Test bank for saunders comprehensive review for the nclex pn examination 7th edition linda anne silv

Test Bank for Saunders Comprehensive Review for the NCLEX-PN Examination, 7th Edition, Linda

Test Bank for Saunders Comprehensive Review for the NCLEX-PN Examination, 7th Edition, Linda Anne Silvestri, To download the complete and accurate content document, go to: https://testbankbell.com/download/test-bank-for-saunders-comprehensive-review-for-t he-nclex-pn-examination-7th-edition-linda-anne-silvestri/

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Chapter 14: Hygiene and Safety Test Bank MULTIPLE CHOICE 1. A client with methicillin-resistant Staphylococcus aureus (MRSA) needs to be placed on contact precautions, and the licensed practical nurse (LPN) in charge asks a newly licensed LPN to initiate contact precautions. Which action by the new LPN would indicate the need to review the procedure for contact precautions?

1. Wears gloves, gown, and goggles when changing the client’s colostomy bag 2. Wears a gown when caring for the client and removes the gown immediately after leaving the client’s room 3. Places the client in a semiprivate room with another client who has active infection with the same microorganism but who has no other infection 4. Places the client in a private room ANS: 2 Rationale: The gown worn by the nurse needs to be removed before he or she leaves the client’s room. Goggles are worn to protect the mucous membranes of the eyes during interventions that may produce splashes of blood, body fluids, secretions, and excretions.

In addition, contact precautions require the use of gloves and a gown if direct client contact is anticipated. The client should be placed in a private room, or if a private room is not available, the client is placed in a semiprivate room with another client who has active infection with the same microorganism but has no other infection.

Test-Taking Strategy: Note the strategic words “need to review the procedure.” These words indicate a negative event query and the need to select the incorrect action. Reading each option carefully and visualizing the procedures instituted for contact precautions will direct you to option 2. If you had difficulty with this question, review transmissionbased precautions.

DIF: Level of Cognitive Ability: Comprehension REF: Harkreader, H., & Hogan, M. (2007). Fundamentals of nursing (3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Safe and Effective Care Environment TOP: Content Area: Fundamental Skills MSC: Integrated Process: Teaching and Learning 2. A nurse is caring for a client who is on airborne precautions. The nurse notes that the client is scheduled for a magnetic resonance imaging (MRI) test. Which of the following nursing actions would be most appropriate in preparing the client for the test?

1. Ask that the MRI department be called to tell the technician that the test will have to be delayed until the airborne precautions are discontinued.

2. Plan to have the MRI performed at the bedside.

3. Ask that the MRI department be called to tell technicians in the department to wear masks.

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4. Place a surgical mask on the client for transport and for contact with other individuals.

ANS: 4 Rationale: If the client is on airborne precautions, client movement and transport should be limited if possible. If transport or movement is necessary, client dispersal of droplet nuclei can be minimized by placing a surgical mask on the client. Option 1 is not within the role of nursing practice. The physician is the individual who would prescribe cancellation or delay of a diagnostic test. Option 2 is unreasonable. Option 3 would not prevent the dispersal of droplet nuclei by the client.

Test-Taking Strategy: Use the process of elimination and focus on the subject of the question, airborne precautions. Eliminate option 1 because the nurse should not delay a prescribed test. Eliminate option 2 because this action is unreasonable. For the remaining options, focus on the route and method of transmission of an airborne infection. This should direct you to option 4. Review these precautions if you had difficulty with this question.

DIF: Level of Cognitive Ability: Application REF: Harkreader, H., & Hogan, M. (2007). Fundamentals of nursing (3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Safe and Effective Care Environment TOP: Content Area: Fundamental Skills MSC: Integrated Process: Nursing Process/Implementation 3. A nurse employed in the ambulatory care department hears a client in the waiting room call out, “Help, fire!” The nurse rushes to the waiting room and finds the wastebasket on fire. The nurse immediately: 1. Removes the clients from the waiting room 2. Activates the fire alarm 3. Confines the fire 4. Extinguishes the fire ANS: 1 Rationale: The order of priority in the event of a fire is to rescue the clients in immediate danger. The next step is to activate the fire alarm. The fire is then confined by closing all doors, and last, the fire is extinguished.

Test-Taking Strategy: Remember the mnemonic RACE to prioritize in the event of a fire.

R (Rescue clients in immediate danger); A (Alarm, sound the alarm); C (Confine the fire by closing all doors); E (Extinguish or evacuate). If you had difficulty with this question, review fire safety.

DIF: Level of Cognitive Ability: Application REF: Harkreader, H., & Hogan, M. (2007). Fundamentals of nursing (3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Safe and Effective Care Environment TOP: Content Area: Fundamental Skills MSC: Integrated Process: Nursing Process/Implementation

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4. A nurse is instructing a group of nursing assistants in the principles of body mechanics.

The nurse determines that a student is using the principles appropriately if the nurse observes the nursing assistant: 1. Positioning a box that is to be lifted between the knees 2. Turning the back to change position while moving a client 3. Helping a client requiring total care into a chair without additional assistance 4. Leaning forward when turning a client in bed ANS: 1 Rationale: The nurse should keep the client or object to be moved as close to the body as possible. If moving an object, the nurse should position the object between the knees when moving it from a low surface. The nurse should turn the feet, not the back, if a change in direction is required when carrying an object or client. When turning a client, the nurse should keep his or her back straight and take small steps.

Test-Taking Strategy: Use the process of elimination and knowledge of the principles of body mechanics to answer the question. Visualizing each of the items in the options will direct you to option 1. Review body mechanics if you had difficulty with this question.

DIF: Level of Cognitive Ability: Comprehension REF: Harkreader, H., & Hogan, M. (2007). Fundamentals of nursing (3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Safe and Effective Care Environment TOP: Content Area: Fundamental Skills MSC: Integrated Process: Teaching and Learning 5. A nurse is working in a long-term care facility and is observing a new nursing assistant caring for a client who requires a security device (wrist restraints). The nurse determines that the nursing assistant is providing safe care if the nurse observes the nursing assistant assessing skin integrity by completely removing the client’s wrist restraints: 1. Every 2 hours 2. Every 3 hours 3. Every 4 hours 4. Every 6 hours ANS: 1 Rationale: Restraints should be completely removed for a brief period at least every 2 hours, and this action should be documented in the nurse’s notes. The color of the extremity should be noted, and the pulse should be assessed. The client should be asked to move the extremity, or range-of-motion exercises should be performed. Agency guidelines regarding the use of restraints should always be followed.

Test-Taking Strategy: Focus on the subject, assessing skin integrity in a client with wrist restraints. In this situation it is best to select the option that identifies the most frequent interval. Review procedures related to the use of a security device if you had difficulty with this question.

DIF: Level of Cognitive Ability: Comprehension REF: Potter, P., & Perry, A. (2009). Fundamentals of nursing: Concepts, process, and practice (7th ed.). St. Louis: Mosby.

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OBJ: Client Needs: Safe and Effective Care Environment TOP: Content Area: Fundamental Skills MSC: Integrated Process: Nursing Process/Evaluation 6. A nurse is assisting in developing a plan of care for an older client to prevent a fall.

Which of the following actions would be least likely to prevent a fall?

1. Placing the bed in the lowest position 2. Placing the call light within the client’s reach 3. Keeping the bathroom light off at nighttime 4. Keeping the side rails up while the client is in bed ANS: 3 Rationale: To prevent falls, a nightlight or bathroom or hall light should be kept on to prevent “sundowning” and an increase in disorientation with approaching darkness.

Options 1, 2, and 4 are appropriate actions to prevent falls.

Test-Taking Strategy: Use the process of elimination, noting the strategic words “least likely” in the query of the question. Reading each option carefully and noting these strategic words should direct you to option 3. Review measures to prevent falls if you had difficulty with this question.

DIF: Level of Cognitive Ability: Application REF: Harkreader, H., & Hogan, M. (2007). Fundamentals of nursing (3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Safe and Effective Care Environment TOP: Content Area: Fundamental Skills MSC: Integrated Process: Nursing Process/Implementation 7. A physician writes an order to apply a heating pad to a client’s back. The nurse implements the prescribed order and avoids which of the following?

1. Setting the heating pad on a low setting 2. Placing the heating pad under the client 3. Assessing the heating pad periodically for proper electrical function 4. Assessing the skin integrity frequently for signs of burns ANS: 2 Rationale: The heating pad should never be placed under the client, but it should be placed lightly against or on top of the involved area. Burns to the skin can occur when the client lies on the pad. Options 1, 3, and 4 are appropriate measures for the use of a heating pad.

Test-Taking Strategy: Use the process of elimination and knowledge of safety measures with the use of a heating pad to answer the question. Note the strategic word “avoids.”

Think about the possible hazards or risks to the client in selecting the correct option. If you had difficulty with this question, review the safety principles regarding the use of a heating pad.

DIF: Level of Cognitive Ability: Application REF: Harkreader, H., & Hogan, M. (2007). Fundamentals of nursing (3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Safe and Effective Care Environment

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TOP: Content Area: Fundamental Skills MSC: Integrated Process: Nursing Process/Implementation 8. A nurse is providing instructions to a client regarding the use of ice packs to treat an eye injury. The nurse instructs the client to: 1. Keep the ice pack on the eye continuously for 24 hours.

2. Place the ice pack directly on the eye.

3. Avoid the use of commercially prepared ice bags.

4. Wrap a plastic bag filled with ice with a pillowcase and place it on the eye.

ANS: 4 Rationale: If an ice pack is placed directly against the skin or left in place for an extended period, it carries a risk of tissue damage similar to that of a hot water bottle or a heating pad. To prevent tissue damage from excessive cold exposure, the ice pack should be removed in most cases after 30 minutes, and after a short time, it may be reapplied. An ice pack should never be placed directly against the skin but should be covered with a pillowcase or towel. Commercially prepared ice bags are appropriate for use as an ice pack.

Test-Taking Strategy: Use the process of elimination to answer the question. Note the words “continuously” in option 1 and “directly” in option 2. These words should assist in eliminating these options. For the remaining options, recall that the use of commercially prepared ice bags is acceptable. Review safety measures for using ice packs if you had difficulty with this question.

DIF: Level of Cognitive Ability: Application REF: Harkreader, H., & Hogan, M. (2007). Fundamentals of nursing (3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Safe and Effective Care Environment TOP: Content Area: Fundamental Skills MSC: Integrated Process: Teaching and Learning 9. A nurse is preparing to clean up a blood spill on the client’s bedside table. The spill occurred when a blood tube containing the client’s blood specimen broke. The nurse avoids doing which of the following when cleaning up the blood spill?

1. Wearing gloves for the cleanup procedure 2. Using tongs to collect any broken glass 3. Blotting up the spill with a face cloth or cloth towel 4. Disinfecting the area of the blood spill with a dilute bleach solution ANS: 3 Rationale: The nurse should blot the spill with an absorbent, disposable material such as paper towels or terry wipes, not a face cloth or cloth towel. Gloves are worn for the procedure, and tongs are used to pick up any broken glass. The area is disinfected with a dilute bleach solution or other agency-required solution.

Test-Taking Strategy: Note the strategic word “avoids” in the query of the question. Use the process of elimination, and visualize the actions identified in each option to assist in directing you to option 3. Review the procedure for cleaning blood spills if you had difficulty with this question.

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Test Bank for Saunders Comprehensive Review for the NCLEX-PN Examination, 7th Edition, Linda

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DIF: Level of Cognitive Ability: Application REF: Harkreader, H., & Hogan, M. (2007). Fundamentals of nursing (3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Safe and Effective Care Environment TOP: Content Area: Fundamental Skills MSC: Integrated Process: Nursing Process/Implementation

Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc .

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