal thrusts. b. Place the child prone and push on the back. c. Use back slaps. d. Use chest thrusts.

ANS: A

Abdominal thrusts are used for both children and adults. The child is not placed prone but supine for removal of the foreign body. The abdominal area, not the back, is compressed.

Back slaps and chest thrusts are used in combination for the infant.

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15. The nurse determines that the patient had a cardiac arrest while ambulating in the hall. Which

method should the nurse use to position the patient properly during cardiopulmonary resuscitation (CPR)? a. Head tilt and right side-lying position b. Logrolling and jaw thrust c. Supine and head tilt d. Jaw thrust and semi-Fowler’s position ANS: B

The nurse uses logrolling to position the patient onto a hard surface for chest compressions because emergency care must be implemented as though the patient has an unstable spine.

Logrolling maintains spine alignment until injury to the spine is ruled out. The nurse uses the jaw thrust to open the airway of a patient with a suspected unstable spine and determines whether the patient has spontaneous respirations without hyperextending the neck. The patient collapsed in the hallway and potentially suffered head or neck trauma; thus, until the status of the spine is determined, the nurse treats the patient as though the spine is unstable. Side-lying position during CPR is contraindicated because it is impossible to deliver effective chest compressions unless the patient is supine on a hard, flat surface. Supine positioning also facilitates blood flow to the brain to minimize cerebral hypoxia.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

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16. A visitor has coded in the hospital cafeteria, and several nurses witnessed the code. What is

the proper procedure for initiating use of the automatic external defibrillator (AED)? a. Provide 5 cycles of cardiopulmonary resuscitation (CPR) before shocking. b. Place AED pads and shock as soon as possible.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. Insert an oropharyngeal airway before shocking. d. Place one AED pad on the upper left sternal border and one pad on the lower right

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

side below the nipple and axilla.

ANS: B

Since the arrest was witnessed, the AED pads should be applied and shock delivered as soon as advised. If the response time is greater than 4 to 5 minutes and the arrest was not witnessed, five cycles of CPR are performed before shock is delivered. An oropharyngeal airway would not be immediately available in the cafeteria, and this would delay resuscitation. One AED pad is placed on the upper right sternal border, and the other pad on the lower left side below the nipple and axilla.

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17. An AED has been applied and a shock delivered to a patient. What action should the nurse

take at this time? a. Provide 2 minutes of cardiopulmonary resuscitation (CPR) before beginning rhythm analysis and the shock sequence again. b. Provide three cycles of CPR before beginning rhythm analysis and the shock sequence again. c. Move nearby furniture away from the patient. d. Announce “clear” and perform a visual check that no one is touching the patient.

ANS: A

Two minutes of CPR are to be performed before beginning the rhythm analysis and the shock sequence again. Delegate someone to remove excess furniture or equipment from the immediate area. Directing personnel to stand clear of the patient should be done before the shock is performed, not after. The patient needs ongoing assessment by the nurse.

DIF: Cognitive Level: Apply OBJ: NCLEX: Physiological Integrity

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18. A nurse is instructing staff nurses in the use of the automatic external defibrillator (AED).

Which information is essential for the nurse to share with the class? a. For children younger than 8 years old, AED pads designed for children should be used. b. The AED takes approximately 30 seconds to analyze the cardiac rhythm. c. The AED is used when the patient is unconscious and has no pulse. d. The AED is placed near the patient’s feet during use.

ANS: A

AED pads designed for children should be used for children younger than 8 years of age. If child pads are not available, use adult pads. The AED takes approximately 5 to 15 seconds to analyze the cardiac rhythm. It is used when the patient is unconscious or not breathing and pulseless and is placed near the patient’s chest or head.

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MULTIPLE RESPONSE Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 1. The nurse is assessing an unconscious patient for placement of an oropharyngeal airway. In

addition to a present gag reflex, what other conditions would make the use of the airway contraindicated? (Select all that apply.) a. A semi-conscious patient b. A patient with a loose tooth c. A patient who had facial trauma d. A patient who has had oral surgery e. A patient with copious secretions ANS: A, B, D

An oropharyngeal airway should never be inserted in a patient with recent oral trauma, oral surgery, or loose teeth. A semi-conscious pateint may vomit or have spasms of the larynx if an airway is inserted. Patients at greater risk for upper airway obstruction are adults with loss of consciousness, seizure disorders, neuromuscular diseases, increased oral secretions or excretions, or facial trauma.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

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2. The nurse is preparing to insert an oropharyngeal airway device. Which interventions will

assist her in this task? (Select all that apply.) a. Place the patient in a supine position. b. Hold the airway curved end up initially. c. Use a padded tongue blade to open patient’s mouth. d. Rotate the airway 90 degrees as you insert it.

ANS: B, C, D

Place the patient in a semi-FowNleUr’Rs SpI osN itG ioT n.BH.oCldOtM he oral airway with the curved end up and insert the distal end until the airway reaches the back of the throat; then turn the airway over 180 degrees and follow the natural curve of the tongue. Option: Hold the airway sideways and insert halfway; rotate the airway 90 degrees while gliding it over the natural curvature of the tongue. Make sure the outer flange is just outside the patient’s lips.

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COMPLETION 1. A

is the cessation of circulating blood flow that greatly reduces oxygen transport and perfusion.

ANS:

cardiac arrest All patients receive cardiopulmonary resuscitation (CPR) in the event of a cardiopulmonary arrest unless otherwise indicated, such as a patient having an advance directive for final health care or a “do not resuscitate” status.

DIF:

Cognitive Level: Remember

REF: Page 782

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning

2. Oral airways devices are only used for unresponsive patients without a

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS:

gag reflex An oral airway device is only used for unresponsive patients without an active gag reflex.

Placement of an oral airway device may stimulate vomiting and possible aspiration or cause laryngospasm if inserted in a semiconscious patient.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Physiological Integrity

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 30: Palliative Care Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. The nurse is caring for a patient who just died. Which action should the nurse take first to

determine if the patient is an organ or tissue donor? a. Delegate the task to nursing assistive personnel (NAP). b. Determine the patient’s legal representative. c. Request a copy of the patient’s driver’s license. d. Ask the spouse to sign an organ donation consent.

ANS: B

The nurse needs to determine if patient is an organ/tissue donor. Federal law mandates that family members be given a chance to authorize organ/tissue donation. The nurse should then call the organ/tissue request and procurement team (consult facility policy). Discussing organ donation and obtaining consent are tasks that the nurse cannot delegate because they require clinical judgment and critical thinking skills and are usually done by a special team. A copy of the patient’s driver’s license can be impractical or impossible to obtain soon enough to donate viable organs; generally the family knows the patient’s wishes about organ donation. If the spouse is the patient’s legal representative, he or she can provide consent.

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2. The family of the patient receiving hospice care is at the bedside expecting an imminent death.

NURSINGTB.C

They become upset when the patient suddenly becomes restless and disoriented. Which should the nurse implement as the patient advocate? a. Apply oxygen with a face mask. b. Ask the family to leave the room. c. Speak to the patient calmly and softly. d. Administer extra pain medication.

ANS: C

Restlessness and agitation are common patient assessments as death approaches and are part of the body’s preparation for death. The nurse explains that the upsetting behavior occurs frequently in the dying process and provides actions for the family to implement. For restlessness and agitation, the family can massage the hands or feet or play soothing music.

Oxygen by face mask can increase patient distress and impair any ability to communicate. The nurse avoids asking the family to leave the room. The nurse explains that the patient’s behavior is very common, reflective more of the dying process than actual distress. The nurse administers pain medication according to the prescription.

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3. During postmortem care, the patient’s family says that the patient didn’t have his dentures to

place in his mouth. Which action should the nurse take at this time?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. Place a rolled-up towel under the patient’s chin. b. Stuff the mouth with cotton to maintain the facial contour.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. Tell the family to take the dentures to the funeral home. d. Ask the family what they want to do about this situation.

ANS: A

If there are no dentures to place in the mouth after death, a rolled-up towel will help keep the patient’s mouth positioned appropriately. Cotton is not used by the nurse to maintain the patient’s mouth position. The dentures are easiest to place in the mouth immediately after death. It could be hours to several days until the patient’s body is taken to the funeral home, depending on whether an autopsy is done or not. The nurse should know what to implement regarding this situation.

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4. The patient is in the final stage of dying. Which action does the nurse implement? a. Maintain a darkened, cool room. b. Elevate the head of the bed. c. Catheterize the patient frequently. d. Provide warm, soothing liquids.

ANS: B

The nurse elevates the head of the bed as tolerated to facilitate breathing; in addition, the patient looks more comfortable slightly elevated in bed, which can be comforting to the family. The nurse does not alter the temperature of the room. The patient may be more relaxed if the lighting is dim rather than brightly lit. Because urine production slows significantly as death approaches, urinary catheters are usually unnecessary. Patients eat less and less as death approaches; simple items such as ice chips, a teaspoon of tea, or an ice pop are usually sufficient.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Psychosocial Integrity

REF: Page 803 TOP: Nursing Process: Implementation

5. The nurse provides postmortem care for an unfamiliar patient. Which approach should the

nurse use to best care for the body after death? a. Ask about the patient’s cultural or spiritual practices. b. Remove tubes and lines before they become difficult to remove. c. Cover the patient and transfer the body to the morgue. d. Remove the old patient identification (ID) band and apply a new one.

ANS: A

To best prepare the patient’s body after death, the nurse should exercise cultural sensitivity by inquiring about cultural or spiritual practices that the patient or family desires and implementing the practices to the best of the nurse’s ability. If family members are present, they often assume the responsibility for these rituals. Depending on the circumstances surrounding the death and on state law, the nurse may be required to leave all equipment and supplies in place. The nurse must check before removing any tubes or lines. He or she implements proper postmortem care for any patient, which includes much more than covering the patient with a sheet. The nurse leaves the original patient ID band to ensure patient identification in the morgue. The postmortem kit usually contains additional tags for patient Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

identification.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf DIF: Cognitive Level: Comprehend OBJ: NCLEX: Psychosocial Integrity

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6. The nurse is caring for a patient who is dying but is receiving palliative care. What reason

should the nurse give to the patient’s family for this type of care? a. It eliminates all adverse symptoms. b. It improves the patient’s quality of life for the time that remains. c. It increases the daily caloric and fluid intake. d. It improves the amount of activity tolerated.

ANS: B

Palliative care focuses on symptom management, including pain control, to improve the quality of the patient’s life up to death. Palliative care is not curative and does not eliminate all adverse symptoms; it does not necessarily increase the daily caloric and fluid intake nor is its focus to improve the patient’s activity tolerance.

DIF: Cognitive Level: Remember OBJ: NCLEX: Psychosocial Integrity

REF: Page 797 TOP: Nursing Process: Planning

7. The nurse is caring for a Hindu patient receiving hospice care. Which does the nurse expect to

facilitate for the family when the patient dies? a. Allowing the family members to wash and prepare the patient’s body b. Helping the family arrange for burial of the body c. Communion and prayers by any type of minister or priest d. Discussion of the finality of death ANS: A

Hindu family members take anNaU ctR ivS eI roNleGiT nB pr.eC paOriMng the body of a family member after death. Cremation, not burial, is traditional. Most likely the family will request the presence of a Brahmin priest who may chant prayers. A belief in reincarnation is held by those of the Hindu religion.

DIF: Cognitive Level: Remember OBJ: NCLEX: Psychosocial Integrity

REF: Page 799 TOP: Nursing Process: Planning

8. The nurse plans nonpharmacological comfort measures for a patient who is dying. What

activity should the nurse include for this type of comfort? a. Keep the head of the bed lowered. b. Provide regular hygiene and skin care. c. Reduce the amount of analgesics given. d. Offer foods and liquids with strong aromas.

ANS: B

Patients near death can be incontinent; thus the nurse provides hygiene and skin care to enhance his or her appearance, provide comfort, and maintain dignity. Skin care should be with an alcohol-free lotion as needed because alcohol can dry out the skin and often a dying patient is not taking in much fluid. Unless the patient is unable to tolerate it, the nurse keeps him or her in semi-Fowler’s position to facilitate breathing. The nurse administers adequate pain relief around the clock for the dying patient. Generally foods or liquids with a strong Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

aroma tend to make a dying patient nauseated.

DIF:

Cognitive Level: Remember

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Implementation

9. The nurse wants to provide specialized nursing care for a patient with a serious degenerative

illness that is not life threatening but for which there is no cure. Which approach would the nurse use in the care of this patient? a. Hospice care b. A combination of hospice care and palliative care c. Palliative care d. Experimental curative therapy with hospice care ANS: C

The nurse knows that palliative care enhances the quality of life for the patient at any time during serious illness and is helpful with a long-term chronic illness. Hospice care is holistic patient care that helps the patient and family prepare for death. A combination of hospice care and palliative care would be used for a patient who is dying. When a patient enters hospice care, there aer no further attempts to cure; rather the focus is on relief of adverse symptoms and promotion of the best quality of life possible for the remaining time a patient has.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Psychosocial Integrity

REF: Page 798 TOP: Nursing Process: Implementation

10. The nurse is caring for a patient who is dying. What should the nurse understand about grief

that can facilitate family grieving? a. Grief can begin long before the patient actually dies. b. The family needs to say good-bye to the patient. c. Update the family on every patient change. d. Provide a list of the area funeral homes and available services.

ANS: A

Grief is a process that often begins before a patient dies. Survivors grieve as they anticipate a loss and continue to feel the grief after the patient dies. The nurse provides support, resources, information, and comfort based on the family’s needs and desires. He or she usually allows the family to visit at will when a patient is near death so that the family can begin grieving and processing the events. Individuals process death and grieve in many different ways, and not everyone wants an opportunity to say good-bye; however, if a family member wishes to do so, the nurse facilitates the family’s wishes. The nurse avoids becoming involved in the decision about the funeral home and declines to offer an opinion about available businesses; however, he or she can provide an area telephone book and a telephone for the family.

DIF: Cognitive Level: Apply OBJ: NCLEX: Psychosocial Integrity

REF: Page 800 TOP: Nursing Process: Implementation

11. The family wants to see their family member who has just died. What actions by the nurse

should be undertaken when the family comes to visit? a. Provide hygienic care, including hair care, in their presence. b. Tell the family to ask any questions that they have about the patient. c. Place the patient’s valuables in the body bag to accompany the patient to the morgue. d. Share past experiences of grief with the family so they understand that what they Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

are feeling is not unique.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: B

When a family suffers a loss, grief can make it difficult to gather coherent thoughts and questions. The nurse should let the family know that they can ask questions when they are ready. The patient should have already been cleaned, including having the hair combed and dentures placed if present. Any patient valuables should be given to the patient’s family. If a wedding ring is to remain on the patient’s finger, a thin strip of tape is placed over it. The nurse’s role is to listen and support, not to talk unless in response to a need or question of the family. The focus is on the family experiencing the loss, not the nurse.

DIF: Cognitive Level: Comprehend OBJ: NCLEX: Psychosocial Integrity

REF: Page 800-803| Page 808 TOP: Nursing Process: Implementation

12. The nurse is explaining to the patient the transition phase from palliative care to hospice care.

Which statement by the patient indicates a good understanding of the process? a. “I will go into a hospice bed.” b. “I will no longer be focused on curative treatment.” c. “My pain management program will change.” d. “My physician team will change.”

ANS: B

As a patient’s condition changes, the goals of care may shift away from curing an illness to care completely focused on symptom management and maintaining the highest possible quality of life. Ideally, patients who receive palliative care would move seamlessly into hospice care when they no longer benefit from curative treatments. They do not necessarily go to a hospice bed, and their pain management program may change but it may stay the same initially. The physician team may also be the same.

DIF: Cognitive Level: ComprehN enUdRSINRGETFB : .PC agOeM798 OBJ: NCLEX: Psychosocial Integrity TOP: Nursing Process: Implementation MULTIPLE RESPONSE 1. The nurse is explaining the similarities between palliative care and hospice care to the family

of a patient. Which statement indicates a need for further education? (Select all that apply.) a. Palliative care is used for patients nearing the end of their life. b. Palliative care is only for those patients who are terminally ill. c. Patients who are receiving palliative care can continue with treatments aimed at cure. d. Patients are active participants in their care and decisions. e. Patients are cared for by an interdisciplinary team.

ANS: A, B

The following are similarities between palliative care and hospice care: Prioritize for quality of life and relief from pain and other distressing symptoms.

Integrate the physical, psychological, social, and spiritual dimensions into the care plan.

Affirm life and regard dying as a normal process.

Involve the patient and family as active participants in all decisions and care.

Rely on the expertise of an interdisciplinary team for planning and implementing care.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Appropriate for all patients, regardless of diagnosis, age, or setting.

DIF:

Cognitive Level: Comprehend

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Planning

COMPLETION 1.

refers to a dynamic dimension of human life, expressed in a person’s search for meaning and hope.

ANS: Spirituality DIF: Cognitive Level: Comprehend OBJ: NCLEX: Psychosocial Integrity

REF: Page 798 TOP: Nursing Process: Planning

refers to a person’s specific beliefs and behaviors associated with a religious

2.

tradition.

ANS: Religion DIF: Cognitive Level: Comprehend OBJ: NCLEX: Psychosocial Integrity

REF: Page 798-799 TOP: Nursing Process: Planning

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Chapter 31: Home Care Safety Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE 1. The nurse is working with a client on her plan of care. Which client behavior does the nurse

recognize as most illustrative that the client will cooperate with a plan of care? a. Willingness to attempt a return demonstration b. Refusal to talk about the needed assistive device c. States that a few days of rest are all that is needed for recovery d. States the equipment is too complex to learn ANS: A

The client who is willing to perform a return demonstration for the nurse is demonstrating a health-seeking behavior; thus the nurse plans interventions to facilitate client motivation and drive to master the task. The client who refuses to talk about the equipment is angry or in denial. The client who states that resting will solve the problem is in denial. The client who states the task is too difficult has a poor self-image and can benefit from slow, steady teaching and encouragement.

DIF: Cognitive Level: Comprehend REF: Page 817 OBJ: NCLEX: Health Promotion and Maintenance TOP: Nursing Process: Assessment 2. The nurse plans discharge teaching for several clients. Which client and family are most likely

to benefit from the nurse’s teaching plan? a. The client’s oxygen saturation ranges from 88% to 90%. b. Client is 2 days postoperative after emergency amputation. c. The family lacks financial resources for supplies and equipment. d. The family looks forward to the therapeutic diet and exercise plan.

ANS: D

The family looking forward to the therapeutic diet and exercise plan is most likely to benefit from the nurse’s teaching plan because the members are enthusiastic and positive, providing motivation and energy to succeed. They are willing to change their behavior when change is required. The hypoxic client will most likely have difficulty following directions and retaining information while struggling for oxygen. The client who had an emergency amputation is not ready for discharge because it is unlikely that the client received enough physical therapy; in addition, the client most likely had significant blood loss and could still be unstable. The client and family lacking financial resources for home health care need community resources before the teaching plan can be implemented.

DIF: Cognitive Level: Analyze REF: Page 817 OBJ: NCLEX: Health Promotion and Maintenance TOP: Nursing Process: Assessment 3. The nurse finishes discharge teaching for the client after a home assessment. Which action by

the client requires follow-up information from the home care nurse?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. Stores a flashlight next to the bed b. Checks batteries in the smoke detector

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf c. Stores the area rugs in the basement d. Leaves a loaded gun in the nightstand ANS: D

The nurse needs to teach the client to keep the gun unloaded in a locked area and the bullets in a separate area for safety. Storing a flashlight, checking smoke detector batteries, and removing area rugs are suitable safety measures.

DIF: Cognitive Level: Comprehend REF: Page 816-817 OBJ: NCLEX: Health Promotion and Maintenance

TOP: Nursing Process: Evaluation

4. A client’s family insists that the client live with one of the family members permanently

because of a shuffling gait, but the client refuses. Which approach is most effective to provide a safe environment while also acting as a client advocate? a. Teach the client to wear shoes with thin, firm soles. b. Explain community services for older clients. c. Help the client check the fit of his sneakers. d. Tell the client that he can do whatever he wants.

ANS: A

The shuffling gait is a safety hazard and could cause the client to fall. Shoes with thin, firm soles and moderate traction provide the best stability for him or her. The nurse should avoid having the client who shuffles wear sneakers; the thicker soles can result in tripping because they can stick on the floor during walking. Explaining the community services available will still not provide safety for this client. Telling the client that he or she can do whatever he or she wants ignores the client’s specific safety needs.

DIF: Cognitive Level: Apply NURSINRGETFB : .PC agOeM817 OBJ: NCLEX: Health Promotion and Maintenance TOP: Nursing Process: Implementation 5. The client’s son tells the nurse that his mother is unable to learn about new medications

because of her advanced age. Which does the nurse include in family teaching? a. Older clients lack the motivation to learn. b. Older clients can learn if one speaks loudly. c. Visual aids are not helpful for older adults. d. The ability to learn remains intact despite aging.

ANS: D

The nurse instructs the family that older clients are willing and able to learn new things, including how to self-administer new medication. In fact, nursing research indicates that learning new things is a stimulant for improved cognitive function. Learning can take more time for older clients, but they are capable nonetheless. Lack of motivation is a generalization.

Many older clients have a hearing impairment; thus the nurse speaks clearly and directly in front of the client to facilitate hearing. Visual aids are as helpful for older adults as they are for any age-group. Using visual aids is more dependent on the client’s learning style than on age.

DIF:

Cognitive Level: Comprehend

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Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf OBJ: NCLEX: Health Promotion and Maintenance TOP: Nursing Process: Implementation

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 6. The nurse instructs the client to perform self-injections of insulin. Which does the nurse

include in client teaching to prevent a home accident to other family members? a. Trains the client to avoid rubbing the injection site b. Instructs the client to store used needles in a hard plastic bottle with a tight lid c. Shows the client how to draw up precise insulin doses d. Ensures that the client has low-dose syringes for small doses ANS: B

The nurse instructs the client to dispose of used needles in a hard plastic bottle with a tight lid to prevent accidental needlestick injuries to other family members; if small children are in the home, the nurse suggests keeping the bottle in a locked cabinet. The nurse instructs the client to protect his or her skin integrity by not rubbing the injection site. The nurse shows the client how to draw up precise doses of insulin and ensures that the client uses the best equipment to avoid hyperglycemic or hypoglycemic emergencies. However, problems in these areas should not cause accidents involving other family members.

DIF: Cognitive Level: Comprehend REF: Page 825 OBJ: NCLEX: Health Promotion and Maintenance TOP: Nursing Process: Implementation 7. The nurse prepares to discharge to home an older client who has fallen in the hospital. Which

safety measure does the nurse include in client and family teaching? a. Install a grab bar near the shower or tub. b. Take all diuretics and antihypertensives at bedtime. c. Install additional towel bars near the shower or tub. d. Wear a well-fitting pair of sneakers.

ANS: A

A grab bar is rigid and can provide effective support in case of a near fall. Sneakers are not necessarily the best shoes for someone who has fallen. The nurse instructs the client to take diuretics and antihypertensives in the morning so the client can sleep through the night and not have to rush to the bathroom. Towel bars are ineffective safety bars; the nurse instructs the client to install safety bars in the bathroom.

DIF: Cognitive Level: Apply REF: Page 817| Page 818 OBJ: NCLEX: Health Promotion and Maintenance TOP: Nursing Process: Planning 8. A frail older client is being driven to the grocery store. Which aspect of safety prevention is

most important for the nurse to stress to this client? a. Tell the client to change positions slowly. b. Move the client’s seat at least 10 inches from the air bag. c. Tell the client to ride in the motorized grocery cart. d. Explain how good the sunshine is for the client.

ANS: B

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Frail older adults should not ride in the passenger seat of the car with airbags unless the seat can be at least 10 inches from the airbag. The impact of the airbag, if deployed, can cause serious injury because of the client’s frailty. There are no data supporting the client’s orthostatic hypotension. He or she should change positions slowly anytime, not only when riding in a car. There are no data that say that the client tires easily or cannot walk when grocery shopping. Sunshine in moderation can lift the spirits and provide vitamin D, but it is not the safety aspect that needs to be stressed.

DIF: Cognitive Level: Apply REF: Page 819 OBJ: NCLEX: Health Promotion and Maintenance

TOP: Nursing Process: Planning

9. The nurse is helping a client with diminished sight to remain as independent in his home as

possible. Which does the nurse include in client teaching to improve home safety for the client? a. Turn on a light before he or she walks into a dark room. b. Clean the top of the stove twice daily. c. Post emergency numbers on the front of the refrigerator. d. Have furniture rearranged while he or she is napping.

ANS: A

The nurse instructs the client with diminished sight to light living areas. This decreases the chance of bumping into things and becoming injured. The top of the stove should be cleaned when it is dirty. The nurse instructs the client to post emergency numbers with large print to increase his or her ability to see them. However, this strategy does not improve client safety.

The client should participate in relocating furniture. He or she could be injured if unaware that furniture had been relocated during a nap.

NURSINGTB .COM

DIF: Cognitive Level: Apply REF: P age 815| Page 818 OBJ: NCLEX: Health Promotion and Maintenance TOP: Nursing Process: Planning 10. The nurse prepares to teach the client about managing multiple medications at home. Which

client outcome does the nurse hope to accomplish as a result of client teaching? a. The client reads each medication label at least twice before taking the drug. b. The client stores the medication bottles on the bathroom counter. c. The client is able to read each medication label and explain when to take each medication. d. The client explains how to put several kinds of medications in the same container.

ANS: C

The nurse’s goal is to ensure that the patient is able to identify and understand each prescription ordered and when to take it. The nurse instructs the client to read the medication label 3 times before taking the drug to ensure accurate medication and dosage; if the client has any questions about the medication, provide resources to him or her for clarification.

Medications should be stored in a dark, locked, dry place, not on an open counter exposed to water. The nurse instructs the client to avoid mixing several medications in the same container because this can cause confusion.

DIF: Cognitive Level: Comprehend REF: Page 823 OBJ: NCLEX: Health Promotion and Maintenance TOP: Nursing Process: Planning Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 11. The nurse is teaching the client how to safely take a diuretic and an antihypertensive pill.

Which information does the nurse write for the client to reduce client risk of falls while maintaining the therapeutic medication regimen? a. Take the diuretic in the morning at 8 AM and the antihypertensive pill at 1 PM. b. Take both medications at the same time so the client can remember. c. Change positions slowly, especially from lying down to standing. d. Take the medications with orange juice to maintain the potassium level.

ANS: A

The nurse instructs the client to take a diuretic early in the day so trips to the bathroom will not interrupt sleep at night. Taking the medications at different times minimizes the side effects (e.g., lowering the blood pressure too fast and causing dizziness, which can lead to falls). The two types of medications taken together could cause a major drop in blood pressure and cause the client to fall. The nurse instructs the older client to change positions slowly, but this doesn’t include instructions about scheduling the medications. There is no information to support whether or not the medications deplete potassium.

DIF: Cognitive Level: Comprehend REF: Page 817 OBJ: NCLEX: Health Promotion and Maintenance TOP: Nursing Process: Implementation 12. The nurse is caring for an older client who has been getting more confused recently. What

other characteristics might the family notice that alerts the nurse that the client may be at risk for wandering? a. The client paces and cannot be redirected easily. b. The client sleeps 6 hours at night and takes a brief nap during the day. c. The client gets tired when cleaning the kitchen after cooking dinner.

NURSINGTB.CO d. The client uses a space heater for supplemental heat.

ANS: A

Pacing with difficulty being redirected is a characteristic that the family needs to report to the nurse. Six hours of sleep at night with a daytime nap is an expected sleep pattern for an older client. Tiring after cleaning the kitchen following cooking dinner is not unexpected for an older client. A space heater is not necessarily a hazard for a client with confusion as long as it does not contain fuel to create the heat.

DIF: Cognitive Level: Apply REF: Page 820 OBJ: NCLEX: Health Promotion and Maintenance

TOP: Nursing Process: Evaluation

13. The nurse completes a home safety assessment and recommends removing a few pieces of

large furniture to widen the pathway for a male client who ambulates with a walker. However, the client refuses to allow furniture to be removed. Which action should the nurse take at this time? a. Remove the furniture because it is a safety hazard. b. Discuss the unsettling nature of change with the client. c. Instruct the client about potential injuries from falls. d. Explain the nursing responsibility to reduce the risk.

ANS: B Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

The nurse invites the client to discuss change and its potential to cause distress (even when the change is desirable) to gather additional information about client refusal to remove a few pieces of furniture. The client can fear loss of control, grieve loss of function, or deny his physical limitations. The more the nurse knows about the client’s feelings and thoughts about the furniture and his mobility issues, the greater the potential for the nurse to facilitate client home safety. The nurse has no right to move the client’s furniture because the client retains the right to self-determination and to refuse therapy. The nurse should provide information about the client’s risk from falling; however, he or she should phrase the information carefully to avoid a threatening or condescending manner. The client’s safety is not about the nurse, and it is unethical for the nurse to use guilt to coerce the client.

DIF: Cognitive Level: Apply REF: Page 815| Page 817| Page 818 OBJ: NCLEX: Health Promotion and Maintenance TOP: Nursing Process: Planning 14. The home care nurse is visiting an adult client who has two young children under the age of 4.

What strategy can the nurse teach the client to best protect the children from hazards in their home? a. Get a medication container cap used by individuals with arthritis to secure the medication bottle. b. Get down on the floor to look at the environment from the children’s view to identify dangers present in the home. c. Place safety plugs in the electrical outlets throughout the house. d. Using a night light in the children’s bathroom.

ANS: B

The nurse instructs the parents or caregivers to get down on the floor and look at the environment from the child ren’Ns Uv R i eS wIt oNiGd T enBti.f yCdOaM n gers present in the home. Childproof containers are very difficult for clients with limited dexterity or hand strength to open. The caps requested by individuals with arthritis are much easier for a child to open. Safety plugs are wonderful to cover the electrical outlets, but other items or situations in the home can be a hazard (e.g., purses placed on the floor that contain pills or lotions that can harm a child when ingested). A night light in the children’s bathroom only takes care of a specific time period in a specific place.

DIF: Cognitive Level: Apply REF: Page 819 OBJ: NCLEX: Health Promotion and Maintenance TOP: Nursing Process: Implementation 15. The nurse teaches an older client about minimizing the risk of falls at home. Which does the

nurse include in client teaching to prevent falls? a. Install extra towel bars in the bathtub and near the toilet. b. Keep furniture so it can be easily walked around and keep pathways clear. c. Have a neighbor check on the client every afternoon. d. Secure throw rugs to the floor with double-sided tape.

ANS: B

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

To prevent falls in the home, the nurse instructs the client to keep furniture arrangements so that the furniture can be walked around easily and keep walking paths free of clutter. If a change must occur, the client should practice moving around in the new arrangement with assistance as much as possible and use full lighting during any ambulation. Towel bars are not sturdy. Safety grab bars should be installed in the bathroom to help prevent falls. The neighbor can help to prevent a fall by assisting the client with awkward tasks. Throw rugs and area rugs are trip hazards because they create an uneven surface, with or without tape.

DIF: Cognitive Level: Apply REF: Page 818 OBJ: NCLEX: Health Promotion and Maintenance

TOP: Nursing Process: Planning

16. The nurse assesses a home care client who has a possible cognitive impairment. Which should

the nurse implement to validate the assessment finding before planning suitable nursing care? a. Collaborate for a psychiatric evaluation. b. Call a social worker to assess client needs. c. Ask family members for additional information. d. Review how the client takes care of things at home.

ANS: D

The nurse reviews home maintenance duties with the client before planning suitable nursing care or follow-up nursing interventions for a client who has a possible cognitive impairment.

After completing the client interview, the nurse compares the client assessment findings to the appearance of the house to evaluate the consistency of client perceptions. This information provides valuable information about client self-care abilities. The nurse does not need a psychiatric evaluation or a social worker yet but can include the request in follow-up nursing care. The nurse completes the client evaluation first before obtaining additional information from the family.

DIF: Cognitive Level: Analyze REF: Page 820 OBJ: NCLEX: Health Promotion and Maintenance

TOP: Nursing Process: Planning

17. The home care nurse assists a client with impaired fine-motor skills. Which should the nurse

implement to benefit the client? a. Large-print medication labels b. An easily opened medication organizer c. A telephone with a vibrating ringer d. A color-coded medication schedule ANS: B

The client with neuromuscular weakness has limited fine-motor skills; the nurse facilitates client self-administration of medications by organizing the medication in easy-open containers. It is easier to flip a lid open than to unscrew or squeeze it; however, this type of medication container is unsuitable in the presence of children. Large-print labels and color-coded systems assist a client with a visual impairment. A telephone equipped with a vibrating ringer assists a client with a hearing impairment.

DIF: Cognitive Level: Apply REF: Page 825 OBJ: NCLEX: Health Promotion and Maintenance

TOP: Nursing Process: Planning

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 18. The nurse prepares the client to self-administer medications at home. Which does the nurse

implement to best increase the chance of client compliance with the therapeutic regimen?

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf a. b. c. d.

Provides client with a list of medication websites Instructs client to decrease dose when feeling better Discusses strategies for client use to prevent addiction Develops a clear medication schedule with client help

ANS: D

Many clients take medication improperly and thereby increase the risks of adverse effects and ineffective therapy. One method to increase client compliance is to simplify medication administration with a schedule for client use. The nurse develops the schedule with the client’s assistance to engage the client in therapy and tailor the schedule to suit the client’s needs. Clients take medication improperly because many misunderstand the risk of noncompliance with therapy; thus the nurse instructs the client about the risks and benefits of therapy and noncompliance to increase client ability to make an informed decision. The nurse instructs the client to take the medication as prescribed. Clients may fear addiction to medication, including medications that are not addictive, primarily from lack of education; the nurse explains that most medications are not addictive. In addition, the nurse explains the low rate of addiction to opioids for clients with real pain. The nurse educates the client on self-administration of other addicting agents and how to avoid addiction.

DIF: Cognitive Level: Apply REF: Page 823-824 OBJ: NCLEX: Health Promotion and Maintenance TOP: Nursing Process: Implementation COMPLETION 1. In older adults living alone,

can be caused by social isolation.

ANS:

depression In addition to mental status and cognitive changes, many older adults suffer from depression.

Depression often results from social isolation (e.g., the older adult is homebound and has few visitors).

DIF: Cognitive Level: Comprehend REF: Page 820 OBJ: NCLEX: Health Promotion and Maintenance TOP: Nursing Process: Assessment 2. In adults with cognitive deficits, medications that cause confusion should be scheduled at

.

ANS:

bedtime This will help to maintain mental status during the day at the maximum level possible.

DIF: Cognitive Level: Comprehend REF: Page 821 OBJ: NCLEX: Health Promotion and Maintenance TOP: Nursing Process: Assessment

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf MULTIPLE RESPONSE

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf 1. The Joint Commission has identified goals related to client safety in the home. These goals

focus on which of the following? (Select all that apply.) a. Patient identification b. Medication safety c. Fall prevention d. Patient education e. Safety risk identification ANS: A, B, C, E

The Joint Commission has identified five goals that include: 1. Identifying patients correctly (following procedure to be sure patients receive the correct medications) 2. Using medicines safely (ensuring a patient has one up-to-date medication list and understands his or her medications) 3. Preventing infection (using hand hygiene) 4. Preventing clients from falling (recognizing fall risks and implementing preventive strategies) 5. Identifying client safety risks (specifically risks associated with oxygen therapy).

DIF: Cognitive Level: Remember REF: Page 813 OBJ: NCLEX: Health Promotion and Maintenance

TOP: Nursing Process: Planning

2. The nurse is assessing a client who has fallen at home using the mnemonic SPLATT. This

refers to what assessment factors? (Select all that apply.) a. Location of fall b. Time of fall c. Severity of fall d. Trauma after fall e. Place of fall f. Activity at time of fall ANS: A, B, D, F

SPLATT refers to: Symptoms at time of fall Previous fall Location of fall Activity at time of fall Time of fall Trauma after fall (Meiner, 2011) DIF: Cognitive Level: Remember REF: Page 814 OBJ: NCLEX: Health Promotion and Maintenance

TOP: Nursing Process: Planning

3. The nurse is working with a client who needs to make adaptations to the home environment

before the client can safety return home. Which of the following principles are important to consider? (Select all that apply.) a. Ask the client about his or her financial situation. b. Make changes that support the patient’s independence. c. Only make the changes necessary to address disabilities.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf d. Let the client make the final decision whenever possible. e. Educate the family about preserving client autonomy.

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf ANS: A, B, D, E

It is important to make changes in the client’s home environment to keep him or her as independent as possible, yet still consider the client’s financial resources. Whenever possible, the client should be the final decision maker in the types of changes to be made. The nurse should consider the client’s physical strengths and remaining functional abilities, not just the disabilities. It is important to educate family caregivers about the importance of preserving client autonomy so they can be supportive of the client.

DIF: Cognitive Level: Apply REF: Page 819 OBJ: NCLEX: Health Promotion and Maintenance

TOP: Nursing Process: Planning

Test Bank for Nursing Interventions & Clinical Skills 6th Edition by Griffin Perry, Potter, & Ostendorf