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

REF: Page 1 TOP: Nursing Process: Implementation

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

REF: Page 3 TOP: Nursing Process: Implementation

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

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

REF: Page 4, Box 1-2 TOP: Nursing Process: Implementation

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

REF: Page 4 TOP: Nursing Process: Implementation

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

REF: Page 5 TOP: Nursing Process: Implementation

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

REF: Page 5-6 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 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. DIF: Cognitive Level: Understand OBJ: NCLEX: Safe and Effective Care

REF: Page 7 TOP: Nursing Process: Implementation

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

REF: Page 8 TOP: Nursing Process: Implementation

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

REF: Page 6

Test Bank for Nursing 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. DIF: Cognitive Level: Analyze OBJ: NCLEX: Safe and Effective Care

REF: Page 3 TOP: Nursing Process: Implementation

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

REF: Page 5 TOP: Nursing Process: Implementation

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

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

Cognitive Level: Analyze

REF: Page 4

Test Bank for Nursing 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

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

REF: Page 7 TOP: Nursing Process: Implementation

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

REF: Page 19 TOP: Nursing Process: Assessment

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

REF: Page 14 TOP: Nursing Process: Evaluation

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

REF: Page 14| Page 24 TOP: Nursing Process: Evaluation

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

REF: Page 14| Page 17| Page 19| Page 24 TOP: Nursing Process: Implementation

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

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

REF: Page 27-28 TOP: Nursing Process: Planning

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

REF: Page 22| Page 24-26 TOP: Nursing Process: Evaluation

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. DIF: Cognitive Level: Analyze REF: Page 17 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 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. DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 22| Page 24-26 TOP: Nursing Process: Planning

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

REF: Page 15-16 TOP: Nursing Process: Assessment

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

REF: Page 13 TOP: Nursing Process: Planning

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

REF: Page 17 TOP: Nursing Process: Evaluation

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

REF: Page 14 TOP: Nursing Process: Planning

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

REF: Page 26 TOP: Nursing Process: Planning

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

REF: Page 14 TOP: Nursing Process: Implementation

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

REF: Page 25 TOP: Nursing Process: Planning

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

REF: Page 22 TOP: Nursing Process: Planning

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

REF: Page 58-60 TOP: Nursing Process: Planning

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

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. DIF:

Cognitive Level: Analyze

REF: Page 67

Test Bank for Nursing 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. DIF: Cognitive Level: Apply OBJ: NCLEX: Safe and Effective Care

REF: Page 50 TOP: Nursing Process: Planning

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

REF: Page 46 TOP: Nursing Process: Planning

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

REF: Page 68 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 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. DIF: Cognitive Level: Analyze OBJ: NCLEX: Safe and Effective Care

REF: Page 47 TOP: Nursing Process: Implementation

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

REF: Page 47 TOP: Nursing Process: Implementation

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

REF: Page 54-55

Test Bank for Nursing 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

REF: Page 57 TOP: Nursing Process: Planning

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

REF: Page 48 TOP: Nursing Process: Assessment

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

REF: Page 56 TOP: Nursing Process: Implementation

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

REF: Page 63 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. 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

REF: Page 65 TOP: Nursing Process: Planning

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

REF: Page 62 TOP: Nursing Process: Implementation

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

REF: Page 54 TOP: Nursing Process: Implementation

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

REF: Page 68 TOP: Nursing Process: Implementation

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

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

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

REF: Page 68 TOP: Nursing Process: Implementation

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

REF: Page 47 TOP: Nursing Process: Implementation

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

REF: Page 55-57 TOP: Nursing Process: Implementation

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

REF: Page 59 TOP: Nursing Process: Implementation

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

REF: Page 84 TOP: Nursing Process: Implementation

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

REF: Page 76| Page 83 TOP: Nursing Process: Implementation

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

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

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

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