Test Bank for Clinical Nursing Skills 9th Edition by Smith
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Smith Chapter 8
1. The nurse who is planning the day will perform morning care at which point?
1. When the client first awakens
2. Before breakfast
3. Before retiring for the night
4. Whenever the client requests it
Correct Answer: 2
Rationale 1: Early-morning care is provided when the client first awakens.
Rationale 2: The nurse generally provides morning care before breakfast.
Rationale 3: Hour of sleep (HS) care is provided before going to bed.
Rationale 4: PRN care is provided as required by the client.
Global Rationale: The nurse generally provides morning care before breakfast. Early-morning care is provided when the client first awakens. Hour of sleep (HS) care is provided before going to bed. PRN care is provided as required by the client.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Basic Care and Comfort
QSEN Competencies: I.B.3. Provide client-centered care with sensitivity and respect for the diversity of human experience
AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings
NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 8.8 Outline the steps in providing morning care..
Page Number: p. 194
2. The nurse is preparing a client for a morning bath. What should be assessed prior to providing personal hygienic care?
Standard Text: Select all that apply.
1. Allergies
2. Culture
3. Ability to provide self-care
4. Social history
5. Diagnosis
Correct Answer: 2, 3, 5
Rationale 1: Allergies are not identified as being assessed prior to hygienic care.
Rationale 2: The client's culture will impact how daily hygiene needs are met
Rationale 3: The client should be encouraged to perform as much of hygiene care as possible, so the nurse must assess the ability to provide self-care.
Rationale 4: The client’s social history is assessed during an admission assessment and not prior to providing personal hygienic care each day.
Rationale 5: The client's diagnosis will impact how much care can be tolerated at one time and the ability to move about in bed.
Global Rationale: The client's culture will impact how daily hygiene needs are met. The client should be encouraged to perform as much of hygiene care as possible, so the nurse must assess the ability to provide self-care. The client's diagnosis will impact how much care can be tolerated at one time and the ability to move about in bed. Allergies are not identified as being assessed prior to hygienic care. The client’s social history is assessed during an admission assessment and not prior to providing personal hygienic care each day.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Basic Care and Comfort
QSEN Competencies: I.B.3. Provide client-centered care with sensitivity and respect for the diversity of human experience
AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings
NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 8.8 Outline the steps in providing morning care.
Page Number: p. 193
3. The nurse is preparing a commercial cleansing system to bathe a client. Which action is the priority for the nurse?
1. Wetting the disposable washcloths
2. Drying the client after using a washcloth
3. Using one washcloth for the lower extremities
4. Warming the washcloth in the microwave
Correct Answer: 4
Rationale 1: The package contains presoaked disposable washcloths.
Rationale 2: Drying is not necessary because the solution on the washcloths is no-rinse cleanser that will dry quickly.
Rationale 3: The nurse uses one washcloth on each area of the body (one for each arm, one for each leg).
Rationale 4: The washcloths must be warmed in the microwave.
Global Rationale: The washcloths must be warmed in the microwave. The package contains presoaked disposable washcloths. Drying is not necessary because the solution on the washcloths is no-rinse cleanser that will dry quickly. The nurse uses one washcloth on each area of the body (one for each arm, one for each leg).
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: II.B.3. Base individualized care plan on client values, clinical expertise, and evidence
AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research
NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8.6 State the advantages of using a commercial bathing system. Page Number: p. 198
4. The nurse is caring for a healthy young adult client who was involved in a motor vehicle crash resulting in a fractured femur. The femur was pinned, and the client was placed in traction. Which type of bath should the nurse provide for this client?
1. Complete bath
2. Therapeutic bath
3. Partial bath
4. Commercial product bath
Correct Answer: 3
Rationale 1: A complete bath is when the nurse bathes all areas of the body, which would not be necessary with a healthy young adult.
Rationale 2: A therapeutic bath is used as part of a treatment regimen for specific conditions, such as skin disorders, burns, high body temperature, and muscular injuries.
Rationale 3: In a partial bath, the face, axilla, hands, back, and genital area are bathed; or the areas the client cannot reach.
Rationale 4: A commercial product bath is a bath using no-rinse solution, which would not be necessary for this client because there is available water and bathing products.
Global Rationale: In a partial bath, the face, axilla, hands, back, and genital area are bathed; or the areas the client cannot reach. A complete bath is when the nurse bathes all areas of the body, which would not be necessary with a healthy young adult. A therapeutic bath is used as part of a treatment regimen for specific conditions, such as skin disorders, burns, high body temperature, and muscular injuries. A commercial product bath is a bath using no-rinse solution, which would not be necessary for this client because there is available water and bathing products.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I.B.3. Provide client-centered care with sensitivity and respect for the diversity of human experience
AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings
NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8.4 Differentiate between bathing a bedridden client and a critically ill client.
Page Number: p. 183
5. The nurse prepares to delegate bathing a client to unlicensed assistive personnel (UAP). Which actions are appropriate prior to delegating this task to the UAP?
Standard Text: Select all that apply.
1. Informing the UAP what type of bath is appropriate
2. Describing precautions specific to the needs of the client
3. Telling the UAP who to notify if there are any concerns
4. Informing the UAP to encourage the client to perform as much self-care as appropriate
5. Having the UAP document the bathing experience for the nurse to read later
Correct Answer: 1, 2, 4
Rationale 1: The nurse would inform the UAP what type of bath is appropriate for the client.
Rationale 2: The nurse would inform the UAP what precautions are appropriate for that specific client's needs.
Rationale 3: The nurse does not need to tell the UAP to whom to report concerns, because they should be reported to the nurse.
Rationale 4: Although it is often faster to perform the entire bath without encouraging client participation, the UAP should take the time needed and encourage the client to perform as much self-care as possible to promote the client's autonomy.
Rationale 5: The nurse should instruct the UAP to report about the bathing experience as soon as it is completed, and the nurse would not wait to read the UAP's documentation.
Global Rationale: The nurse would inform the UAP what type of bath and what precautions are appropriate for that specific client's needs. Although it is often faster to perform the entire bath without encouraging client participation, the UAP should take the time needed and encourage the client to perform as much self-care as possible to promote the client's autonomy. The nurse does not need to tell the UAP to whom to report concerns, because they should be reported to the nurse. The nurse should instruct the UAP to report about the bathing experience as soon as it is completed, and the nurse would not wait to read the UAP's documentation.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members
AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team
NLN Competencies: Teamwork: Practice; Manage delegation effectively.
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 8.3 Outline the steps in bathing a bedridden adult client.
Page Number: p. 215
6. The nurse is caring for a client who is on bed rest with bathroom privileges. While the client is in the bathroom, the nurse changes the client's bed and should make the bed in what way?
1. Unoccupied open bed
2. Occupied open bed
3. Unoccupied closed bed
4. Surgical bed
Correct Answer: 1
Rationale 1: The bed is unoccupied, and the nurse would make an open bed, with the top sheets folded back, so the bed is ready for the client to return to.
Rationale 2: An occupied bed would be used if the client were unable to get out of bed.
Rationale 3: A closed bed is made with the top covers over the entire bed to keep the bed clean when not in use.
Rationale 4: A surgical bed would be made using extra materials in preparation for the returning postoperative client.
Global Rationale: The bed is unoccupied, and the nurse would make an open bed, with the top sheets folded back, so the bed is ready for the client to return to. An occupied bed would be used if the client were unable to get out of bed. A closed bed is made with the top covers over the entire bed to keep the bed clean when not in use. A surgical bed would be made using extra materials in preparation for the returning postoperative client.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Basic Care and Comfort
QSEN Competencies: II.B.3. Base individualized care plan on client values, clinical expertise, and evidence
AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice,
and research
NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8.1 Compare and contrast the steps in making an occupied and unoccupied bed.
Page Number: p. 186
7. When delegating bed-making to unlicensed assistive personnel (UAP), on which items should the nurse instruct the UAP?
Standard Text: Select all that apply.
1. Proper disposal of linens that contain drainage
2. What tubes or dressings the client might have
3. How to make hospital corners
4. Whom to inform if they notice anything unusual
5. Placing the call bell in a specific location for a client with mobility concerns
Correct Answer: 1, 2, 5
Rationale 1: The nurse should instruct the UAP on how to dispose of linens that contain drainage.
Rationale 2: The nurse should inform the UAP of any tubes or dressings the client may have in place
Rationale 3: The nurse should not have to teach the UAP how to make a bed, because the UAP should be familiar with the procedure.
Rationale 4: There is no need to inform the UAP whom to notify because the UAP should inform the nurse if anything unusual occurs.
Rationale 5: The nurse should instruct the UAP on the importance of placing the call bell in a specific location for a client with mobility concerns.
Global Rationale: The nurse should instruct the UAP on how to dispose of linens that contain drainage, and should inform the UAP of any tubes or dressings the client may have in place and the importance of placing the call bell in a specific location for a client with mobility concerns. The nurse should not have to teach the UAP how to make a bed, because the UAP should be familiar with the procedure. There is no need to inform the UAP whom to notify because the UAP should inform the nurse if anything unusual occurs.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members
ACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team
NLN Competencies: Teamwork: Practice; Manage delegation effectively.
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8.1 Compare and contrast the steps in making an occupied and unoccupied bed.
Page Number: p. 187
8. The nurse is making beds on the medical–surgical unit. What should the nurse do differently when making a surgical bed versus an open unoccupied bed?
Standard Text: Select all that apply.
1. Strip the bed.
2. Do not tuck, miter, or toe-pleat the top covers.
3. Fold top sheets into a triangle at the side of the bed.
4. Place pillows on the chair beside the bed.
5. Raise the bed to a comfortable working height.
Correct Answer: 2, 3, 4
Rationale 1: The old linen should be stripped prior to making the fresh bed.
Rationale 2: When making a surgical bed, the top covers would not be tucked, mitered, or pleated.
Rationale 3: When making a surgical bed, the top covers should be folded to the side of the bed, forming a triangle so the bed is prepared for the client to slide from the stretcher to the bed.
Rationale 4: Pillows are removed from the bed and placed in the chair at the side of the bed because they will be in the way when the client is transferred from the stretcher.
Rationale 5: The bed should always be raised to a comfortable working height to avoid back strain for the nurse when making a bed.
Global Rationale: When making a surgical bed, the top covers would not be tucked, mitered, or pleated, but rather folded to the side of the bed, forming a triangle, so the bed is prepared for the
client to slide from the stretcher to the bed. Pillows are removed from the bed and placed in the chair at the side of the bed because they will be in the way when the client is transferred from the stretcher. The bed should always be raised to a comfortable working height to avoid back strain for the nurse when making a bed, and the old linen should be stripped prior to making the fresh bed.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Basic Care and Comfort
QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice
AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span
NLN Competencies: Quality and Safety: Knowledge: Current best practices
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8.1 Compare and contrast the steps in making an occupied and unoccupied bed.
Page Number: p. 186
9. Which explanation is the most accurate when describing PM care to a client?
1. Providing for elimination needs, washing face and hands, giving oral care, and possibly a back massage.
2. Providing care when the client awakens to include providing urinal or bedpan, washing of face and hands, and giving oral care
3. Providing care that includes elimination needs, a bath or shower, perineal care, and oral, nail, and hair care.
4. Providing care required by the client such as changing of linen and clothes when they become soiled.
Correct Answer: 1
Rationale 1: Providing for elimination needs, washing face and hands, giving oral care, and possibly a back massage occur during PM care.
Rationale 2: Providing care when the client awakens to include providing urinal or bedpan, washing of face and hands, and giving oral care describes early morning care.
Rationale 3: Providing care that includes elimination needs, a bath or shower, perineal care, and oral, nail, and hair care describes morning care.
Rationale 4: Providing care required by the client such as changing of linen and clothes when they become soiled describes as-needed (prn) care.
Global Rationale: Providing for elimination needs, washing face and hands, giving oral care, and possibly a back massage occur during PM care. Providing care when the client awakens to include providing urinal or bedpan, washing of face and hands, and giving oral care describes early morning care. Providing care that includes elimination needs, a bath or shower, perineal care, and oral, nail, and hair care describes morning care. Providing care required by the client such as changing of linen and clothes when they become soiled describes as-needed (pm) care.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Basic Care and Comfort
QSEN Competencies: I.B.3. Provide client-centered care with sensitivity and respect for the diversity of human experience
AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings
NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 8.8 Outline the steps in providing morning care.
Page Number: p. 194
10. Routine hygienic care has been provided to 1 client, with no abnormal findings assessed. What should the nurse document in the medical record?
1. Foot care
2. Hair care
3. Removal or insertion of a hearing aid
4. Type of bath provided and client's ability to provide self-care
Correct Answer: 4
Rationale 1: Foot care usually is not documented unless there are unexpected assessment findings.
Rationale 2: Hair care is not documented unless there are unexpected assessment findings.
Rationale 3: Removal or insertion of a hearing aid usually is not documented unless there are unexpected assessment findings.
Rationale 4: The nurse would document what type of bath was provided to the client and the client's ability to assist or provide self-care.
Global Rationale: The nurse would document what type of bath was provided to the client and the client's ability to assist or provide self-care. Foot care, hair care, and removal or insertion of a hearing aid usually is not documented unless there are unexpected assessment findings.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: VI.B.4. Document and plan client care in an electronic health record
AACN Essential Competencies: IV.5. Use standardized terminology in a care environment that reflects nursing’s unique contribution to client outcomes
NLN Competencies: Quality and Safety: Practice; Carefully maintain and use electronic and/or written health records
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8.14 Complete client charting for morning and evening care on nurses’ notes.
Page Number: p. 202
11. The nurse delegates the making of an occupied bed to unlicensed assistive personnel (UAP). Which statement made by the UAP indicates the need for further instruction prior to this assignment?
1. "I will be sure to inform you of any wound drainage."
2. "I will inform you if any of the client’s tubes are loose."
3. "I will assess the client’s IV tubing."
4. "I will inform you of any problems."
Correct Answer: 3
Rationale 1: Although the UAP cannot assess the client, it is appropriate for the UAP to inform the nurse if there is any wound drainage.
Rationale 2: It is appropriate for the UAP to inform the nurse if the client has any loose tubes.
Rationale 3: The UAP cannot assess the client’s IV tubing. This is outside the scope of practice for the UAP.
Rationale 4: It is expected that the UAP will inform the nurse of any problems that occur during the task that is delegated.
Global Rationale: The UAP cannot assess the client’s IV tubing. This is outside the scope of practice for the UAP. Although the UAP cannot assess the client, it is appropriate for the UAP to inform the nurse if there is any wound drainage or if any tubes are loose. It is expected that the UAP will inform the nurse of any problems that occur during the task that is delegated.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members
ACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team
NLN Competencies: Teamwork: Practice; Manage delegation effectively.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 8.1 Compare and contrast the steps in making an occupied and unoccupied bed.
Page Number: p. 185
12. The nurse is preparing to bathe clients assigned for the shift. Which client should the nurse wear gloves to bathe?
1. The client diagnosed with HIV/AIDS
2. The newborn just admitted from the delivery room
3. The client with psoriasis
4. The postoperative client
Correct Answer: 2
Rationale 1: The client with HIV/AIDS would not require the nurse to wear gloves unless there was bleeding or drainage from open wounds.
Rationale 2: The nurse should wear gloves when bathing the newborn just admitted from the delivery room because of the high likelihood of blood and body fluids found on the baby.
Rationale 3: The client with psoriasis would not require the nurse to wear gloves unless there was bleeding or drainage from open wounds.
Rationale 4: The nurse would not need to wear gloves to bathe a postoperative client unless there was bleeding or drainage from open wounds.
Global Rationale: The nurse should wear gloves when bathing the newborn just admitted from the delivery room because of the high likelihood of blood and body fluids found on the baby. The client with HIV/AIDS or psoriasis, or the postoperative client, would not require the nurse to wear gloves unless there was bleeding or drainage from open wounds.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Basic Care and Comfort
QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice
AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span
NLN Competencies: Quality and Safety: Knowledge; Current best practices
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8.5 Compare and contrast the differences in bathing an infant, a child, and an adult client.
Page Number: p. 200
13. The nurse is reviewing bed making with newly hired unlicensed assistive personnel (UAP). What should the nurse explain as the reason for mitering the corners of the bed linen?
1. Keeps the bed linens tight
2. Helps the client stay in bed
3. Makes raising the side rails easier
4. Prevents the mattress from moving
Correct answer: 1
Rationale 1: Mitered corners keep bed linens tight and wrinkle-free.
Rationale 2: Mitered corners are not used to help keep the client in bed.
Rationale 3: Mitered corners are not used to make raising the side rails easier.
Rationale 4: Mitered corners do not prevent the mattress from moving.
Global Rationale: Mitered corners keep bed linens tight and wrinkle-free. Mitered corners are not used to help keep the clients in bed, make raising the side rails easier, or prevent the mattress from moving.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members
ACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team
NLN Competencies: Teamwork: Practice; Manage delegation effectively.
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8.2 Demonstrate the skill of folding a mitered corner.
Page Number: p. 186
14. The nurse notes that a client has extremely dry skin. How should the nurse document this finding?
1. Pallor
2. Cyanosis
3. Xeroderma
4. Poor skin turgor
Correct answer: 3
Rationale 1: Skin that is pale in color would be documented as pallor.
Rationale 2: Skin that is bluish in color would be documented as cyanosis.
Rationale 3: Xeroderma is extremely dry skin.
Rationale 4: Skin that does not return to the original position when pinched is described as poor skin turgor.
Global Rationale: Xeroderma is extremely dry skin. Skin that is pale in color would be documented as pallor. Skin that is bluish in color would be documented as cyanosis. Skin that does not return to the original position when pinched is described as poor skin turgor.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: IV.B. 4. Document and plan patient care in an electronic health record
AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches
NLN Competencies: Context and Environment; Knowledge; Functionality of clinical and financial systems (data entry, documentation, data retrieval); interoperability of systems
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8.9 Describe the skin assessment steps that must be completed on a daily basis.
Page Number: p. 204
15. A critically ill client needs to be repositioned in bed. Which action will help prevent tearing this client’s skin?
1. Sliding with a lift sheet
2. Raising the foot of the bed
3. Pulling to one side of the bed
4. Pulling up from the head of the bed
Correct Answer: 1
Rationale 1: Using a lift sheet when moving clients at risk for developing skin tears helps prevent tears resulting from friction or shearing.
Rationale 2: Raising the foot of the bed could cause shearing when moving up in bed.
Rationale 3: Pulling the client to one side of the bed could cause skin tears.
Rationale 4: Pulling the client up from the head of the bed could cause skin tears.
Global Rationale: Using a lift sheet when moving clients at risk for developing skin tears helps prevent tears resulting from friction or shearing. Raising the foot of the bed could cause shearing when moving up in bed. Pulling the client to one side of the bed could cause skin tears. Pulling the client up from the head of the bed could cause skin tears.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care
AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8.11 Describe the changes in skin that occur with aging and appropriate nursing interventions to prevent a skin tear.
Page Number: p. 208
16. The nurse is completing evening care for a client. What should the nurse do before documenting that this care has been completed?
1. Straighten top linens
2. Raise upper side rails
3. Remove any unnecessary equipment
4. Fluff pillow and turn cool side next to client
Correct Answer: 2
Rationale 1: The top linens should be straightened after assisting the client with bathing.
Rationale 2: The upper side rails should be raised before documenting the care has been provided.
Rationale 3: Unnecessary equipment should be removed after bathing the client.
Rationale 4: The pillow should be fluffed and turned with the cool side to the client after bathing.
Global Rationale: The upper side rails should be raised before documenting the care has been provided. The top linens should be straightened after assisting the client with bathing.
Unnecessary equipment should be removed after bathing the client. The pillow should be fluffed and turned with the cool side to the client after bathing.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care
AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8.12 Describe briefly the components of evening care.
Page Number: p. 212
17. The nurse decides to use tapotement when providing a client with an evening back rub. What should the nurse keep in mind when using this massage stroke?
1. Avoid the kidney area
2. Use a continuous motion
3. Maintain constant skin contact
4. Focus on the shoulders and along back
Correct Answer: 1
Rationale 1: The tapotement stroke stimulates the skin as the hands move up and down the back. The kidney area should be avoided.
Rationale 2: A continuous motion is used with the effleurage stroke.
Rationale 3: Constant skin contact occurs when moving hands in figure-eight motion from shoulder to buttocks and back.
Rationale 4: The petrissage, or kneading stroke, is issued over the shoulders and along back.
Global Rationale: The tapotement stroke stimulates the skin as the hands move up and down the back. The kidney area should be avoided. A continuous motion is used with the effleurage stroke. Constant skin contact occurs when moving hands in figure-eight motion from shoulder to buttocks and back. The petrissage, or kneading stroke, is issued over the shoulders and along back.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care
AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8.13 Define the three back care strokes and their use in back care.
Page Number: p. 213