TEST BANK for Timby's Fundamental Nursing Skills and Concepts 12th Edition

Chapter 1 1. A client reports to the emergency department with ankle pain due to a minor road accident.

By asking the client to describe the accident, which type of nursing skill is the nurse using?

A. assessment skills B. comforting skills C. counseling skills D. caring skills Answer: A Rationale: By asking the client to describe the accident, the nurse is using assessment skills to collect more information about the client's condition. The nurse is interviewing the client to collect related data. The nurse is not using comforting skills, as the nurse is not providing any emotional support. The counseling skills of the nurse are also not used, as no health education is provided. Caring skills include assistance provided with the activities of daily living, which is not applicable in this scenario.

Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 15 2. One of the nursing achievements in the Crimean War was that the death rate of soldiers dropped from 60% to 1%. What is the most appropriate reason for the fall in the death rate?

A. increased motivation among the soldiers B. decreased rate of infection and gangrene C. increased funds courtesy of donations from families D. college-based education and training of nurses Answer: B Rationale: During the Crimean War, the death rate of British soldiers was 60%, which dropped to 1% due to the nursing care provided. The nurses improved the ventilation, nutritional, and sanitary conditions of the soldiers, leading to decreased rates of infection and gangrene. As a result, the death rate dropped. The families and the soldiers donated funds after the war, not during the war, through which an organized education and training facility for nurses was started.

Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 3

3. A nurse at a health care facility provides information, assistance, and encouragement to clients during the various phases of nursing care. In which activity does the nurse use counseling skills?

A. educating a group of young girls about AIDS B. telling a client to localize the pain in his abdomen C. encouraging a client to walk without support D. assisting a lactating mother in feeding her child Answer: A Rationale: The activity of educating a group of young girls about AIDS is based on the nurse using counseling skills. Telling a client to localize his pain is an assessment skill.

Encouraging a client to walk without support can be both a comforting skill and a caring skill. Assisting a lactating mother in feeding her baby is an example of a caring skill.

Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Understand Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Client Needs: Health Promotion and Maintenance Client Needs Pn: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 15 4. A nurse is conducting an interview of a 40-year-old client who is admitted with chest pain.

Which action by the nurse indicates active listening?

A. listening to the client silently B. interrupting after each sentence C. asking for clarifications and repetitions D. talking about the nurse's own experience Answer: C Rationale: Active listening is an important component of counseling skills. It encourages the client to open up and express their concerns. The nurse may ask the client to repeat and clarify statements. Interrupting after every sentence may annoy the client. When the nurse listens to the client silently, the client may feel that the nurse is not interested. On the other hand, if the nurse talks about the nurse's own experience, the focus of the session shifts to the nurse rather than to the client.

Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 15 5. A student wants to attend a nursing program that prepares its graduates for both staff and managerial positions. Which type of nursing program should the nurse suggest for this student?

A. hospital-based diploma

B. baccalaureate nursing program C. associate degree program D. continuing nursing program Answer: B Rationale: Baccalaureate-prepared nurses have the greatest potential for qualifying for nursing positions at both staff and managerial levels. Hospital-based diploma programs are 3year courses and provide maximum exposure to clinical nursing. Students becoming nurses through the associate degree program would not be expected to work in a management position. Continuing nursing programs are on-the-job educational programs.

Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Remember Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 11 6. A client is brought to the emergency department with a head injury following an all-terrain vehicle (ATV) accident. The nurse asks the family members to describe how the accident occurred. The nurse is implementing which type of skill?

A. assessment skills B. caring skills C. counseling skills D. comforting skills Answer: A Rationale: The immediate requirement when a client is brought to the emergency department with a head injury is to assess the injury and the system affected, as well as a description of how the accident occurred. This requires implementation of assessment skills. Subsequently, the nurse can implement caring skills, counseling skills, and comforting skills; however, assessment should be the priority.

Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 15 7. Training schools for nurses were established in the United States after the Civil War. The standards of U.S. schools deviated from those of the Nightingale paradigm. Which statement is true about U.S. training schools?

A. Training schools were affiliated with a few select hospitals.

B. Training of nurses provided no financial advantages to the hospital.

C. Training was formal, based on nursing care.

D. Training schools eliminated the need to pay employees.

Answer: D

Rationale: Training schools in the United States profited by eliminating the need to pay employees because students worked without pay in return for training, which usually consisted of chores. U.S. training schools were established by any hospital; there was no formal training. Training was an outcome of work, which eliminated the need to pay employees. Nightingale training schools were affiliated with a few select hospitals, training of nurses provided no financial advantages to the hospital, and the training was formal, based on nursing care.

Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Remember Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 5 8. In a nursing unit, the RN delegates nursing tasks to the LPN. Keeping in mind the delegation guidelines, which statement denotes the right task for the LPN? A. Make beds with the help of unlicensed assistive personnel.

B. Assist clients with nasogastric tube feeds.

C. Take orders from an in-house physician.

D. Assess the client's needs and start an intravenous line.

Answer: B Rationale: Assisting clients with nasogastric tube feeding is an appropriate task for an LPN, as it does not require independent decisions and sophisticated techniques. According to the delegation guidelines, "right task" means that the task should be assigned according to the competency of the caregiver. LPNs may not be authorized to make independent decisions, like starting an IV line, for the client. Bed making is a very basic task and may not be appropriate for an LPN if the UAP is already present. When the RN and LPN are present, the RN takes the physician's orders.

Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 8 9. A 50-year-old client reports to a primary care unit with an open wound due to a fall in the bathroom. Which nursing actions represent caring skills?

A. The nurse cleans the wound and applies a dressing to it.

B. The nurse inspects and examines the wound for swelling.

C. The nurse tells the client to take care while on slippery surfaces.

D. The nurse informs the client that the wound is small and will heal easily.

Answer: A Rationale: The nursing action of cleaning the wound and applying a dressing indicates caring skills. Caring skills involve nursing interventions that restore or maintain a person's health.

The nurse implements assessment skills while inspecting and examining the wound. The nurse counsels the client to take care when walking on slippery surfaces. By informing the client about the wound's condition, the nurse uses comforting skills.

Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Caring Reference: p. 15 10. The scope and character of nursing practice underwent significant changes in the years following the Civil War. Which activity exemplifies nursing practice in the early years of the 20th century?

A. providing basic health care to recent immigrants to the United States B. contributing to the scientific knowledge base of nursing by conducting research C. participating in collaborative practice with physicians D. establishing school nursing as a recognized specialty in urban settings Answer: A Rationale: In the early 20th century, some nurses moved into communities and established "settlement houses" where they lived and worked among poor immigrants. This period of history was not characterized by collaboration between physicians and nurses due to the subservient view of nursing that prevailed. Research and school nursing were not major focuses at this time.

Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 4 11. A nursing student has begun a clinical placement at a large hospital that serves a diverse population. The student has consequently acquired a new appreciation for the fact that nursing combines art with science. What is the clearest manifestation of the scientific basis for nursing?

A. mentoring students and junior nurses B. providing evidence-based nursing care C. maintaining an attitude of curiosity D. participating in continuing educational activities Answer: B Rationale: By developing an accumulating body of unique scientific knowledge, it is now possible to predict which nursing interventions are most likely to produce desired outcomes, a process referred to as evidence-based practice (EBP). EBP is possible because of the scientific basis that underlies nursing. Mentoring, maintaining curiosity, and participating in continuing education are beneficial, but these are not direct manifestations of the scientific basis for nursing.

Question format: Multiple Choice

Chapter 1: Nursing Foundations Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 6 12. Beginning with Florence Nightingale, many definitions of nursing have been put forth by individual nurses and by nursing organizations. Which statement best describes an aspect of the changes in these definitions over time?

A. drawing a clear distinction between the art of nursing and science of nursing B. definitions of nursing that have become narrower in scope over time C. characterization of nursing as a discipline that is a distinct alternative to medical treatment D. definition of an independent health care practice that is not solely dependent on physicians Answer: D Rationale: The most recent definitions of nursing specify that nursing has an independent area of practice in addition to traditional dependent and interdependent functions involving physicians. This does not mean, however, that nursing is an alternative to medical treatment.

Definitions have become broader over time and address the fact that nursing combines art with science.

Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 6 13. A team of nurses who provide care in a community hospital have been encouraged to participate in continuing educational activities. Why is continuing education needed in nursing?

A. Continuing education helps to delineate the distinctions between nurses and physicians.

B. Continuing education increases the public visibility of individual nurses and the nursing profession.

C. Continuing education has the potential to partially alleviate the nursing shortage.

D. Continuing education allows for safer division of labor on hospital units and more effective delegation of tasks.

Answer: C Rationale: Health care officials hope that enrollment in all nursing programs and continuing education will reduce the current and projected critical shortage of nurses. Continuing education is not driven by a desire to increase the visibility of nursing, to draw distinctions between nursing and medicine, or to facilitate the division of labor.

Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 11

14. A nurse has completed a hospital-based educational program that has allowed the nurse to become cross-trained. A nurse who is cross-trained is able to: A. perform certain nonnursing duties in addition to traditional nursing duties.

B. adopt a work schedule that deviates from the normal shift rotation at the hospital.

C. orientate new graduates and nursing students to the hospital.

D. retire with full benefits at an earlier date than a nurse who is not cross-trained.

Answer: A Rationale: A nurse who is cross-trained is able to assume nonnursing jobs, depending on the census or levels of client acuity on any given day. This does not necessarily guarantee changes to work scheduling or earlier retirement. Cross-training does not address the orientation of new employees or students.

Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 12 15. A medical-surgical unit manager intends to have licensed practical nurses (LPNs) in the unit administer intravenous push (IVP) medications. What source would the manager contact to include this procedure in the LPNs' practice?

A. American Nurses Association (ANA) B. state nurse practice act (NPA) C. facility policies and procedures committee D. National League of Nursing (NLN) Answer: B Rationale: Each state has its own NPA, which determines what the nurse is allowed to do in each particular state, providing constraints within which nurses practice. The NPA delineates scope of practice. Therefore, the manager would contact the NPA in this scenario. The other sources are not appropriate given the context of the scenario.

Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Management of Care Reference: p. 8 16. The nurse is caring for a client who cannot meet health needs independently. Which action made by the nurse depicts concern and attachment?

A. telling the client, "I will be back in 15 minutes to change your dressing."

B. asking the client, "How are you today? I am really worried about you."

C. talking about diabetes and teaching the client how to do foot care D. organizing the work for the day and evaluating how the day went Answer: B

Rationale: Concern and attachment are the result of a close relationship of one human being with another. Thus, asking the client how the client is feeling and expressing concern exemplifies caring. Stability and security, communication and teaching, and organization and evaluation are physical care themes that are part of nursing care.

Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Caring Reference: p. 15 17. A registered nurse (RN) is caring for four clients on a medical-surgical unit. Which task is most appropriate for the nurse to delegate to the licensed practical nurse (LPN)?

A. administering bedside blood glucose testing B. administering blood products C. administering intravenous push medication D. administering chemotherapy Answer: A Rationale: The LPN, under the nurse practice act (NPA), is permitted to administer testing for bedside blood glucose. The nurse must recognize the scope of practice of the delegate, and remember that client needs and activities delegated must be matched to skill level. The RN would not delegate administration of blood products, intravenous push medication, or chemotherapy to the LPN, as these tasks are not covered under the LPN's NPA. Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 8 18. A middle-aged nurse is concerned about a potential shortage of nurses when the baby boomer generation retires. What proactive intervention can the nurse take to address this anticipated deficit of nurses?

A. develop a community program related to healthy nutrition and exercise B. recruit more nurses to the acute care facility C. encourage parents to immunize their children D. lobby to increase the retirement age Answer: A Rationale: The promotion of wellness is important not only in community, but also in nationwide health. Promotion of healthy habits and nutrition/exercise will be able to decrease some of the risk factors leading to acute and chronic illnesses and will lead to a decrease in hospital admissions. If effective, it would contribute to the management of issues that require an increase in the number of nurses required. Nurses fill roles other than in acute care facilities and the recruitment of more nurses to those facilities does not address the issue of the shortage in other areas of nursing. Immunization of children does not affect the nursing shortage directly because there is not a relationship between the lack of immunization

increasing the risk of illness to the present nurses employed in the field . Increasing the retirement age can have a detrimental affect on those nurses being required to work with agerelated changes affecting health.

Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 8 19. The nurse is caring for a client at the end stage of life. The client is crying and states to the nurse, "I just cannot believe I am going to be leaving my children without a parent. I am not ready to go." What response by the nurse demonstrates the expression of empathy to the client?

A. "This is so sad and I feel so bad that you are in this situation."

B. "It sounds as though you are most concerned about how your children will feel."

C. "I am so sorry that I am crying with you when you need my support the most."

D. "This just is not fair at all and I do not understand why this is happening to you."

Answer: B Rationale: The nurse is demonstrating empathy when reiterating what the client is saying.

This helps the nurse become effective at providing for the client's emotional needs while maintaining detachment. The other responses indicate that the nurse is feeling sympathy for the client, which includes feeling as emotionally distraught as the client. While this may be an unavoidable response, it may not help the client move through the grieving process as effectively.

Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 15 20. The nurse is delegating tasks to the unlicensed assistive personnel (UAP) prior to beginning the shift on the acute care unit. Which task would be appropriate to delegate to the UAP? A. starting an IV for a client with dehydration B. inserting a nasogastric tube for a client with a small bowel obstruction C. assisting an older adult client with using the bedside commode D. performing an assessment on a newly-admitted client Answer: C Rationale: When delegating tasks to UAPs, the nurse should perform the rights of delegation prior to delegating. Assisting the client with activities of daily living such as transfers, assisting with toileting, and feeding are some of the tasks that are able to be performed by the UAP. Inserting a nasogastric tube, starting an IV, and performing an assessment for a newlyadmitted client are tasks that the nurse must perform and are outside of the scope of practice for the UAP.

Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 15

Chapter 2 1. A client with HIV has been admitted to a health care facility. Which nursing diagnosis should be the priority, keeping in mind the client's condition?

A. Risk for Activity Intolerance B. Risk for Ineffective Coping C. Risk for Infection D. Risk for Imbalanced Nutrition Answer: C Rationale: Clients with HIV have decreased immunity and are prone to infections. Infection in a client with HIV is life-threatening, because it makes the client vulnerable to other infections, and also impairs their already weakened immune functions. Clients with HIV may not have problems with other activities and food. They may often feel depressed, but this is not the highest priority.

Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 25 2. A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which data collected can be classified as subjective data?

A. Blood pressure B. Nausea C. Heart rate D. Respiratory rate Answer: B Rationale: Subjective data are those that only the client can experience and describe. Nausea is subjective data, as it can only be described and not measured. Blood pressure, heart rate, and respiratory rate are measurable factors and are therefore objective data.

Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Reduction of Risk Potential Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 20 3. A client who has to undergo a parathyroidectomy is worried about possibly having to wear a scarf around the neck after surgery. What nursing diagnosis should the nurse document in the care plan?

A. Risk for Impaired Physical Mobility due to surgery

B. Ineffective Denial related to poor coping mechanisms C. Disturbed Body Image related to the incision scar D. Risk of Injury related to surgical outcomes Answer: C Rationale: The client is concerned about the surgery scar on the neck, which would disturb the client's body image; therefore, the appropriate diagnosis should be Disturbed Body Image related to the incision scar. Risk for Impaired Physical Mobility may be present after surgery, but is not related to the concerns expressed by the client. Likewise, Ineffective Denial related to poor coping mechanisms and Injury related to surgical outcomes are also not related to the client's concern.

Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Apply Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 25 4. A nurse is giving postoperative care to a client after knee arthroplasty. What is a possible short-term goal for this client?

A. The client will ambulate with assistance by the nurse to a bedside chair.

B. The client will return to performing activities of daily living.

C. The client will walk 1 mile briskly five times per week.

D. The client will not undergo repeat surgery.

Answer: A Rationale: The short-term goal in this case is to help the client ambulate to the bedside chair.

The other goals, like helping the client return to activities of daily living, to maintain a healthy and active lifestyle, and to prevent repeat surgery are long-term goals and may take weeks or months to achieve. On the other hand, short-term goals can be achieved in a day or a week.

Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 25 5. A nurse, who is caring for a client admitted to the patient care unit with acute abdominal pain, formulates the care plan for the client. Which nursing diagnosis is the priority for this client?

A. Impaired Comfort B. Disturbed Body Image C. Disturbed Sleep Pattern D. Activity Intolerance Answer: A

Rationale: Acute pain in the abdomen disturbs all the systems of the body. Relieving the pain should be the nurse's first priority. According to Maslow, physiologic needs are the highest priority. The client may have Disturbed Body Image, Disturbed Sleep Pattern, or Activity Intolerance, but all these are secondary to pain.

Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 25 6. A nurse is interviewing an asthmatic client who has a high respiratory rate and is having difficulty breathing. The client is consequently restless and can only speak a few words before pausing to catch a breath. What appropriate nursing diagnosis should the nurse document?

A. Impaired Gas Exchange related to the disease condition B. Impaired Verbal Communication related to the breathing problem C. Inability to Speak due to ineffective airway clearance D. Impaired Physical Mobility related to tachypnea Answer: B Rationale: The client has a high respiratory rate and difficulty breathing; the client therefore has trouble communicating. Impaired Verbal Communication related to the breathing problem is the appropriate diagnosis. Although Impaired Gas Exchange may occur in an asthma attack, it does not relate to the concern regarding the client's ability to communicate nor would it be of primary concern in this case. There is no evidence that the client is experiencing Impaired Physical Mobility due to the condition. Inability to Speak due to ineffective airway clearance is not a properly structured nursing diagnosis (it should include "related to" rather than "due to") and is not accurate, in that the client is able to speak, although the speech is impaired.

Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 25 7. A client is brought to the emergency department in an unconscious condition. The client's spouse hands over the previous medical files and points out that the client suddenly fell unconscious after trying to get out of bed. Which is a primary source of information in this case?

A. The client's spouse B. The client's medical documents C. The client's test results D. The client's assessment data Answer: A

Rationale: In this case, the primary source of information is the client's spouse, as the client, who is normally the primary source of information, is unconscious. The spouse can provide a detailed description of the incident as well as provide the medical history of the client. The client's medical files, test results, and assessment data are secondary sources of information.

Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Apply Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 20 8. A nurse is caring for a client with Parkinson's disease. Which nursing diagnosis identified by the nurse should be the priority?

A. Impaired Physical Mobility B. Risk for Memory Loss C. Ineffective Role Performance D. Potential for Injury Answer: D Rationale: Clients with Parkinson's disease are at higher risk of injury due to their physical limitations and cognitive deficiencies. Therefore, it becomes important for the nurse to ensure that the environment is safe. The client may also have Impaired Physical Mobility, Risk for Memory Loss, and Ineffective Role Performance, but the highest priority is to prevent injury, as it may lead to other grave conditions.

Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 25 9. Which action is a priority role of the nurse when caring for a client with collaborative problems?

A. Assessing the client's understanding of risk factors B. Resolving health issues through independent nursing measures C. Reporting trends that suggest the development of complications D. Managing an emerging problem with the help of another registered nurse Answer: C Rationale: For a client with collaborative problems, the nurse should report trends that suggest the development of complications to bring to notice the need for collaborative intervention for the client. Collaborative problems are physiologic complications that require both nurse- and physician-prescribed interventions. Actions that exclude members of other disciplines are not characteristic of collaborative problem management. The development of complications is a priority over assessment of the client's knowledge of risk factors, even though the nurse must assess these.

Question format: Multiple Choice

Chapter 2: Nursing Process Cognitive Level: Apply Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 24 10. A nurse is evaluating and revising a plan of care for a client with cardiac catheterization.

Which action should the nurse perform before revising a plan of care?

A. Discuss any lack of progress with the client.

B. Collect information on abnormal functions.

C. Identify the client's health-related problems.

D. Select appropriate nursing interventions.

Answer: A Rationale: The nurse should discuss any lack of progress with the client so that both the client and the nurse can speculate on what activities need to be discontinued, added, or changed.

Collecting information on abnormal functions and risk factors is done during the assessment.

Identification of the client's health-related problems is done during diagnosis. Nurses select appropriate nursing interventions and document the plan of care in the planning stage of the nursing process, not during evaluation.

Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 28 11. Which action would the nurse perform in the assessment phase of the nursing process?

A. Developing a plan to manage the client's health problems B. Coming up with a nursing diagnosis based on a potential health risk C. Asking the client whether the client has cultural preferences D. Determining whether the client's goals for wellness have been met Answer: C Rationale: Assessing the client involves gathering information about the client's physical and emotional health; cognition; spiritual, cultural, or religious preferences; and sociodemographics. Developing a plan to manage the client's health problems falls within the planning phase of the nursing process. Coming up with the nursing diagnosis falls within the diagnosing phase of the nursing process. Determining whether the client's goals for wellness have been met occurs in the evaluation phase of the nursing process.

Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 20

12. The novice nurse demonstrates proper understanding of collaborative problems by making which statement?

A. "A medical diagnosis of heart failure with the possible consequence of fluid in the lungs could lead to the collaborative problem of pulmonary edema."

B. "The collaborative problem is the combination of the nursing diagnosis and the medical diagnosis, once it is approved by the physician."

C. "A physiologic human need could possibly result in a collaborative nursing diagnosis of Impaired Swallowing."

D. "The client has reached the goals, because treatment was implemented consistently, so nursing orders can be discontinued on the basis of collaborative problems."

Answer: A Rationale: Physicians and nurses work together on collaborative problems. Understanding collaborative problems involves piecing together the medical diagnosis or medical treatment with the possible consequence. The combination of the nursing diagnosis and medical diagnosis does not equate to a collaborative problem. When discussing physiologic needs, this relates to the nursing diagnosis process. Describing client goals pertains to outcomes from evaluation.

Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 24 13. A client is administered an anxiolytic. Which nursing action demonstrates the nurse evaluating the client?

A. Asking whether the client feels less anxious 30 minutes after administering the medicine B. Assigning the client a new nursing diagnosis based on the client's controlled anxiety C. Devising a plan for the client to practice anti-anxiety exercises at home D. Collecting data about the client's history with anxiety Answer: A Rationale: Evaluation allows the nurse to determine whether the client has met the goal. By analyzing the client's response to the anxiolytic, the nurse determines the effectiveness of the nursing care. The other actions demonstrate other parts of the nursing process: assessment (collecting data about the client's history with anxiety), diagnosis (assigning the client a new nursing diagnosis based on the client's controlled anxiety), and planning (devising a plan for the client to practice anti-anxiety exercises at home).

Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 28 14. Which is an example of a subjective finding that the nurse would likely obtain when performing a review of systems (ROS)?

A. A blood glucose level of 108 mg/dL B. A client report of shooting pain up the left leg C. Grip weakness in the right hand D. Crackles in bilateral lung bases Answer: B Rationale: Subjective data consists of information that the client can describe, also known as symptoms. Therefore, a client report of pain in the leg is an example of a subjective finding that the nurse would likely obtain when performing an ROS. A blood glucose level of 108 mg/dL, an observation of weakness in the right hand, and auscultation of crackles in bilateral lung bases are examples of objective data that the nurse or health care provider can observe and measure.

Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 20 15. The nurse is caring for a client who is suspected of having a kidney infection. Which scenario involves the use of subjective data from the primary source?

A. The nurse tells the client to attempt to void.

B. The client tells the nurse that there is a burning sensation when voiding.

C. The physician prescribes medication to help the client void.

D. The client's spouse reports the client experienced incontinence a few days ago.

Answer: B Rationale: Subjective data consist of information that only the client can describe, such as feelings, sensations, or experiences. An example of subjective data is a client's report of pain or fatigue. Objective data are those that can be measured and observed by others, a fever or a broken bone. The primary source is the client. Secondary sources include family members, reports, test results, and other health care providers.

Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 20 16. Which scenario represents a nurse demonstrating the critical thinking process?

A. assessing whether physician help is needed B. assessing why a physician encounter form is missing from the record C. collaborating with the respiratory therapist and physical therapist to address a complication D. using power for more control and freedom over the daily tasks Answer: A

Rationale: Critical thinking involves consistency, relevancy, and logical thinking. It enables the nurse to make decisions. Therefore, assessing whether physician help is needed is an example of the critical thinking process. The other actions support other nursing soft skills.

Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 19 17. Which statement made by the nurse indicates data that would be documented as part of an objective assessment?

A. "The client's sister reports that the client has unrelieved pain."

B. "The client's right leg is cold to the touch, from the knee to the foot."

C. "The client reports nausea following eating."

D. "The client reports having heartburn after breakfast."

Answer: B Rationale: Objective data are information that is observable and measurable, such as observing that the client's right leg is cold to the touch. Subjective data relate to phenomena that only the client can experience, such as unrelieved pain, nausea, or heartburn.

Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 20 18. The client reports, "I have a few drinks with friends every week." Which nursing action exemplifies using a focused assessment in this case?

A. Obtaining data regarding the amount and frequency of drinking B. Interviewing friends to ascertain the client's exercise habits C. Asking the client to discuss social functioning D. Performing an abdominal assessment Answer: A Rationale: A focused assessment is information that provides more details about specific problems and expands the original database. Obtaining data regarding the amount and frequency of drinking qualifies as a focused assessment. The other actions do not relate to the client's drinking habits or potential for alcohol overuse and thus would not be included in a focussed assessment of these issues.

Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 20

19. A client is admitted to the mental health center after attempting suicide. Which client concern is the priority for the nurse to manage?

A. Risk of self-harm B. Lack of support C. Low self-esteem D. Feelings of not belonging Answer: A Rationale: Safety and security are the priority for the client, so the risk of self-harm is what the nurse must address first. Lack of support, low self-esteem, and feelings of not belonging, although still important to address, are not as critical as safety and security.

Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 25 20. A client is admitted to a psychiatric treatment unit with psychosis. What is the priority diagnosis for this client?

A. Self-Care Deficit B. Disturbed Thought Processes C. Risk for Self-Harm D. Risk for Imbalanced Nutrition: Less Than Body Requirements Answer: B Rationale: A client with psychosis is unable to recognize reality, their communication is impaired, and they cannot identify people. The client may also experience hallucinations and delusions. Therefore, Disturbed Thought Process is the most appropriate nursing diagnosis for such a client. The client may be at risk for suicidal thoughts, have difficulty in dressing and grooming, and may not eat properly; however, the priority is the thought process because it is the main reason for all other symptoms.

Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 25 21. The nurse is assisting with the creation of a plan of care for a client with newly diagnosed diabetes mellitus. When creating the plan of care, what is the priority action for the nurse?

A. involving the client with all the steps of the process in care development B. ensuring the client is informed after decisions are made with care delivery C. requiring the client to evaluate the plan of care after implementation D. implementing the standard plan of care for all clients with diabetes mellitus Answer: A

Rationale: Because the plan of care should be client-centered, the client should be directly involved with all phases of the creation of the care plan. This will involve assessing the learning needs of the client as well as goal setting, implementation, and evaluation. The client should be involved and not just informed of decisions regarding care during the evaluation phase. The client may be involved with the evaluation but the nurse will assess to determine if the plan of care is effective and if the client's goals are being met. Standard plans of care do not address the needs of the individual and should be tailored to the individual client.

Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Apply Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 19 22. The home health nurse is performing an assessment related to the client's ability to manage activities of daily living in the home environment. Which assessment is the nurse performing?

A. comprehensive assessment B. database assessment C. focused assessment D. functional assessment Answer: D Rationale: The nurse is performing a functional assessment that focuses on areas that relate to the physical performance of activities, such as how the client is able to meet activities of daily living, demonstration of cognitive abilities, and social functioning. A comprehensive assessment encompasses all of the assessment data for the client. The focused assessment relies on one area of funcitoning such as the respiratory system if a client is having an asthma attack. The database assessment is performed during the initial history and physical portion of the client's illness and represents a comprehensive and all inclusive initial collection of data.

Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Understand Client Needs Pn: Health Promotion and Maintenance Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 20

Chapter 3 1. A client who has undergone resection of the intestine is NPO with a nasogastric (NG) tube in place. A food tray with regular food comes to the room, and the client insists that the health care provider be called. The nurse insists that it is okay and encourages the client eat the food. The client complies and later develops complications that require another operation.

Which action constitutes the primary breach of duty in this situation?

A. The nurse did not call the health care provider when requested.

B. The nurse did not realize the importance and purpose of the NG tube.

C. The dietary department sent the wrong diet for the client.

D. The nurse encouraged the client to eat.

Answer: B Rationale: Negligence is defined as harm that occurs because the person did not act reasonably. Establishing liability for negligence requires four elements: duty, breach of duty, causation, and damages. In this case, the primary breach of duty is that the nurse did not realize that the client was on an NG tube and should consequently have been on liquid feeds after intestinal surgery; as a result, the client at the food and developed complications. The acts of not calling the physician and insisting the client have food are not the primary breach of duty, as they are logical based on the assumption that the client could take food by mouth.

The dietary department sending the wrong food is unrelated to the nurse.

Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 38 2. A client who is scheduled for hernioplasty needs clarification regarding the procedure. The nurse calls the physician at the client's insistence. The physician, who is in a bad mood, is overheard telling the client that the nurse does not know anything. Which legal tort has the physician committed?

A. Libel B. Battery C. Assault D. Slander Answer: D Rationale: The physician has committed slander by defaming the nurse orally. Slander is a character attack uttered orally in the presence of others. Libel refers to damaging statements written and read by others. Assault is an act in which bodily harm is threatened or attempted.

Battery is unauthorized physical contact, not applicable in this situation.

Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Management of Care

Integrated Process: Communication and Documentation Reference: p. 38 3. A nurse enters a client's room and finds that the client is lying on the floor. The nurse makes the client comfortable on the bed and completes an examination. She informs the physician and the nursing supervisor about this incident and also completes an incident report. Which action by the nurse indicates correct knowledge of handling an incident report?

A. The nurse documents a complete description of the happenings in the client's records.

B. The nurse makes a copy of the incident report and places it in the client's records.

C. The nurse makes a copy of the incident report to give to the physician.

D. The nurse mentions in the client's report that an incident report was completed.

Answer: A Rationale: An incident report is a written account of an unusual, potentially injurious event involving a client, employee, or visitor. It is kept separate from the medical record. The incident report is a legal document and making a copy of it is not advisable. It should not be placed in the client's records; however, the nurse can mention the incident in the client's records without mentioning the incident report.

Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Communication and Documentation Reference: p. 40 4. A nurse is caring for a client with multiple sclerosis. The client informs the nurse that a lawyer is coming to prepare a living will and requests the nurse to sign as witness. Which action should the nurse take?

A. State that the physician will be a witness.

B. Arrange for other colleagues to sign as a witness.

C. Note that the nurse caring for the client cannot be a witness.

D. Inform the physician about the living will.

Answer: C Rationale: A living will is an instructive form of an advance directive. It is a written document that identifies a person's preferences regarding medical interventions to use in a terminal condition, irreversible coma, or persistent vegetative state with no hope of recovery.

Employees of the health care facility cannot sign as witnesses; therefore, the nurse cannot sign as witness. Refusing a client may not be a good communication method; instead, the nurse could politely indicate her reason. Calling for a physician or asking another colleague to sign is an inappropriate action.

Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 44

5. An HIV-positive client discovers that the client's name is published in a research report on HIV care prepared by the client's nurse. The client is hurt and files a lawsuit against the nurse. Which offense has the nurse committed?

A. Unintentional tort B. Invasion of privacy C. Defamation of character D. Negligence of duty Answer: B Rationale: The nurse has committed the tort of invasion of privacy. Personal names and identities should be concealed or obliterated in case studies or research work. Invasion of privacy is a type of intentional tort. Defamation is an act in which untrue information harms a person's reputation and is therefore not applicable here. Negligence is the harm that results because a person did not act reasonably.

Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 38 6. A nurse warns a client that he may fall off his bed during a seizure attack if he does not put on the side rails of the bed. Before leaving the client's room, the nurse puts on the side rails, but after the nurse has left, the client lowers them again. Later, the client has a fall from the bed and holds the nurse responsible for it. Which legal provision protects the nurse in this case?

A. Good Samaritan law B. statute of limitations C. common law D. assumption of risk Answer: D Rationale: The nurse is protected by the provision of assumption of risk. If a client is forewarned of a potential safety hazard and chooses to ignore the warning, the court may hold the client responsible. It is essential that the nurse documents warning the client and that the client disregarded the warning. Good Samaritan laws provide legal immunity to passersby who provide emergency first aid to accident victims. The statute of limitations is the designated time within which a person can file a lawsuit. Common laws are decisions based on prior similar cases.

Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Reference: p. 40

7. A client informs the nurse that the client wants to discontinue treatment and go home.

Later, the nurse finds the client dressed to leave. Which action should the nurse take in this situation?

A. Let the client go after signing a document stating that the client is going against medical advice.

B. Restrain the client until medical treatment is over.

C. Call the physician and get the discharge paper signed.

D. Warn the client that the client may not be able to access health care again.

Answer: A Rationale: If a client wishes to go before the client's medical treatment is finished, the nurse should have the client sign a document indicating personal responsibility for leaving against medical advice. The nurse should not restrain the client, as it would make the nurse liable for legal action. The nurse may call the physician and get the discharge paper signed, but this is not appropriate. The nurse should not warn the client that the client will be denied health care in the future, because it is the client's right to access the health care facility whenever needed.

Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 37 8. A client is admitted with symptoms of psychosis. The nurse hurries to the client's room on hearing the client calling for help. The nurse finds the client lying on the ground. The nurse assists the client back to the bed and performs a thorough assessment. The nurse informs the physician and completes the incident report. Which statement should the nurse document in the incident report?

A. The client was trying to lower the side rails.

B. The client was found lying on the floor.

C. The client was trying to get out of the bed.

D. The client was not aware that the client had fallen.

Answer: B Rationale: An incident report is a written account of an unusual, potentially injurious event involving a client, employee, or visitor. All of the details given in the incident report should be accurate and not assumed. Accurate and detailed documentation helps to prove that the nurse acted reasonably or appropriately in the circumstance. The nurse should document that the client was found lying on the floor. The other statements are assumptions and should not be included in the incident report.

Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Communication and Documentation Reference: p. 40

9. A nurse assesses a client with psychotic symptoms and determines that the client needs vest restraints. However, the client asks the nurse not to put on vest restraints. What would be the best nursing action?

A. Contact the physician and obtain necessary orders.

B. Restrain the client with vest restraints.

C. Apply restraints after giving a sedative.

D. Apply wrist restraints instead of vest restraints.

Answer: A Rationale: If a nurse feels that a client needs to be restrained, the nurse should inform the physician and obtain necessary orders. The nurse should also discuss this with the client's family members and ask their opinion. The nurse should not sedate the client and then restrain him, as the nurse could be charged with battery if there is restraint without orders.

Applying a wrist restraint instead of a vest restraint is like compromising with the client, which is unethical.

Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs Pn: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Communication and Documentation Reference: p. 37 10. A nurse is caring for a client who has undergone coronary angioplasty. The cardiac monitor is showing abnormal electrocardiogram waves, indicating atrial fibrillation. The nurse does not recognize the importance of the sign; as a result, the client's condition deteriorates and the client has to be taken up for an emergency procedure. Which describes the nurse's legal liability?

A. Felony B. Defamation C. Tort D. Slander Answer: C Rationale: A tort is a cause of action in which one person asserts that a physical, emotional, or financial injury was a consequence of another person's actions or failure to act. A tort implies that one breached one's duty to another person. In this case, the nurse had a duty that was breached. A felony is a serious criminal offense, such as murder. Defamation is an act in which untrue information harms a person's reputation. Slander is a character attack uttered orally in the presence of others.

Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Understand Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 38

11. A nurse, while off-duty, tells the physiotherapist that a client who was admitted to the nursing unit contracted AIDS at the age of 18. The client discovers that the nurse has revealed the information to the physiotherapist, and learns that the nurse wrongfully attributed the disease to the client's contact with sex workers. With what legal action could the nurse be charged?

A. libel B. slander C. malpractice D. tort Answer: B Rationale: The nurse can be charged with slander, which is a character attack uttered orally in the presence of others. Libel includes damaging statements written and read by others. The description is also not appropriate for tort or malpractice.

Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 38 12. A nurse is caring for a very weak client with multiple pregnancies. Which view would a teleologist have in such a situation?

A. Support the procedure of selective abortion.

B. Argue that destroying any fetus is wrong.

C. Avoid telling the truth to the client.

D. Avoid analyzing ethical dilemmas of a case.

Answer: A Rationale: A teleologist would argue that selective abortion is ethical because it will ensure the full-term birth of those who remain. Teleologists analyze ethical dilemmas on a case-bycase basis. A deontologist would argue that destroying any fetus is wrong on moral grounds.

Deontologists believe that lying is never acceptable because it violates the duty to tell the truth to those entitled to honest information.

Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 42 13. A nurse is applying for professional liability insurance. The nurse knows that professional liability insurance is important for which reason?

A. to obtain sound compensation B. to be familiar with legal mechanisms C. to upgrade professional knowledge D. to obtain free medication for family

Answer: B Rationale: The number of lawsuits involving nurses is increasing. It is to every nurse's advantage to obtain liability insurance and to become familiar with legal mechanisms, such as Good Samaritan laws and statutes of limitations that may prevent or relieve culpability and provide a sound legal defense. Professional liability insurance does not focus on enhancing the nurse's professional knowledge, does not offer free medication for family, or obtain sound compensation to a nurse.

Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Remember Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 39 14. A home care nurse is caring for a paralyzed client who needs regular position changes and back massages. A man identifying himself as a family friend inquires if he can be of any help to the family. What should be the nurse's response?

A. The nurse should ask the man to talk to the family directly.

B. The nurse should invite the man to learn the caring techniques.

C. The nurse should state that the family does not need any help.

D. The nurse should refer the man to the local social worker.

Answer: A Rationale: The nurse should ask the man to talk to the family directly. Revealing information about the client's care is a violation of the client's privacy. The nurse should not invite the man for a learning session because it would be a breach of the client's right to privacy.

Referring him to a social worker is not an appropriate choice.

Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 38 15. A nurse finds that a colleague is intoxicated while on duty. What appropriate action should the nurse take?

A. Inform the nursing supervisor.

B. Tell the colleague to take a 30-minute break.

C. Inform the physician.

D. Watch the colleague closely during the shift.

Answer: A Rationale: When a colleague is intoxicated while on duty, the nurse should immediately inform the nursing supervisor, who may take necessary action. It would be an irresponsible action if the nurse tells the colleague to take a rest. Likewise, informing a physician is not the

appropriate response. The nurse should not ignore the incident and simply observe the colleague because client care may be affected.

Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Communication and Documentation Reference: p. 46 16. A client with a bone infection had a central venous catheter ordered for the long-term administration of antibiotics. The intravenous line was inserted at the bedside by a qualified nurse, but the nurse was observed to make a serious lapse in aseptic technique and the client developed sepsis. What type of law most directly addresses this situation?

A. criminal law B. civil law C. common law D. statutory law Answer: B Rationale: This nurse has committed a breach of duty, which is an offense under civil law. It is unlikely that this constitutes a criminal offense. Statutory law and common law do not address such events that involve an act between two individuals.

Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 35 17. After several years of providing bedside care in an inpatient setting, a nurse has taken a position with the state board of nursing. In this role, the nurse may contribute to which activities of a state board of nursing?

A. issuing and transferring nursing licenses within the state B. providing consultation on ethically challenging clinical situations C. promoting the visibility of the nursing profession within the state D. allocating financial resources within clinics and hospitals in the state Answer: A Rationale: State boards of nursing perform multiple roles, including issuing and transferring licenses of nurses in the state. Consultations on ethics, allocation of resources, and promotion of the nursing profession are not typical activities of state boards of nursing.

Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 34

18. A group of nursing students is reviewing the ANA's current code of ethics. A code of ethics is important in the nursing profession because: A. nurses are highly vulnerable to criminal and civil prosecution in the course of their work.

B. nurses interact with clients and families from diverse cultural and religious backgrounds.

C. nursing practice involves numerous interactions between laws and individual values.

D. nurses are responsible for carrying out actions that have been ordered by other individuals.

Answer: C Rationale: A code of ethics is necessary to guide nurses' conduct, especially with regard to the interaction between laws and individual values. Diversity and legal liability do not provide the main justification for a code of ethics, though each is often a relevant consideration. The fact that nurses often carry out the orders of others is not the justification for a code of ethics.

Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Caring Reference: p. 42 19. A group of nurses who work at a large, long-term care facility have become embroiled in controversy over a large number of residents who are refusing a seasonal influenza vaccination. Specifically, there is controversy around the appropriate amount of influence that nurses can exercise when encouraging residents to become immunized. A teleological perspective on this issue would prioritize what consideration?

A. the "rightness" or "wrongness" of coercion B. the legal rights of the individual C. the greatest good for the greatest number D. historical precedents Answer: C Rationale: Teleology is ethical theory based on final outcomes. It is also known as utilitarianism because the ultimate ethical test for any decision is based on what is best for the most people. Deontology focuses on the morality of an act. Teleology does not prioritize historical precedent or the legal rights of the individual.

Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 42 20. An illegal immigrant with no health insurance sustained life-threatening injuries in an automobile accident. Which action in this case demonstrates the ethical principle of justice?

A. Airlifting the client to a local trauma center for emergency surgery B. Avoiding treating the client so as to not do any additional harm C. Filing the paperwork for the client to receive retroactive health insurance D. Telling the client honest information about the client's medical condition and prognosis

Answer: A Rationale: The ethical principle of justice mandates that clients be treated impartially without discrimination according to age, gender, race, religion, socioeconomic status, weight, marital status, or sexual orientation. An immediate airlift to the local trauma center demonstrates that this client is begin treated impartially. Avoiding causing the client additional harm would demonstrate nonmaleficence. Attempting to help the client obtain health insurance would demonstrate beneficence and advocacy. Telling the client the truth about the client's medical condition and prognosis would demonstrate integrity and honesty (veracity).

Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Caring Reference: p. 43 21. A nurse who is infected with human immunodeficiency virus (HIV) accidentally gets a cut while debriding a wound, exposing the client to possible HIV infection. Failure of the nurse to report this incident violates which ethical principles? Select all that apply.

A. Justice B. Autonomy C. Nonmaleficence D. Veracity E. Fidelity Answer: C, D, E Rationale: Nonmaleficence means "doing no harm" or avoiding an action that deliberately harms a person. By not reporting this incident, the nurse is deliberately harming the client.

Veracity means the duty to be honest and avoid deceiving or misleading a client. Fidelity means being faithful to work-related commitments and obligations, such as reporting the incident. Justice and autonomy do not apply in this scenario.

Question format: Multiple Select Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Communication and Documentation Reference: p. 42 22. A nurse completing admission paperwork asks the client about having an advanced directive. The client states, "I do not know, what is an advanced directive?" What is the nurse's best response?

A. "It is a written document that identifies a person's preferences regarding which medical interventions to use in the event of a terminal condition."

B. "It is an agreement that authorizes the hospital to make decisions on your behalf, if you become incapacitated."

C. "I will contact the hospital social worker to come and discuss the development of an advance directive with you."

D. "It is a document created by you and your attorney naming a beneficiary to handle your estate if you become terminally ill."

Answer: A Rationale: An advance directive is a written statement identifying a competent person's preferences regarding which medical interventions to use in the event that the client cannot make a decision for themselves concerning terminal care. The other responses are not correct.

Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 44 23. During a nursing shift, which events warrant completion of an incident report? Select all that apply.

A. A nurse reports that a client is crying and distraught over a diagnosis of metastatic cancer.

B. An intravenous antibiotic was administered 2 hours late because the IV site infiltrated.

C. A visitor slipped and fell in the hallway, but was not injured.

D. A client falls while being transferred from the bed to the chair.

E. A nurse asks an unlicensed assistive personnel (UAP) to feed a client.

Answer: B, C, D Rationale: An incident report is a written account of an unusual, potentially injurious event involving a client, employee, or visitor. Late administration of medication is considered a medication error and is potentially injurious to the client. A visitor fall and a client fall are both reportable situations. A client crying following a diagnosis of cancer could be expected, and a nurse delegating appropriate care to a UAP is not reportable. Therefore, these actions do not require an incident report to be filed.

Question format: Multiple Select Chapter 3: Laws and Ethics Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Communication and Documentation Reference: p. 40 24. An oncology nurse is caring for a client suffering from metabolic encephalopathy and end-stage kidney disease. The client has no known family and no advance directives. Upon entering the room, the nurse observes the client is pale and has no spontaneous respiration.

What is the priority action the nurse should take?

A. Contact the physician.

B. Call the coroner.

C. Notify the charge nurse.

D. Begin CPR. Answer: D

Rationale: A code status refers to how health care providers are required to manage care in the case of cardiac or respiratory arrest. A full code means that all measures to resuscitate the client are used. The nurse should immediately begin CPR. Although it is necessary to notify the physician and charge nurse, this is not the priority. It is not appropriate to contact the coroner at this time.

Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 45-46 25. A nurse is caring for a client with hypertension whose blood pressure has increased from 154/78 mmHg to 196/98 mmHg with a heart rate of 110 beats per minute during the past hour. The nurse goes to lunch without reporting the change to the health care provider, and the client experiences a cardiac arrest. What tort has the nurse likely committed?

A. Negligence B. Battery C. Invasion of privacy D. False imprisonment Answer: A Rationale: Negligence, such as not reporting a change in a client condition, is harm that results because a person did not act reasonably. Based on the definition of negligence, harm resulted due to the nurse's lack of action (omission). Battery, invasion of privacy, and false imprisonment did not occur in this scenario. Battery includes willful, angry, and violent or negligent touching of another person's body or clothes or anything attached to or held by that other person. Invasion of privacy is a breach in confidentiality in which one's personal information is given to another without the person's consent. False imprisonment is unjustified retention or prevention of the movement of another person without proper consent.

Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 38 26. A nurse is called to a deposition for a malpractice charge that has resulted in the death of a client. As the chart is reviewed, the prosecuting attorney questions the nurse about several defaming comments written in the medical record about the client. What charges can be filed against the nurse due to these comments?

A. Malpractice B. Slander C. Libel D. Negligence Answer: C

Rationale: Libel is damaging statements written and read by others. Because defaming comments were written in the chart, libel charges could be appropriate. Malpractice is negligence in performing or failing to perform expected duties of one's profession. Slander is oral defamation of character. Negligence is performing an action a reasonable person would not perform or failing to perform an action that a reasonable person would perform, resulting in harm to another.

Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 38 27. A nurse is caring for a hospitalized client. Which nursing actions demonstrate a caring and compassionate attitude? Select all that apply.

A. Leaving the room promptly once care is completed B. Notifying the client before leaving for lunch C. Offering snacks and beverages to visiting family D. Explaining all nursing procedures clearly E. Listening to the client tell stories about past experiences Answer: B, C, D, E Rationale: One of the best methods for avoiding lawsuits is to administer compassionate care.

Notifying the client before leaving for lunch, offering snacks and beverages to visiting family, explaining all nursing procedures clearly, and listening to the client tell stories are examples of a caring and compassionate attitude. Leaving the room promptly once care is completed does not demonstrate care or compassion.

Question format: Multiple Select Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Caring Reference: p. 39 28. A nurse who works on a palliative care unit has participated in several clinical scenarios that have required the application of ethics. Ethics is best defined as: A. the relationship between law and culture.

B. moral values that are considered to be universal.

C. the principles that determine whether an act is right or wrong.

D. the laws that govern acceptable and unacceptable behavior.

Answer: C Rationale: Ethics involves moral or philosophical principles that direct actions as being either right or wrong. Laws are often rooted in ethics, but the two terms are not synonymous.

Similarly, morals and values are closely associated with ethics, but these do not constitute the definition of ethics. Ethics are not universally agreed upon, as many different applications exist.

Question format: Multiple Choice

Chapter 3: Laws and Ethics Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Caring Reference: p. 41 29. A nurse witnesses a traffic accident in which a child is badly hurt. The nurse dresses the open wounds sustained by the child. The family tries to give monetary compensation, which the nurse refuses. Later, in the hospital, the child develops complications due to infection in the wound. The family holds the nurse responsible for the complications and wants to file a lawsuit. Which of the following statements is true regarding the Good Samaritan law?

A. The Good Samaritan law will provide legal immunity to the nurse.

B. The Good Samaritan law will not protect the nurse, as she did not accept the compensation.

C. The Good Samaritan law is not applicable to health care workers.

D. The Good Samaritan law provides absolute exemption from prosecution.

Answer: A Rationale: Good Samaritan laws provide legal immunity to passersby who provide emergency first aid to victims of accidents. Therefore, the law is applicable to the nurse as well; moreover, the nurse did not accept any compensation for the service provided. The law is equally applicable to everyone, but does not provide absolute exemption from prosecution in cases of negligence. Paramedics, ambulance personnel, physicians, and nurses who stop to provide assistance are still held to a higher standard of care because they have training above and beyond that of the average layperson. In cases of gross negligence, health care workers may be charged with a criminal offense.

Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 40

Chapter 4 1. A nurse is caring for a child with Huntington's chorea, a hereditary condition. Which statement is true of hereditary conditions?

A. The symptoms are manifested immediately after birth.

B. The condition is due to maternal exposure to toxins.

C. The condition is acquired from genes of one or both parents.

D. The course is associated with exacerbations and remissions.

Answer: C Rationale: Hereditary conditions are acquired from genes of one or both parents. The symptoms may or may not be manifested immediately after birth. Some hereditary diseases, including Huntington's chorea, remain asymptomatic and undiagnosed until adulthood.

Hereditary conditions are not due to abnormalities in embryonic development.

Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 51 2. A nurse is caring for a client who is confined to bed due to paralysis. The client has a medical history of stroke, hypertension, and diabetes mellitus for the past five years, besides having asthma since childhood. Which is a secondary illness seen in the client?

A. diabetes mellitus B. asthma C. hypertension D. stroke Answer: D Rationale: Stroke is a secondary illness caused by high blood pressure. Secondary illness is a disorder that develops from a preexisting condition. In this case, the client had a history of hypertension, which is a primary illness that caused a stroke. Diabetes mellitus and asthma represent primary illnesses in the client, as there are no preexisting conditions predisposing the client to asthma and diabetes mellitus.

Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 51 3. A client with Crohn's disease in remission is admitted to the nursing unit for follow-up care. The remission state is characterized by: A. permanent relief from the signs and symptoms.

B. disappearance of signs and symptoms associated with the disease.

C. periodic occurrence in clients with long-standing diseases.

D. reactivation of the disease and presence of symptoms.

Answer: B Rationale: Remission is a temporary state of disappearance of the signs and symptoms related to a particular disease. It is of short duration, but the duration is unpredictable. It is a condition opposite to exacerbation, which is characterized by reactivation of symptoms.

Remission is not permanent, but is rather a temporary relief from signs and symptoms.

Exacerbation is the periodic occurrence of disease in clients with chronic diseases.

Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 51 4. A client admitted for hernioplasty is discharged two days later than the calculated time due to postoperative complications. The client is insured through a capitation scheme. In the event of late discharge of the client, who is at loss?

A. the client B. the hospital C. the insurers D. the doctors Answer: B Rationale: The hospital is at loss if the client is discharged late from the hospital. The client is insured through a capitation scheme, which provides a pre-set fee per member to the health care provider, regardless of whether the member requires services. If a client is discharged earlier, the hospital keeps the difference; if the client is discharged late, the hospital is at loss.

The client is not at loss because he pays a fixed amount to the provider whether he utilizes the care or not. The doctors and the health care workers are not affected.

Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 54 5. A nurse is caring for a client who has undergone total hip replacement and is advised to undergo physiotherapy after discharge. Which level of care is the physiotherapy center?

A. continuity of care B. extended care C. secondary care D. tertiary care Answer: B

Rationale: Physiotherapy is an example of extended care. It does not involve acute care and is not compulsorily done on hospital premises. The hospital providing surgical facilities is a tertiary care center. The client, after being discharged from tertiary care, joins a physiotherapy unit for extended care.

Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 52 6. A client arrives at a health care facility complaining of pain in the abdomen and diarrhea.

The physician diagnoses the client with colitis, an acute illness. Why is colitis considered an acute illness?

A. The onset is sudden.

B. It lasts for a long time.

C. It is difficult to treat.

D. It is not curable.

Answer: A Rationale: Colitis, in this case, is an acute illness because the onset is sudden. Acute illnesses affect a person for a short duration and are cured in a short time. Acute illnesses are not difficult to treat and are curable. On the other hand, chronic illnesses have a gradual onset and require a longer period to be cured. In some cases, the illness may remain lifelong.

Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Remember Client Needs Pn: Physiological Integrity: Physiological Adaptation Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 50 7. A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The nurse explains to the client that COPD is a chronic disease. Why is COPD considered a chronic disease?

A. It persists for a long time.

B. It is a sequela of acute illness.

C. It takes a long time to cure.

D. It has a gradual onset and lasts for a long time.

Answer: D Rationale: Chronic illness has a gradual onset and lasts for a long time. It is usually seen in old age. It may or may not be due to acute illness. Chronic diseases are a major cause of morbidity in the population.

Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Remember Client Needs Pn: Physiological Integrity: Physiological Adaptation

Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 50 8. A client who suffered a stroke is discharged from a health care unit and the nurse is assigned to provide nursing care to the client at home. This is an example of which kind of care?

A. extended care B. secondary care C. tertiary care D. primary care Answer: A Rationale: Extended care represents services that meet the health needs of clients who no longer require acute hospital care. It includes skilled nursing care in a person's home or a nursing home and hospice care for dying clients. Primary care is provided by the family physician, the nurse, or any health care facility that is the first contact for the client.

Secondary care and tertiary care are provided at specialized health care units.

Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Understand Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 52 9. Consultation and diagnostic tests are included in which level of health care?

A. Primary care B. Secondary care C. Tertiary care D. Extended care Answer: B Rationale: Consultation and diagnostic tests are included in the secondary level of health care. The first contact with a general physician is the primary care, and the reference to a highly specialized facility for desensitization is the tertiary care level. The secondary and tertiary care facilities are equipped to provide highly specialized care. Extended care is care provided to clients who no longer require acute hospital care.

Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Remember Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 51

10. A client arrives at a health care facility reporting diarrhea and abdominal pain for the past 24 hours. The helath care provider diagnoses the client with gastritis, an acute illness. Why is gastritis considered an acute illness?

A. The onset is sudden.

B. It lasts for a long time.

C. It is difficult to treat.

D. It is not curable.

Answer: A Rationale: Gastritis in this case is an acute illness because the onset is sudden. Acute illnesses affect clients for a short duration and are cured in a short time. Acute illnesses are not necessarily difficult to treat and are often curable. Whereas, chronic illnesses have a gradual onset and require a longer period to be cured. In some cases, the illness may remain for a lifetime.

Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Client Needs Pn: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 50 11. A middle-aged client is distraught at receiving a diagnosis of type 2 diabetes in spite of being conscientious about her health for the majority of her adult life. The client tells the nurse, "I can't believe I no longer have my health." The nurse should be aware that the World Health Organization defines health as: A. the absence of acute and chronic health issues that affect the client's quality of life.

B. a level of function that is equal to or superior to individuals of similar age.

C. the ability to contribute unimpeded to the quality of life on oneself and others.

D. a state of physical, mental, and social well-being.

Answer: D Rationale: The WHO defines health as "a state of complete physical, mental, and social wellbeing, not merely the absence of disease or infirmity." This definition does not preclude the other listed aspects of health, but none of these is considered definitive by the WHO. Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Client Needs Pn: Health Promotion and Maintenance Integrated Process: Communication and Documentation Reference: p. 48 12. A nurse has become involved in political efforts to ensure that a greater percentage of Americans have access to affordable health care, regardless of their individual circumstances.

This view of health is reflective of what belief?

A. Health is a limited resource.

B. Health is a right.

C. Health is inevitable.

D. Health is personal responsibility.

Answer: B Rationale: Efforts to eradicate health disparities are often rooted in the belief that health care is a right. The belief that health care is a limited resource underlies views of the preciousness of preserving health. Personal responsibility is foundational to the view of individual ownership of one's health status. It is unrealistic to believe that health is inevitable.

Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Client Needs Pn: Health Promotion and Maintenance Integrated Process: Communication and Documentation Reference: p. 48 13. After experiencing an ST-wave elevation myocardial infarction, a 64-year-old man has been admitted to the cardiac unit of the hospital for care. The nurse has completed a comprehensive assessment and is creating a plan of care that is holistic in its focus. How can the nurse best integrate the principles of holism into the client's care?

A. by creating a plan of care that utilizes the knowledge and skills of disciplines other than nursing B. by continually evaluating the efficacy of nursing interventions and by making changes as needed C. by prioritizing the client's spiritual and psychosocial needs over his physical needs D. by integrating each of the various dimensions of the client's identity into his care Answer: D Rationale: Holism is considered to be the sum of physical, emotional, social, and spiritual health. Care that reflects this multidimensional nature of individuals can be considered to be holistic. Interdisciplinary care and continual evaluation are congruent with holistic care, but they are not definitive. It is not appropriate to prioritize nonphysical needs in every client; prioritization of needs should be determined on an individual basis.

Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Apply Client Needs: Psychosocial Integrity Client Needs Pn: Health Promotion and Maintenance Integrated Process: Culture and Spirituality Reference: p. 49 14. A nurse has learned that more than 8% of the population are currently living with diabetes mellitus. This statistic represents what epidemiological concept?

A. morbidity B. mortality C. distribution D. onset

Answer: A Rationale: Morbidity is the incidence of a specific disease, disorder, or injury and refers to the rate or numbers of people affected. Mortality denotes the number of people who died from a particular disease or condition. Onset and distribution are not concepts that are central to epidemiology.

Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Client Needs Pn: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 50 15. Which client growth needs are included in the love and belonging level of Maslow's hierarchy? (Select all that apply.)

A. Family B. Self-respect C. Intimacy D. Status E. Friendships Answer: A, C, E Rationale: Love and belonging includes the need for affection, belonging, and meaningful relations with others (family, intimacy, friendships). Self-esteem includes self-respect and status.

Question format: Multiple Select Chapter 4: Health and Illness Cognitive Level: Remember Client Needs: Psychosocial Integrity Client Needs Pn: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 50 16. A nurse is explaining A1C diagnostic testing to a client with diabetes. What level of health care delivery does this test suggest?

A. Quanternary B. Secondary C. Tertiary D. Primary Answer: D Rationale: Primary care delivery is provided by the first healthcare provider or agency a person contacts and includes teaching and basic care. Quaternary care is an extension of tertiary care and includes experimental medicine and procedures and highly uncommon, specialized surgeries. Secondary care delivery is when primary caregivers refer clients for consultation and additional testing. Tertiary care is health services provided at hospitals or medical centers that have complex technology and specialists.

Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Understand Client Needs Pn: Health Promotion and Maintenance Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 51 17. Which nursing activity reflects care given on the tertiary level of healthcare delivery?

A. Educating the client about safe habits B. Recommending regular exams C. Assisting with transplant surgery D. Teaching the client about exercise programs Answer: C Rationale: Tertiary care is health services provided at hospitals or medical centers that have complex technology and specialists. Educating the client about safe habits, recommending regular exams, and teaching the client about exercise programs are examples of primary care.

Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Apply Client Needs Pn: Health Promotion and Maintenance Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 51 18. The nurse is working in an acute care setting and performs primary, secondary, and tertiary prevention. Which activity performed by the nurse is classified as tertiary prevention?

A. Promoting safety in the home B. Instructing a client on how to use crutches C. Counseling a client about a low-sodium diet D. Assessing a client's blood glucose level Answer: B Rationale: Tertiary prevention is used after an injury or sickness to help rehabilitate the client or to decrease potential risk and further damage, such as instructing the client on how to use crutches. Promoting safety in the home and counseling a client about a low-sodium diet are examples of primary prevention (preventing a disease from occurring in the first place).

Assessing blood glucose level is an example of secondary prevention (screening to detect a disease early).

Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Client Needs Pn: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 51

19. A pregnant client at 10 weeks' gestation is receiving education by the nurse about the importance of abstaining from alcohol while pregnant. What statement made by the client demonstrates an understanding of the education provided?

A. "If I drink alcohol while pregnant, my child will have a hereditary disorder."

B. "Abstaining from alcohol will prevent any type of congenital disorder."

C. "I should abstain from alcohol to prevent the development of a fetal alcohol specturm disorder."

D. "Alcohol use while pregnant will predispose my child to idiopathic illness."

Answer: C Rationale: Congenital disorders such as fetal alcohol spectrum disorders may be prevented by the client abstaining from alcohol while pregnant. Fetal alcohol spectrum disorders are congenital disorders caused by an undetermined amount of alcohol ingested by the mother which affects the fetus in the developmental stages of growth. Abstaining from alcohol will not prevent all types of congenital disorders, but clients should be educated about a variety of preventative measures in order to prevent interruption of the growth and development of the fetus. An idiopathic illness is one in which the cause is undetermined. A hereditary disorder is genetic and not altered by substance intake during pregnancy.

Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Client Needs Pn: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 53-54 20. A client is seeking health care at a local rural clinic for frequent and debilitating headaches. The nurse is making a referral to a university teaching facility 60 miles away from the clinic for evaluation of the headaches. Which form of care will this client be receiving?

A. primary care B. secondary care C. tertiary care D. extended care Answer: C Rationale: The client will be referred to a tertiary care facility where complex care, testing, and evaluation can be performed to evaluate the client's condition. Primary care can be provided at the rural health care clinic. Secondary care is provided at a lower level for additional testing and consultation. Extended care would be received in a long-term care facility or a rehabilitation center.

Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Client Needs Pn: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 51

21. The nurse is working in a clinic in a rural setting that has a diverse population of clients.

Which client will the nurse refer to the case manager to determine eligibility for Medicaid?

A. a 65-year-old client retiring from a job with the school system B. a client who is changing jobs and will be without medical coverage for 60 days C. a client who is disabled from a work-related accident D. a client with four children who works part-time in a fast food restaurant making minimum wage Answer: D Rationale: The client in the low income category of a part-time job with four children would most likely qualify for the Medicaid program. Medicaid is a federally funded, stateadministered health care program that provides for those in the low-income category. The 65year-old client qualifies for Medicare benefits. The Consolidated Omnibus Budget Reconciliation Act (COBRA) protects clients who are transferring jobs. Thus, a client who is transferring jobs will be given the option of coverage from the previous insurance until the new insurance becomes active.

Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Apply Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 52 22. The nurse is caring for a client who has recovered from injuries incurred from a motor vehicle accident where two other family members did not survive. The client informs the nurse that he or she will grieve without demonstrating ineffective coping mechanisms. Which type of health behaviors does the nurse identify the client is exhibiting?

A. physical health B. emotional health C. spiritual health D. social health Answer: B Rationale: The client is exhibiting the holistic concept of emotional health since the client is demonstrating an ability to cope with a stressor effectively. Physical health is an optimal state of physical functioning when body organs function normally. Social health is an outcome of feeling accepted and useful. Spiritual health is the feeling that one's life has a purpose and function.

Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Understand Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Caring Reference: p. 49

23. A client with chronic obstructive pulmonary disease (COPD) is admitted to the hospital for the second time in 2 months with wheezing, dyspnea, and use of accessory muscles when breathing. Which type of situation does the nurse identify is occurring with this client?

A. The client is experiencing the effects of a terminal illness.

B. The client is having an exacerbation of the COPD. C. This is the effect of a secondary illness.

D. The client is experiencing remission of the COPD. Answer: B Rationale: COPD is a chronic illness that has periods when the client goes from a chronic state to an acute state such as an acute onset of symptoms. The client will experience periods of exacerbation according to certain precipitating circumstances. Remission occurs in illnesses such as cancer when the symptoms or clinical manifestations disappear. A secondary illness is caused by complications from a primary illness. Clients with a terminal illness have no hope of recovery.

Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Analyze Client Needs Pn: Physiological Integrity: Reduction of Risk Potential Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 51 24. The nurse manager of the acute care unit has decided to implement a team nursing approach for client care. One of the staff members asks, "Will we each take care of our own clients?" What is the appropriate response by the manager?

A. "Each registered nurse (RN) will be assigned a client and be responsible for planning and evaluating care."

B. "I will plan the care based on the client's diagnosis or type of case."

C. "The care will be divided and the registered nurse (RN) will have a licensed practical/vocational nurse (LPN/LVN) and unlicensed assistive personnel (UAP) to provide care together."

D. "One person will provide skilled care, one will give medications, and one will help with hygienic needs."

Answer: C Rationale: The team nursing approach is organized and directed by a team leader who assigns and supervises the care of the team and may also contribute to the care. Functional nursing is when each nurse is assigned specific tasks to perform, such as medication administration or wound care. This is more of a task-oriented role. A case-based approach is used when the nurse manager assigns tasks based on the client's diagnosis.

Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Apply Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 55

25. The client experienced a stroke with left-sided weakness. The case manager determines that the client no longer requires acute care but currently is unable to return to the home environment. Which health care environment will be the appropriate referral option for this client?

A. primary care B. secondary care C. tertiary care D. extended care Answer: D Rationale: The client who is unable to return to the home environment but no longer requires acute care will be referred to an extended care facility to meet the rehabilitation needs after a stroke. Primary care is delivered in an office or clinic setting with a health care provider.

Secondary care is a referral made from the primary care provider for specialty consultation or additional testing. Tertiary care is the environment from which the client is being released that provides acute care.

Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Understand Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 52

Chapter 5 1. The nurse is caring for a client who is a doctor in a general hospital. He complains about the stressful condition of his job. Lately, he has become increasingly susceptible to colds, headaches, muscular tension, excessive tiredness, and many other symptoms. At what stage of stress is the client?

A. alarm stage B. exhaustion stage C. resistance stage D. secondary stage Answer: B Rationale: The client is in the exhaustion stage, when one or more adaptive/resistive mechanisms can no longer protect the person experiencing a stressor; this results in exhaustion. The effects of stress-related neurohormones suppress the immune system, and the body is open to various ailments. In the alarm stage, the person is prepared for a fight-orflight response. In the resistance stage, the client's body is returned to the homeostasis state.

Consequently, one or more organs or physiologic processes may eventually lead to increased vulnerability to stress-related disorders, or progression to the stage of exhaustion. The secondary stage is not a stage related to stress.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Apply Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Reference: p. 66 2. A client visits a health care facility after his spouse's death. The client is quite depressed and feels very lonely. The nurse asks him to confront the reality and be emotionally strong.

What type of strategy is the nurse following in this case?

A. nontherapeutic coping strategy B. therapeutic coping strategy C. negative coping strategy D. sensory manipulation strategy Answer: B Rationale: Therapeutic coping strategies usually help the person acquire insight, gain confidence to confront reality, and develop emotional maturity. People use nontherapeutic coping strategies such as mind- and mood-altering substances, hostility and aggression, excessive sleep, avoidance of conflict, and abandonment of social activities. Sensory manipulation involves altering moods, feelings, and physiologic responses by stimulating pleasure centers in the brain, using sensory stimuli. Negative coping strategies may provide immediate temporary relief from a stressor, but they eventually cause problems.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Apply

Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 66 3. A nurse is trying to calm an upset client who has been involved in an accident. The client escaped with minor bruises from the accident. What should the nurse do in order to calm the client?

A. prescribe sedatives to calm the nerves B. ask family members to take the client for a vacation C. explain that things could have been worse D. advise the client to file a claim on their accident insurance Answer: C Rationale: The nurse, using alternative thinking techniques, should explain to the client that the situation could have been worse. Alternative thinking techniques are those that facilitate a change in a person's perceptions from negative to positive. Sedatives have a temporary effect in calming a person, but reframing the mind is a better way of coping with the stress. The client may need to file an insurance claim, but that is not the nurse's priority intervention.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Apply Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Caring Reference: p. 69 4. A client visits a health care facility reporting work-related stress that alters his mood when he comes home. The nurse suggests that the client make changes to his home décor to include vibrant colors and bright lighting, and listen to soothing music when he returns home. Which stress-reducing technique is the nurse following in this case?

A. sensory manipulation technique B. alternative thinking technique C. nontherapeutic technique D. alternative behavior technique Answer: A Rationale: The nurse is using a sensory manipulation technique. Sensory manipulation involves altering moods, feelings, and physiologic responses by stimulating pleasure centers in the brain, using sensory stimuli. For example, certain colors, full-spectrum lighting in the home and workplace, music, and food help change a person's mood. Alternative thinking techniques are those that facilitate a change in a person's perceptions from negative to positive. A behavioral technique for modifying stress is to take control rather than become immobilized by stress. Nontherapeutic techniques would involve using mind- and moodaltering substances, which are not appropriate in this case.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Understand

Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Caring Reference: p. 69 5. A 7-year-old child is admitted to a health care facility. His parents explain that the child is not able to interpret what they say and so is not able to speak clearly. The child is also not able to remember anything he is taught in school. What should the nurse conclude about the part of the brain that is affected in this case?

A. The cortex is affected.

B. The subcortex is affected.

C. The mid-brain is affected.

D. The brainstem is affected.

Answer: A Rationale: The cortex is considered the higher-functioning portion of the brain. It enables people to think abstractly, use and understand language, accumulate and store memories, and make decisions about information received. Therefore, the nurse can conclude that the client's cortex is affected. The subcortex consists of the structures in the mid-brain and brainstem.

The subcortical structures are primarily responsible for regulating and maintaining physiologic activities that promote survival. They regulate breathing, heart contraction, blood pressure, body temperature, sleep, appetite, and stimulation and inhibition of hormone production.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Understand Client Needs: Psychosocial Integrity Client Needs Pn: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 61 6. A client visits the medical unit with the client's father for a scheduled checkup. The client's father has been recently diagnosed with hypertension. The nurse suggests that the client get his blood pressure regularly checked to avoid possible problems. What level of prevention is the nurse following in this case?

A. primary level B. secondary level C. general guidance level D. tertiary level Answer: B Rationale: The nurse is following secondary prevention, which includes screening for risk factors and providing a means for early diagnosis of disease. An example is regularly measuring the blood pressure of a client with a family history of hypertension. Primary prevention involves eliminating the potential for illness before it occurs. Tertiary prevention minimizes the consequences of a disorder through aggressive rehabilitation or appropriate management of the disease. Note that there is no general guidance level of prevention.

Question format: Multiple Choice

Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Client Needs Pn: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 67 7. When discussing his problem, a client tells the nurse that he is always doing small, petty jobs for everyone and he is not happy about it. Because of this, he is feeling stressed and has been getting into fights with his wife. What should the nurse suggest to help the client overcome this problem?

A. change jobs B. avoid people who dump tasks on him C. take control of the situation D. avoid doing petty jobs Answer: C Rationale: A behavioral technique for modifying stress is to take control rather than become immobilized. This is also known as alternative behavior. Another behavioral approach to reduce stress is to sometimes say "no" in order to avoid becoming overwhelmed and more stressed. Changing jobs, avoiding the person, or avoiding the petty jobs would not help.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Apply Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 69 8. When discussing his concerns with the nurse, the client discloses that when he comes home from work, he plays with his pet dog and this makes him feel relaxed. His friends make fun of him because of this, however. The nurse explains that this is perfectly normal and is not a cause of worry. In this case, how is the client relieving stress?

A. by adopting an alternative lifestyle B. by adopting alternative behaviors C. by adopting alternative thinking D. by adopting alternative hobbies Answer: A Rationale: In alternative lifestyles, people with pets find it soothing and relaxing to stroke and touch an animal that responds affectionately, regardless of a person's age, physical characteristics, or accomplishments. Pets seem to improve a person's feelings of self-worth in a way that extends to human relationships as well. Alternative thinking techniques are those that facilitate a change in a person's perceptions, from negative to positive. Alternative behaviors are behavioral techniques for modifying stress, which encourage one to take control rather than become immobilized. Making choices and pursuing actions promote selfconfidence over feeling victimized.

Question format: Multiple Choice

Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Understand Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 70 9. A client who is a drug addict visits a health care facility for treatment. During counseling, he discloses that he took to drugs because it helped him deal with stressful situations. The nurse explains that he is not using the correct coping strategy to overcome his stress-related problems. What kind of strategy has the client used in this case?

A. nontherapeutic coping strategy B. therapeutic coping strategy C. stress-reduction strategy D. antidepressant strategy Answer: A Rationale: The client has used nontherapeutic coping strategies such as mind- and moodaltering substances to cope with stress. Negative coping strategies may provide immediate temporary relief from a stressor, but they eventually cause problems. Therapeutic coping strategies usually help the person to acquire insight, gain confidence to confront reality, and develop emotional maturity. Also, the client has not used an antidepressant strategy.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Understand Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 66 10. A client who tends to volunteer to complete major assignments but forgets to complete his own work is stressed because of this. The nurse suggests that the client prioritize the work, complete the difficult part of the work first, and delegate the rest of the work to colleagues. In this case, what technique is the nurse asking the client to follow?

A. alternative lifestyle B. alternative behaviors C. alternative coping D. negative technique Answer: B Rationale: Alternative behaviors means behavioral approaches that help to reduce stress, including prioritizing what needs to be accomplished and initially attending to that which is most important or difficult. Less important activities may be postponed or delegated to others. A negative technique may provide immediate temporary relief from a stressor, but it will eventually cause problems.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Understand

Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 69 11. A client, while driving, hits a small child crossing the road. The child survives with some minor bruises and cuts. The client feels very stressed and is depressed when thinking of the child's injury. Which technique should the nurse implement in this case?

A. alternative thinking B. alternative behaviors C. alternative lifestyles D. adaptive activities Answer: A Rationale: Alternative thinking techniques are those that facilitate a change in a person's perceptions from negative to positive. Reframing helps a person analyze a stressful situation from various perspectives and ultimately conclude that the situation is not as bad as it once seemed. Alternative behavior is a technique for modifying stress by taking control rather than becoming immobilized. Making choices and pursuing actions promotes self-confidence over feeling victimized.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Understand Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Communication and Documentation Reference: p. 69 12. A nurse is assisting a neurologist, who is assessing the norepinephrine (noradrenaline) level of a client who is reporting stress. Which function does norepinephrine (noradrenaline) perform?

A. stabilizes mood and regulates temperature B. promotes coordinated movement C. heightens arousal and increases energy D. transmits sensation of pain Answer: C Rationale: Norepinephrine (noradrenaline) heightens arousal and increases energy.

Acetylcholine and dopamine promote coordinated movement. Serotonin stabilizes mood, induces sleep, and regulates the temperature of a person. Substance P transmits the sensation of pain, whereas endorphins and enkephalins interrupt the transmission of substance P and promote a sense of well-being.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Physiological Adaptation Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process

Reference: p. 60-61 13. A nurse is assessing a client with stress-related problems. Which factor influences responses to stressors?

A. eating habits B. social support C. economic status D. personal hygiene Answer: B Rationale: A person's response to stressors depends on social support, intensity of the stressor, number of stressors, duration of the stressor, physical health status, life experiences, coping strategies, personal beliefs, attitudes, and values. A person's response to stressors is independent of education, eating habits, economic status, or personal hygiene.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Understand Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 63-64 14. A nurse is caring for a client who is an investment banker. The client is stressed because of the sudden fall of share prices in the stock exchange. Which stress-reduction technique should the nurse use with this client?

A. advocate on behalf of the client to others B. discourage family from interacting with the client C. avoid referring the client to other organizations D. avoid discussing the client's condition with client's family Answer: A Rationale: The nurse should advocate on behalf of the client to others. If need be, the nurse should refer the client and his family to organizations or people who provide post-discharge assistance. The nurse should keep the client and the client's family informed about the client's condition and encourage the family members to interact with the client.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Apply Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 67 15. A nurse is assessing an obese teenager who is unhappy and stressed out because she has not lost weight despite working out at the gym. The physician asks the nurse to try the modeling intervention for stress management for the client. Which action should the nurse perform when adhering to the modeling intervention?

A. ask the client to change her exercise regimen

B. introduce the client to someone with a positive attitude C. ask the client to cut down on her food intake D. ask the client to undergo liposuction surgery Answer: B Rationale: The nurse should introduce the client to a person who demonstrates a positive attitude or behavior, as this promotes the ability to learn an adaptive response. The nurse should not ask the client to change her exercise regimen, cut down on her food intake, or undergo liposuction surgery as that could lead to further medical complications.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Apply Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 69 16. A client had an argument at work about his salary. The client has been consuming a lot of caffeine. The client suffers from insomnia and gets angry quickly. Which technique should the nurse promote to help the client?

A. Nontherapeutic coping strategy B. Negative coping strategy C. Therapeutic coping strategy D. Sensory manipulation strategy Answer: C Rationale: Therapeutic coping strategies usually help the person to acquire insight, gain confidence to confront reality, and develop emotional maturity. Maladaptation results when people use nontherapeutic coping strategies such as mind- and mood-altering substances, hostility and aggression, excessive sleep, avoidance of conflict, and abandonment of social activities. Sensory manipulation involves altering moods, feelings, and physiologic responses by stimulating pleasure centers in the brain using sensory stimuli. Negative coping strategies may provide immediate temporary relief from a stressor, but they eventually cause problems.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Apply Client Needs Pn: Psychosocial Integrity Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 66 17. A client who is an intravenous drug user visits a health care facility for treatment. During counseling, the client discloses that he initially took drugs because it helped him deal with stressful situations. The nurse recognizes that he is not using an effective coping strategy to overcome his stress-related problems. What kind of strategy has the client used in this case?

A. nontherapeutic coping strategy B. therapeutic coping strategy C. stress-reduction strategy

D. antidepressant strategy Answer: A Rationale: The client has used nontherapeutic coping strategies such as mind- and moodaltering substances to cope with stress. Negative coping strategies may provide immediate temporary relief from a stressor, but they eventually cause problems. Therapeutic coping strategies usually help the person to acquire insight, gain confidence to confront reality, and develop emotional maturity. Also, the client has not used an antidepressant strategy.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Analyze Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 66 18. A nurse is working with a client whose quality of life is impacted by the presence of numerous comorbid health problems. The nurse is aware that the client's body is attempting to maintain homeostasis, a process that primarily involves: A. minimizing the body's exposure to external influences.

B. maximizing the serum levels of hormones.

C. ensuring a stable level of blood glucose.

D. responding appropriately to internal and external influences.

Answer: D Rationale: Homeostasis is dependent on the body maintaining constancy by adjusting and readjusting in response to changes in the internal and external environment that foster disequilibrium. This does not always involve a stable blood glucose level or high levels of hormones. As well, homeostasis is not dependent on minimizing exposure to external influences, though this may often be necessary.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Understand Client Needs Pn: Health Promotion and Maintenance Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 59 19. A nurse is planning the care of a client who will soon begin radiotherapy for the treatment of breast cancer. The nurse has been identifying interventions that are rooted in the notion of holism, which states that: A. interactions between the mind and the body can profoundly influence health.

B. an individual's medical diagnosis has local, but not systemic, effects.

C. most physical illnesses do not require pharmacologic interventions or surgery.

D. a client's illness affects friends and family in the same way that the client is affected.

Answer: A

Rationale: Holism is the foundation of two commonly held beliefs: (1) both the mind and the body directly influence humans, and (2) the relationship between the mind and the body can potentially sustain health as well as cause illness. This does not necessarily mean that the medical interventions are unnecessary or that others are affected in the same way as the client. Holism does not preclude the presence of systemic effects of disease.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Remember Client Needs Pn: Health Promotion and Maintenance Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Culture and Spirituality Reference: p. 59 20. A client is receiving treatment in the intensive care unit for sepsis, a systemic infection that poses a grave threat to the body's homeostasis. The body is adapting to numerous threats, a process that primarily involves the integration of what body systems? Select all that apply.

A. central nervous system B. autonomic nervous system C. endocrine system D. cerebellar system E. integumentary system Answer: A, B, C Rationale: Neurotransmitters mediate homeostatic adaptive responses by coordinating functions of the central nervous system, autonomic nervous system, and endocrine system.

The cerebellum controls balance, which is only peripherally involved in adaptation. The integumentary system (skin and associated structures) is not a major contributor to adaptation.

Question format: Multiple Select Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 60 21. A client who has been dealing with numerous physical, interpersonal, and financial stressors appears to be experiencing the final stage of Selye's general adaptation syndrome (GAS). Individuals in the final stage of the GAS are likely to experience: A. resumption of normal life roles.

B. resumption of normal hormone levels.

C. increased susceptibility to illness.

D. increased stamina.

Answer: C Rationale: The stage of exhaustion is the last phase in the GAS. It occurs when one or more adaptive or resistive mechanisms are no longer able to protect the person experiencing a stressor. Consequently, the person is vulnerable to illness. This stage of the GAS is not

associated with the adoption of normal life roles or increased stamina. Hormone levels are abnormal in the exhaustion stage.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 64 22. A client has been admitted to the emergency department following a motorcycle accident and is experiencing major physiological and psychological stressors during this period. What sign or symptom may be attributable to the parasympathetic effects of stress?

A. increased muscle tone B. increased perspiration C. increased bronchoconstriction D. increased heart rate Answer: C Rationale: Contraction of the bronchial muscles is associated with the parasympathetic stress response. Increased heart rate, muscle tone, and perspiration are characteristics of sympathetic stress effects.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Physiological Adaptation Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 62 23. A nurse is providing care for client who experienced a stroke. Which nursing intervention reflects the tertiary level of prevention?

A. provide care transition at discharge for speech therapy B. assess blood pressure every 4 hours C. conduct mental status assessment every 2 hours D. discuss family history of hypertension Answer: A Rationale: Tertiary prevention minimizes the consequences of a disorder through aggressive rehabilitation or appropriate management of the disease. An example is speech therapy to help restore ability. Blood pressure and mental status exams are examples of secondary prevention associated with the acute stroke. Discussing family history is also secondary prevention in terms of assessing for further risk factors.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 67

24. A client with persistent nausea is diagnosed with somatization. What is the appropriate nursing action when the client reports nausea?

A. Immediately administer an antiemetic.

B. contact the primary care provider C. sit with the client and ask them about their feelings D. explain that the physical symptoms are all in their head Answer: C Rationale: Somatization is manifesting an emotional stress through a physical disorder.

Treating the nausea with an antiemetic will not get at the root cause of the emotional issue.

Contacting the primary care provider is not appropriate, as the diagnosis of somatization is present. Explaining that the physical symptoms are all in the client's head is not therapeutic.

Sitting with the client to explore what is really going on is most appropriate nursing response.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 66 25. A client experienced a fight-or-flight response immediately following a car accident.

What clinical symptoms would the nurse expect to assess? Select all that apply.

A. increased heart rate B. decreased digestion C. heightened awareness D. pallor E. pupil constriction F. relaxed muscle tone Answer: A, B, C, D Rationale: When a situation occurs that the mind perceives as dangerous, the sympathetic nervous system prepares the body for a fight-or-flight response. Increased heart rate, decreased digestion, heightened awareness, and pallor are all clinical presentations of the sympathetic nervous system. Pupil constriction and relaxed muscle tone are associated with the parasympathetic nervous system, which restores equilibrium when danger is no longer present.

Question format: Multiple Select Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 62 26. A client is experiencing a stress response each time the family visits the room. What nursing intervention is most appropriate?

A. tell the family they are causing too much stress B. limit the family visits to once daily

C. explain that family visits and support are important D. do not intervene and allow the client to work out the family issue Answer: B Rationale: When a person is experiencing a stressor, it is important for the nurse to reduce or eliminate the stress. In this case, it is appropriate to limit the family visiting time to allow the client to recover without experiencing a stress response. Telling the family they are causing the stress is not therapeutic. Telling the client that the family should be there invalidates the client's feelings. Doing nothing is not an appropriate response to decrease or remove the stressor.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Apply Client Needs: Psychosocial Integrity Client Needs Pn: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 67 27. A nursing student is engaging in a conversation with a nursing instructor whom the student intensely dislikes. Which nursing student behavior is consistent with reaction formation?

A. imitating the speech of the nursing instructor B. accusing the nursing instructor of being prejudiced C. being extremely nice to the nursing instructor D. developing stomach pain during each conversation with the nursing instructor Answer: C Rationale: Reaction formation involves acting just the opposite of one's true feelings; thus, being extremely nice to the nursing instructor is the opposite of what the student feels.

Imitating the speech of the nursing instructor is consistent with identification. Accusing the nursing instructor of being prejudiced is consistent with projection. Developing stomach pains when talking with the nursing instructor reflects somatization.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Understand Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Communication and Documentation Reference: p. 66 28. A Spanish-speaking client is admitted to the emergency department with a urinary tract infection and is experiencing a stress response from hospitalization. What is the priority nursing intervention?

A. begin taking a client history B. contact a translator C. collect a urine specimen D. administer a broad-spectrum antibiotic

Answer: B Rationale: In order to decrease the stress response, it is important to provide explanations in understandable language. Contacting a translator to facilitate communication is the priority nursing intervention. While taking a history, collecting urine, and starting antibiotics are important; they are not emergent. Effective communication takes precedence especially when a stress response is present.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 63 29. The nurse is caring for four clients. Which client does the nurse identify as the highest risk for social readjustment concerns?

A. 77-year-old whose spouse just died B. 54-year-old who is undergoing marital separation C. 32-year-old who has recently been incarcerated D. 40-year-old who was fired from work last month Answer: A Rationale: Death of a spouse ranks as the most stressful life event on The Social Readjustment Rating Scale. The client whose spouse just died is at highest risk for social readjustment concerns.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Analyze Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 68 30. The nurse is caring for a client diagnosed with terminal cancer who wishes to use meditation and prayer to be cured. What is the appropriate nursing action?

A. Advocate for the client's choice.

B. Explain that meditation and prayer are not curative.

C. Arrange for a chaplain to visit with the client.

D. Prepare to administer chemotherapy as ordered.

Answer: A Rationale: Nurses are accountable to act as a client's advocate, even if the client's choices are not in alignment with the nurse's personal choices. The nurse should not assume that a chaplain is desired, nor administer chemotherapy without further dialoguing with the client.

Explaining that meditation and prayer are not curative is not helpful in supporting the client's wishes.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Apply

Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Culture and Spirituality Reference: p. 67 31. A client asks the nurse how cortisol works. What is the appropriate nursing response?

A. "It strengthens lymphoid tissue."

B. "It increases capillary permeability to prevent tissue swelling."

C. "It suppresses the immune response."

D. "It causes release of proinflammatory mediators."

Answer: C Rationale: Cortisol suppresses the immune response, causes atrophy of lymphoid tissues, decreases capillary permeability to prevent tissue swelling, and prevents release of proinflammatory mediators. It does not strengthen lymphoid tissue, increase capillary permeability, or cause the release of proinflammatory mediators.

Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 65

Chapter 6 1. A client is admitted to the health care facility with hypoglycemia. After the client is stable, the nurse discovers that the client has not had the prescribed medicines. The client believes that eating saffron will keep blood sugar under control. What is the most appropriate response by the nurse?

A. "Saffron does not have any effect on blood sugar level."

B. "Why don't you take the medicines, too, and benefit from both?"

C. "Yes, I agree that you should continue taking saffron for diabetes."

D. "Let me inform the health care provider that you are not taking your medicines."

Answer: B Rationale: Although the nurse may disagree with the client's beliefs concerning the cause of health or illness, respect for these beliefs helps the nurse to achieve health care goals. Asking the client to consider the benefits of medicine is appropriate because the nurse, without disrespecting the client's beliefs, persuades the client to have medicines also. Stating that saffron does not have any effect on blood sugar level is inappropriate, as it disregards the client's beliefs. Agreeing with the client may encourage him or her and indicate low faith in the present treatment. It is inappropriate to call the health care provider and report on the client.

Question format: Multiple Choice Chapter 6: Culture and Ethnicity Cognitive Level: Apply Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Culture and Spirituality Reference: p. 80 2. When giving a tepid sponge bath to a black client who has high fever, the nurse notices brown discoloration on the washcloth. What should the nurse's reaction be in this case?

A. Assume that it is due to high fever.

B. Educate the client about personal hygiene.

C. Consider it to be normal in the client.

D. Bathe the client again, assuming it is dirt.

Answer: C Rationale: The brown discoloration on the washcloth is normal in dark-skinned clients due to the shedding of dead cells that are brown in color. The nurse should consider it as normal because it is common in the specified culture. Fever does not lead to brown discoloration. To educate the client about personal hygiene, having made the assumption that it is dirt, may likewise not be appropriate, as the client may feel offended. Also, the nurse need not bathe the client again.

Question format: Multiple Choice Chapter 6: Culture and Ethnicity Cognitive Level: Analyze Client Needs: Physiological Integrity: Basic Care and Comfort

Integrated Process: Culture and Spirituality Reference: p. 76 3. A black client reports to the primary health center with reports of itching and rashes after consumption of shellfish. On examination, the nurse finds a keloid on the client's back. What is the most appropriate response by the nurse?

A. Inform the physician about it.

B. Consider it as normal.

C. Request biochemical investigations.

D. Consider it as an allergic reaction to shellfish.

Answer: B Rationale: The nurse should consider the appearance of keloids as normal in black individuals. Keloids are irregular, elevated, thick scars found commonly in dark-skinned clients. Informing the physician or requesting biochemical investigations is inappropriate, as this condition is not pathologic. Also, keloids are not the result of allergic reactions.

Question format: Multiple Choice Chapter 6: Culture and Ethnicity Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 76 4. A nurse is caring for a client immediately postpartum. As the client seems exhausted after birth, the nurse offers her warm milk to drink. The client refuses, saying that her cultural belief does not permit her to have any food before 24 hours have passed. What is the most appropriate response by the nurse?

A. Put in an IV and start intravenous fluid to avoid dehydration.

B. Call the nurse supervisor and inform her about the client.

C. Tell the client that her beliefs are misguided and she needs to have food.

D. Describe the importance of the mother's nutritional status for lactation.

Answer: D Rationale: The nurse should respect the client's cultural beliefs and explain the importance of the nutritional status for the mother's, as well as the baby's, health. IV fluids are given only when the client cannot take food orally. Informing the nurse supervisor is inappropriate and irrelevant. Telling the client that her beliefs are wrong and she needs to have food devalues the client's beliefs.

Question format: Multiple Choice Chapter 6: Culture and Ethnicity Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Reference: p. 86 5. A nurse who works in a large, urban hospital provides care for a diverse client population.

When performing integumentary (skin) assessments, the nurse modifies assessment practices

for certain clients to identify clinically meaningful data. This practice is most justified by the fact that clients differ according to: A. race.

B. ethnicity.

C. culture.

D. preference.

Answer: A Rationale: Race (biologic variations) is a term used to categorize people with genetically shared physical characteristics. The biological variations necessitate differences in skin assessment, both in terms of technique and interpretation of results. Ethnicity and culture are psychosocial concepts that certainly have relationships to race, but neither specifically warrants changes in integumentary assessments.

Question format: Multiple Choice Chapter 6: Culture and Ethnicity Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Culture and Spirituality Reference: p. 73 6. Two nurses are discussing appropriate care of culturally diverse populations, and a nurse has made the point that the country is diverse but anglicized. Why is the United States considered to be anglicized?

A. because English financial institutions have the most economic influence in the United States B. because political relations between Britain and the United States have been traditionally cooperative C. because United States culture evolved primarily from the early English settlers D. because English is the official language of government at all levels Answer: C Rationale: U.S. culture can be described as anglicized, or English-based, because it evolved primarily from its early English settlers. Language use, economic influence, and political relations are not the justification for the fact that U.S. culture is described as anglicized.

Question format: Multiple Choice Chapter 6: Culture and Ethnicity Cognitive Level: Remember Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 74 7. A nurse is performing an assessment of a newly admitted hospital client and has documented the client as being a member of the Native American/First Nations subculture. A subculture is best described as: A. a cultural group that has fewer than 5 million members.

B. a unique cultural group with unspecified geographic origins.

C. a cultural group with values that are incongruent with those of the dominant culture.

D. a unique cultural group that exists within the larger culture.

Answer: D Rationale: Subcultures are unique cultural groups that coexist within the dominant culture.

They are not defined according to the size of their membership or the lack of specific geographic origins. They may have some values that differ from those of the dominant culture, but this is not their defining characteristic.

Question format: Multiple Choice Chapter 6: Culture and Ethnicity Cognitive Level: Understand Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 74 8. A 22-year-old woman who recently immigrated to the country has been admitted to the hospital with an ovarian cyst. Both the client and spouse do not speak the dominant language of the new country, and this has complicated the ability of the care team to obtain informed consent for surgery. What action should the care team take to communicate with the client?

A. Arrange for a trusted family member to come in to translate.

B. Organize professional interpretation, either in person or by telephone.

C. Communicate with the client and spouse nonverbally.

D. Encourage the client to write out concerns on paper.

Answer: B Rationale: All clients have a right to unencumbered communication with a health provider; consequently, a professional interpreter is necessary. It is insufficient to communicate nonverbally, and it is usually inappropriate to have a family member translate. Having the client write concerns does not resolve this problem.

Question format: Multiple Choice Chapter 6: Culture and Ethnicity Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Culture and Spirituality Reference: p. 72 9. Which statement about diversity is true?

A. "Diversity demonstrates differences among groups of people."

B. "Diversity has been learned from birth and is shared by members of a group."

C. "Diversity is reflective of the values, beliefs, and practices of a particular group."

D. "Diversity includes language, communication style, religion, art, music, and clothing."

Answer: A Rationale: Diversity represents the differences among groups of people. All other answers represent characteristics of culture.

Question format: Multiple Choice Chapter 6: Culture and Ethnicity Cognitive Level: Remember Client Needs: Psychosocial Integrity

Integrated Process: Culture and Spirituality Reference: p. 72 10. When teaching a group of unlicensed assistive personnel (UAP) about race, which statement by a UAP requires intervention by the nurse?

A. "Race is a term used to categorize people with genetically shared physical characteristics."

B. "Skin color, eye shape, and texture of hair are methods of categorizing race."

C. "People with common physical features share the same culture."

D. "Caucasian, Negroid, and Mongoloid are names for races."

Answer: C Rationale: Nurses should not equate race with any particular cultural group. It is wrong to assume that all people with common physical features share the same culture and that all people with physical similarities have cultural values, beliefs, and practices that differ from the dominant culture. The other statements do not require intervention.

Question format: Multiple Choice Chapter 6: Culture and Ethnicity Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Reference: p. 73 11. The nurse is caring for a terminally ill client who immigrated from Mexico. Which nursing intervention regarding spiritual care is appropriate?

A. Inquire if the client desires the Sacrament of the Sick.

B. Ask the client if a spiritual leader is desired.

C. Do nothing unless the client requests spiritual assistance.

D. Call a Roman Catholic priest to visit the client.

Answer: B Rationale: The appropriate response is to ask the client if a spiritual leader is desired, which is observant of the client's preferences. The nurse should not generalize that a Latino client is Roman Catholic, nor should the nurse refrain from inquiring about spiritual needs.

Question format: Multiple Choice Chapter 6: Culture and Ethnicity Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Culture and Spirituality Reference: p. 74 12. Which nursing intervention reflects practice according to Madeline Leininger's transcultural nursing theory?

A. Contacting a chaplain for every client B. Providing the same care to each client who has had a myocardial infarction C. Planning dietary interventions according to physiological condition D. Incorporating the client's request for complementary treatment therapy Answer: D

Rationale: Leininger's theory of transcultural nursing includes assessing a cultural nature, accepting each client as an individual, having knowledge of health problems that affect particular cultural groups, and planning of care within the client's health belief system to achieve the best health outcomes. Therefore, incorporating the client's request for complementary treatment therapy is an example of this theory. The others do not support this theory.

Question format: Multiple Choice Chapter 6: Culture and Ethnicity Cognitive Level: Understand Client Needs: Psychosocial Integrity Integrated Process: Culture and Spirituality Reference: p. 76 13. Which nursing intervention reflects culturally appropriate care when addressing a client?

A. "Good morning, Mr. Smith. I am your nurse, John."

B. "You can sit in this chair, Sally."

C. "Thank you for coming to the clinic today."

D. "I see you are here because you have a sinus infection."

Answer: A Rationale: The nurse can demonstrate professionalism and culturally appropriate care by addressing clients by their last names and introducing oneself. The nurse should follow up thoroughly with requests, respect the client's privacy, and ask open-ended rather than direct questions until trust has been established.

Question format: Multiple Choice Chapter 6: Culture and Ethnicity Cognitive Level: Apply Client Needs: Psychosocial Integrity Reference: p. 76 14. A client who does not speak the dominant language has been admitted to the health care facility reporting chest pain. Because the assigned nurse does not know the client's language, what would be the most appropriate solution for communication until a professional interpreter can be obtained?

A. The nurse should request the help of a family member if available, if not care should be administered that is in the best interest of the client.

B. The nurse should get a language dictionary and attempt to translate basic information in order to obtain consent for treatment.

C. The nurse should ask the supervisor for a different nurse to take this client that is fluent in the client's native language.

D. The nurse should communicate with the client nonverbally and proceed with care as needed.

Answer: A Rationale: The nurse should request the help of a professional interpreter to communicate effectively with the client who does not speak the same language as the nurse. If this is not readily available in an emergency situation, the nurse can ask a family member to help in

basic communication if available. The nurse is responsible for providing care to stabilize the client regardless of language barriers. Trying to use a language dictionary to help communicate may be troublesome and time-consuming. The nurse cannot shun nursing responsibilities by asking for a different assignment or asking for a different nurse to take the case. Asking the client to communicate nonverbally may lead to a break in communication or misinterpretations.

Question format: Multiple Choice Chapter 6: Culture and Ethnicity Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 76 15. A nurse is caring for a postoperative client after knee arthroplasty. The nurse plans to help the client ambulate but is aware that the client may feel threatened by physical closeness because the client is from a culture that tends to prefer more personal space when interacting with others. Using the principles of culturally competent care, what would be the most appropriate nursing action?

A. Let the client ambulate slowly on his or her own when stable.

B. Explain the purpose and need for assistance during ambulation.

C. Instruct family members to assist in ambulating the client.

D. Ambulate the client explaining it is an expected outcome of their treatment.

Answer: B Rationale: The nurse should explain the purpose of ambulation and the need for assistance while ambulating to the client. This would relieve the client's anxiety associated with physical closeness. However, the client won't be able to ambulate without assistance. Even though the nurse can instruct a family member to ambulate the client, this is not an appropriate action. Ambulating the client without recognizing the cultural difference is nontherapeutic, as the nurse would be not be performing culturally competent care by not acknowledging cultural practice.

Question format: Multiple Choice Chapter 6: Culture and Ethnicity Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Culture and Spirituality Reference: p. 79 16. The nurse is caring for a client from China and assisting the client with the lunch tray.

Which item on the tray should the nurse question the client about being able to ingest?

A. sliced oranges B. baked chicken breast C. milk D. sliced ham Answer: C Rationale: The nurse should question the client about the ability to ingest milk or dairy products because lactase deficiency is common among Chinese people. Cramping, intestinal

gas, and diarrhea may occur if this deficiency is present. Citrus fruits, chicken, and ham do not have lactase and should be tolerated in this client.

Question format: Multiple Choice Chapter 6: Culture and Ethnicity Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 83 17. The nurse is performing an assessment for a Native American/First Nations client who is hesitant to answer questions related to psychosocial history. What action by the nurse will facilitate communication between the nurse and the client?

A. Wait to write down notes or put the information in the computer until after the interview, if possible.

B. Have another family member with the client to answer questions that the client will not respond to.

C. Inform the client that the questions must be answered for the client to receive the health care needed.

D. Instruct the client that the interview is quick and answers should be brief.

Answer: A Rationale: A Native American/First Nations client may be very private and not feel comfortable discussing personal situations with the nurse, considering these questions to be intrusive. The client may opt not to answer questions asked. The family member should not be asked the questions if the client does not choose to answer the question since this may also be determined as disrespectful. The client should not be made to feel pressured to answer questions with the threat of treatment withheld since this is not a valid or therapeutic response. The nurse should be patient when awaiting a response from the client after asking a question and not rush through the interview. Waiting to write down or input the conversation into the computer will facilitate a more trusting and respectful relationship between the nurse and the client.

Question format: Multiple Choice Chapter 6: Culture and Ethnicity Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Reference: p. 77 18. Upon admission, the client noted practicing Orthodox Judaism. Upon receiving the meal tray, the client states, "I cannot eat this. Please remove the tray." Which item on the tray is the client referring to because of kosher dietary laws?

A. a tossed salad with tomatoes, lettuce, and cucumbers B. a fruit salad with oranges, pineapples, and grapes C. a baked pork chop with gravy D. a roll with butter Answer: C

Rationale: The kosher dietary laws indicate that any animal which chews its cud is allowed in the diet. Pork products are prohibited, as pigs do not chew their cud. The nurse should remove the entire tray and obtain another tray that meets the required kosher laws for the client. Vegetables, fruits, and bread made without lard are allowed items.

Question format: Multiple Choice Chapter 6: Culture and Ethnicity Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 81 19. The nurse is educating a client of Chinese descent regarding the reduction and elimination of lactose in the diet. Which statement(s) made by the client indicates that the education was effective? Select all that apply.

A. "When I drink coffee or tea, I should use a non-dairy creamer instead of milk or cream."

B. "I should replace 2% milk with lactose-free milk."

C. "I can use foods that use milk solids since those are not milk products."

D. "If I drink milk, I should drink one large glass a day and none at any other time."

E. "I can use kosher parve foods because they are prepared without milk."

Answer: A, B, E Rationale: The nurse determines that the client understands and can apply the education provided when the client states the intention to substitute milk for non-dairy coffee creamer, substitute milk for a lactose-free milk product, and use kosher parve (kosher neutral) products, which are not made with milk products. The statement about drinking a large glass of milk once daily instead of several times a day indicates the client requires further education, because the client should avoid milk or only drink small amounts. Dry milk solids contain milk and should be avoided; examples include some bread, cereals, puddings, gravy mixes, caramels, or chocolate.

Question format: Multiple Select Chapter 6: Culture and Ethnicity Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Client Needs Pn: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 83 20. A client who practices Islam dies at the hospital surrounded by family members. Which action by the nurse demonstrates cultural sensitivity related to the client's death?

A. consulting the family member prior to performing post-mortem care B. informing the family members they may say their goodbyes so that care can be provided C. having the family members consult with the funeral home for transport D. allowing the family to remain present when the nurse washes the client prior to shrouding Answer: A Rationale: Only family members may touch or wash the body of a deceased individual who practiced the Islamic faith, so the nurse should ask for permission prior to providing postmortem care. The family may choose to remain, but the nurse will not be allowed to wash the

body. It will be the nurse's responsibility to arrange for transport to the funeral home after care is rendered by the family.

Question format: Multiple Choice Chapter 6: Culture and Ethnicity Cognitive Level: Apply Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Culture and Spirituality Reference: p. 82 21. The nurse is admitting a client who practices the Jewish faith to the acute care unit and calls the dietary department to order a kosher dietary tray without consulting the client about food preferences. Which behavior is the nurse demonstrating when performing this action?

A. ethnocentrism B. generalization C. ageism D. stereotyping Answer: B Rationale: The nurse is demonstrating generalization by ordering a kosher dietary tray when not all Jewish people keep kosher. The nurse is assuming that all Jewish people only eat kosher foods or all hold the same behaviors and beliefs. Stereotyping prevents seeing and treating another person as unique while generalizing suggests possible commonalities that may or may not be individually valid. The nurse is not demonstrating ethnocentrism, which is a belief that one's own culture or religion is superior to another. Ageism is the discrimination of a person due to their age and treating them differently.

Question format: Multiple Choice Chapter 6: Culture and Ethnicity Cognitive Level: Apply Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Culture and Spirituality Reference: p. 74 22. The nurse works in an urban hospital and cares for a diverse population of clients. Which action(s) by the nurse demonstrates the delivery of culturally sensitive care to clients? Select all that apply.

A. indicating that the cultural groups should adapt to the Anglo-American culture B. maintaining direct eye contact during conversations with all cultural groups C. asking the client questions regarding health care beliefs related to the client's culture D. allowing the client to keep a religious necklace on until going into the operating room E. integrating the client's cultural practices when assisting with the creation of the plan of care Answer: C, D, E Rationale: There are many ways in which nurses should deliver culturally sensitive care, but the priority is to understand the difference in culture and ethnicity and integrate these beliefs into the care delivery system. Asking questions related to culture is important since not all

cultural groups follow a general belief practice. This should be considered whenever the plan of care is being developed. Allowing a client to wear a religious necklace until going into the operating room and keeping it in a safe place to be returned after a procedure is a demonstration of cultural sensitivity. Implying that a cultural group should adapt to the Anglo-American way is not culturally sensitive. Not all cultural groups respond to direct eye contact and the nurse should be aware of how this may be perceived.

Question format: Multiple Select Chapter 6: Culture and Ethnicity Cognitive Level: Apply Client Needs Pn: Psychosocial Integrity Client Needs: Health Promotion and Maintenance Integrated Process: Culture and Spirituality Reference: p. 76 23. A parent brings a newborn into the clinic for a 3-month wellness visit and when assessing the back, the nurse observes a dark blue area on the lower back resembling ecchymosis that does not elicit a pain response when pressure is applied. What action should the nurse take to address this finding?

A. questioning the parent as to the possiblity of an injury to the lower back B. notifying child protective services of the potential for abuse C. documenting the finding as a "Mongolian spot" D. asking the parent if the child has spina bifida Answer: C Rationale: The nurse has observed a Mongolian spot, which is hyperpigmentation commonly seen in darkly pigmented infants and children usually located on the lower back, abdomen, thighs, shoulders, or arms. This is caused by the migration of melanocytes into the fetal epidermis, and the spots usually fade by age 5 years. The nurse should document the finding as a normal assessment finding and continue with the assessment. This is not a sign of child abuse and child protective services would not be brought into the situation. An injury in a 3month-old is unlikely in the area of the lower back and if injury was expected, it would elicit a pain response from the infant. Spina bifida occulta is the only form of spina bifida that does not have an obvious sign and may only appear as a dimple or a tuft of hair, not a dark blue area.

Question format: Multiple Choice Chapter 6: Culture and Ethnicity Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Client Needs Pn: Health Promotion and Maintenance Integrated Process: Culture and Spirituality Reference: p. 82-83 24. An adolescent informs the nurse at the clinic, "I do not know what is happening to me, my skin is turning very white in spots all over my hands." The nurse assesses hypopigmented areas on the hands and documents the finding. Following evaluation by the health care provider, what education will the nurse provide to the client?

A. Using a pigmented cream will help to even the skin tones.

B. The hypopigmented areas will be confined to the present location.

C. There may be a slight stinging sensation when washing the hands.

D. This is due to sun exposure, so your pigmented areas should be covered in sunscreen.

Answer: A Rationale: The adolescent is experiencing hypopigmentation, which is called vitiligo and can affect clients of any ethnic group. Vitiligo may be embarrassing for the person affected. A pigmented cream can be used to cover the area and make the skin tones more evenly blended.

There are no physical symptoms such as stinging, and the disorder is not caused by sun exposure. The condition may affect different areas of the body and is not necessarily confined to the present area.

Question format: Multiple Choice Chapter 6: Culture and Ethnicity Cognitive Level: Apply Client Needs Pn: Physiological Integrity: Basic Care and Comfort Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 82-83 25. The nurse is caring for an older adult client who has been hesitant to seek health care.

Which action(s) by the nurse would develop a trusting nurse–client relationship? Select all that apply.

A. addressing the client by title and last name B. following through with requests by the client C. asking direct questions and waiting for responses D. touching the client's arm when speaking directly E. respecting the client's privacy Answer: A, B, E Rationale: The nurse should make all efforts to establish trust. Addressing the client professionally by using the title and last name of the client until told otherwise is an appropriate way for the nurse to establish a positive nurse–client relationship. When the client makes a request of the nurse, it should be performed in a timely fashion or with an explanation as to when it will be done. The nurse should proceed with open-ended questions rather than direct questions until trust has been established. Touch should not be employed unless it is acceptable to the client since many cultures are not comfortable with touch.

Question format: Multiple Select Chapter 6: Culture and Ethnicity Cognitive Level: Apply Client Needs: Psychosocial Integrity Client Needs Pn: Health Promotion and Maintenance Integrated Process: Culture and Spirituality Reference: p. 76

Chapter 7 1. A family has lost a member who was treated for leukemia at a nursing unit. The nurse provides emotional support to the family and counsels them to cope with their loss. Which quality should the nurse use in this situation?

A. Indifference B. Pity C. Sympathy D. Empathy Answer: D Rationale: The nurse should empathize with the family for their loss. Empathy helps the nurse to provide effective care and support without being emotionally distraught by the family's condition. If the nurse becomes indifferent to the family's condition, the nurse may not be able to assess their needs. The nurse should not pity, or provide sympathy to, the family for their loss, as it would involve the nurse emotionally.

Question format: Multiple Choice Chapter 7: The Nurse–Client Relationship Cognitive Level: Apply Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Communication and Documentation Reference: p. 91 2. The nurse has arranged to start an IV line for a client with pancreatitis. The nurse notes that the client appears anxious about the procedure. What is the most appropriate response by the nurse to decrease the client's anxiety?

A. "I will start an IV, which should not take much time."

B. "I will start an IV with the number 18 catheters."

C. "I will start an IV that will add fluids directly to the blood stream."

D. "I will start an IV, which should not cause you too much pain."

Answer: C Rationale: The nurse should explain the procedure and its purpose. The nurse telling the client that it should not take much time does not convey the purpose of the procedure. It is unnecessary for the nurse to inform the client about the technical details of the catheter.

Additionally, the nurse should not give false reassurance by telling the client that the procedure will not be painful.

Question format: Multiple Choice Chapter 7: The Nurse–Client Relationship Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Reference: p. 94

3. A client reports to a primary care physician with aggravated chest pain. The physician orders a stress test. The client tells the nurse that the client does not want to take the test and would prefer instead to continue taking medication a little longer. Understanding that the client is anxious, what is the most appropriate response by the nurse?

A. "Emergency equipment is always kept ready during stress tests."

B. "Tell me more about how you are feeling."

C. "Don't you want to improve your health?"

D. "Most people tolerate the procedure quite well."

Answer: B Rationale: The client's desire to not undergo the stress test may be due to fear and anxiety related to the test. The nurse should try to explore the client's feelings by inviting the client to express them. Asking the client open-ended questions is best because it expresses concern for the client and encourages the client to verbalize feelings. Stating that emergency equipment is always kept ready would evoke more fear and interrupt communication. Questioning whether the client wants to get well or stating that others have tolerated this procedure quite well is inappropriate.

Question format: Multiple Choice Chapter 7: The Nurse–Client Relationship Cognitive Level: Analyze Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Communication and Documentation Reference: p. 94 4. A client is scheduled for thoracentesis. The nurse assesses that the client appears anxious about the procedure and needs honest support and reassurance. What is the most appropriate response by the nurse to this client?

A. "I will be by your side throughout the procedure; the procedure will be painless if you don't move."

B. "The needle causes pain when it goes in, but I will be by your side throughout and will help you hold your position."

C. "The procedure may take only 2 to 3 minutes, so you might get through it by mentally counting up to 120."

D. "You might feel a little bit uncomfortable when the needle goes in, but you should breathe rhythmically; I will be here to coach you."

Answer: B Rationale: Thoracentesis is a painful procedure and it is important to sit still to avoid injuring the pleura. The nurse should reassure the client that she will be present during the procedure and help throughout. The nurse should provide correct knowledge as well as reassurance.

Likewise, the nurse should avoid giving false reassurance about the procedure being painless.

Additionally, the nurse should abstain from stating reasons that could scare the client. The nurse should not use an authoritarian approach. Describing the process as "a little bit uncomfortable" understates the discomfort and provides false expectations.

Question format: Multiple Choice Chapter 7: The Nurse–Client Relationship Cognitive Level: Apply

Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Communication and Documentation Reference: p. 94 5. A nurse pays a house visit to a client who is on parenteral nutrition. The client reports missing enjoying food with the client's family. What is the most appropriate response by the nurse?

A. "Tell me more about how it feels to eat with your family."

B. "You can sit with your family at meal times, even though you don't eat."

C. "In a few weeks you may be allowed to eat a little; you may enjoy it then."

D. "I know that you must be missing your favorite foods."

Answer: A Rationale: The nurse should help the client to verbalize feelings and cope with aspects of illness and treatment. Asking open-ended questions is most appropriate as the nurse encourages the client to express feelings. The other options block communication and are not appropriate. Telling the client that the client can sit with his family but must avoid eating does not consider the client's feelings. Informing the client that the client will be able to eat food in a few weeks changes the subject and stops communication. Stating that the client is missing the client's favorite dishes is empathic but does not help the client further verbalize feelings as does inviting the client to share more.

Question format: Multiple Choice Chapter 7: The Nurse–Client Relationship Cognitive Level: Apply Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Communication and Documentation Reference: p. 94 6. A client reports to the primary health care facility reporting chest pain. After the investigations and initial treatment, the client anxiously inquires if he had a heart attack.

What should be the nurse's reply?

A. "The physician wants to monitor you and control your pain."

B. "Yes, you had a heart attack; this is why you are here with us."

C. "Yes, you had a heart attack, but the damage is very minimal."

D. "No; we can assure you that you will not have a heart attack."

Answer: A Rationale: The nurse should give true information to the client. Stating that the physician wants to monitor the client and control his pain is true information. The nurse telling the client that he had a heart attack may increase his anxiety. Assuring the client that he will never have a heart attack is also an inappropriate statement because no one can ensure against a disease condition.

Question format: Multiple Choice Chapter 7: The Nurse–Client Relationship Cognitive Level: Apply Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity

Integrated Process: Communication and Documentation Reference: p. 94 7. A nurse is caring for a client with depression. The nurse finds that the client is withdrawn and does not communicate with others. What is the most appropriate response by the nurse?

A. "Did you sleep well last night?"

B. "Is that a new shirt you're wearing?"

C. "Did you like the dinner yesterday?"

D. "I guess you don't feel like talking today."

Answer: B Rationale: When the client is not talking, the nurse should use the observation technique of therapeutic communication. The nurse should complement the client to get the client's attention. Wearing a new shirt is an observation about the client that would draw communication from the client. The nurse should avoid direct questions to a client who is experiencing depression.

Question format: Multiple Choice Chapter 7: The Nurse–Client Relationship Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Reference: p. 94 8. A nurse is caring for a terminally ill client whose death is imminent. The nurse has developed a close relationship with the family. Which intervention is most appropriate?

A. Encourage family discussions of feelings.

B. Make decisions for the family in difficult situations.

C. Remain with the family but maintain silence.

D. Tell the family to leave the client alone.

Answer: A Rationale: The nurse should facilitate open and effective communication among those threatened by the loss of a family member. The nurse should abstain from making decisions on the family's behalf. Inappropriate silence may generate anxiety in the family members, so the nurse should not remain silent. It is inappropriate to tell the family to leave the client alone when death is imminent.

Question format: Multiple Choice Chapter 7: The Nurse–Client Relationship Cognitive Level: Apply Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Communication and Documentation Reference: p. 94 9. A nurse is asking a client health-related questions during a medical assessment. The client has developed lesions on the skin and warts around the mouth. Which factor affects oral communication?

A. attention and concentration

B. cultural differences C. nursing skills D. client's lifestyle Answer: A Rationale: Factors affecting oral communication between the client and the nurse include attention and concentration; language compatibility; verbal skills; hearing and visual acuity; motor functions involving the throat, tongue, and teeth; sensory distractions; interpersonal attitudes; literacy; and cultural similarities. Factors such as the client's lifestyle, nursing skills, and cultural differences do not affect oral communication in the client.

Question format: Multiple Choice Chapter 7: The Nurse–Client Relationship Cognitive Level: Apply Client Needs Pn: Physiological Integrity: Physiological Adaptation Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Communication and Documentation Reference: p. 94 10. A nurse and an older adult client with chronic back pain are in the working phase of the nurse–client relationship. Which activity occurs in the working phase?

A. The client identifies one or more health problems.

B. The nurse tries to avoid hampering the client's independence.

C. The nurse is courteous and actively listens to the client.

D. The nurse ensures that the client manages independently.

Answer: B Rationale: In the working phase of a nurse–client relationship, the nurse tries not to hamper the client's independence, because doing too much for the client is as harmful as doing too little. In the introductory phase, the client identifies one or more health problems, and the nurse is courteous and actively listens to the client's problems to ensure that the relationship begins positively. In the termination phase, the nurse ensures that the client manages independently and that the client's health condition has improved.

Question format: Multiple Choice Chapter 7: The Nurse–Client Relationship Cognitive Level: Apply Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Communication and Documentation Reference: p. 93 11. A nurse is examining a 3-year-old child with conjunctivitis. During the examination, the child starts crying and refuses to sit still. Which statement is appropriate for the nurse to tell the child?

A. "Would you like to see my flashlight?"

B. "Don't be scared, the light will not hurt you."

C. "I know you are upset; we can do this later."

D. "If you sit still, this will be over in no time."

Answer: A Rationale: Toddlers are scared of procedures. To decrease the fear, children should be actively involved. Asking the child if he or she wants to see the flashlight would be most appropriate, as it engages the child in an activity. The nurse telling the child not to get scared teaches the child to fear the hurt, and therefore it is inappropriate. Postponing the procedure is also inappropriate. The nurse should not tell the child to sit still and the procedure will soon be completed because it disregards the child's feelings.

Question format: Multiple Choice Chapter 7: The Nurse–Client Relationship Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Reference: p. 94 12. A nurse is working with a client who is in postoperative day 2 following a total knee replacement. The client has briefly mobilized using a wheeled walker and with the assistance of the physical therapist. However, the client is reluctant to progress further with mobilization for fear of injuring herself. In response to this, the nurse has liaised with the physical therapist to create a plan of care that creates specific goals for the client's mobility. In doing so, this nurse has exemplified what role?

A. nurse as educator B. nurse as caregiver C. nurse as delegator D. nurse as collaborator Answer: D Rationale: The nurse acts as a collaborator when he or she works with others to achieve a common goal. This is especially evident when the nurse works cooperatively with members of other health disciplines. This differs from delegation, in which tasks are assigned to other members of the care team. This nurse's actions are not indicative of the educator or caregiver roles.

Question format: Multiple Choice Chapter 7: The Nurse–Client Relationship Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 92 13. A nurse who has been practicing for three decades has seen significant changes in the roles that clients are expected to perform in the course of their care. What is a role that clients are normally expected to perform while they are receiving care?

A. bring a high level of knowledge about their disease or health problem B. avoid consuming an inordinate amount of caregivers' time C. participate actively in the planning and execution of their care D. defer to the nurse's knowledge and authority Answer: C

Rationale: Clients are generally expected to participate in their care in an active way. A passive and deferent demeanor is not encouraged, though cooperation and adherence to treatment are expected. Clients should not be made to feel guilty for requiring time and attention from care providers. Some clients are highly knowledgeable about their health problems, but this is not necessarily an expectation of all clients.

Question format: Multiple Choice Chapter 7: The Nurse–Client Relationship Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Communication and Documentation Reference: p. 92 14. A nurse is working with an adult client who has been admitted with hyperglycemia following a period of poor glycemic control. The nurse has many similarities to the client with regard to age, gender, and socioeconomic status but is careful to utilize therapeutic communication techniques rather than social communication. How does therapeutic communication differ from social communication?

A. Therapeutic communication relies heavily on technical medical vocabulary while social communication uses colloquialisms.

B. Therapeutic communication focuses primarily on problems while social communication addresses positive aspects of the client's life.

C. Therapeutic communication focuses on the requirements of the nurse while social communication is more reciprocal.

D. Therapeutic communication is focused on a particular goal while social communication is more superficial in content.

Answer: D Rationale: Social communication is superficial; it includes common courtesies and exchanges about general topics. Therapeutic verbal communication involves the use of words and gestures to accomplish a particular objective. This does not mean, however, that therapeutic communication depends heavily on technical vocabulary or is focused solely on problems.

Therapeutic communication is focused on the needs of the client, not the nurse.

Question format: Multiple Choice Chapter 7: The Nurse–Client Relationship Cognitive Level: Understand Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Reference: p. 94 15. A nursing student is conducting a client interview in order to determine the client's health history. The student's instructor observes that the student frequently twists her hair with her fingers while asking the client questions. What is the most plausible meaning of the student's nonverbal communication?

A. The student feels insecure during the interview.

B. The student is unconsciously conveying authority.

C. The student is unsure how to interpret the client's responses.

D. The student feels superior to the client in some way.

Answer: A

Rationale: If the nurse plays with her hair during a client interaction, this can communicate insecurity. Superiority or confusion is less likely to underlie this form of nonverbal communication.

Question format: Multiple Choice Chapter 7: The Nurse–Client Relationship Cognitive Level: Understand Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Reference: p. 96 16. A nurse is collecting a health history on a client. When asked about alcohol, tobacco, and drug use, the client states, "I quit smoking 10 years ago." However, the nurse observes an open package of cigarettes in the client's shirt pocket. What is the most appropriate response by the nurse?

A. "I know that you are lying about not smoking, so tell me how much you smoke each day."

B. "Are you having difficulty quitting smoking?"

C. "Why did you tell me you quit smoking?"

D. "You said that you do not smoke, but you have an open package of cigarettes in your pocket."

Answer: D Rationale: Confrontation calls attention to manipulation, inconsistencies, or lack of responsibility. Verbal techniques such as disapproval, belittling, and demanding an explanation are non-therapeutic communication styles.

Question format: Multiple Choice Chapter 7: The Nurse–Client Relationship Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Reference: p. 96 17. A nurse is assessing vital signs on a pregnant client during a routine prenatal visit. The client states, "I know labor will be so painful, it sounds awful. I am sure I will not be able to stand the pain; I really dread going into labor." What is the best response from the nurse?

A. "Don't worry about labor, I have been through it and it is not so bad."

B. "There are many good medications to decrease the pain; it will not be so bad."

C. "You're worried about how you will tolerate the pain associated with labor."

D. "I would recommend keeping a positive attitude."

Answer: C Rationale: Reflecting or paraphrasing confirms that the nurse is following the conversation and demonstrates listening, thus allowing the client to elaborate further. False reassurance may initially relieve the client's anxiety, but it actually closes off communication by trivializing the client's unique feelings and discourages further discussion. Using clichés provides worthless advice and curtails exploring alternatives.

Question format: Multiple Choice Chapter 7: The Nurse–Client Relationship

Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Reference: p. 94 18. A nurse needs to complete an assessment and vital signs on a client who has Alzheimer disease. How should the nurse approach this client to gain cooperation? Select all that apply.

A. Approach the client from the front.

B. Use the client's name.

C. Focus on the nursing tasks.

D. Speak loudly and clearly.

E. Smile and maintain eye contact.

Answer: A, B, E Rationale: Techniques that facilitate communicating with a client who has Alzheimer disease include gaining the client's attention by approaching from the front and using the client's name, smiling to convey friendliness, maintaining eye contact to evaluate the client's attention and comprehension, assuming a relaxed posture to avoid agitating the client, and speaking naturally at a normal rate and volume. It is not effective to focus on nursing tasks and speak loudly and clearly to gain the client's cooperation.

Question format: Multiple Select Chapter 7: The Nurse–Client Relationship Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Reference: p. 94 19. A nurse is interviewing a client who has come to the clinic for a follow-up visit. The nurse notices the client does not make eye contact and speaks while looking down. How should the nurse respond?

A. Assume a position at eye level with the client and continue with the interview.

B. Stop the interview and ask, "How are you feeling?"

C. Sit silently until the client looks up and makes eye contact.

D. Touch the client's hand and say, "You seem upset, is there something bothering you?"

Answer: A Rationale: When communicating with most clients, it is best to position oneself at the client's level and make frequent eye contact. Eye contact is perhaps among the most culturally variable nonverbal behaviors, and can be misunderstood as embarrassment, nervousness, or a problem with the client. Asian, Native American/First Nations, Indochinese, Arabian, and Appalachian people may consider direct eye contact impolite or aggressive, and they may avert their eyes during the interview. Stopping the interview, staying silent, touching the client, and forcing eye contact will make the client uncomfortable and should be avoided.

Question format: Multiple Choice Chapter 7: The Nurse–Client Relationship Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation

Reference: p. 96 20. A nurse is caring for an older adult client hospitalized following a hip fracture. Which actions by the nurse will promote the development of a therapeutic relationship? Select all that apply.

A. Talking with another nurse during a bedside change of shift report B. Addressing the client by the client's first name C. Asking the client when the client would like to have the bed linens changed D. Encouraging the client to talk about the client's life E. Assisting the client with the completion of all activities of daily living Answer: C, D Rationale: The nurse can promote the development of a therapeutic relationship by asking the client about personal preferences, such as when the bed linens should be changed, as well as encouraging the client to share personal stories. The other choices do not support or promote the development of a therapeutic relationship because they are not focused on the client.

Question format: Multiple Select Chapter 7: The Nurse–Client Relationship Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Reference: p. 94 21. The child of a client who just died in a hospice unit arrives and asks, "May I please stay and sit at the bedside? I really wanted to be here so my dad would not die alone." Which statement made by the nurse best demonstrates the use of empathy?

A. "You are too late for that, but you may stay for a while if you would like."

B. "I tried to contact you earlier, but you did not answer your phone."

C. "I will close the door so you can spend some quiet time at the bedside."

D. "I understand. I lost my dad last year, and he died alone."

Answer: C Rationale: Nurses use empathy, an intuitive awareness of what a client is experiencing, to perceive the client's emotional state and need for support. Empathy helps nurses become effective at providing for the client's needs while remaining compassionately detached.

Sympathy, belittling, and defending are all nontherapeutic forms of communication.

Question format: Multiple Choice Chapter 7: The Nurse–Client Relationship Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Reference: p. 94 22. A nurse is completing a health history on a client who has a hearing impairment. Which action should the nurse take first to enhance communication?

A. Assess how the client would like to communicate B. Use facial and hand gestures C. Contact a person skilled in sign language

D. Provide paper and pencil for written communication Answer: A Rationale: Clients with hearing impairment pose unique challenges for communication.

Assessing how the client communicates best is important. For example, if a deaf client can read and write, writing can facilitate communication. If the client knows sign language, the nurse could use a person trained in sign language. Using hand gestures and exaggerated facial movements does not allow for adequate acquisition of knowledge.

Question format: Multiple Choice Chapter 7: The Nurse–Client Relationship Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Communication and Documentation Reference: p. 99 23. A nurse is caring for an older adult client. Which strategy should the nurse utilize to confirm the client's understanding of instructions?

A. Use active listening during communication.

B. Ask open-ended questions.

C. Ask the client to repeat the instructions.

D. Provide written instructions.

Answer: C Rationale: By asking the client to repeat instructions, the nurse can confirm a client's understanding. During all communications the nurse should use active listening and ask open-ended questions to learn more, but this alone does not confirm learning. Providing written instructions is a good option to reinforce learning but should not completely be relied upon to communicate nor confirm a client's understanding.

Question format: Multiple Choice Chapter 7: The Nurse–Client Relationship Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Reference: p. 94 24. The nurse has requested that the unlicensed assistive personnel (UAP) turn and reposition a client as well as change the bed linens. What is the appropriate action by the nurse after delegating this task?

A. verify that the task has been completed and determine the client outcome B. request that the other UAP check to be sure that the task was completed C. inform the UAP that there are other tasks that must be completed for the remainder of the shift D. tell the UAP that you trust that the task was completed as requested and the client is comfortable Answer: A

Rationale: The person requesting who assigns the task will verify that the task is completed as requested and that the client has received the outcome that was expected. The nurse should not simply "trust" that the task was completed because the nurse retains responsibility for completion and positive outcomes. For the same reason, it would be inappropriate to request that another UAP check the task. The UAP may have other tasks to complete, but the initial task should be verified prior to moving on to the next.

Question format: Multiple Choice Chapter 7: The Nurse–Client Relationship Cognitive Level: Apply Integrated Process: Communication and Documentation Reference: p. 92 25. The nurse is caring for a client who had a stroke with residual affective aphasia. What is an effective method(s) for the nurse to communicate with the client? Select all that apply.

A. speak loudly and clearly to the client.

B. finish the sentence for the client when the client is unable to express a word C. provide the client with a tablet or whiteboard to attempt communication D. patiently await the client's responses after asking question E. have the client point to common phrases or spell with alphabet letters on a laminated form Answer: C, D, E Rationale: There are several methods that the nurse can use to communicate with a verbally impaired client. Creativity with methods will include offering the client a whiteboard to write down responses if able or to make requests. Giving the client a laminated form so that the client may be able to point to letters of the alphabet or commonly used phrases may be helpful. The client is not hearing impaired so there is no need to speak loudly. The nurse should be patient while waiting for responses and not rush the client through conversation or answers to questions asked.

Question format: Multiple Select Chapter 7: The Nurse–Client Relationship Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Communication and Documentation Reference: p. 94 26. The client confronts the nurse, stating, "No one has come into my room to give me the pain medication I requested 2 hours ago. I am in pain!" Which response by the nurse indicates the nurse is using a "defending" communication technique?

A. "You could not be huring that much if you are able to watch television."

B. "That is not true, you did not indicate that you were in need of pain medication that immediately."

C. "Why did not you put your light on again and remind me?"

D. "I have been busy with other clients that required my immediate attention."

Answer: D Rationale: The nurse is demonstrating defending behaviors and statements when attempting to justify the reason for not returning with a client's pain medication. This response places the client in the defensive stance as well. The nurse demonstrates belittling when indicating that

the client is not feeling the degree of pain reported. The nurse is disagreeing with the client's statement which is nontherapeutic communication techniques. A more appropriate technique for the nurse to use would be to acknowledge the client's pain and administer the medication as prescribed. The nurse is not acknowledging the client's report of pain as valid when stating that "That's not true" which is inappropriate and will be detrimental to the nurse-client relationship. Informing the client that they should have reminded the nurse about the pain medication is not the client's responsibility.

Question format: Multiple Choice Chapter 7: The Nurse–Client Relationship Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Reference: p. 94

Chapter 8 1. A nurse is providing health education to a client who has been admitted to the health care facility. How can the nurse best determine that the education standards have been met?

A. Ask the client's opinion about the quality of education.

B. Document teaching and learning in the client's medical record.

C. Ask the client's primary care provider about the teaching standards followed.

D. Observe changes in the client's behavior after teaching.

Answer: D Rationale: The best proof of compliance with education standards is to observe a change in the way that the client behaves. Asking the client or the physician doesn't necessarily prove that the education standards have been followed.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 107 2. When caring for a client, the nurse also plans to provide health education to the client. On which subject area should the nurse primarily focus?

A. maintaining a steady daily routine B. post-discharge exercise program C. self-administration of medications D. guidance to client's relatives Answer: C Rationale: Teaching the client about the self-administration of medications is one of the primary subject areas on which to focus during the health education. Discussing the daily routine, post-discharge exercise program, and providing guidance to the client's relatives are included in the education program but are not the primary subject areas.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Client Needs Pn: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 104 3. A client is scheduled for an outpatient procedure and will be discharged the same day.

Why will it be important for the nurse to initiate teaching immediately?

A. There is limited hospitalization time.

B. The client may not be in the condition to learn afterward.

C. The client may take a longer time to learn.

D. The client doesn't think there is anything to learn.

Answer: A Rationale: It is important for a nurse to begin teaching as soon as possible after admission of the client because there is the possibility of limited hospitalization time. The nurse should avoid making assumptions about the client's condition in the future, the client's learning style, and the time needed for learning before the teaching begins.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 103 4. When caring for a client, the nurse observes that the client enjoys reading books and magazines. In which learning domain does the client's learning style fall?

A. Cognitive B. Affective C. Psychomotor D. Interpersonal Answer: A Rationale: As the client enjoys reading books and magazines, the client's learning style would fall in the cognitive domain, where information is processed by listening or reading facts and descriptions. The affective domain is a style of processing that appeals to a person's feelings, beliefs, or values. The psychomotor domain is a style of processing that focuses on learning by doing. The interpersonal domain is a style of processing that focuses on learning through social relationships.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Client Needs Pn: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 104 5. The nurse observes that a client responds better to health education when the nurse motivates him and assures him about the benefits of the teaching. In which of the following learning domains does the client's learning style fall?

A. cognitive domain B. affective domain C. psychomotor domain D. interpersonal domain Answer: B Rationale: Since the client responds better to health education when he is motivated and is assured about its benefits, the client's learning style falls into the affective domain. The affective domain is a style of processing that appeals to a person's feelings, beliefs, or values.

This learning style would be suitable for this client. The cognitive domain is a style of processing information by listening to, or reading, facts and descriptions. The psychomotor domain is a style of processing that focuses on learning by doing. The interpersonal domain is a style of processing that focuses on learning through social relationships.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Client Needs Pn: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 105 6. When caring for a diabetic client, the nurse notes that the client learns better when practicing the self-administration of the insulin injection alone. In which learning domain does this client's learning style fall?

A. Cognitive B. Affective C. Psychomotor D. Interpersonal Answer: C Rationale: Because the client learns better by practicing the self-administration of the insulin injection alone, the client's learning style falls in the psychomotor domain. The psychomotor domain is a style of processing that focuses on learning by doing. The client's learning style does not fall in the cognitive, affective, or interpersonal domain. The cognitive domain is a style of processing information by listening to, or reading, facts and descriptions. The affective domain is a style of processing that appeals to a person's feelings, beliefs, or values.

The interpersonal domain is a style of processing that focuses on learning through social relationships.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Client Needs Pn: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 105 7. A nurse is caring for a 45-year-old male client who lost function in both of his legs due to an automobile accident. Which of the following should the nurse do first to personalize the learning?

A. Gather pertinent information from the client.

B. Analyze the client's behavior.

C. Prepare the training plan for the client.

D. Develop confidence in the client.

Answer: A

Rationale: To personalize the learning, the nurse must first gather pertinent information from the client. Analyzing the client's behavior, preparing the training plan for the client, and developing confidence in the client are the next steps to personalize the learning.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Client Needs Pn: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 109 8. The nurse is caring for a 10-year-old client with gastritis. During the health education, which of the following points should the nurse keep in mind with regard to the characteristics of pedagogic learners?

A. They are goal-oriented.

B. They think abstractly.

C. They respond to competition.

D. They are crisis learners.

Answer: C Rationale: When caring for a 10-year-old client, the nurse should keep in mind that pedagogic clients respond better to competition. They are not goal-oriented and do not think abstractly. They are not crisis learners. Andragogic learners are goal-oriented and think abstractly. Gerogogic learners are crisis learners.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 106 9. When caring for a client at a health care facility, the nurse discovers that the client is unable to read or write. Which of the following teaching approaches is most useful for the client?

A. Provide all the needed education at one time rather than breaking it up.

B. Use verbal and visual modes of communication.

C. Keep the education session short.

D. Check the client's understanding frequently.

Answer: B Rationale: Using verbal and visual modes of instruction is most appropriate for a client who is unable to read or write. Keeping the session short and checking understanding often will not meet the special needs of the client who is unable to read or write. Lengthy education sessions do not enhance learning.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Apply Client Needs: Health Promotion and Maintenance

Client Needs Pn: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 107 10. The nurse notes that a diabetic client has been readmitted to the health care facility with a high blood sugar level as the client had not followed the proper diet. The client is unable to read and speak English properly and can only sign their name. Which category does the client fall into?

A. functionally illiterate B. moderately illiterate C. illiterate D. literate Answer: A Rationale: The client in this case is functionally illiterate. Functionally illiterate people possess minimal literacy skills, which means they can sign their names and perform simple mathematical tasks. Literacy is the ability to read and write. An illiterate person cannot read or write. This does not mean moderately illiterate.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 107 11. During a health teaching session, the nurse notes that the client is not attentive and loses concentration easily. Which of the following techniques is most appropriate to grab the attention of the client during the education?

A. Repeat directions several times.

B. Show the relevance of teaching.

C. Use verbal and visual modes of instruction.

D. Involve the client in an active way.

Answer: D Rationale: Involving the client in an active way is recommended for a client who has low attention and concentration power. Repeating directions several times and using verbal and visual modes of instruction are appropriate for clients with functional illiteracy. Showing the relevance of teaching is not the best way to provide health education to the client with low attention and concentration power.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Client Needs Pn: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 108

12. When caring for a client, the nurse gives day-to-day examples to explain certain points of the health education. The nurse also notes the client's concentration level and educates when the client is active. Which aspect related to learning is the nurse targeting in this approach to teaching the client?

A. Motivation B. Attention and concentration C. Learning readiness D. Learning needs Answer: B Rationale: The client's attention and concentration affect the duration, delivery, and education methods used. It is helpful to observe the client and implement health education when the client is most alert and comfortable. This also means involving the client in an active way by providing examples of day-to-day activities. Learning is optimal when a person has a purpose for acquiring new information. In this example, the nurse is not targeting the client's motivation, readiness to learn, or learning needs.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Client Needs Pn: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 107-108 13. When conducting health teaching for a client, the nurse uses the client's name frequently throughout the instructional period. Which learning barrier is the nurse trying to resolve?

A. functional illiteracy B. sensory deficits C. cultural differences D. shortened attention span Answer: D Rationale: The nurse uses the client's name frequently throughout the instructional period to refocus his or her attention. The abilities to see and to hear are essential for almost every learning situation. Older adults tend to have visual and auditory deficits. These are known as sensory deficits. The nurse must modify his teaching approach if the client cannot speak English or if English is a second language. This can lead to cultural differences. Functionally illiterate people are people who possess minimal literacy skills, which means they can sign their names and perform simple mathematical tasks.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Client Needs Pn: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 107

14. When caring for a client at the health care facility, the nurse observes that the client is having difficulty understanding the health education. Which action is most appropriate?

A. Assess for cultural differences.

B. Boost the morale of the client.

C. Delegate the health education to a colleague.

D. Replace one-on-one teaching with written materials.

Answer: A Rationale: When the client is having difficulty learning, it may be possible that the client does not understand the language that the nurse speaks. In such a case, the nurse should take the necessary steps to break the cultural barrier and then proceed with the education. Written materials can enhance many clients' learning, but will not necessarily overcome many of the common barriers to understanding, including cultural and linguistic factors. The nurse should take action to overcome any barriers to the learning process before delegating to a colleague.

The client's morale is not pertinent to the client's difficulty understanding the teaching.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Client Needs Pn: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 107 15. A client is admitted to the health center with chronic diarrhea. When should the nurse begin imparting health teaching about the benefits of proper diet to the client so that the risk of diarrhea is minimized?

A. When admitting the client B. When providing treatment C. When discharging the client D. When performing follow-up care Answer: A Rationale: Potential teaching needs should be identified from the time when the client is admitted. The client would therefore need to be taught the benefits of a proper diet during admission so as to minimize the risk of diarrhea. There is a greater probability of the client retaining the teaching if the teaching starts during admission. The teaching may be amended during the caring, treatment, and discharge phases, as well as during any follow-up treatment.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Client Needs Pn: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 103 16. The nurse is caring for a 70-year-old client with a fractured wrist. Which is the best method to determine whether the client has retained the information taught?

A. Observe the change in client's behavior for a month.

B. Ask the client to recall after approximately 15 minutes.

C. Test the client on the health education and information imparted.

D. Ask the client to administer the doses of drug himself.

Answer: B Rationale: Asking a client to recall what has been discussed after approximately 15 minutes helps determine what information the client has actually retained. Observing the change in the client's behavior for a month is not feasible or timely. Testing the client on the health education and information imparted would be time-consuming and unnecessarily involved.

Asking the client to self-administer the doses of drug (if even appropriate) would help demonstrate the client's understanding of how to actually administer the drug but not any other aspect of teaching related to a fracture.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Client Needs Pn: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 107 17. A nurse is teaching the importance of personal hygiene and proper bowel movement to a group of clients using gerogogy. Which client is the nurse addressing?

A. elderly people B. pregnant women C. infants D. adults Answer: A Rationale: Gerogogy is a technique that enhances learning among elderly clients. Pedagogy is the science of teaching children or those with cognitive abilities comparable to children.

Androgogy is the science of teaching adult learners.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Client Needs Pn: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 106 18. The nurse is caring for a 60-year-old client with an improper bowel movement regimen.

Which is the most appropriate method for the nurse to use in teaching this client?

A. Refer the client to internet resources on proper bowel health.

B. Have the client join a small group of other clients with the same problem and facilitate group discussions.

C. Begin the session with a reference to the client's actual experience.

D. Talk to the client's relatives and get a detailed account of the client's history.

Answer: C

Rationale: Beginning the session with a reference to the client's actual experience will help provide a link to which the new learning can connect. Although it may be appropriate to refer the client to online resources on proper bowel health, to encourage the client to join a support group, and to consult the client's family regarding the client's history, the nurse should first engage with the client to find out the client's experience and specific issues.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Client Needs Pn: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 109 19. A nurse is working with a client who has recently had an ostomy created after bowel resection surgery. The client is preparing to be discharged home and the nurses in the hospital unit have been performing and documenting relevant client education. Client teaching is specifically mandated for health care organization accreditation by the: A. Centers for Disease Control and Prevention (CDC).

B. Joint Commission.

C. National League of Nursing (NLN).

D. US Department of Health and Human Services.

Answer: B Rationale: Health teaching is a mandated nursing activity. State nurse practice acts require health teaching, and The Joint Commission on Accreditation of Healthcare Organizations has made it a criterion for accreditation. The CDC, NLN, and HHS are unanimously supportive of health education but have not specifically mandated the practice.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Reference: p. 103 20. A client has been admitted to the health care facility and a plan of nursing care has been created. The nursing care plan specifies that client education should begin as soon as possible, and a nurse has begun an assessment in preparation for this education. What assessment parameter should the nurse prioritize during this assessment?

A. the client's occupation B. the client's social support network C. the client's motivation D. the client's coping skills Answer: C Rationale: All of the listed factors may be relevant to client education for some clients.

However, the client's motivation to learn is paramount, since this has a significant bearing on the content and style of education.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 104 21. A nurse on a cardiac care unit performs client education at many different points during clients' treatment. However, the nurse has recently been assigned to teach a formal, group education series for adults who have undergone recent cardiac bypass graft surgery. When preparing to provide formal teaching, the nurse should: A. ensure that all teaching materials are no higher than a third grade reading level.

B. divide the learners into small groups based on their culture of origin.

C. create a learning plan that identifies specific learning outcomes and learning activities.

D. have the learners teach one another the material rather than the nurse presenting it directly to the group.

Answer: C Rationale: Formal teaching necessitates a learning plan. Without a plan, teaching becomes haphazard. Materials must be broadly accessible, but a third grade reading level is a standard that is too low to convey many important teaching points. It is not normally appropriate to divide groups according to culture or ethnicity. Participant-to-participant teaching can be effective but it should not wholly replace instruction from the nurse.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 109 22. A client is scheduled for discharge from the hospital and the client's primary care provider has prescribed subcutaneous injections of an anticoagulant for the next 10 days. The nurse has to teach the client how to correctly self-administer the medication but the client speaks very little English. How should the nurse meet this client's learning needs?

A. Write out the instructions in English and arrange for the pharmacy to have them translated.

B. Arrange for a professional interpreter to be present when the nurse performs client education.

C. Demonstrate the correct technique for injecting the medication while relying on nonverbal communication.

D. Find a website in the client's language that shows correct technique and provide the client with the address.

Answer: B Rationale: Language barriers do not justify omitting health teaching. In most cases, if neither the nurse nor the client speaks a compatible language, a translator or acceptable alternative is needed. It would be inappropriate to limit teaching to nonverbal communication or a website.

Client education should not be delegated to the pharmacist.

Question format: Multiple Choice

Chapter 8: Client Teaching Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 108 23. A client with a history of type 1 diabetes is discussing their medication regimen with the nurse. The client is able to relate the pathophysiology of diabetes to each of the potential complications of the disease and is well-versed in different types of insulin and oral antihyperglycemics. The nurse should recognize that this client demonstrates a high level of: A. health autonomy.

B. personal responsibility.

C. health literacy.

D. learning needs.

Answer: B Rationale: Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Health literacy is not synonymous with personal responsibility. This client is likely to have fewer learning needs than an individual who has a smaller knowledge base.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 111 24. The nurse is caring for a client who has been admitted for a new diagnosis of hypertension. When should the nurse begin client teaching?

A. During the admission process B. After all of the diagnostic testing has been completed C. After having venipuncture for laboratory work D. Immediately prior to discharge Answer: A Rationale: Limited hospitalization time demands that nurses begin teaching as soon as possible. The client should be educated during the process of admission regarding what to expect, patient rights, etc. The client should be educated prior to diagnostic testing. Waiting until immediately prior to discharge to begin teaching does not give the opportunity for return demonstration or to adequately determine whether the education was successful.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 103

25. The nurse is preparing discharge teaching for a client with diabetes. Which information should the nurse include? Select all that apply.

A. Meal planning B. Community resources C. Appropriate use of a glucometer D. Instructions to follow up with the health care provider E. Ways to pay for hospitalization and outpatient care charges Answer: A, B, C, D Rationale: The nurse should teach the client with diabetes about meal planning, community resources, appropriate use of a glucometer, and instructions for follow-up care. The social worker will work with the client on methods of payment, if necessary.

Question format: Multiple Select Chapter 8: Client Teaching Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 104 26. The nurse has provided teaching for a client with a sinus infection who has been prescribed antibiotics and a decongestant. The client states, "I'm not sure how many days I'm supposed to take this antibiotic." What is the nurse's appropriate response?

A. Ask the client to restate the teaching that was provided.

B. Reteach the length of time to take the prescription.

C. Tell the client to take the antibiotic until symptoms subside.

D. Proceed with teaching about the decongestant.

Answer: B Rationale: Client teaching requires a circular approach, specifically if the client has not understood the teaching. The nurse needs to reteach the information that has not been understood. Asking the client to restate the teaching, telling the client to take the antibiotic, and proceeding with teaching about the decongestant are not effective teaching methods.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 104 27. The nurse has completed teaching. Which client behavior demonstrates understanding within the affective domain?

A. Provides return demonstration of use of an inhaler B. States, "I feel comfortable using my walker" C. Verbalizes key points of a brochure about diabetes that was read D. Provides a description of how appropriate wound healing should look Answer: B

Rationale: A client's learning style refers to how a person prefers to acquire knowledge.

Learning styles fall within three general domains: cognitive, affective, and psychomotor. The cognitive domain is a style of processing information by listening or reading facts and descriptions (such as verbalizing key points of a brochure or describing wound healing). The affective domain is a style of processing information that appeals to a person's feelings, beliefs, or values. The psychomotor domain is a style of processing information that focuses on learning by doing (such as demonstrating the use of an inhaler). In this scenario, the client has shown learning in the affective domain by expressing feelings.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 105 28. The nurse has completed teaching. Which client behaviors demonstrate understanding within the cognitive domain? Select all that apply.

A. Provides return demonstration of use of an inhaler B. States, "I feel comfortable using my walker" C. Verbalizes key points of a brochure about diabetes that was read D. Provides a description of what appropriate wound healing should look like E. Expresses a belief system in a higher power Answer: C, D Rationale: The cognitive domain is a style of processing information by listening or reading facts and descriptions. In this scenario, the client has shown learning in the cognitive domain by reading a brochure and articulating key points and by providing a description of what appropriate wound healing should look like. Providing return demonstration of how to use the inhaler demonstrates learning in the psychomotor domain. Expressing comfort with the walker and expressing a belief system demonstrate learning in the affective domain.

Question format: Multiple Select Chapter 8: Client Teaching Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 104 29. The nurse is preparing to teach four clients. Which client will the nurse plan to teach using principles associated with gerogogy?

A. 4-year-old who likes to play with blocks B. 31-year-old who continuously used the internet C. 56-year-old who likes to take notes on paper D. 79-year-old who has slight cognitive changes Answer: D Rationale: Gerogogy is the unique techniques that enhance learning among older adults.

Therefore, the nurse will use gerogogy with the 79-year-old client. Pedagogy is the science of teaching children or those with cognitive ability comparable to children, and would be

appropriate for the 4-year-old client. Andragogy is the principles of teaching adult learners, and would be appropriate for the 31-year-old client and the 56-year-old client.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 106 30. The nurse is teaching an 80-year-old client how to instill eye drops for glaucoma. The client's daughter asks, "How do you know that my mother understands what to do?" What is the appropriate nursing response?

A. "After I demonstrate it once, your mother will be able to do it."

B. "When 15 minutes have passed, I will ask your mother to show me how to instill the drops."

C. "We can never be completely sure that your mother understands instructions."

D. "I will have you bring your mother back next week to see how things are going."

Answer: B Rationale: Older clients may interact in a socially appropriate manner and may indicate that they understand the material being taught. Asking a client to recall what has been discussed after approximately 15 minutes have passed may help determine what information has actually been retained. Saying that the client will understand what to do after observing the nurse demonstrate the skill is not necessarily true and does not address the daughter's concern. Waiting a week to determine whether the client understands the teaching is too late, as the client must begin using this skill before then.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 107 31. The nurse is caring for a client who demonstrates a health literacy concern. The nurse adjusts client teaching in which way?

A. uses medical terminology to help the client feel smarter B. provides general teaching instead of specificity regarding diagnosis C. gives instructions in multiple ways so the client will understand D. uses videos, diagrams, and pictures rather than focusing on verbal teaching Answer: D Rationale: To address health literacy concerns, the nurse should avoid technical language, limit information to three to five key points, and be specific rather than general. Using medical terminology to help the client feel smarter, providing general teaching instead of specific teaching, and giving instructions in multiple ways are not effective ways to adjust client teaching for those who demonstrate low health literacy.

Question format: Multiple Choice Chapter 8: Client Teaching

Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 107 32. The nurse is planning to provide teaching to a client who is recovering from abdominal surgery. When is the most appropriate time to teach the client?

A. When the meal tray arrives B. As the client is sitting quietly, reading a book C. At the time of pain medication administration D. Immediately before discharge to home Answer: B Rationale: A client is most ready to learn when the client is comfortable, nourished, pain-free, and has time to learn. It is not an appropriate time to educate the client when the meal tray arrives, at the time of pain medication administration, or immediately before discharge home, as the client may be distracted.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 103 33. The nurse is preparing to teach a client from Generation X about hypertension. Which teaching approach should the nurse plan to implement?

A. Provide brochures about low-sodium foods.

B. Ask a family member to do meal planning to alleviate the burden for the client.

C. Demonstrate the MyFoodPyramid phone app, to show the best food choices on a lunch tray.

D. Have the client repetitively choose appropriate foods from various menus.

Answer: C Rationale: Those who represent Generations X, Y, and Z may share many learning characteristics. They are or will be technologically literate, having used or grown up with computers, smart phones, and tablet devices. Therefore, it is most appropriate to teach them using some form of multimedia, such as a phone app. The other teaching approaches are less appropriate for this client population.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 106 34. The nurse is providing education to a client recently diagnosed with diabetes. Which action should the nurse take first to address the client's educational needs?

A. teaching spontaneously and assessing the result

B. instructing the client to read a booklet and make notes C. showing enthusiasm when the client states correct information D. creating a plan with the client based upon needs Answer: D Rationale: Creating a plan is an essential component of education. Teaching spontaneously is an unplanned activity and does not include the client in ownership of the knowledge. Using handouts and showing enthusiasm assists in the teaching, but are not used to determine priorities in client education.

Question format: Multiple Choice Chapter 8: Client Teaching Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 107

Chapter 9 1. A nurse is documenting the plan of care for a client with AIDS. Which of the following is most important when documenting the plan of care?

A. Avoid disclosing the client's name and address on the plan of care.

B. Ensure that the client's medical record and nursing interventions are written.

C. Ask one particular nurse to revise and update the plan of care daily.

D. Ensure that the client's medical insurance number is stated on the sheet.

Answer: B Rationale: The nurse should document the client's medical record and the planned nursing interventions in the plan of care as per the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirements. To communicate the plan of care, each nurse assigned to the client refers to the sheet, reviews it, and revises it daily. Stating the medical insurance number of the client on the sheet is of secondary importance as it ensures reimbursement from insurance companies. Nurses usually make certain that the client's name and address are written on the plan of care sheet.

Question format: Multiple Choice Chapter 9: Recording and Reporting Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 116 2. When maintaining health care records for a client, the nurse knows that a health care record also serves as a legal document of evidence. What should the nurse do to ensure legally defensible charting?

A. Ensure that the client's name appears on all pages.

B. Leave spaces between entries and signature.

C. Use abbreviations wherever possible.

D. Record all facts and subjective interpretations.

Answer: A Rationale: The nurse should ensure that the client's name appears on all pages to ensure legally defensible charting. The nurse should not leave spaces between entries and signature so that the document is legally acceptable. The nurse should use only abbreviations approved by the facility, and should not use abbreviations wherever possible. The nurse should record all the facts, but not any subjective interpretations, to ensure that the document is legal evidence.

Question format: Multiple Choice Chapter 9: Recording and Reporting Cognitive Level: Apply Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 115

3. A nurse caring for a client who is being treated by three health care providers uses the source-oriented format for documentation. What are the benefits of using this format of documentation?

A. Information is documented in separate forms by each health care personnel.

B. It is a unified, cooperative approach for resolving the client's problems.

C. It is organized at one location according to the client's health problems.

D. It is compiled to facilitate communication among health care professionals.

Answer: A Rationale: Source-oriented documentation is a record organized according to the source of documented information. This type of record contains separate forms on which health care personnel make written entries about their own specific activities in relation to the client's care. The problem-oriented method of recording demonstrates a unified, cooperative approach to resolving the client's problems. Source-oriented records are organized at numerous locations; there is not one location for information. The problem-oriented record is compiled to facilitate communication among health care professionals.

Question format: Multiple Choice Chapter 9: Recording and Reporting Cognitive Level: Remember Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 116 4. A nurse is maintaining a problem-oriented medical record for a client. Which component of the record describes the client's responses to what has been done and revisions to the initial plan?

A. data base B. problem list C. plan of care D. progress notes Answer: D Rationale: In a problem-oriented medical record, the progress notes describe the client's responses to what has been done and revisions to the initial plan. The data base contains initial health information about the client. The problem list consists of a numeric list of the client's health problems. The plan of care identifies methods for solving each identified health problem.

Question format: Multiple Choice Chapter 9: Recording and Reporting Cognitive Level: Remember Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 116

5. A nurse charting the health care record for a client knows that which form of charting involves writing information about the client and client care in chronological order?

A. FOCUS charting B. SOAP charting C. narrative charting D. PIE charting Answer: C Rationale: Narrative charting involves writing information about the client and client care in chronological order. In SOAP charting, everyone involved in the client's care makes entries in the same location in the chart. FOCUS charting follows a data, action, and response (DAR) model to reflect the steps in the nursing process. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

Question format: Multiple Choice Chapter 9: Recording and Reporting Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 116 6. Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation?

A. It documents assessments on separate forms.

B. It records progress under problems, intervention, and evaluation.

C. It provides and refers to a client's problem by a number.

D. It provides quick access to abnormal findings.

Answer: D Rationale: Charting by exception (CBE) provides quick access to abnormal findings, as it does not describe normal and routine information. When using the PIE charting method, assessments are documented on separate forms. The PIE charting method, not charting by exception, records progress under problems, intervention, and evaluation. The client's problems are given a corresponding number in the PIE charting method, which is used in the progress notes when referring to interventions and the client's responses.

Question format: Multiple Choice Chapter 9: Recording and Reporting Cognitive Level: Remember Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 118 7. When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nurse implementing?

A. FOCUS charting B. SOAP charting C. PIE charting

D. narrative charting Answer: B Rationale: The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort through the lengthy notation for specific information that correlates the client's problems with care and progress. FOCUS charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

Question format: Multiple Choice Chapter 9: Recording and Reporting Cognitive Level: Remember Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 116 8. A health care facility plans to evaluate and revise the plan of care for a client based on the client's health care records. The physician, dietitian, and nurse involved in the client's care are required to collate all of the information for easy access. Which style would the nurse conclude that the facility is following in order to record the client details?

A. FOCUS charting B. narrative charting C. PIE charting D. SOAP charting Answer: D Rationale: In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. Narrative charting is time-consuming to write and read, as it involves sorting through the lengthy notation for specific information that correlates the client's problems with care and progress. FOCUS charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

Question format: Multiple Choice Chapter 9: Recording and Reporting Cognitive Level: Apply Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 116 9. A health care agency is applying for accreditation, and the accrediting agency is conducting audits of randomly selected medical records. To support the agency's accreditation, these medical records should include:

A. evidence of home care and nursing follow-up for six weeks following discharge.

B. self-reflection from nursing and other care providers about the quality of their care.

C. evidence that nurses have set goals for improving their future practice.

D. evidence that nursing interventions have been evaluated in terms of the client's response.

Answer: D Rationale: The medical record serves multiple purposes, including a role in accreditation.

Accreditors look for evidence of evaluation following interventions. The medical record is not the correct venue for nurses' self-reflection or personal goal setting. Many clients do not require community-based follow-up after they have been discharged.

Question format: Multiple Choice Chapter 9: Recording and Reporting Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 113 10. A nurse has received the change-of-shift report and is briefly reviewing the documentation about a client in the client's medical record. A recent entry reads, "Client was upset throughout the morning." To improve the charting entry, it should: A. include clearer descriptions of the client's mood and behavior.

B. avoid mentioning cognitive or psychosocial issues.

C. list the specific reasons that the client was upset.

D. specify the subsequent interventions that were performed.

Answer: A Rationale: Entries in the medical record should be precise, descriptive, and objective. An adjective such as "upset" is unclear and open to many interpretations. As such, the nurse should elaborate on this description so that a reader has a clearer understanding of the client's state of mind. Stating the apparent reasons that the client was "upset" does not resolve the ambiguity of this descriptor. Cognitive and psychosocial issues are valid components of the medical record. Responses and interventions should normally follow assessment data, but the data themselves must first be recorded accurately.

Question format: Multiple Choice Chapter 9: Recording and Reporting Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 124 11. A client who is bedridden is scheduled to receive subcutaneous injections of heparin at 8:00 a.m. and 8:00 p.m. each day. The client's medication administration record would present these times as: A. 0800 and 1800.

B. 800 and 2200.

C. 0800 and 2000.

D. 0800 and 2200.

Answer: C Rationale: 8:00 a.m. is 0800 in military time, and 8:00 p.m. is 2000.

Question format: Multiple Choice Chapter 9: Recording and Reporting Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Communication and Documentation Reference: p. 122 12. An older adult client has been admitted to the hospital with a suspected bowel obstruction. The nurse is reviewing the admitting physician's orders and reads the order "NPO." Based on this order, what action should the nurse take?

A. Apply oxygen by nasal prongs if necessary.

B. Ensure that the client does not eat or drink anything.

C. Ensure that the client's record is made available to the insurer.

D. Insert a nasogastric or oropharyngeal tube if necessary.

Answer: B Rationale: The abbreviation "NPO" denotes that the client should take nothing by mouth. It is irrelevant to insurance status, oxygenation, or gastric intubation.

Question format: Multiple Choice Chapter 9: Recording and Reporting Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Communication and Documentation Reference: p. 122 13. While covering a colleague's lunch break, a nurse on an orthopedic unit has responded to a client's call light. The client has requested assistance in transferring from the bed to the bathroom. The nurse has not previously provided care for this client and is unsure of the client's current activity orders. The client's current level of activity can be most easily verified by consulting what written source?

A. nursing care plan B. nursing Kardex C. checklist D. flow sheet Answer: B Rationale: The nursing Kardex provides a succinct and accessible record of many aspects of a client's current orders. The care plan would address the issue of mobility but may not specify the current orders for the client's activity at this point in recovery. Checklists and flow sheets are not places where current orders are recorded and updated.

Question format: Multiple Choice Chapter 9: Recording and Reporting Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Communication and Documentation

Reference: p. 123 14. The nurse is caring for a client with hypertension, and only documents a blood pressure of 170/100 mmHg when all other vital signs are normal. This reflects what type of documentation?

A. SOAP B. narrative C. focus D. charting by exception Answer: D Rationale: Charting by exception is a documentation method in which nurses chart only abnormal assessment findings or care that deviates from a standard norm. In the scenario, the BP is abnormal and is documented by exception. The other types of documentation are not being represented in this scenario.

Question format: Multiple Choice Chapter 9: Recording and Reporting Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 118 15. A client made a formal request to review his or her medical records. With review, the client believes there are errors within the medical record. What is the most appropriate nursing response?

A. "According to HIPAA, medical records cannot be changed."

B. "HIPAA legislation allows for you to change any information."

C. "According to HIPAA legislation, you have a right to request changes to inaccurate information."

D. "HIPAA legislation only allows access to review the medical record."

Answer: C Rationale: The Health Insurance Portability and Accountability Act (HIPAA) gives clients the right to see their own medical records. They may also update their health record if inaccurate, get a list of the disclosures that a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations, request a restriction on certain uses or disclosures, and choose how to receive health information.

Question format: Multiple Choice Chapter 9: Recording and Reporting Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 120 16. The nursing student is discussing the benefits of electronic charting with a precepting nurse who is frustrated with computerized documentation. Which statement by the student requires intervention from the nursing instructor?

A. "You don't have to worry about trying to read poor handwriting."

B. "The computer reminds the nurse to enter information and inhibits omissions."

C. "You save time because you don't have to look for the physical chart."

D. "You can make extra money with overtime pay with end-of-shift charting."

Answer: D Rationale: There are many benefits to electronic charting, though there may be some learning curves involved in knowing how to use electronic formats. It is incorrect to suggest that overtime pay can be earned with end-of-shift charting. Therefore, this statement requires intervention. The other statements are appropriate.

Question format: Multiple Choice Chapter 9: Recording and Reporting Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 118 17. A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate?

A. "Be sure to write down specific information for your clinical paperwork."

B. "You can get an electronic printout of client lab data to take with you."

C. "Clipboards with client data should not leave the unit."

D. "Be sure to put the client's name and room number on all paperwork."

Answer: C Rationale: HIPAA has created several changes that protect client confidentiality and affect the workplace. One such change is that the names of clients on charts can no longer be visible to the public, and clipboards must obscure identifiable names of clients and private information about them. Therefore, writing down clinical information, taking the data off the unit, and including client identifiers are inappropriate.

Question format: Multiple Choice Chapter 9: Recording and Reporting Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 120 18. Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication?

A. "I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin."

B. "I am calling about the patient in room 212. He has new onset diabetes mellitus, and I wondered if you would like to adjust the sliding scale of insulin."

C. "I am calling about Mr. Jones in room 212. His blood glucose is 250 mg/dL (13.875 mmol/L), and I think that is high."

D. "I am calling about Mr. Jones, who has diabetes mellitus. His blood sugar seems high, and I think he needs more insulin."

Answer: A Rationale: SBAR refers to: S (situation): what is the situation you are calling about?; B (background): pertinent background information related to the situation; A (assessment): what is your assessment of the situation?; R (recommendation): explain what is needed or wanted. These elements must be included in the communication for the SBAR format to be effective. When some of this information is omitted, it does not demonstrate proper use of the SBAR format.

Question format: Multiple Choice Chapter 9: Recording and Reporting Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 127 19. The nurse is documenting morning care for a client with diabetes. Which documentation is most appropriate for this client?

A. 8:00: Pt is resting in bed and appears to be comfortable.

B. 0800: Resting in bed, eating some breakfast. Complains of headache.

C. 0800: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10.

D. 0800: Side rails up, call light in reach. Bed in high position.

Answer: C Rationale: Pt is not an appropriate abbreviation for patient and it is understood that all entries are specific to the patient. Avoid the phrases "appears to be" and "seems to be," as they suggest uncertainty. Military time should be used to avoid confusion. Specific, detailed information should be included when possible, such as consumed 80% of breakfast and a reported pain level. Bed in high position is not appropriate for patient safety.

Question format: Multiple Choice Chapter 9: Recording and Reporting Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 121 20. The nurse documents that a client does not have pain prior to the administration of pain medication. The client, however, requested medication for increasing postsurgical pain. What is the appropriate action to correct the pain assessment documented in the client's paper medical record?

A. Scribble through the entry.

B. Obtain white-out to cover the entry.

C. Write over the entry in another color pen.

D. Place one line through the entry and initial it.

Answer: D Rationale: The appropriate action is to place one line through the entry and initial it. Any written documentation that cannot be clearly read, or that is vague, scribbled through, whited out, written over, or erased makes for a poor legal defense.

Question format: Multiple Choice Chapter 9: Recording and Reporting Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 113 21. A nurse is documenting information related to a client's condition. When documenting this information in the paper chart, the nurse makes an error documenting vital signs, entering 86/132. What is the best technique for recording the error made in documentation?

A. Erase the incorrect statement and write 132/86.

B. Cross out 86/132 using a black sharpie marker.

C. Use correction fluid to cover up 86/132 in the record.

D. Cross out 86/132 with a single line and place the nurse's initials above it.

Answer: D Rationale: When recording an error in documentation, the nurse should always cross out the incorrect statement with a single line so that it remains readable, add the date, initial, and then document the correct information. The nurse should not erase the incorrect statement and replace it with the correct one. The nurse should not cross out the wrong statement in a way that makes the statement unreadable. The nurse should not use correction fluid to obliterate what has been written. These methods render the medical record a poor legal defense.

Question format: Multiple Choice Chapter 9: Recording and Reporting Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 121 22. A nurse in the intensive care unit has just reported for duty. A client is being transferred to the medical floor after change of shift. Which action would the nurse take to ensure maximum efficiency of change-of-shift or transfer reports?

A. Call the receiving nurse with a list of the client's medication.

B. Ask the physician to provide transfer report to the receiving nurse.

C. Print the client's medical record to accompany the client during transfer.

D. Utilize the electronic medical record while providing report to the receiving nurse.

Answer: D Rationale: To ensure that all information is relayed to the receiving nurse, the nurse should utilize the electronic medical record to report vital signs, medications, and appropriate lab values to the receiving nurse. The nurse would not print the entire electronic medical record for a transfer in the same facility. The physician would not provide transfer report to the receiving nurse. When providing transfer report, the nurse would include more information than only medications Question format: Multiple Choice Chapter 9: Recording and Reporting Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care

Integrated Process: Communication and Documentation Reference: p. 124 23. The nurse is caring for a client who is prescribed a pain medication by mouth every 4 to 6 hours. When assessing pain status, the client states not wanting to take any medication right now. Which principle should the nurse consider when documenting interventions regarding medication administration for this client?

A. Medication should be documented along with the time and the amount given or not given each time medication is scheduled to be administered.

B. The client's pain should be documented on a scale of 0 to 10 when documenting the administration of pain medication.

C. Medication that is not administered should be documented along with the reason.

D. Steps taken to encourage the client to comply should be documented along with assessment findings.

Answer: C Rationale: Accurate and timely documentation prevents medication from being administered too frequently or withheld unnecessarily. Therefore, it is most appropriate to document that the pain medication was given immediately following administration. However, in circumstances where medication cannot be given or the client refuses medication, this information should be documented with detailed information about the reason. While assessing the client's pain management is important, it is not the culminating factor to administer prescribed medication or in documenting the actual administration. While it is important to encourage clients to take the medication, if a client refuses pain medication steps taken to encourage the client to comply is not an intervention for documenting administration.

Question format: Multiple Choice Chapter 9: Recording and Reporting Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 114 24. The nurse is taking verbal medication prescriptions from the provider by hand to be documented in the clients eMAR for administration of medication. How should the nurse correctly document this information?

A. Sertraline 100 mg per os HS 20:00. JD, RN. B. 0800-Amoxicillin 250mg PO with water. J. Doe, RN. C. Celecoxib 100 mg @ 0800 with applesauce, Jane Doe RN. D. 1200-Tramadol 50mg PO with OJ for pain rated 6 out of 10. Jane Doe RN. Answer: B Rationale: When documenting information in a client's health care record, the nurse should sign each entry by name, first initial and last name, and title. Correct documentation also includes recognition of those abbreviations and terms on the "Do Not Use" list such as "per os" and "OJ" which can be confused with other terminology meanings. Time stamps should also be included in documentation.

Question format: Multiple Choice

Chapter 9: Recording and Reporting Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 120 25. The unlicensed assistive personnel (UAP) has taken vital signs on a newly admitted client. The client asks the nurse how this information is recorded in the chart, since the UAP is not licensed. Which response by the nurse is best?

A. "The UAP will tell me what the vital signs are, and I will record them in the record so the health care provider can review them."

B. "Vital signs do not need to be recorded unless they are abnormal."

C. "The UAP logs in under my name and documents the vital signs."

D. "The UAP is able to log in and enter the information so all members of the health care team can see it."

Answer: D Rationale: Each person who makes entries in the client's electronic health record (EHR) is responsible for the information he or she records and can be summoned as a witness to testify concerning what has been documented. Although the licensed registered nurse has accountability, the UAP can document data that has been collected in the EHR. It is not appropriate to document for someone else, and all users should always log out of the computer prior to allowing another person to document.

Question format: Multiple Choice Chapter 9: Recording and Reporting Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 114 26. The nurse caring for an older adult client suspects that the client is being neglected at home due to several observations obtained in the ongoing assessment. What is the appropriate nursing action in this situation?

A. immediately report the suspected abuse of the client.

B. avoid reporting the abuse as it would be a privacy and confidentiality violation C. inform the client's family that the client is being neglected at home D. discuss the abuse with coworkers to determine what should be done Answer: A Rationale: The nurse is a mandatory reporter and state laws take precedence over Health Insurance Portability and Accountability Act (HIPAA)/ Personal Information Protection and Electronic Document Act (PIPEDA) regulations. The priority action by the nurse is to report the suspected abuse to the adult protective service department so that it can be investigated. It is not appropriate to involve the family members at this point because it may mask any abuse that is occurring. The fewer people involved in this situation is better. The nurse should not discuss this with coworkers unless they are directly involved with the client's care.

Question format: Multiple Choice Chapter 9: Recording and Reporting

Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 124 27. The nurse is caring for a client who requests to see one's medical record since admission to the hospital. What is the appropriate response by the nurse?

A. "The hospital owns your records and does not have to allow you access while you are a client here."

B. "I will have to review the policy that determines what procedure is in place for client access."

C. "Let me open up the computer access so that you can see what information is of interest to you."

D. "You may not understand all of the information and it will confuse you so I will help you decipher it all."

Answer: B Rationale: Clients have the right to see their own medical records and request changes to documentation that may be in error. Most facilities have a policy in place for the client to obtain medical records and the nurse should ensure that the policy is followed by being familiar with that policy prior to giving the client free access to the record. The nurse should not demean the client by assuming that the information may be confusing. The nurse should not allow the client access to the computer while using the nurse's password or login information. While the hospital maintains responsibility for the record, the client has the right to see it.

Question format: Multiple Choice Chapter 9: Recording and Reporting Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 120 28. A nurse receives a subpoena for a lawsuit involving a client who retained a foreign body after undergoing a surgical procedure. The nurse reviews the chart prior to the court date and observes that some data are missing from the document and some entries are incorrect. What is the appropriate action by the nurse?

A. fill in the entries that should be in the document since the chart has not gone to court yet B. use "white-out" to cover the incorrect information in the document C. draw a line through the information that is incorrect and write corrections on the document D. continue reviewing the document without making any written corrections to what is present Answer: D Rationale: The nurse should not make any changes to the document. Once the nurse is subpoenaed, it is likely that the attorney for the defendant has already seen the documents and any new entries by the nurse will be seen as an effort to cover up. White-out or any other method that obscurs words should never be used in a legal document since evidence of this may cause suspicion that the document was tampered with.

Question format: Multiple Choice Chapter 9: Recording and Reporting Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 121

Chapter 10 1. A nurse is caring for a client with Lyme disease. What causes Lyme disease?

A. rickettsiae B. fungi C. protozoans D. mycoplasmas Answer: A Rationale: Rickettsiae that resemble bacteria cause Lyme disease. Intermediate life forms such as fleas, ticks, lice, or mites transmit rickettsial diseases to humans. Fungi include yeasts and molds, which cause infections in the skin, mucous membranes, hair, and nails. Examples of fungal infections include ringworm, athlete's foot, and vaginal yeast infection. Protozoans are single-celled animals classified according to their ability to move. Mycoplasmas infect the surface linings of the respiratory, genitourinary, and gastrointestinal tracts. Fungi, protozoans, and mycoplasmas do not cause Lyme disease.

Question format: Multiple Choice Chapter 10: Asepsis Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 134 2. A nurse is attending to a client with an infectious disease. After changing the linen and caring for the patient, the nurse does a hand antisepsis with an alcohol-based hand rub. Which of the following is a reason for the nurse to use an alcohol-based hand rub?

A. It destroys active microorganisms on the skin.

B. It provides the greatest reduction in microbial counts.

C. It destroys the dry bacterial cells on the outer layer of the skin.

D. It controls viral replication on the skin.

Answer: B Rationale: The nurse uses an alcohol-based hand rub as it provides the fastest and greatest reduction in microbial counts on the skin. Other advantages include: alcohol-based hand rubs are more accessible because they do not require sinks or water; they increase compliance because they are easier to perform; they reduce costs by eliminating paper towels and waste management; and they are less irritating and drying than soap because they contain emollients. Disinfectants destroy active microorganisms. Antivirals do not destroy the infecting viruses; rather, they control viral replication (copying) or release from the infected cells.

Question format: Multiple Choice Chapter 10: Asepsis Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs Pn: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process

Reference: p. 139 3. A nurse needs to visit the intensive care unit to administer an enema to a client. Which step should the nurse take when using the sterile solution located at the entrance to the intensive care unit?

A. Loosen the cap or the seal on the bottle.

B. Hold the container from the top.

C. Pour and discard a small amount of the solution.

D. Clean the nozzle area with a damp cloth.

Answer: C Rationale: Before each use of a sterile solution, the nurse should pour and discard a small amount to wash away airborne contaminants from the mouth of the container. To avoid contamination, the nurse should place the cap upside down on a flat surface or hold it during pouring. The nurse should control the height of the container to avoid splashing the sterile field, causing a wet area of contamination. The nurse should not loosen the cap or hold the container from the top. The nurse also should not clean the nozzle area with a damp cloth, as this would lead to contamination of the solution.

Question format: Multiple Choice Chapter 10: Asepsis Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 144 4. A nurse is preparing an operating room theatre for a surgical procedure. Which point regarding the principles of surgical asepsis should the nurse keep in mind when preparing sterilized surgical instruments?

A. When a sterile item touches something that is not sterile, it may not be contaminated.

B. Any partially uncovered sterile package need not be considered contaminated.

C. A commercially packaged surgical item is not considered sterile if past expiration date.

D. Sterility may not be preserved even when one sterile item touches another sterile item.

Answer: C Rationale: When preparing the operation theater for a surgical procedure, the nurse should remember that a commercially packaged surgical item is not considered sterile if it has passed its recommended expiration date. When a sterile item touches an item that is not sterile, then the sterile item is contaminated. If a sterile item touches another sterile item, it is not considered contaminated. A partially uncovered sterile package is considered contaminated.

Question format: Multiple Choice Chapter 10: Asepsis Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs Pn: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 144 5. A nurse should perform hand hygiene in which circumstance?

A. whenever hands are visibly soiled B. only after removing gloves C. whenever the nurse has not performed hand hygiene for 15 minutes D. after making contact with an item in a public space Answer: A Rationale: Hand hygiene is necessary when hands are visibly soiled, before and after contacts with all clients, after contact with any source of microorganisms, before and after performing invasive procedures, and before and after removing gloves. The CDC does not recommend handwashing only after removing gloves, but rather both before and after removing gloves.

The nurse needs to always wear gloves if she has any breaks in the skin of the hands.

Question format: Multiple Choice Chapter 10: Asepsis Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 138 6. An operating room nurse is caring for a client who will soon undergo an appendectomy.

Which handwashing technique is most appropriate for the nurse to use when caring for this client?

A. Wash hands with soap or detergent.

B. Perform hand antisepsis using a designated bleach solution.

C. Perform surgical hand scrub using detergent.

D. Apply alcohol-based handrub up to the mid-forearm Answer: C Rationale: The nurse should perform a surgical hand scrub using detergent when caring for a client undergoing surgery. Bleach solutions are not used and a basic handwash is not sufficient. Alcohol-based rubs may be used in many situations that do not involve surgery.

Question format: Multiple Choice Chapter 10: Asepsis Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs Pn: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 139 7. A nurse is explaining the different procedures used to break the chain of infection to a nursing student. In which link in the chain of infection should a nurse provide special attention to the respiratory and gastrointestinal tracts?

A. exit route B. vehicle of transmission C. infectious microorganism D. susceptible host Answer: A

Rationale: The nurse should provide special attention to the respiratory and gastrointestinal tracts as potential exit routes.

Question format: Multiple Choice Chapter 10: Asepsis Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs Pn: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 135 8. A nurse is observing the housekeeping staff when they are cleaning a health care facility.

Which principle should the housekeeping staff follow for medical asepsis?

A. Wet-mop floors to avoid distributing microorganisms.

B. Clean grossly dirty areas before less-soiled areas.

C. Dust the furniture with a dry cloth to avoid spreading microorganisms.

D. Place clean items carefully on the floor.

Answer: A Rationale: Housekeepers who follow the principles of medical asepsis carry out concurrent disinfection methods. The housekeeping personnel should wet-mop floors and damp-dust furniture to avoid distributing microorganisms on dust and air currents. They should never place clean items on the floor or on the furniture. They should always clean less-soiled areas before grossly dirty ones.

Question format: Multiple Choice Chapter 10: Asepsis Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 137 9. A nurse is required to clean the open wounds of a client who has been involved in an automobile accident. What intervention would the nurse need to perform when cleaning a client's open wounds to protect the nurse from infection?

A. Wash hands with alcohol-based hand wash after the procedure.

B. Wear a clean pair of latex or latex-free gloves.

C. Use sterilizing acid to clean the injury.

D. Use sterile solutions such as normal saline.

Answer: B Rationale: In order to protect themselves from infections when dealing with open wounds, nurses should wear gloves. Though washing hands with an alcohol-based hand wash helps kill the microorganisms, it will not protect the nurse from being infected during the cleaning of the wound. Sterilizing acid is used to sterilize heat-sensitive instruments and is not applied to wounds. Sterile solutions such as normal saline are used to avoid contamination of the wound itself, not to protect the nurse.

Question format: Multiple Choice Chapter 10: Asepsis Cognitive Level: Apply

Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 142 10. A nurse is preparing a sterile field in order to perform a dressing change for a client.

Which step should the nurse take when preparing to pour a sterile solution into the dressing tray?

A. Shake the solution vigorously prior to use.

B. Grasp the lip of the container when pouring.

C. First pour and discard a small amount of the solution.

D. Clean the lip of the container with a damp cloth.

Answer: C Rationale: Before each use of a sterile solution, the nurse should pour and discard a small amount to wash away airborne contaminants from the mouth of the container. The nurse should not clean the nozzle area with a damp cloth or grasp it, as this would lead to contamination of the solution. Solutions should not normally be shaken prior to use.

Question format: Multiple Choice Chapter 10: Asepsis Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 144 11. When caring for a client with a bacterial respiratory infection and an active cough, what action should the nurse take in order to prevent becoming infected?

A. Get monthly immunizations against infections.

B. Wear a mask when caring for the client.

C. Wear sterile gloves when touching the client.

D. Avoid all physical contact with the client.

Answer: B Rationale: When caring for a client with a respiratory infection, the nurse washes the hands frequently and thoroughly and wears a mask. The nurse need not get monthly immunizations against infections. Avoiding contact with the client is also not a good alternative, as the nurse needs to be near the client to provide adequate care. Gloves may be necessary, but these do not need to be sterile.

Question format: Multiple Choice Chapter 10: Asepsis Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Reference: p. 141 12. Health care professionals are required to follow certain principles to ensure that nosocomial infections do not occur in the health care facility. What contributes to infections in health care settings?

A. health professionals with short hair B. health professionals donning artificial nails

C. health professionals with leather footwear D. health professionals with earrings Answer: B Rationale: In order to ensure that nosocomial infections do not occur at the health care facility, nurses are prohibited from wearing artificial nails. Health professionals with short hair, earrings, or leather footwear do not contribute inordinately to infections.

Question format: Multiple Choice Chapter 10: Asepsis Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 138 13. A nurse is informing a nursing student about infection control practices for hand asepsis.

Which guideline is in compliance with infection control standards for hand washing?

A. washing when hands are visibly soiled B. washing only after removing gloves C. washing hands for 5 to 10 seconds D. washing when initiating contact with another client Answer: A Rationale: The CDC recommends hand washing when hands are visibly soiled, before and after contacts with all clients, after contact with any source of microorganisms, before and after performing invasive procedures, and before and after removing gloves. The CDC does not recommend hand washing only after removing gloves, but rather both before and after removing gloves. Hand asepsis with soap and water should not take less than 15 seconds.

Question format: Multiple Choice Chapter 10: Asepsis Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Reference: p. 138 14. A labor and delivery nurse will be participating in a client's emergency caesarean section and intends to apply the principles of surgical asepsis appropriately. Surgical asepsis is most clearly characterized by: A. Antibiotics are applied as a preventative measure against infection.

B. The principles of medical asepsis will be applied in a surgical setting.

C. Viral contamination takes precedence over bacterial contamination.

D. Steps are taken to render an item completely free of microorganisms.

Answer: D Rationale: Surgical asepsis means those measures that render supplies and equipment totally free of microorganisms. This exceeds the standards of medical asepsis and both viral and bacterial contaminations are vigilantly addressed. Prophylactic antibiotics are not normally a component of surgical asepsis.

Question format: Multiple Choice

Chapter 10: Asepsis Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 144 15. The nurse is discussing antiviral medication with a client diagnosed with human immunodeficiency virus (HIV). Which client statement indicates a need for further teaching?

A. "The antiviral medication will stop the virus from multiplying."

B. "I will need to take the antiviral medication every day."

C. "The antiviral medication will cure the virus from my body."

D. "The antiviral medication will limit the viral load in my body."

Answer: C Rationale: The discovery and use of antiviral medications has turned once deadly viral infections, such as HIV, into chronic diseases. The antiviral will not cure the virus, however, it will decrease the viral load and limit multiplication of the virus. The antiviral medication will need to be taken daily for life.

Question format: Multiple Choice Chapter 10: Asepsis Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 138 16. The nurse is caring for four clients. Which client presents the most susceptibility for infection?

A. 4-year old receiving antibiotics for strep throat B. 46-year old with a foley catheter following anesthesia C. 36-year old female experiencing her menstrual cycle D. 30-year old experiencing esophageal reflux Answer: B Rationale: Indwelling equipment, such as a urinary catheter, makes the client more susceptible to infection. Antibiotics, when used appropriately to treat a known illness such as strep, do not increase the risk of infection. A female experiencing menstruation is a normal body process, and is not at increased risk of infection. Esophageal reflux does not place the client at additional risk of infection.

Question format: Multiple Choice Chapter 10: Asepsis Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 135 17. A student nurse is performing hand washing in the clinical setting. Which observation would require the nursing instructor to intervene?

A. washes hands for 15 seconds

B. has manicured nails that are 1-in. (2.5-cm) long C. has wedding band on ring finger D. drains hands lower than the wrist Answer: B Rationale: Fingernails should be less than ¼-in. (0.625-cm) long, as this reduces the reservoir for flora to accumulate and decreases the chance of tearing or puncturing gloves. Washing hands for 15 seconds is appropriate. A flat wedding band is acceptable. Allowing the hands to drain lower than the wrist promotes gravity drainage.

Question format: Multiple Choice Chapter 10: Asepsis Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 138-139 18. The nurse applies an alcohol-based hand rub upon entering the client's room. The client becomes upset stating, "You did not wash your hands!" Which response by the nurse is most appropriate?

A. "Washing the hands with soap and water is not necessary."

B. "Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin."

C. "I won't be touching you, so using the alcohol hand rub is the quickest method to perform hand hygiene."

D. "We only wash our hands when they are visibly soiled."

Answer: B Rationale: By explaining that alcohol-based hand rubs are effective in preventing the spread of microbes, the nurse directly addresses the client's concern. While washing with soap and water may not be necessary, it doesn't address the client's concern. Alcohol-based hand rub is an appropriate method for hand hygiene even when you plan to touch the client.

Question format: Multiple Choice Chapter 10: Asepsis Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 139 19. A nursing student is donning sterile gloves to perform routine tracheostomy care for a client. Which behavior by the student would require immediate intervention from the instructor?

A. washes hands for 20 seconds with soap and water B. picks up the glove at the folded edge with the thumb and forefinger C. stretches the glove over the hand without touching the unsterile area D. reaches down to the bed to pick up a sterile drape Answer: D

Rationale: The sterile gloves should always stay above waist level. Reaching down to the bed could create contamination to the sterile field and the student should be stopped and asked to don sterile gloves again. Washing the hands for 20 seconds with soap and water meets the expectation of 15 seconds. Picking up the folded edge of the glove is the appropriate step to get the glove on while maintaining sterility. The glove must be stretched over the hand carefully.

Question format: Multiple Choice Chapter 10: Asepsis Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 158 20. The nurse is monitoring a student who is performing surgical hand asepsis. Which student actions indicate the need for further education from the nurse? Select all that apply.

A. wearing a gold wedding band B. washing the nails and all surfaces of each finger C. using at least five strokes for cleansing in each area D. dropping hands to side when the wash is complete E. dropping the soapy sponge in the sink to discard F. cleaning beneath each fingernail with a file Answer: A, C, D Rationale: Jewelry cannot be worn during surgical hand asepsis, as these items can contain abundant microorganisms. The appropriate number of strokes for each cleansing area is 10.

Following cleansing, the hands must stay above the waist to avoid the potential for contamination. The other interventions are appropriate steps in surgical hand asepsis.

Question format: Multiple Select Chapter 10: Asepsis Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 139 21. A nurse is caring for four clients. Which client has the highest risk of infection?

A. older male with an enlarged prostate B. toddler with a benign heart murmur C. woman in second trimester of pregnancy D. young woman with a history of scoliosis Answer: A Rationale: An older male with an enlarged prostate can have urine trapped in the bladder leading to urinary tract infections. A toddler with a benign heart murmur is developmental in nature and does not place them at an increased risk of infection. Pregnancy can alter immunity; however, this is not the highest risk. Scoliosis has no impact on infection.

Question format: Multiple Choice Chapter 10: Asepsis Cognitive Level: Analyze

Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 137 22. The client is concerned about "catching the flu." What primary information can the nurse teach the client to best prevent the spread of infection?

A. Hand hygiene B. Good nutrition and getting enough rest C. Avoid crowded areas and people who have the flu D. How to properly wear a mask during flu season Answer: A Rationale: Hand hygiene is the most effective way to control the spread of microorganisms.

While it is true that the client may be less susceptible to illness when well rested, exposure to a pathogen can still result in influenza. Avoiding those with the flu is also appropriate; however, hand washing remains the best answer for prevention. Wearing a mask all season may or may not prevent the flu and is not the most reasonable choice.

Question format: Multiple Choice Chapter 10: Asepsis Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 137 23. A client admitted for fever, crackles in the lungs, and cough asks the nurse, "If they do not know what type of bacteria caused my pneumonia, why are they giving me these antibiotics?" What is the appropriate response by the nurse?

A. "We are giving you broad spectrum antibiotics because they are active for many types of bacteria."

B. "You cannot be admitted to the hospital with pneumonia without receiving some sort of antibiotics."

C. "We give antibiotics to treat the virus that are causing your the pneumonia."

D. "The antibiotics we are giving you will boost your immune system and help fight off whatever pathogen is present."

Answer: A Rationale: Many bacteria are susceptible to broad-spectrum antibiotics and prior to the diagnosis of a specific bacteria, a broad-spectrum antibiotic will be prescribed to help eradicate the present bacteria until a culture result is returned. A client may be admitted to the hospital with pneumonia without receiving antibiotics, although it is likely that an antibiotic will be given at some point during hospitalization. Antibiotics do not boost the immune system and may destroy normal healthy flora. Antibiotics are used to treat bacterial infections, not viral infections; antibiotics do not kill viruses.

Question format: Multiple Choice Chapter 10: Asepsis Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process

Reference: p. 138 24. An older adult client from a long-term care facility is being admitted to the hospital with an infected wound on the left foot. What action should the nurse perform upon admission related to the client's residential occupancy?

A. Insert an indwelling urinary catheter.

B. Perform a nasal swab to identify colonization with methicillin-resistant Staphylococcus aureus (MRSA).

C. Ask the client if any other clients in the facility have infected wounds.

D. Give the client a complete bath to make sure the pathogens from the wound are decreased.

Answer: B Rationale: Hospitals are now obtaining nasal cultures of clients to identify any that have been colonized with MRSA and placing them in contact isolation until the culture reports come back negative. This prevents the potential spread of the pathogen to other clients as well as health care providers. There is no indication that the client requires an indwelling catheter which could be another source of pathogen invasion. Other client wounds would not be a relevant question to ask, and the client is not likely to have the answer. Giving a bath does not reduce the pathogen spread from the infected wound.

Question format: Multiple Choice Chapter 10: Asepsis Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 135 25. The circulating nurse is observing a surgical technician donning a surgical gown. Which action by the technician indicates that the nurse should intervene to maintain sterile donning technique?

A. picking up the gown at the sterile neckline B. holding the gown away from the body and other unsterile objects C. unfolding the gown while avoiding contact with the floor D. inserting an arm within each sleeve while touching the outer surface of the gown Answer: D Rationale: To maintain sterile technique while donning the sterile gown, the gown should be picked up at the sterile neckline to preserve the sterility of the outer gown surface. Holding the gown away from the body and any unsterile surfaces or objects prevents contamination of the sterile gown. Allowing the gown to unfold and not touch the floor in the process will prevent contamination. The nurse should intervene and supply a new gown when observing the surgical technician touching the outer surface of the gown.

Question format: Multiple Choice Chapter 10: Asepsis Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 146

26. A client is having an open cholecystectomy and requires a saline irrigation. What action will reduce the spread of pathogens to the client and other clients?

A. Pour a small amount of solution out of the container prior to pouring it into the sterile basin.

B. After pouring the solution into the sterile basin, recap the solution for use later.

C. Pour the solution below the level of the waist while the surgical technician holds the sterile basin.

D. Have the surgical technician take the bottle of solution and pour directly into the open abdomen.

Answer: A Rationale: When using a sterile solution, the circulating nurse should pour the solution from above the waist level and avoid splashing the solution onto the sterile field and avoid touching any sterile areas within the field. The nurse should pour and discard a small amount of solution to wash away airborne contaminants. The unused solution should be discarded and not used in the future either for the surgical client or any other client.

Question format: Multiple Choice Chapter 10: Asepsis Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 145

Chapter 11 1. A client admitted to the health care facility for minor surgery is given a booklet by the nurse about the health care facility. Which of the following is a purpose of this booklet?

A. to orient the client to the facility B. to provide light reading moments to the client C. to explain the procedure involved in the surgery D. to list the cost of diagnostic tests Answer: A Rationale: The booklet helps to orient the client to the facility. It contains information such as gift shop hours, newspaper deliveries, location of the chapel, and name of the chaplain. The booklet is not for providing light reading moments, and it does not explain the procedures involved in the surgery or list the costs of the various diagnostic tests.

Question format: Multiple Choice Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 164 2. A client has been admitted to the health care facility for less than 24 hours for observation.

The client has a gold ring, watch, reading glasses, and other personal belongings. What care should the nurse take with regard to these objects?

A. Ask the client's relatives to take the belongings home.

B. Keep the client's belongings secured in a locker.

C. Allow the client to wear them unless moving out of the room.

D. Hand over the belongings to the admitting department.

Answer: B Rationale: The nurse should keep the client's belongings secured in a locker. This is what is normally done for clients who are not expected to stay longer than 24 hours in the health care facility. Relatives of clients who may stay for a longer time will be asked to take back the belongings. Health care facilities do not permit clients to wear ornaments or keep their belongings with them during their stay at the facility. The admitting department does not take responsibility for clients' belongings.

Question format: Multiple Choice Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 164 3. A nurse is taking note of a client's belongings by recording their details in the medical record. How should the nurse best describe a client's ring?

A. Describe the color of the ring.

B. Describe the size of the ring.

C. Describe the type of metal and stones in the ring.

D. Describe the weight of the ring.

Answer: C Rationale: Rather than simply indicating that the nurse placed a ring in the safe, it is important to describe the type of metal and stones in the ring. Color, size, and weight of the ring are secondary.

Question format: Multiple Choice Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Reference: p. 164 4. When keeping a client's personal belongings in a locker, the nurse should ensure that the envelope is sealed and signed by which of the following people?

A. client and a relative B. supervisor and nurse C. client and a colleague D. client, supervisor, and nurse Answer: D Rationale: It is best to have a second nurse's, supervisor's, or security person's signature along with the client's signature on the envelope containing secured valuables.

Question format: Multiple Choice Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 164 5. A nurse is caring for a client with a fracture in his hand. How should the nurse assist the client to change his clothes?

A. Roll the client from side to side.

B. Lift the client's head to guide the garment over it.

C. Gather the garment and work it up and over the body.

D. Ask the client to lift his hips to slide clothes up or down.

Answer: C Rationale: The nurse should gather the garment and work it up and over the body. The nurse should not roll the client from side to side or ask the client to lift his head or hips as the client may be weak and tired. The client can sit on the edge of the bed and can help the nurse in the process. The nurse should first release any fasteners such as zippers and buttons and remove the item of clothing in whatever way is most comfortable and least disturbing.

Question format: Multiple Choice Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Remember

Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Caring Reference: p. 165 6. Once a client is admitted and all the admission data are collected, the nurse is expected to develop an initial plan for the client's care. By what point after admission should the nurse develop the plan?

A. no later than 48 hours B. no later than 24 hours C. no later than 72 hours D. no later than 30 hours Answer: B Rationale: Once all admission data are collected, the nurse develops an initial plan for the client's care as soon as possible but no later than 24 hours following admission. The nurse cannot delay developing the initial plan for the client's care beyond 24 hours.

Question format: Multiple Choice Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 166 7. A physician is examining the client during the client's initial physical examination. After collecting all the data, the physician writes R/O in the medical records and suggests some more tests and examinations. What does the physician mean by R/O? A. rule out B. revise order C. record out D. refill out Answer: A Rationale: If the physician is unsure of the actual medical diagnosis, the physician uses the term rule out, or the abbreviation R/O, to indicate that a condition is suspected, but additional diagnostic data must be obtained before confirmation. R/O does not mean revise order, record out, or refill out.

Question format: Multiple Choice Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 166 8. During a round at night, the nurse finds that a client is missing from his room. The client returns early next morning. What procedure is followed by the health care facility with regard to this client?

A. The client needs to sign an "against medical advice" form.

B. The client needs to leave the facility.

C. The client needs to repeat the admission procedure.

D. The client needs to have a discharge form signed by a physician.

Answer: C Rationale: A client who goes missing from a health care facility and returns the next morning needs to repeat the admission procedure and is treated as a new admission. A client who informs the nurse that he is leaving the facility against a physician's advice is officially discharged at midnight after he signs the AMA (against medical advice) form. The client is not asked to leave the facility, nor does the physician sign the client's discharge form.

Question format: Multiple Choice Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 163 9. A nurse is caring for a client who is to be transferred to another unit in the same facility.

Which of the following is a responsibility of the nurse during the transfer of the client?

A. Prepare a discharge plan for the client.

B. Refer the client to home health care.

C. Hand over the client's belongings to the family.

D. Provide a written review of the client's status.

Answer: D Rationale: The nurse should provide a written review of the client's status to the nurse at the transferred unit. The nurse prepares a discharge plan for the client when the client is leaving the health care facility for his home. The nurse may refer the client to home health care at the time of discharge from the facility. The nurse should not hand over the client's belongings to the family during the transfer; instead, the nurse should arrange to transfer the client's belongings to the other unit.

Question format: Multiple Choice Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 171 10. A client admitted to the health care facility is assessed using a minimum data set. How often is the minimum data set repeated for a client?

A. every 15 days B. every month C. every 2 months D. every 3 months Answer: D Rationale: The minimum data set for a client is repeated every 3 months or whenever the client's condition undergoes a change. Problems identified on the MDS are then reflected in

the nursing care plan. The minimum data set for a client is not repeated every 15 days, every month, or every 2 months.

Question format: Multiple Choice Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 175 11. An elderly client with a tracheostomy is to be discharged from a health care facility.

Which of the following extended care facilities should the nurse suggest to the client for continued care until complete recovery?

A. intermediate care facility B. skilled nursing facility C. basic care facility D. extended custodial care Answer: B Rationale: The nurse should suggest a skilled nursing facility for the client for continued care until complete recovery. A nursing home licensed as a skilled nursing facility provides 24hour nursing care under the direction of a registered nurse. An intermediate care facility provides health-related care and services to people who, because of their mental or physical condition, require institutional care but not 24-hour nursing. A basic care facility or an agency that provides extended custodial care provides shelter, food, and laundry services in a group setting where the clients assume much responsibility for their own activities of daily living such as hygiene and dressing, preparing for sleep, and joining others for meals.

Question format: Multiple Choice Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 173 12. A client with medically complicated pregnancy has expressed frustration about the disparities in advice and treatment that the client has received at various sites over the past several months. How can the nurse best ensure that there is continuity in the care that the client receives?

A. Communicate clearly and frequently with other care providers.

B. Ensure that client education is provided whenever possible.

C. Explain the rationale for each assessment and treatment that the client receives.

D. Maximize the number of people who contribute to a client's care.

Answer: A Rationale: Continuity of care can be fostered by providing detailed and timely communication between different individuals who contribute to a client's care. Maximizing the number of people who contribute to a client's care is likely to reduce rather than enhance continuity of care. Client education is beneficial to care, but does not necessarily provide continuity of care.

Question format: Multiple Choice Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 166 13. A client admitted to a health care facility uses a walker for support. What is the nurse's responsibility with regard to the walker when admitting the client to the nursing unit?

A. Provide the client with another walker during their stay at the facility.

B. Mark the client's walker with a large, easily readable label.

C. Keep the walker in a locker until the client is discharged.

D. Ask relatives to bring the walker only at the time of discharge.

Answer: B Rationale: The nurse should mark the client's walker with a large, easily readable label to enable easy identification. The nurse need not provide the client with another walker during the client's stay at the facility, keep the walker in a locker until the client is discharged, or ask relatives to bring the walker only at the time of discharge.

Question format: Multiple Choice Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 164-165 14. A client states that the client is "fed up" with the care that the client has been receiving in the hospital and plans to leave immediately. What procedure is followed with regard to this client?

A. The client needs to demonstrate the ability to care for herself independently.

B. The client needs to be informed that it is illegal to leave against medical advice.

C. The client needs to sign a form releasing the physician and agency from responsibility.

D. The client needs to have a friend or relative accompany the client from the hospital.

Answer: C Rationale: If the client is determined to leave a health care facility, the nurse asks the client to sign a special form. This signed form may release the physician and agency from future responsibility for any complications. The client does not need to demonstrate self-care ability or be accompanied by another person. This action is detrimental but is not illegal.

Question format: Multiple Choice Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 169 15. An elderly client fell 2 days ago on the sidewalk near home and has been admitted to the hospital with a hip fracture. Since the subsequent surgery, the client has been insistent on

wearing their own sweater and cap. The nurse is aware that the client is not cold, has no cognitive deficits, and has participated cooperatively in all aspects of his treatment. What is the most plausible rationale for the client's action?

A. The client wishes to maintain and assert their personal identity.

B. The client is preparing to leave against medical advice.

C. The client is experiencing postoperative delirium.

D. The client is unaware that wearing a gown is the norm in a hospital.

Answer: A Rationale: Admission to a health care facility may temporarily deprive a person of identity.

Because clients are required to wear hospital gowns that tend to look alike, the client may be asserting their individual identity. Based on the client's history, it is less likely that the client is preparing to leave AMA, is delirious, or is unaware of hospital norms.

Question format: Multiple Choice Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Analyze Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 169-170 16. A nurse is aware that clear and accurate communication is necessary whenever clients are transferred or referred. Which situation best demonstrates a referral?

A. A client is moved from a subacute hospital unit to the intensive care unit following a hypertensive crisis.

B. A client is relocated from the orthopedic ward to a rehabilitation ward after recovery from a knee replacement.

C. The nurse arranges for a client with a diabetic foot ulcer to see a podiatrist in a community.

D. The nurse gives report to the hospital's radiology department before a client is sent down for an x-ray.

Answer: C Rationale: A referral is the process of sending someone to another person or agency for special services, such as podiatry. Inpatient diagnostic testing is not considered to be a transfer or referral, since the client will return to the original unit after the procedure.

Movement to another setting in the same agency is a transfer.

Question format: Multiple Choice Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 175 17. An 81-year-old resident of an intermediate care facility has been assessed and the nurse believes that a move to a skilled nursing facility may be justified. What aspect of the resident's health would warrant a move to a skilled nursing facility?

A. The resident has been referred to the Visiting Nurses' Association.

B. The resident's husband of many decades recently died.

C. The resident has been prescribed oral anticoagulants to prevent stroke.

D. The resident has developed pressure ulcers on the backs of the heels.

Answer: D Rationale: Conditions that require active medical treatment, such as pressure ulcers, may warrant a move to a skilled nursing facility. The death of a spouse, involvement of the VNA, or use of anticoagulants would not normally justify this move.

Question format: Multiple Choice Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 173 18. A client has a diagnosis of stage 4 non-small cell lung cancer (NSCLC). The nurse consulted social services for discharge planning regarding appropriate level of care needed after chemotherapy. The client is able to provide partial self-care and will need pain medication. What setting is most appropriate for the client?

A. basic care B. skilled care C. rehabilitation D. extended care Answer: D Rationale: Extended care is a health care agency that provides care for those that do not meet criteria for the hospital. Examples include assisted living, home health care, and hospice agencies. Basic care facility is an agency that provides shelter, food, and laundering services.

Skilled care provides 24-hour skilled nursing care and must be referred by a physician.

Rehabilitation care is for clients who need physical and or occupational therapy on a daily basis.

Question format: Multiple Choice Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 173 19. The client has been assessed by the emergency department physician and nurse. The physician wants the client to be observed overnight. The client refuses and wants to leave.

What are the components of a properly executed against medical advice (AMA) discharge based on this scenario? Select all that apply.

A. capacity to refuse B. all risks disclosed C. medication reconciliation D. security notified E. consent properly documented Answer: A, B, E

Rationale: The parts of a properly executed AMA discharge include the client signing a release form (consent) for proper documentation, determining if the client has the capacity to refuse, and all risks must be disclosed to the client. Medication records do not need to be reconciled, and security does not need to be notified.

Question format: Multiple Select Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Reference: p. 169-170 20. The client is a disabled veteran with bilateral above the knee amputations (AKA). The client frequently has tender, erythemic areas along bilateral incision lines. Which type of facility will provide appropriate care for this client?

A. intermediate B. assisted C. skilled D. extended Answer: A Rationale: Intermediate care provides health-related care, ADLs, and supervision. Assisted care provides basic care, food, shelter, and laundering services. Skilled care provides 24-hour nursing care that also provides rehabilitation services. Extended care is designed for people who do not meet hospitalization criteria.

Question format: Multiple Choice Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 174 21. A nurse is transferring a client with myocardial infarction (MI) to a tertiary care center.

What referral information is most important for the nurse to relay to the receiving nurse so the client receives appropriate follow-up care?

A. vital signs from transferring hospital B. operatory report C. summary of treatment started and current client condition D. medication record Answer: C Rationale: Transferring a client includes preparing a transfer summary and a review of the client's current status. Vital signs, medication record, and operatory report (if applicable) may also be sent as part of the medical record, but a transfer summary including the review of the client's current status is most important.

Question format: Multiple Choice Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Apply

Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 175 22. The nurse is transferring a stroke client to a long-term care facility. The client lived at home prior to the illness, but now is aphasic and unable to provide independent care. Which action made by the nurse demonstrates appropriate completion of the client's medication reconciliation?

A. Copy the medication record and have the client take it home.

B. Read the medication record to the client.

C. Ask the client which medications are currently in use.

D. Verify current medications with the client's physician.

Answer: D Rationale: If the current medication cannot be classified with the client or family, the discrepancy is communicated to the client's physician. The nurse could ask the client about medications, copy the medication record, or read the record to the client, but would be unsure if the client understood, could read, or may not recall which medications are used because of the extent of the stroke.

Question format: Multiple Choice Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 165 23. The nurse is performing a comprehensive assessment of functional capability on a client who lives in a certified nursing home. What federally mandated process is the nurse completing?

A. minimum data set (MDS) B. integrated delivery system C. health maintenance organization (HMO) D. Patient Protection and Affordable Care Act Answer: A Rationale: The MDS is a comprehensive assessment. It includes assessing cognitive function, communication and hearing, vision, physical functioning, strength problems, continence, psychosocial well-being, mood and behavior, activity pursuit, disease diagnosis, health conditions, oral and nutritional status, oral and dental status, skin condition, medication use, and special treatment and procedures. Therefore, the nurse is completing the MDS for the client in the scenario. Integrated delivery system is a network that provides a full range of health care services in a cost-effective manner. HMOs are corporations that provide health care. Patient Protection and the Affordable Care Act is a reform law requiring citizens to get health insurance.

Question format: Multiple Choice Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care

Integrated Process: Communication and Documentation Reference: p. 175 24. The nurse enters the room and the client is grimacing and guarding the abdomen. The client reports, "I have pain." What is the nurse's priority action?

A. taking vital signs B. asking about the last void C. asking about abdominal operations D. assessing the client's level of pain Answer: D Rationale: Assessment is the priority when the client has subjective and objective signs/symptoms. Taking vital signs, measuring output, and asking about abdominal operations would be part of the assessment of the client.

Question format: Multiple Choice Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Communication and Documentation Reference: p. 165 25. The nurse is caring for the same client this week as last week, and the week before.

Continuity of care is the process in which the client and the care team are involved in ongoing health care management. What is the function of continuity of care?

A. protecting against threats to health B. ensuring quality of care over time C. keeping existing problems from getting worse D. targeting populations that have risk factors Answer: B Rationale: Continuity of care is uninterrupted care despite a change in caregivers. The function of continuity of care is to maintain quality of care over time. Continuity of care may help protect against threats to health and keep existing problems from getting worse, but these are not functions of continuity of care. Continuity of care does not target populations that have risk factors.

Question format: Multiple Choice Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 175 26. The client has had an acute exacerbation of multiple sclerosis symptoms. What type of facility will provide the most appropriate care for this client?

A. intermediate B. assisted C. skilled D. extended

Answer: C Rationale: Skilled care provides 24 hour nursing care, which also provides rehabilitation services. Intermediate care provides health-related care, ADLs, and supervision. Assisted care provides basic care, food, shelter, and laundry services. Extended care is designed for people who do not meet hospitalization criteria.

Question format: Multiple Choice Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 173 27. The nurse is admitting a client that asks that jewelry and money be taken and locked away safely. When collecting these items for safe keeping, what is the priority action by the nurse?

A. Put the items in an envelope and give it to the security officer.

B. Make an inventory list and have the nurse, supervisor, and client sign the envelope they are located in.

C. Give the items to another nurse for processing and safe keeping.

D. Inform the client that you will have the neighbor take the valuables home until the client is discharged.

Answer: B Rationale: The nurse should be sure that if possible, the items are inventoried with the client and placed in an envelope. A second nurse, supervisor, or security personel should be present along with their signature. The client should sign the inventory list as well as when any additional item is placed in the envelope. This will help reduce the incidence of accusations of theft or lost property. It would not be appropriate to delegate this task to another nurse to reduce the incidence of loss or theft.

Question format: Multiple Choice Chapter 11: Admission, Discharge, Transfer, and Referrals Cognitive Level: Apply Integrated Process: Communication and Documentation Reference: p. 164

Chapter 12 1. A nurse is caring for a client with subnormal temperature. Which actions should the nurse perform to provide heat to the client's internal organs?

A. raise the room temperature B. provide warm fluids C. apply layers of dry clothing D. warm blankets in a blanket warmer Answer: B Rationale: The nurse should provide the client with warm fluids, because fluids conduct heat to internal organs. Raising the room temperature warms the body surface, not the internal organs, whereas applying layers of dry clothing helps trap body heat next to the skin.

Warming blankets and clothing in a blanket warmer or microwave helps to raise the temperature of woven fabrics and thus body surfaces, but not necessarily the temperature of organs.

Question format: Multiple Choice Chapter 12: Vital Signs Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 197 2. A nurse is caring for a client who has a lack of appetite. What is most likely to influence a client's core body temperature?

A. minerals B. proteins C. fiber D. vitamins Answer: B Rationale: The nurse should recommend an increase in protein in the client's diet, as it has the greatest thermic effect. Food intake, or lack of it, affects thermogenesis, or heat production.

When a person consumes food, the body requires energy to digest, absorb, transport, metabolize, and store nutrients. Thus, both the amount and type of food eaten affect body temperature. Dietary restrictions can contribute to decreased body heat as a result of reduced processing of nutrients. Increased intake of fiber would lead to decreased heat production.

Vitamins and minerals would not help in increasing the client's appetite, nor would they reduce appetite.

Question format: Multiple Choice Chapter 12: Vital Signs Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 185-186

3. A nurse is caring for a newborn. The nurse knows that the body temperature of infants and older adults is prone to fluctuations. Which of these is the most probable cause for fluctuations in the infant's body temperature?

A. large amount of subcutaneous white adipocytes (fat cells) B. increased ability to shiver and perspire C. ability to independently forestall or reverse heat loss or gain D. great surface area relative to mass and very high metabolic rate Answer: D Rationale: Newborns and young infants tend to experience temperature fluctuations because they have a 3 times greater surface area relative to their mass from which heat is lost and a metabolic rate twice that of adults. Infants and older adults have difficulty maintaining normal body temperature because they have limited, not large, amounts of subcutaneous white adipocytes (fat cells that provide heat insulation and cushioning of internal structures).

The ability of both young and old to shiver and perspire also may be inadequate, putting them at risk for abnormally low or high body temperatures. Infants and older adults are less able to independently forestall or reverse heat loss or gain than are other clients.

Question format: Multiple Choice Chapter 12: Vital Signs Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 186 4. The nurse notes that a client's temperature has increased from 102°F (38.9°C) to 103.6 °F (39.8°C). Which is the most appropriate action for the nurse to take in this situation?

A. consult the physician and give antipyretics to the client B. provide physical cooling measures to the client C. suggest that the client rest and take plenty of fluids D. cover the client's head with a cap or a towel Answer: A Rationale: The nurse should consult the physician and give the client antipyretics.

Antipyretics are drugs that reduce fever, such as acetaminophen, and would be helpful in this case when the client's body temperature is between 102°F (38.9°C) and 104°F (40°C).

Physical cooling measures are used when the temperature is between 104°(40°C) and 105.8°F (41°C). When the temperature is below 102°F (38.9°C) and the client does not have any chronic medical condition, the nurse will ask the client to take plenty of fluids and rest and will monitor the fever. The nurse will cover the client's head with a cap or a towel when the client has subnormal temperature, not when the client's temperature is above normal, since this measure helps reduce heat loss.

Question format: Multiple Choice Chapter 12: Vital Signs Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 195

5. A nurse is caring for a client with fever. The nurse is assessing the client's core body temperature. Which of these sites corresponds most closely to the client's core body temperature?

A. ear B. rectum C. axilla D. mouth Answer: A Rationale: The ear, or the tympanic membrane, is the peripheral site that most closely reflects core body temperature. The most practical and convenient temperature assessment sites are the ear, mouth, rectum, and axilla. The rectal site temperature differs by about 0.2°F (0.1° C) from core temperature, and rapid fluctuations in temperature may not be identified for one hour. The oral site generally measures 0.8°F (0.4°C) to 1.0°F (0.5°C) below core temperature. The temperature at the axilla site, or underarm, is generally 1.0°F (0.5°C) lower than that obtained at the oral site and reflects shell rather than core temperature, except in newborns.

Question format: Multiple Choice Chapter 12: Vital Signs Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Reduction of Risk Potential Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 187 6. A nurse has been asked to record a client's body temperature every hour, using a digital thermometer. After recording the temperature, the nurse has to clean the thermometer. Which measure should the nurse follow to clean the thermometer?

A. soak in isopropyl alcohol B. wipe with isopropyl alcohol C. soak in water mixed with alcohol D. wash with soap and water, followed by alcohol Answer: B Rationale: A digital thermometer is cleaned by wiping the thermometer with isopropyl alcohol. Disposable plastic sheaths can be used to cover the probe with each use as an alternative sanitary measure. Glass thermometers, not digital thermometers, are cleaned by soaking in isopropyl alcohol. Digital thermometers are also not cleaned by soaking in water mixed with alcohol.

Question format: Multiple Choice Chapter 12: Vital Signs Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 193

7. A nurse is assessing a client's body temperature. The nurse could obtain an accurate body temperature at the oral site for a client: A. who is 18 months old.

B. who is recovering from oral surgery.

C. who is confused and talkative.

D. with a nasogastric tube in situ.

Answer: D Rationale: The nurse can obtain an accurate body temperature at the oral site for a client with a nasogastric tube in situ. Oral temperature measurement is contraindicated in a client after an oral surgery. The nurse cannot obtain an accurate body temperature at the oral site for clients who are very young and clients who continue to talk during temperature assessment.

Question format: Multiple Choice Chapter 12: Vital Signs Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 188 8. A nurse is caring for a client with low body temperature. Which of these thermometers should be the nurse's first choice to measure the client's body temperature?

A. glass B. tympanic C. electronic D. digital Answer: B Rationale: Cold body temperatures are measured with a tympanic thermometer. Clinical thermometers, such as glass, electronic, or digital, cannot be used, as they have no capacity to measure temperatures in hypothermic ranges, since blood flow in the mouth, rectum, or axilla generally is reduced.

Question format: Multiple Choice Chapter 12: Vital Signs Cognitive Level: Remember Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 187 9. When assessing a client's pulse, the nurse is able to palpate the pulse for some time before losing it upon exerting a little bit more pressure. The pulse is beating at 80 bpm. Which of these should the nurse document as the character of the client's pulse?

A. strong pulse B. thready pulse C. rapid pulse D. bounding pulse Answer: B

Rationale: A feeble, weak, or thready pulse describes a pulse that is difficult to feel or, once felt, is obliterated easily with slight pressure. A normal pulse is described as strong when it can be felt with mild pressure over the artery. A pulse is considered rapid when the beats exceed 100 bpm, which is not the case here. A bounding or full pulse produces a pronounced pulsation that does not easily disappear with pressure. A strong pulse is felt with a very mild pressure over the artery.

Question format: Multiple Choice Chapter 12: Vital Signs Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Reduction of Risk Potential Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 198 10. A nurse is assessing the apical heart rate of a healthy person. In order to hear the heartbeats loud and clear, where should the nurse place the stethoscope?

A. slightly below the left nipple B. over the sternum at the midpoint between the nipples C. 4 in (10 cm) below the left clavicle D. on the center of the rib cage Answer: A Rationale: The heartbeats are best heard or felt in a healthy client slightly below the left nipple, in line with the middle of the clavicle. The nurse does not place the stethoscope on the center of the rib cage, between the nipples, or 4 in (10 cm) below the left clavicle to accurately assess the apical heart rate of a healthy person.

Question format: Multiple Choice Chapter 12: Vital Signs Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 198-199 11. A nurse needs to measure the blood pressure of a client with an electronic manometer.

Which advantage does an electronic manometer provide over an aneroid manometer or mercury manometer?

A. ability to read gauge from any direction B. accurate for practitioners with hearing loss C. inexpensive, depending on quality D. need for readjustment is eliminated Answer: B Rationale: An electronic manometer is excellent for persons with hearing loss because it eliminates the need for a stethoscope. However, an electronic manometer requires a calibration check and readjustment every 6 months, unlike a mercury manometer, which does not require readjustment. An electronic manometer is expensive, depending on quality when

compared to an aneroid manometer. A nurse can read the gauge of an aneroid manometer, not an electronic manometer, from any direction.

Question format: Multiple Choice Chapter 12: Vital Signs Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Reduction of Risk Potential Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 201 12. A nurse is assessing a client's vital signs at a health care facility. The nurse observes that the client is sweating profusely. What area of the brain causes a client to sweat?

A. medulla B. hypothalamus C. cerebellum D. pituitary gland Answer: B Rationale: The anterior hypothalamus promotes heat loss through vasodilation and sweating.

In humans, the hypothalamus acts as the center for temperature regulation. The posterior hypothalamus promotes heat conservation and heat production. The medulla, which contains the respiratory center in the brain, controls ventilation, whereas the pituitary gland secretes hormones for a variety of regulatory functions. The cerebellum regulates balance.

Question format: Multiple Choice Chapter 12: Vital Signs Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 185 13. A nurse has assessed a client's blood pressure near the beginning of a shift and obtained a systolic blood pressure of 138 mmHg and a diastolic blood pressure of 71 mmHg. The systolic blood pressure: A. represents the client's blood pressure between heartbeats.

B. represents peak pressure in the client's arteries.

C. peaks when the client's heart is filling with blood.

D. corresponds directly to the client's heart rate.

Answer: B Rationale: Systolic blood pressure is the pressure within the arterial system when the heart contracts. Diastolic blood pressure is the pressure when the heart relaxes and fills with blood.

Both are reflections of pressure in the arterial vessels, not the veins. SBP does not correspond directly with heart rate, though heart rate is one factor among many that influence blood pressure.

Question format: Multiple Choice Chapter 12: Vital Signs Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort

Integrated Process: Nursing Process Reference: p. 204-205 14. A nurse has responded to a client's call light and found the client gasping and saying, "I can't get my breath." The nurse applied supplementary oxygen and repositioned the client, which led to the relief of the client's symptoms. When documenting this event, the nurse should note that the client was experiencing: A. bradypnea.

B. orthopnea.

C. Cheyne–Stokes breathing.

D. dyspnea.

Answer: D Rationale: Dyspnea is difficult or labored breathing. Bradypnea is an abnormally slow breathing rate, and orthopnea is breathing facilitated by sitting up or standing. Cheyne–Stokes respiration refers to an ominous breathing pattern in which the depth of respirations gradually increases, followed by a gradual decrease, and then a period when breathing stops briefly before resuming again.

Question format: Multiple Choice Chapter 12: Vital Signs Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 200 15. The nurse is performing client education with a 58-year-old client who is being treated for hypertension. What lifestyle modification should the nurse recommend in order to help the client control their blood pressure?

A. reduce sodium intake B. ensure adequate amounts of sleep C. increase intake of soluble fiber D. perform regular range-of-motion exercises Answer: A Rationale: Reducing intake of sodium has been shown to significantly reduce blood pressure.

Exercise is also important, but range-of-motion (i.e., flexibility) exercises are less effective than aerobic and weight-bearing exercise. Sleep and fiber intake are important aspects of health but do not have major effects on blood pressure.

Question format: Multiple Choice Chapter 12: Vital Signs Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 207 16. A client has an axillary temperature of 102.6 F (39.2°C). Which clinical manifestations would the nurse anticipate? Select all that apply.

A. respiratory rate 30/min

B. headache C. hunger D. cold, clammy skin E. red or flushed skin Answer: A, B, E Rationale: The following are clinical signs associated with a fever: pinkish or red skin (skin that is warm to the touch), headache, and above-normal pulse or respiratory rates. Clients who are febrile may or may not be hungry. Clients who are febrile have warm, not cold and clammy, skin.

Question format: Multiple Select Chapter 12: Vital Signs Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 187 17. A client presents to the Emergency Department with a temperature of 100.6F (38.1°C) and BP of 108/60 mmHg. What intervention does the nurse anticipate providing?

A. acetaminophen B. oral fluids C. ibuprofen D. cooling blanket Answer: B Rationale: A fever is considered an important body defense. Therefore, as long as the fever remains below 102°F (38.9°C) and the person does not have a chronic medical condition, fluids or rest may be all that is necessary. Therefore, it is not necessary, at this time, to provide acetaminophen, ibuprofen, or a cooling blanket.

Question format: Multiple Choice Chapter 12: Vital Signs Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 196 18. A client reports feeling "different" than earlier in the day. When would the nurse anticipate assessing vital signs?

A. once per day B. according to medical orders C. immediately D. every 4 hours Answer: C Rationale: Vitals signs should be assessed whenever there is a change in the client condition.

Because the client reports feeling "different," this indicates an immediate vital sign

assessment. Therefore, it is not appropriate to assess vital signs once per day, according to medical orders, or every 4 hours.

Question format: Multiple Choice Chapter 12: Vital Signs Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 184 19. The client is self-monitoring blood pressure at home and reports that every reading is 150/90 mmHg. What is the priority nursing intervention?

A. ask the client to demonstrate self-blood pressure assessment B. provide the client with a larger blood pressure cuff C. recommend lower sodium in the client's diet D. report readings to primary care provider Answer: A Rationale: While all of these interventions would be appropriate if the client is hypertensive, it is important to assess whether the client is measuring their BP correctly before assuming that hypertension is present. It would be very rare to have a BP of the exact same measurement with every assessment. Therefore, providing the client with a larger blood pressure cuff, recommending lower sodium in the client's diet, and reporting the readings to the primary care provider are not priority actions at this time.

Question format: Multiple Choice Chapter 12: Vital Signs Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 207 20. The nurse assesses that a client is shivering. Which intervention is most appropriate to prevent further stress on the body?

A. applying a cooling blanket B. applying a blanket C. raising the room temperature D. providing warm fluids Answer: B Rationale: Covering prevents heat loss, and the shivering will not stop until the hypothalamus readjusts to a higher set point. A cooling blanket will make the shivering worse, because it will make the client feel cold. Raising the room temperature warms the body surface and is only appropriate for subnormal temperatures. Warm fluids conduct heat to internal organs and this client is febrile; the goal is to reduce to heat.

Question format: Multiple Choice Chapter 12: Vital Signs Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process

Reference: p. 196 21. A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client?

A. "Dizziness when you change position can occur when fluid volume in the body is decreased."

B. "Dizziness can occur due to changes in the hospital environment."

C. "Dizziness can occur when baroreceptors overreact to the changes in BP." D. "Dizziness is caused by very low blood pressure when you lie down."

Answer: A Rationale: Dehydration is a cause for orthostatic hypotension, which causes a temporary drop in BP when the client rises from a reclining position. Dizziness is not associated with environmental changes. Dizziness or changes in orthostatic BP occurs when baroreceptors do not respond quickly enough to restore adequate circulation to the brain. Dizziness may be caused by low blood pressure. However, the client is dizzy with ambulation not when lying down.

Question format: Multiple Choice Chapter 12: Vital Signs Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 207-208 22. A nurse is caring for a client with orthostatic hypotension. Which nursing interventions are appropriate to decrease the risk of falls? Select all that apply.

A. encourage oral fluid intake B. encourage slow movement from the bed to the chair C. encourage intake of protein-rich foods D. encourage removal of compression stockings E. encourage the client to use the call light prior to getting out of bed F. encourage the use of the call light for help to the bathroom Answer: A, B, E, F Rationale: The nurse can reduce the fall risk associated with postural hypotension by restoring adequate hydration, making sure the client stays seated and moves slowly from sitting to standing, and encouraging the client to use the call light for help when ambulating.

Protein-rich foods have no bearing on postural hypotension. Compression stockings should be applied to reduce the pooling of blood in the extremities when the client is standing.

Question format: Multiple Select Chapter 12: Vital Signs Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 207-208 23. The nurse is assessing a client's blood pressure and is having difficulty hearing Korotkoff sounds. What is the most appropriate nursing action?

A. ask the client to stand while assessing the BP B. ask the client to make a fist after cuff inflation C. wait a few minutes and then try to assess the BP D. contact the primary care provider for further instruction Answer: B Rationale: Korotkoff sounds result from the vibrations of blood within the arterial wall and changes in blood flow. These sounds occur in phases and correlate with blood pressure measurement. They can be increased by asking the client to make a fist after cuff inflation.

Standing for BP assessment is not appropriate, as blood volume changes. Waiting to assess the BP could be problematic if the client is experiencing low BP or an acute change.

Contacting the PCP is not appropriate, as there is further nursing action that can be taken.

Question format: Multiple Choice Chapter 12: Vital Signs Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 204 24. When assessing an adult client's pulse at 125 beats/min, which step would the nurse take first to determine intervention?

A. Determine cause B. Evaluate pulse rate quality C. Evaluate blood pressure D. Assess for history of heart disease Answer: A Rationale: Following the assessment of the pulse of 125 beats/min, the nurse would first determine the cause for the high rate. This will lead to determining an appropriate intervention. Anxiety, medications, caffeine, and other stimulants and disorders can cause tachycardia. The nurse will also need to check the quality of the pulse to determine regularity, but this would be included in assessing for causes and interventions. The nurse also will check the client's blood pressure, temperature, and pain level because an increase in any of these can be correlated with increased pulse, but again not what should be done first. While assessing a history of heart disease is important, this is not a first step alone and should be included in a full interview upon client intake and triage.

Question format: Multiple Choice Chapter 12: Vital Signs Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 197 25. A nurse needs to count a client's heart rate. For which reason would the nurse assess the client's apical pulse?

A. The blood pressure is elevated.

B. A baseline pulse rate is needed.

C. The carotid pulse is bounding.

D. The radial pulse is difficult to obtain.

Answer: D Rationale: Auscultation of the apical pulse provides the most accurate assessment of the pulse rate and is the preferred site when the peripheral pulses are difficult to assess or the pulse rhythm is irregular. While this is an excellent method to determine baseline pulse, it is not the reason for using the apical pulse method. Elevated blood pressure and bounding carotid pulse are not reasons to obtain an apical pulse.

Question format: Multiple Choice Chapter 12: Vital Signs Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 198 26. A nurse received the following information about clients during shift report. Which client would the nurse assess first?

A. An adult client with a blood pressure of 120/60 mm Hg who verbalizes anxiety about today's scheduled tests.

B. An adult postoperative client with a temperature 99.9°F (37.7°C) who is due for a surgical dressing change.

C. An adult client with a respiratory rate 26 breaths/min who slept in an upright position during the night.

D. An adult client with a heart rate of 88 beats/min and a respiratory rate of 20 breaths/min.

Answer: C Rationale: The normal adult respiratory rate is 14 to 20 breaths/min. A respiratory rate of 26 breaths/min is abnormal and requires additional nursing assessment. In addition, sleeping in an upright position could indicate that the client is having trouble breathing. Blood pressure of 120/60 mmHg, heart rate of 88 beats/min, and temperature of 99.9°F (37.7°C) are within normal parameters for adults. Anxiety about testing requires client education and is not an urgent matter. A scheduled surgical dressing change is not an urgent matter.

Question format: Multiple Choice Chapter 12: Vital Signs Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 200 27. A parent of a 9-year-old child states to the nurse, "I have not noticed any fever yet but my child describes feeling achy and not well." Which phase of the fever does the nurse identify the child may be experiencing?

A. prodromal B. invasion C. stationary D. resolution Answer: A

Rationale: Often, the child will experience symptoms prior to the fever surfacing, which is called the prodromal phase and includes the nonspecific symptoms that occur before the body temperature rises. The onset or invasion phase indicates an elevation in body temperature, as well as symptoms related to the fever such as shivering. The stationary phase is when the fever is sustained. The final phase is the resolution or defervescence phase when the temperature abates and returns to the child's baseline temperature.

Question format: Multiple Choice Chapter 12: Vital Signs Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 194 28. The nurse is assessing the pulse of a young adult who is training for a triathlon competition. The pulse rate is 48 beats/min. What education should the nurse provide to the client?

A. A medication regimen to bring the heart rate up will be required.

B. The client will have to be very careful when changing positions since the heart rate is low.

C. The heart rate is within normal limits due to the exercise regimen the client is following.

D. There is a conduction abnormality that is most likely congenital since the client is young.

Answer: C Rationale: The client who is young and athletic is exhibiting a training effect where the heart rate is lower than the normal 60 to 100 beats/min. The heart becomes more efficient at supplying body cells with sufficient oxygenated blood with fewer beats. There is no indication that the client should be placed on medications to increase the heart rate since this is most likely a normal state for the client.

Question format: Multiple Choice Chapter 12: Vital Signs Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 197

Chapter 13 1. A nurse is performing a physical assessment for a client using the palpation technique.

What is one of the purposes of using this technique?

A. to assess the sounds from the heart, lungs, and abdomen B. to determine the density of structures underlying the skin's surface C. to check the skin temperature and moisture D. to observe specific parts for normal or abnormal characteristics Answer: C Rationale: The nurse uses the palpation technique to obtain information about the skin temperature and moisture. The percussion technique is used to determine the location, size, and density of the underlying structure as per the quality of sound produced by the tapping.

The auscultation technique is used to listen to the sound of the heart, lungs, and abdomen.

The inspection technique is used to observe specific parts for normal or abnormal characteristics.

Question format: Multiple Choice Chapter 13: Physical Assessment Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 227 2. A nurse is caring for a client reporting lower back pain. The nurse uses the body systems approach to assess the client. What are the advantages of using this approach for data collection?

A. It makes problems more easily identifiable, as findings tend to be clustered.

B. It prevents overlooking certain aspects of data collection.

C. It reduces the number of position changes required of the client.

D. It takes less time, as the nurse is not constantly moving around the client.

Answer: A Rationale: The body systems approach makes problems more easily identifiable, as findings tend to be clustered. The head-to-toe approach to client assessment prevents the nurse from overlooking certain aspects of data collection, reduces the number of position changes required of the client, and takes less time.

Question format: Multiple Choice Chapter 13: Physical Assessment Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 230 3. A nurse is conducting a mental status assessment for a client admitted to a health care facility following a motor vehicle accident. Under which conditions would the nurse need to collect more objective assessment data?

A. when the client is able to think clearly B. when the client pays attention to the nurse's instruction C. when the client has taken an overdose of drugs D. when the client is able to recall previous events Answer: C Rationale: The nurse would need to collect more objective assessment data if the client had taken an overdose of drugs. However, objective assessment data would not be required if the client is able to think clearly, can pay attention to the nurse's instruction, and can recall past incidents.

Question format: Multiple Choice Chapter 13: Physical Assessment Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 231 4. A nurse is assessing a client who seems to have developed a hearing impairment after working at a construction site for a few months. The nurse is using the Weber test to assess the client's hearing acuity. What is the purpose of the Weber test?

A. It compares air versus bone conduction of sound.

B. It measures hearing acuity at various sound frequencies.

C. It tests air conduction of sound in the tested ear.

D. It determines the equality or disparity of bone-conducted sound.

Answer: D Rationale: The Weber test helps to determine the equality or disparity of bone-conducted sound. The Rinne test compares the air versus bone conduction of sound as well as testing air conduction of sound in the tested ear. Audiometry measures hearing acuity at different sound frequencies.

Question format: Multiple Choice Chapter 13: Physical Assessment Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 232-233 5. During the physical assessment of a 12-year-old child who sustained injuries in a bicycle fall, the nurse observes an area near the elbow that has been rubbed away by friction. How should the nurse document this finding?

A. wound B. abrasion C. laceration D. scar Answer: B

Rationale: The finding should be documented as an abrasion. A wound is a break in the skin.

A laceration is a torn, jagged wound. A scar is a mark left by the healing of a wound or lesion.

Question format: Multiple Choice Chapter 13: Physical Assessment Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 235 6. A nurse is assessing the skin of a client who had been on a hiking trip and developed a number of inflamed red patches on his hands and face as an allergic reaction. How should the nurse document this finding?

A. erythema B. pallor C. flushed D. ecchymosis Answer: A Rationale: The nurse should document this finding as erythema. If the skin appears pale, it is documented as pallor. The skin of a client with fever and hypertension appears pink and is documented as flushed. The presence of purple patches on the skin, due to trauma to soft tissue, is documented as ecchymosis.

Question format: Multiple Choice Chapter 13: Physical Assessment Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 235 7. When assessing lung sounds, the nurse applies the stethoscope's chest piece to the client's upper back but avoids placing it over the scapulae or ribs. How does this intervention help in the assessment?

A. It helps to clear the air passages and open the alveoli.

B. It reduces sound from air turbulence that would distort findings.

C. It ensures that friction with hair does not distort assessment findings.

D. It facilitates hearing sounds in the upper and lower lobes.

Answer: D Rationale: The nurse should avoid placing the chest piece over the scapulae or ribs when applying the chest piece to the upper back in order to facilitate hearing sounds in the upper and lower lobes. If crackles and gurgles are audible during the assessment, the nurse may ask the client to cough or breathe deeply, as doing so helps to clear the air passages and open the alveoli. The nurse instructs the client to breathe in and out through an open mouth, deeply but slowly, in order to reduce the sound from air turbulence and to prevent hyperventilation. The nurse listens for one complete ventilation (inspiration and expiration) at each area auscultated to ensure that characteristics during each phase of ventilation are heard. Avoiding placement

over the ribs and scapulae does not address the possibility that friction with hair will distort the findings.

Question format: Multiple Choice Chapter 13: Physical Assessment Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 240 8. During the physical assessment of a client, the nurse observes flat, round, colored, nonpalpable areas on the face. How should the nurse document this finding?

A. papules B. macules C. pustules D. nodules Answer: B Rationale: The nurse should document this finding as macules. A papule is an elevated, palpable solid. A pustule is an elevated, raised border filled with pus. A nodule is an elevated, solid mass, deeper and firmer than a papule.

Question format: Multiple Choice Chapter 13: Physical Assessment Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 236 9. The nurse is performing a physical assessment of an older adult female client. The nurse documents scoliosis as part of the spinal assessment. What is scoliosis?

A. a gentle concave and convex curve of the spine B. an exaggerated lumbar curve of the spine C. an increased curve in the thoracic area D. a pronounced lateral curvature of the spine Answer: D Rationale: Scoliosis is a pronounced lateral curvature of the spine. The normal spine appears in midline with gentle concave and convex curves when viewed from the side. Lordosis is a condition in which the natural lumbar curve of the spine is exaggerated. Kyphosis causes an increased curve in the thoracic area.

Question format: Multiple Choice Chapter 13: Physical Assessment Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 237 10. A nurse is assessing the lung sounds of a client with respiratory disorders. What is a normal bronchial sound?

A. shorter on inspiration than expiration, with a pause between them B. longer on inspiration than expiration, with no noticeable pause C. equal in length during inspiration and expiration, separated by a brief pause D. equal in length during inspiration and expiration, with no noticeable pause Answer: A Rationale: Normal bronchial sounds are shorter on inspiration than expiration, with a pause between them. Vesicular sounds are longer on inspiration than expiration, with no noticeable pause. Tracheal sounds are equal in length during inspiration and expiration, separated by a brief pause. Bronchovesicular sounds are equal in length during inspiration and expiration, with no noticeable pause.

Question format: Multiple Choice Chapter 13: Physical Assessment Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 239 11. A nurse is listening to the lung sounds of a severely dehydrated client. The nurse hears sounds that are described as grating or leathery. What type of adventitious sounds are these?

A. crackles B. rubs C. wheezes D. gurgles Answer: B Rationale: Rubs are grating or leathery sounds caused by two dry, pleural surfaces moving over each other. Crackles are intermittent, high-pitched, popping sounds, which are heard in distant areas of the lungs during inspiration. Wheezes are whistling or squeaking sounds caused by air moving through a narrow passage, which can be heard throughout the chest during expiration or inspiration. Gurgles are low-pitched, continuous, bubbling adventitious sounds, which are prominent during expiration and are heard in larger airways.

Question format: Multiple Choice Chapter 13: Physical Assessment Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 239 12. A nurse is examining a client with cirrhosis of the liver for edema. The nurse notes that the indentation remains for several seconds and the skin swelling is obvious on inspection.

How should the nurse quantify the severity of the finding?

A. 1+ pitting edema B. 2+ pitting edema C. 3+ pitting edema D. 5+ brawny edema Answer: C

Rationale: The nurse should quantify the finding as 3+ pitting edema since the indentation remains for several seconds and a skin swelling is obvious by general inspection. In case of 1+ pitting edema, there is a slight indentation (2 mm) with normal contours and the associated interstitial fluid volume is 30% above normal. 2+ pitting edema indicates that the indentation is deeper after pressing (4 mm) and lasts longer than a 1+, with fairly normal contours. In the case of 5+ brawny edema, there is no pitting; tissue palpates as firm or hard, and the skin surface appears shiny, warm, and moist.

Question format: Multiple Choice Chapter 13: Physical Assessment Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 242 13. A nurse is assessing the bowel sounds of a client with abdominal pain. The nurse would describe the client's bowel sounds as hypoactive: A. if sounds occur 30 to 34 times a minute.

B. if sounds occur frequently.

C. if sounds occur after a long interval.

D. if no sound is heard for 3 to 5 minutes.

Answer: C Rationale: Bowel sounds can be described as hypoactive if sounds occur after a long interval.

Bowel sounds can be described as normal if they occur 5 to 34 times within a minute, hyperactive if they occur frequently, and absent if no sound is heard for 3 to 5 minutes.

Question format: Multiple Choice Chapter 13: Physical Assessment Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 242-243 14. The nurse is examining the anus of a client with a history of chronic constipation. What is indicative of chronic constipation?

A. presence of rectal fissures B. area is more pigmented than adjacent skin C. area is moist and hairless D. presence of signs of trauma Answer: A Rationale: The presence of rectal fissures is indicative of chronic constipation. The anal area is normally more pigmented than adjacent skin, moist, and hairless. Trauma also may be present if the client has participated in anal intercourse.

Question format: Multiple Choice Chapter 13: Physical Assessment Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care

Integrated Process: Nursing Process Reference: p. 245 15. When assessing the sensory skin perception of an older adult client, the nurse strokes the skin with a cotton ball at various places on both sides of the body. What information does the nurse obtain from this assessment?

A. ability to identify sharp and dull touch B. ability to identify fine touch C. ability to differentiate temperature change D. ability to sense vibrations Answer: B Rationale: Stroking the client's skin with a cotton ball at various places on both sides of the body helps to determine the client's ability to identify fine touch. The nurse uses both the pointed and curved ends of a safety pin to determine if the client can discriminate between sharp and dull touch. The nurse touches the client with warm and cold containers to assess the client's ability to identify differences in temperature. The client's ability to sense vibrations is determined by striking a tuning fork and placing the stem on bony areas, such as the wrist or along the shin.

Question format: Multiple Choice Chapter 13: Physical Assessment Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 243 16. A nurse greets a new client and asks the client to accompany the nurse to an appropriate location for assessment. During this initial interaction with the client, the nurse is able to ascertain the client's: A. judgment and insight.

B. health maintenance.

C. level of consciousness.

D. coping skills.

Answer: C Rationale: The client's response to the nurse's introduction and direction gives useful information about the client's level of consciousness. During this brief interaction, the nurse would be less able to determine the client's judgment, insight, health maintenance, or copings skills, though some elements of these may be evident.

Question format: Multiple Choice Chapter 13: Physical Assessment Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 229 17. A nurse has explained the purpose and procedure for a comprehensive assessment and has directed the client to an appropriate position on the bed. The nurse has also provided a drape

with which to cover the client. What is the primary purpose of providing a drape during the assessment process?

A. to keep the client warm while body parts are exposed B. to provide a barrier during palpation and percussion to ensure objective interpretation of findings C. to provide the client with modesty during the assessment D. to keep the client's skin dry during the assessment Answer: C Rationale: A drape provides more modesty than warmth. A drape is not used in order to keep the client's skin dry, and it would be incorrect to palpate or percuss through the drape.

Question format: Multiple Choice Chapter 13: Physical Assessment Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 229-230 18. A nurse is teaching a client how to perform a self breast exam. Place the following examination techniques in the order they should be performed.

A. a mirror, look at both breasts with the arms relaxed at the side, with the hands pressing on the hips, and with the hands elevated above the head looking for dimpling in the skin or retraction of either nipple.

B. a pillow under the shoulder on the side where the first breast will be examined.

C. of the fingers in an up-and-down pattern from the underarm and across the breast from the clavicle to the base of the ribs to feel for changes in any area of the breast.

D. axilla of each arm to determine if there are any lumps or hard or thickened areas.

E. between the thumb and index finger to determine if there is any clear or bloody discharge.

Answer: A, B, C, D, E Rationale: The nurse should teach the client to stand in front of a mirror, look at both breasts with the arms relaxed at the side, with the hands pressing on the hips, and with the hands elevated above the head looking for dimpling in the skin or retraction of either nipple. Then, lie down and place a pillow under the shoulder on the side where the first breast will be examined. Use the flat surface of the fingers in an up-and-down pattern from the underarm and across the breast from the clavicle to the base of the ribs to feel for changes in any area of the breast. Then, feel upward toward the axilla of each arm to determine if there are any lumps or hard or thickened areas. Squeeze the nipple gently between the thumb and index finger to determine if there is any clear or bloody discharge.

Question format: Drag and Drop Chapter 13: Physical Assessment Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 238

19. A nurse is preparing for a skin care certification course and needs to correctly identify various lesions that may be seen on the skin. Which definitions are correct? Select all that apply.

A. A cyst is an elevated, circumscribed lesion filled with fluid.

B. A papule is an elevated palpable solid mass.

C. A vesicle is an elevated, round lesion filled with serum.

D. A nodule is an elevated solid mass.

E. A wheal is an elevated round, solid mass under the skin.

Answer: B, C, D Rationale: A papule is an elevated palpable solid mass. Vesicles are elevated, round, and filled with serum. Nodules are elevated solid masses. A cyst is an encapsulated, round, fluidfilled, or solid mass beneath the skin. A wheal is an elevated mass with an irregular border and no free fluid.

Question format: Multiple Select Chapter 13: Physical Assessment Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 236 20. A nurse is completing vital signs on a client who was brought into the emergency department by ambulance. Which assessment findings require immediate attention? Select all that apply.

A. Temperature is 101.4° F (38.6 C.).

B. Blood pressure is 130/78 mmHg. C. Respiratory rate is 16 bpm.

D. Heart rate is 130 beats per minute.

E. Oxygen saturation is 90%.

F. Pain is 8 on scale of 1 to 10.

Answer: A, D, E, F Rationale: Findings that would require immediate attention include high or low temperature, high or low blood pressure, high or low number of respirations per minute, high or low heart rate, oxygen saturation less than or equal to 92%, or pain greater than 4 on a scale of 1 to 10.

Therefore, the temperature, blood pressure, heart rate, oxygen saturation, and pain require immediate intervention, whereas the blood pressure and respiratory rate do not.

Question format: Multiple Select Chapter 13: Physical Assessment Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 226 21. A nurse is completing an assessment on a client with no history of nutrition-related problems. Which activity should the nurse complete as part of an initial nutritional screening?

A. calorie count B. vital signs

C. height and weight D. abdominal girth Answer: C Rationale: The nurse documents the client's weight and height because these measurements provide more reliable data than a subjective assessment of body size, asking the client to provide the information, or measuring abdominal girth.

Question format: Multiple Choice Chapter 13: Physical Assessment Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 229 22. During assessment, the nurse observes that the client has a yellow discoloration on the skin. What is the nurse's appropriate action?

A. Auscultate the lungs and abdomen.

B. Inspect the sclera and mucous membranes.

C. Observe for cyanosis or ecchymosis.

D. Assess oxygen saturation level.

Answer: B Rationale: Jaundice is exhibited by a yellow color on the skin, sclera, and mucous membranes by bilirubin. Auscultation of the lungs and abdomen will not provide information about jaundice. Cyanosis is a bluish coloring of the skin, often related to poor circulation or oxygenation. Ecchymosis is a type of skin discoloration that results from blood underneath the skin's surface, such as in the case of a bruise.

Question format: Multiple Choice Chapter 13: Physical Assessment Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 235 23. A nurse is assessing a client and observes jaundice on the skin and hard palate on the sclera bilaterally. What is the appropriate action of the nurse?

A. Percuss the spleen for tenderness.

B. Palpate the liver for enlargement.

C. Assess the client's temperature.

D. Auscultate the lungs for crackles.

Answer: B Rationale: Jaundice is exhibited by a yellow color, which indicates rising amounts of bilirubin in the blood due to liver disease, kidney disease, or destruction of red blood cells.

Palpation of the liver will provide information on possible liver disease. Percussing the spleen, assessing temperature, and auscultating the lungs will not provide information on the cause of the jaundice.

Question format: Multiple Choice Chapter 13: Physical Assessment Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 235 24. A nurse is completing a vision exam with the Snellen eye chart and records the client's vision as 20/30 or 6/9. The client asks the nurse, "What does that mean?" How should the nurse respond?

A. "Your vision is perfect; you can read the entire chart, and you do not need glasses."

B. "You are able to read at 20 ft (6 m) what a person with normal vision can read at 30 ft (9 m)."

C. "Your vision in your right eye is slightly different than that of your left eye."

D. "Your vision is better than average; you can read from 30 ft (9 m) what a person with normal vision can read from 20 ft (6 m)."

Answer: B Rationale: The first number indicates the distance the person is standing from the chart; the second number gives the distance at which a normal eye can see it. It is not appropriate or correct to tell the client that vision is perfect, that one eye is better than the other, or that vision is better than average.

Question format: Multiple Choice Chapter 13: Physical Assessment Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 231 25. A nurse is performing the diagnostic positions test to observe extraocular movements on a client during a routine eye exam. Which of the findings would the nurse expect to observe?

A. convergence of the eyes B. coordinated movement of both eyes C. nystagmus in all positions D. constriction of both pupils Answer: B Rationale: A normal response for the diagnostic positions test is parallel tracking or coordinated movement of both eyes. Eye movement that is not parallel indicates weakness of an extraocular muscle or dysfunction of the cranial nerve innervating it and may suggest other neurological pathology. During the diagnostics positions test, the eyes should not converge; there should be no nystagmus in any position, and the pupils should remain round and equal in size.

Question format: Multiple Choice Chapter 13: Physical Assessment Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process

Reference: p. 231 26. Which technique should the nurse use to assess the pupillary light reflex on a client?

A. Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction.

B. Ask the client to follow the penlight in six directions and observe for bilateral pupil constriction.

C. Have the client focus on a distant object, then ask the client to look at the penlight being held about 4 cm from the nose and observe for pupil constriction.

D. Use an ophthalmoscope to focus light on the sclera and observe for a reflection on each eye.

Answer: A Rationale: To test the pupillary light reflex, the nurse should advance a light in from the temple and note the direct and consensual pupillary constriction. The diagnostic positions test and test for accommodation will not provide the pupillary reflex information.

Question format: Multiple Choice Chapter 13: Physical Assessment Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 232 27. A nurse is auscultating the lungs of a client during a physical exam. The nurse notes lowpitched, soft breath sounds over the posterior middle lobes with intermittent, high-pitched, popping sounds in the posterior lower lobes, primarily during inspiration. What is the nurse's correct interpretation of these findings?

A. Crackles are audible in the posterior bases bilaterally, and they are abnormal.

B. Bronchovesicular breath sounds are audible in the posterior lobes.

C. Pleural friction rub is occurring in the posterior middle lower lobes.

D. Gurgling is occurring in the lower posterior lobes, indicating that the client needs to cough.

Answer: A Rationale: Crackles, also called rales, are intermittent, high-pitched, popping sounds heard in distant areas of the lungs, primarily during inspiration. They are attributed to the opening of partially collapsed alveoli (terminal air sacs) or the movement of air over minute amounts of fluid in the periphery of the lungs during deep inspiration. The other options are not the correct interpretations.

Question format: Multiple Choice Chapter 13: Physical Assessment Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 239

Chapter 14 1. A client visits the health clinic with a report of slight chest discomfort. Which test should the client undergo in order to determine the cause of the discomfort?

A. radionuclide imaging B. radiography C. endoscopy D. ultrasonography Answer: B Rationale: The client should undergo radiography in order to determine the cause of the chest pain. The physician should advise the client to have a chest x-ray done to learn the exact cause of the discomfort. Radionuclide imaging is used to visualize areas within organs and tissues that are not possible with a standard x-rays. Endoscopy is used for the visual examination of internal structures in the human body. Ultrasonography is a form of soft tissue examination that uses sound waves in ranges beyond human hearing. Radionuclide imaging, endoscopy, and ultrasonography are not used to examine chest problems.

Question format: Multiple Choice Chapter 14: Special Examinations and Tests Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 256 2. A client has been admitted to a health care facility with high fever and severe body pain.

When assessing the client's temperature every 30 minutes, the nurse notes that the client's condition has not been improving. The nurse has been directed by the physician to prepare the client for a blood test to check for viral infection. What is the first step the nurse should take before collecting the blood sample for the test?

A. The nurse should inform the laboratory assistant before taking the sample.

B. The nurse should inform the laboratory of the test before taking the sample.

C. The nurse should explain to the client the purpose and need for the test.

D. The nurse should ready the examination area before taking the sample.

Answer: C Rationale: Before conducting the test, the nurse should explain to the client the need for the test and obtain the client's consent for the test. Once the client agrees to the test, the nurse prepares the client, obtains equipment and supplies, and then proceeds with the test.

Informing the laboratory assistant or the laboratory is not a primary task.

Question format: Multiple Choice Chapter 14: Special Examinations and Tests Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 251

3. A physician directs the nurse to get written consent from a client who has to undergo multiple laboratory and diagnostic examinations. As a rule, the written consent must confirm that the client understands the tests and will undergo them voluntarily. What other information should form a part of the client's written consent?

A. date of conducting the test B. time of conducting the test C. time taken to conduct the test D. capacity of the sample taken Answer: D Rationale: In addition to the client's confirmation of comprehension and voluntariness, the written consent should also contain information about the capacity of the sample taken. A signed consent form is required before the performance of examinations or tests. To be legally sound, consent must contain three elements: capacity, comprehension, and voluntariness. Details such as date, time of conducting, or time taken for conducting the test are not primary information and therefore are not as important as the client's consent.

Question format: Multiple Choice Chapter 14: Special Examinations and Tests Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 251 4. A client is admitted to a health care facility with a report of nausea, headache, and abdominal pain. The physician suggests that the client undergo a series of tests to determine the exact cause of the client's condition. After the physician leaves, the client appears restless and anxious. What should the nurse do in this case?

A. The nurse must repeat the need for the test to the client.

B. The nurse should call the physician again.

C. The nurse should call the laboratory assistant.

D. The nurse should provide medication to calm the client.

Answer: A Rationale: The nurse should repeat the need for the test to the client. Although physicians are responsible for giving clients sufficient information to obtain their informed consent, not all clients fully understand the information. Some are too anxious to process details, whereas others feel too insecure to ask questions, and still others express additional concerns after the physician has left. Often the nurse must repeat, simplify, clarify, or expand the original explanation. Calling the physician or the laboratory assistant or providing medication will not help the client in this case.

Question format: Multiple Choice Chapter 14: Special Examinations and Tests Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 251

5. A diabetic client visits the health care facility for a blood glucose test. How should the nurse ensure that the test is accurate?

A. by modifying the diet to get the correct glucose level B. by withholding food and fluids to check the glucose level C. by asking the client to eat just an hour before taking the test D. by asking the client to fast for 12 hours before taking the test Answer: B Rationale: To check the glucose level of a diabetic client, the nurse should ensure that the client is withholding food and fluids to ensure the test's accuracy. Modifying the diet or asking the client to fast for 12 hours before the test is not a good method of ensuring test accuracy in this case. In addition, eating just before the test will also not ensure accurate results.

Question format: Multiple Choice Chapter 14: Special Examinations and Tests Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 262 6. A 30-year-old client is scheduled for a blood glucose test. The nurse helps the client to change into an examination gown, applies an identification bracelet, and takes the client's vital signs. What else should the nurse ensure before the client undergoes the test?

A. that the client drinks ample water before the test B. that the client provides written consent before the test C. that the client empties his bladder just before the test D. that the client eats enough food an hour before the test Answer: B Rationale: Before the client undergoes the test, the nurse should ensure that a written consent has been taken from the client. For testing blood glucose, the client need not empty his bladder or drink ample water. It may not be necessary for the client to eat before the test.

Question format: Multiple Choice Chapter 14: Special Examinations and Tests Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 251 7. A physician has ordered an ECG for a client with a report of chest pain. Apart from obtaining the equipment needed to conduct the test, what important task should the nurse perform before the test is administered?

A. The nurse should cover the examination table with a sheet.

B. The nurse should keep a lined receptacle nearby for disposal of soiled items.

C. The nurse should cover the examination table with a paper dispensed from a roll.

D. The nurse should check the instruments that require electric power.

Answer: D

Rationale: The ECG is done using equipment that requires an electrical connection. Before the physician arrives, the most important task the nurse should perform is to check the instruments that require electric power, batteries, or lights so that they can replace any nonfunctioning equipment. The test is done by the client's bedside so there is no need to cover the examination table with a sheet or with paper dispensed from a roll. Although the nurse will need a lined receptacle to dispose of soiled items, it is not the most important task that the nurse needs to perform before the ECG. Question format: Multiple Choice Chapter 14: Special Examinations and Tests Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 252 8. A client with an infection on the genitalia visits a health care facility. In order to inspect the infection, the nurse assists the client into a reclining position with knees bent. What type of position has the nurse placed the client in for inspection?

A. dorsal recumbent position B. lithotomy position C. Sims' position D. knee–chest position Answer: A Rationale: The nurse has placed the client in the dorsal recumbent position to inspect the infection on the client's genitals. The dorsal recumbent position is a reclining position with the knees bent, hips rotated outward, and feet flat. It is commonly used for various examinations. The lithotomy position is a reclining position with the feet in metal supports called stirrups. It is used to facilitate gynecologic (female reproductive) examinations. In the Sims' position, the client lies on the left side with the chest leaning forward, the right knee bent toward the head, the right arm forward, and the left arm extended behind the body. This position provides access to the anus and rectum when the client requires instillation of enema solution. In the knee–chest position, also called the genupectoral position, the client rests on the knees and chest. The client turns the head, which is supported on a small pillow, to one side. This position is assumed for gynecologic or rectal examination.

Question format: Multiple Choice Chapter 14: Special Examinations and Tests Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 253 9. A pregnant client visits a health care facility for her scheduled checkup before her delivery date. The physician needs to check the client's reproductive organs for any kind of irritation or discomfort. The physician asks the nurse to help the client into the lithotomy position.

Which statement describes the lithotomy position?

A. The client should be in a reclining position with the knees bent, hips rotated outward, and feet flat.

B. The client should be in a reclining position with the feet in stirrups.

C. The client should lie on the left side with the chest leaning forward and the right knee bent toward the head.

D. The client should rest on the knees and chest, supported by a small pillow, with the head to one side.

Answer: B Rationale: The lithotomy position is a reclining position with the feet in metal supports called stirrups. It is used to facilitate gynecologic (female reproductive), urologic, and sometimes rectal examinations. The dorsal recumbent position is a reclining position with the knees bent, hips rotated outward, and feet flat. In the Sims' position, the client lies on the left side with the chest leaning forward and the right knee bent toward the head. In the knee–chest position, the client rests on the knees and chest. He or she turns the head, which is supported on a small pillow, to one side.

Question format: Multiple Choice Chapter 14: Special Examinations and Tests Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 253 10. A nurse is caring for an arthritic client who needs administration of an enema. Which position should the nurse ask the client to maintain to administer the enema solution?

A. dorsal recumbent position B. lithotomy position C. Sims' position D. knee–chest position Answer: C Rationale: The nurse should assist the client into the Sims' position to instill enema solution.

The nurse would use the dorsal recumbent position for vaginal examination, whereas the lithotomy position could be used for internal pelvic examination in female clients. The knee– chest position should be used for prostate gland examination.

Question format: Multiple Choice Chapter 14: Special Examinations and Tests Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 253 11. The physician needs to assess the vaginal area of a pregnant client. The nurse assists the client into a position where the client rests on her knees and chest. The client's head is supported on a small pillow, to one side. Which position has the nurse helped the client to assume?

A. dorsal recumbent position B. lithotomy position C. Sims' position D. genupectoral position

Answer: D Rationale: The nurse has helped the client to assume the knee–chest position, also known as the genupectoral position. This position is assumed for gynecologic or rectal examination. In the Sims' position, the client lies on the left side with the chest leaning forward, the right knee bent toward the head, the right arm forward, and the left arm extended behind the body. The dorsal recumbent position is a reclining position with the knees bent, hips rotated outward, and feet flat. The lithotomy position is a reclining position with the feet in metal supports called stirrups.

Question format: Multiple Choice Chapter 14: Special Examinations and Tests Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 253 12. Before performing a blood glucose test using a glucometer, the nurse asks the client if he has ever had his blood glucose level measured using a glucometer before. Which statement is a possible reason for the nurse to ask this question?

A. provides basis for teaching B. aids in reducing blood glucose levels C. determines if test strips are appropriate for use D. ensures that the test is accurate Answer: A Rationale: Asking if the client has had his blood glucose levels measured with a glucometer before provides the nurse with a basis for teaching. The nurse should check the expiry date on the container of test strips to determine if the test strips are appropriate for use. The nurse should discard unused test strips stored in a vial 4 months after they are opened to ensure accuracy.

Question format: Multiple Choice Chapter 14: Special Examinations and Tests Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 262-263 13. A nurse is assisting a physician in examining a client. During the procedure, the nurse hands the physician one instrument at a time. What other method can the nurse use to assist the physician promptly and properly?

A. Place all the necessary instruments near the physician.

B. Place the instruments near the physician's dominant hand.

C. Check with the physician before handing over any instrument.

D. Keep all of the necessary instruments behind the physician.

Answer: B Rationale: The nurse should place the instruments and equipment on the side of the physician's dominant hand, if possible. If not, the nurse should anticipate what will be needed

during the procedure and hand the physician one item at a time. Placing all of the instruments near the physician or behind the physician will not help the physician perform the procedure promptly. Also, it is not a good practice to ask the physician every time the nurse needs to hand over an instrument. The nurse must be familiar with the examination equipment and the order of its use.

Question format: Multiple Choice Chapter 14: Special Examinations and Tests Cognitive Level: Understand Client Needs: Psychosocial Integrity Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 251-252 14. To ensure an accurate analysis, the nurse collects a specimen in an appropriate container, labels the container with correct information, attaches the proper laboratory request form, and ensures that the specimen does not decompose before it is examined. What is the last step that the nurse must take to ensure the accurate analysis of the specimen?

A. Deliver the specimen to the laboratory as soon as possible.

B. Deliver the specimen to the physician for final verification.

C. Keep the specimen refrigerated before sending it for analysis.

D. Shift the specimen to some other container to keep it fresh.

Answer: A Rationale: The final step the nurse should take to ensure accurate analysis of the specimen is to make sure it is delivered to the laboratory as soon as possible. To ensure accurate analysis, the nurse does the following: collects the specimen in an appropriate container, labels the specimen container with correct information, attaches the proper laboratory request form, ensures that the specimen does not decompose before it can be examined, and delivers the specimen to the laboratory as soon as possible. The specimen is not taken to the physician for final verification, nor is it refrigerated or shifted to another container before being sent for analysis.

Question format: Multiple Choice Chapter 14: Special Examinations and Tests Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 255 15. A client with a bacterial infection has been asked to give a sample for culture. The culture will go through the gram staining process to identify the type of bacteria present. The staining process results in the bacteria changing color to red. Which type of bacteria is present?

A. gram-positive bacteria B. gram-negative bacteria C. gram-staining bacteria D. streptococci bacteria Answer: B

Rationale: The client has gram-negative bacteria. The gram-staining process helps to determine whether bacteria are gram-positive or gram-negative. Gram-positive bacteria appear violet after staining. Those that repel the violet dye but appear red, the color of a counter stain, are called gram-negative bacteria. Streptococci are round, grow in chains, and are gram-positive.

Question format: Multiple Choice Chapter 14: Special Examinations and Tests Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 262 16. A physician directs the nurse to get written consent from a client who has to undergo multiple laboratory and diagnostic examinations. As a rule, the written consent must confirm that the client understands the tests and will undergo them voluntarily. What else is necessary to make the client's written consent valid?

A. The client must have preauthorization from an insurance carrier.

B. The client must be older than 21 years.

C. The client must have explored alternatives.

D. The client must be able to make rational decisions.

Answer: D Rationale: To be legally sound, consent must contain three elements: capacity, comprehension, and voluntariness. Preauthorization is not necessary. The client should understand the relative risks and benefits, but it is not necessary to actively explore alternatives. Individuals younger than 21 years are able to provide legal consent.

Question format: Multiple Choice Chapter 14: Special Examinations and Tests Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 251 17. A nurse who provides care on a busy medical unit works with clients who typically undergo numerous tests and examinations during their time in the hospital. Which is an example of a client who has had a laboratory test?

A. a client whose blood sample will be checked for the presence of bacteria B. a client whose trachea and bronchi have been examined with an endoscope C. a client who has had a chest x-ray to determine whether the client aspirated some food D. a client who reported sudden fatigue and was ordered to have an electrocardiogram Answer: A Rationale: A diagnostic examination is a procedure that involves physical inspection of body structures and evidence of their functions. Examples include ECGs, endoscopy, and radiography. A laboratory test is a procedure that involves the examination of body fluids or specimens, including examination for bacteria.

Question format: Multiple Choice Chapter 14: Special Examinations and Tests

Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 260 18. A nurse has notified an 80-year-old client's physician that the client's laboratory values indicating kidney function have fallen below the minimum reference range. The nurse should be aware of what consideration that affects the interpretation of laboratory values in elderly clients?

A. Levels of most laboratory values in older adults are more stable than those of younger people.

B. Laboratory values are considered an unreliable indicator of health status in older adults.

C. Laboratory values must be measured after a period of fasting in order to be considered accurate in older adults.

D. An older adult may have "normal" laboratory values that would be considered abnormal in a younger adult.

Answer: D Rationale: The norms of some lab values change somewhat with age. An abnormality in a younger person may be normal for an older person or vice versa. Not all lab values require fasting. Laboratory values of older clients have the potential to be volatile and unstable.

Question format: Multiple Choice Chapter 14: Special Examinations and Tests Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 251 19. The nurse is caring for an older adult client. Which gerontologic consideration regarding laboratory values does the nurse anticipate?

A. Laboratory values change minimally or not at all.

B. Chronic conditions do not impact laboratory results.

C. Vitamins and minerals do not affect laboratory values.

D. Baseline laboratory values are not needed for comparison.

Answer: A Rationale: Laboratory results change minimally, or not at all, with age. Chronic conditions, and vitamin and mineral consumption, can alter laboratory results, so all prescription, overthe-counter, and herbal substances that the client takes should be reviewed. Baseline laboratory values should be used as a basis for comparison with current findings.

Question format: Multiple Choice Chapter 14: Special Examinations and Tests Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Reference: p. 251 20. The nurse is preparing a client to undergo an endoscopy. What is the appropriate nursing responsibility? Select all that apply.

A. preparing the examination room B. giving information to obtain informed consent C. obtaining equipment and supplies for the procedure D. ensuring the client has an identification bracelet present E. reporting any incorrect test preparations promptly before the procedure Answer: A, C, D, E Rationale: The nurse will prepare the examination room, including obtaining and setting up equipment and supplies associated with the procedure. The nurse will ensure that the client has an appropriate identification bracelet present, and will report any incorrect test preparations in case the procedure needs to be delayed or rescheduled. The nurse may witness the consent, but the provider will give information to the client concerning the endoscopy, including the risks of the procedure.

Question format: Multiple Select Chapter 14: Special Examinations and Tests Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Reference: p. 251 21. The nurse is preparing a client who is having a routine prostate examination. Into what position will the nurse place the client?

A. supine B. lithotomy C. knee-chest D. modified standing Answer: D Rationale: Modified standing position is used for examining the prostate gland in men.

Supine, lithotomy, and knee-chest positions are used for other types of examinations and procedures.

Question format: Multiple Choice Chapter 14: Special Examinations and Tests Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 253 22. The nurse is caring for a client who is undergoing an internal diagnostic gynecologic test.

The client expresses to the nurse, "I am afraid that this will hurt." What is the appropriate nursing response?

A. Offer to stay with the client during the test.

B. Request that unlicensed assistive personnel (UAP) sit with the client.

C. Reassure the client that the diagnostic test will not hurt.

D. Tell the healthcare provider to cancel the test because the client is afraid.

Answer: A

Rationale: The nurse should undertake comfort measures when the nurse assesses that the client is physically or emotionally uncomfortable. Offering to stay with the client provides a reassuring presence. Having a nurse's aide sit with the client is not as helpful as having the nurse stay with the client, because the client has reached out emotionally to the nurse. The nurse should not give false hope that a diagnostic test will not be painful even if the test is not known to cause discomfort; this does not fully address the client's fear. It is not necessary to have the test canceled when the nurse can implement comfort measures to assist the client through the diagnostic test.

Question format: Multiple Choice Chapter 14: Special Examinations and Tests Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 253 23. The nurse is preparing a female client of childbearing age for a radiographic examination.

What is the priority nursing intervention?

A. Assess vital signs before the procedure.

B. Direct the client to remove metal jewelry.

C. Shield the client with a lead apron.

D. Encourage fluids to flush the contrast medium.

Answer: C Rationale: As the priority, the nurse must act to protect the client of childbearing age in case of pregnancy. A lead apron will be used to protect a fetus and/or female reproductive organs.

The nurse will also assess vital signs, have the client remove metal jewelry or clothing, and educate the client to drink fluids after the procedure if a contrast medium was used. However, these are not the priority actions.

Question format: Multiple Choice Chapter 14: Special Examinations and Tests Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 256-257 24. The nurse is caring for a client who just underwent endoscopy. Which assessment finding requires immediate nursing intervention?

A. temperature 98.9ºF B. oxygen saturation 87% C. gag reflex has returned D. drowsy, but easy to arouse Answer: B Rationale: An oxygen saturation of 87% is abnormal and requires immediate nursing intervention. A client who has just undergone endoscopy should be fever-free, and have a returning gag reflex within several hours of the procedure. The client may be a bit drowsy, but should be easy to arouse.

Question format: Multiple Choice

Chapter 14: Special Examinations and Tests Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 258 25. A client who will undergo radionuclide imaging asks the nurse if she can be sexually active after the procedure. What is the appropriate nursing response?

A. "No, sexual activity is not recommended."

B. "You can immediately be sexually active following this procedure."

C. "You are radioactive for a brief period of time, usually less than 24 hours."

D. "Use an effective contraception for the short period, during which radiation continues to be present in your system."

Answer: D Rationale: A client who has undergone radionuclide imaging should be taught to abstain from intercourse or use an effective contraceptive method for the short period, during which radiation continues to be present. Energy released from this procedure is harmful to rapidly growing cells of an infant or fetus. Telling the client "no" does not address the question fully and is nontherapeutic; although the client may choose to be sexually active, and will be radioactive for a brief period of time, further teaching is needed to fully address the client's question.

Question format: Multiple Choice Chapter 14: Special Examinations and Tests Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 258 26. The nurse is teaching a client who will undergo electroencephalography (EEG) testing tomorrow. Which client statement reflects that teaching has been effective?

A. "I will shampoo my hair tomorrow morning before testing."

B. "Because I'm having a sleep-deprived EEG, I must stay awake after 3 AM." C. "I should not drink coffee, tea, or caffeinated beverages for 4 hours before the procedure."

D. "My health care provider will tell me whether I should withhold my scheduled medications before the procedure."

Answer: D Rationale: A client who will undergo EEG testing should not shampoo the evening before the procedure to facilitate firm attachment of electrodes. Coffee, tea, and caffeinated beverages should not be consumed after midnight prior to testing. Those having sleep-deprived EEGs must stay awake after midnight. The health care provider will tell the client whether to withhold scheduled medications before the procedure, especially medications that affect neurologic activity.

Question format: Multiple Choice Chapter 14: Special Examinations and Tests Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance

Integrated Process: Teaching/Learning Reference: p. 259 27. The nurse is teaching a client about proper use of a glucometer. Which teaching will the nurse provide?

A. All glucometers operate exactly the same way.

B. Only clients with Type I diabetes need to utilize glucometers.

C. Since capillary blood is obtained, bloodborne pathogen risks do not exist.

D. Blood glucose levels are obtained 30 minutes before eating, and before bedtime.

Answer: D Rationale: Blood glucose levels are obtained 30 minutes before eating, and before bedtime to determine the lowest levels of glucose and adjust food consumption or administer insulin (for clients with Type I diabetes). There are several types of glucometers available. Clients with Type I or Type II diabetes benefit from blood glucose monitoring. Any blood may contain bloodborne pathogens.

Question format: Multiple Choice Chapter 14: Special Examinations and Tests Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 263

Chapter 15 1. A nurse is caring for a visually impaired client. How should the nurse manage the feeding for this client?

A. Request a full-liquid, mechanically soft diet for the client.

B. Develop a rapport with the client and promote continuity of care.

C. Inform the client about what kind of food is being offered with each mouthful.

D. Ensure that one portion of food is swallowed before offering another.

Answer: C Rationale: It is important to inform visually impaired clients about the food in each mouthful, to help them eat properly. The importance of developing a rapport with the client is not specific to visually impaired clients. It is necessary to provide liquid or soft diets to clients who have missing teeth or have had recent oral surgery. When caring for clients who have difficulty chewing and swallowing food, the nurse must determine that the client has swallowed one portion of food before offering another.

Question format: Multiple Choice Chapter 15: Nutrition Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 296 2. A nurse is caring for a client who reports chest pain. Which test levels would indicate whether the client is at risk for cardiac and vascular disease?

A. unsaturated fats B. cholesterol C. balanced proteins D. calories in each food intake Answer: B Rationale: Health care providers test cholesterol and lipoprotein levels to assess clients' risks for cardiac and vascular disease. Measuring levels of protein, calories, or unsaturated fats will not help to assess if a client is at risk for cardiac and vascular disease.

Question format: Multiple Choice Chapter 15: Nutrition Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 281 3. A nurse is caring for a client with a history of cardiac and vascular disease. Which fats should the nurse allow in the client's diet for his condition?

A. unsaturated fats B. trans fats C. saturated fats

D. hydrogenated fats Answer: A Rationale: Unsaturated fat is a healthier form of fat than saturated fat, because it contains less hydrogen, and therefore can be included in the client's diet. Saturated fats are lipids that contain as much hydrogen as their molecular structure can hold and are generally solid. Most saturated fats are found in animal sources, such as the marbled fat in meat. Saturated fats are responsible for cardiac and vascular diseases. Trans fats are unsaturated fats that have been hydrogenated, a process in which hydrogen is added to the fat. Consumption of trans fats, saturated fats, and hydrogenated fats increases the risk of coronary heart disease.

Question format: Multiple Choice Chapter 15: Nutrition Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 281 4. A nurse is caring for a pregnant client who is a strict vegetarian. What type of diet should the client follow?

A. rich in fat B. rich in sodium C. rich in protein D. lower in calcium and iron Answer: C Rationale: A vegetarian diet can be inadequate in protein, the need for which increases during pregnancy. Therefore, a diet rich in plant proteins will help. Calcium and iron intake needs to be higher in a vegan diet and also during pregnancy. Diets high in sodium or fat are not needed during pregnancy.

Question format: Multiple Choice Chapter 15: Nutrition Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Client Needs Pn: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 286 5. A nurse notes that vomiting occurs with great force in a client with gastrointestinal bleeding. How should the nurse document this condition?

A. retching B. regurgitation C. projectile vomiting D. emesis Answer: C Rationale: The nurse should document this condition as projectile vomiting. Projectile vomiting occurs with great force and is associated with increased pressure in the brain and

gastrointestinal bleeding. The act of vomiting without producing vomitus is known as retching, whereas regurgitation is the process of bringing stomach contents to the throat and mouth without the effort of vomiting. Emesis is the substance that is vomited.

Question format: Multiple Choice Chapter 15: Nutrition Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 292 6. A client visits a health care facility reporting loss of appetite following a prolonged illness.

How should the nurse document the client's condition?

A. emaciation B. cachexia C. anorexia D. nausea Answer: C Rationale: The nurse should document the loss of appetite following prolonged illness as anorexia. Emaciation is excessive leanness. Cachexia is the general wasting away of body tissue. Nausea usually precedes vomiting and is associated with gastrointestinal sensations.

Question format: Multiple Choice Chapter 15: Nutrition Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 291 7. A nurse is caring for a client who is reporting nausea. Which is a sign of nausea?

A. dizziness and perspiration B. impaired swallowing C. slow pulse rate D. emotional distress Answer: A Rationale: Nausea usually precedes vomiting. It is associated with dizziness and perspiration.

Impaired swallowing is associated with clients who have dysphagia and not typically nausea.

Slow pulse rate is not a symptom of nausea. Emotional distress may or may not be related to the client's condition.

Question format: Multiple Choice Chapter 15: Nutrition Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 292 8. A nurse is caring for a client, who is a vegan, at the health care facility. What must be included in the client's diet?

A. vitamin A B. vitamin B C. vitamin C D. vitamin D Answer: D Rationale: A vegan diet should include vitamin D. Vegans rely exclusively on plant sources for protein, which may be inadequate in providing vitamin D. Vitamins A, B, and C are found in vegan diets to a certain extent. A vegan diet should be skillfully planned to provide complete protein, calcium, riboflavin, vitamins B12 and D, and iron.

Question format: Multiple Choice Chapter 15: Nutrition Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 286 9. The nurse is caring for a client with dysphagia. What is a primary responsibility of the nurse with regard to feeding the client?

A. Inform the client about the kind of food being offered with each mouthful.

B. Keep oral and pharyngeal suctioning equipment at the client's bedside.

C. Develop a rapport with the client and promote continuity of care.

D. Reinforce the desired response by praising, touching, and smiling at the client.

Answer: B Rationale: Clients with dysphagia have difficulty chewing and swallowing food. The nurse should ensure that oral and pharyngeal suctioning equipment is kept at the client's bedside.

Informing the client about the kind of food being offered with each mouthful is done for visually impaired clients. For a client with dementia, the nurse should develop a rapport with the client, promote continuity of care, and reinforce a desired response by praising, touching, and smiling at the client.

Question format: Multiple Choice Chapter 15: Nutrition Cognitive Level: Apply Client Needs Pn: Safe, Effective Care Environment: Safety and Infection Control Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 294 10. When feeding a client, the nurse arranges for finger foods to be prepared for the client.

The nurse is caring for what type of client?

A. visually impaired client B. client with a tracheostomy C. client with dysphagia D. older adult client Answer: A

Rationale: When feeding a visually impaired client, the nurse arranges for finger foods to be prepared for the client. When feeding a client with a tracheostomy, the nurse should ensure that the cuff is inflated. Eliminating distractions and removing wrappers or containers are good measures to take for older adult clients. Clients with dysphagia should be served a liquid or semi-liquid diet.

Question format: Multiple Choice Chapter 15: Nutrition Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 296 11. The physician has prescribed routine exercises for an elderly client to perform on a daily basis. What is a benefit of exercising for an elderly client?

A. Exercise helps in increasing appetite.

B. Exercise helps in reducing neurological disorders.

C. Exercise helps in reducing joint pain.

D. Exercise helps in the digestion of food.

Answer: A Rationale: Exercise may lead to increased appetite in elderly clients. Elderly clients may become more sedentary and should be taught the benefits of exercise within their abilities.

Sitting exercises may be indicated if balance or functional abilities decline. Exercise will not help in digestion, nor will it reduce neurological disorders or joint pain.

Question format: Multiple Choice Chapter 15: Nutrition Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Client Needs Pn: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 284 12. A nurse is caring for a client with complaints of xerostomia. The nurse should encourage the client to: A. drink adequate noncaffeinated and nonalcoholic beverages.

B. take nutrient-dense foods or to combine plant-based proteins.

C. take protein-based liquid supplements.

D. get dental care and practice dental hygiene daily.

Answer: A Rationale: Xerostomia, or dry mouth, is a common problem in older adults that often results from medications or the effects of disease. It interferes with chewing, swallowing, and enjoyment of meals. The nurse should encourage clients with xerostomia to drink adequate noncaffeinated and nonalcoholic beverages or to chew sugarless gum to promote salivation.

Including proteins or protein-based liquids in the diet will not help to care for xerostomia.

Dental care is necessary but is not specifically beneficial for xerostomia.

Question format: Multiple Choice Chapter 15: Nutrition

Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 296 13. A nurse is caring for a client with Alzheimer disease. What action should the nurse perform when feeding a client with Alzheimer disease?

A. Guide the hand with the food to the client's mouth if necessary.

B. Use the analogy of a clock when describing the location of food.

C. Describe the benefits of nutrition in simple terms.

D. Have the client watch television during meals.

Answer: A Rationale: When feeding a client with Alzheimer disease, the nurse should guide the hand with the food to the client's mouth. The nurse should use the analogy of a clock to describe the location of food when feeding a visually impaired client. The nurse should ensure that there are no distractions such as television when feeding the client with Alzheimer disease, as this will enable the client to concentrate on having the meal. Descriptions of the benefits of nutrition are not likely to benefit the client with impaired cognition.

Question format: Multiple Choice Chapter 15: Nutrition Cognitive Level: Analyze Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 296 14. A client reports a nauseous feeling during a physical assessment. What is the first thing the nurse should do to distract the client's attention from this unpleasant sensation?

A. Encourage the client to move and be active.

B. Make negative comments about the food.

C. Check whether an annoying odor is contributing to nausea.

D. Assist the client in taking deep breaths.

Answer: D Rationale: In order to distract the client's attention from his nausea, the nurse should assist the client in taking deep breaths. The nurse should limit the client's movement and activities, as movement may shift gastrointestinal structures and their contents, intensifying the stimulation of the vomiting center. The nurse should avoid making negative comments about the food, as verbal comments create visual images that may cause psychogenic stimulation of the vomiting center. Having distracted the client with deep breathing, the nurse may check if a simple annoying odor or sight is contributing to nausea, as offensive sensory data can stimulate the vomiting center in the brain.

Question format: Multiple Choice Chapter 15: Nutrition Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 292

15. When providing for a client's nutritional needs, the nurse arranges for finger foods to be prepared for the client. The nurse is likely caring for what type of client?

A. a client with dementia B. a client with a tracheostomy C. a client with anorexia D. a client with diabetes Answer: A Rationale: When feeding a client who has dementia, the nurse may arrange for finger foods to be prepared for the client in order to foster participation. This action is not specifically indicated in the care of clients with diabetes, anorexia, or a tracheostomy.

Question format: Multiple Choice Chapter 15: Nutrition Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 296 16. A 78-year-old woman who lives alone has been admitted to the hospital with a diagnosis of failure to thrive. Assessment reveals that the woman has malnutrition, a problem related to her lack of finances, transportation, and a social support network. Malnutrition is defined as: A. a body mass index that is in the lowest third of the population.

B. a condition related to a chronic lack of sufficient nutrients.

C. excessive consumption of fats and sugars accompanied by inadequate vegetables.

D. a condition in which the body is unable to adequately metabolize nutrients.

Answer: B Rationale: Malnutrition is a condition resulting from a lack of proper nutrients in the diet. A low BMI is not necessarily indicative of malnutrition and people with malnutrition are not lacking the ability to metabolize their food. An unbalanced diet can lead to malnutrition, but this is not the definition of the problem.

Question format: Multiple Choice Chapter 15: Nutrition Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 279 17. A postsurgical client is recovering in hospital following bowel surgery. The client's family is eager to bring the client some of the client's favorite foods to make the client's stay more pleasant and has asked the nurse whether this practice is acceptable. The client is currently on a clear liquid diet, which will be changed as the client tolerates intake. What food item is currently acceptable within this hospital diet?

A. black tea B. skim milk C. cream of chicken soup D. tomato juice

Answer: A Rationale: Milk, cream soup, and tomato juice are acceptable in a full liquid diet but not in a clear liquid diet. Tea is an acceptable component of a clear liquid diet.

Question format: Multiple Choice Chapter 15: Nutrition Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 293 18. The nurse is caring for four clients. Which does the nurse identify as highest risk for development of cardiometabolic syndrome?

A. 23-year old with ankle fracture and anxiety B. 36-year old with obesity who smokes C. 44-year old with hypertension and undernutrition D. 59-year old with lupus who exercises three times weekly Answer: B Rationale: Cardiometabolic syndrome is a cluster of modifiable risk factors that can potentially lead to cardiovascular diseases and type 2 diabetes mellitus, if uncontrolled. The syndrome includes combinations of obesity (particularly abdominal fat), hypertension, elevated blood glucose (insulin resistance), abnormal blood fat levels, smoking, and inflammatory markers. The patient with two of these modifiable factors – insulin resistance, and who smokes – is at highest risk for developing cardiometabolic syndrome. The other clients are not at as high of a risk for cardiometabolic syndrome.

Question format: Multiple Choice Chapter 15: Nutrition Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 281 19. Which client(s), at risk for poor nutritional intake, would benefit from nutritional counseling from the nurse? Select all that apply.

A. pregnant teenagers B. children of middle-income parents C. people with substance use problems D. older adults living on fixed incomes E. individuals who prefer to purchase food from local farmers Answer: A, C, D Rationale: Examples of those in the United States at risk for an inadequate nutritional intake include older adults who are socially isolated or living on fixed income, homeless people, children of economically deprived parents, pregnant teenagers, people with substance use problems, and clients with eating disorders. Children of middle-income parents and individuals who prefer to purchase food from local farmers are not necessarily at risk.

Question format: Multiple Select Chapter 15: Nutrition Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Reference: p. 279 20. A client with diabetes mellitus must monitor carbohydrate intake. Which client statement requires nursing intervention?

A. "I like to eat eggs for breakfast."

B. "I'll monitor my intake of fruit juice."

C. "My favorite drink is coffee with sugar."

D. "At every meal, I eat a small portion of lean meat."

Answer: C Rationale: Foods containing added sugar as a major ingredient tend to supply calories but few, if any, other nutrients. A client monitoring carbohydrate intake should be mindful of the intake of extra sugar. The other answer choices are appropriate for a client diagnosed with diabetes mellitus who is monitoring carbohydrate intake.

Question format: Multiple Choice Chapter 15: Nutrition Cognitive Level: Analyze Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 289 21. When teaching a client, which laboratory tests will the nurse identify that assess cardiac and vascular disease risk? Select all that apply.

A. cholesterol level B. lipoprotein level C. triglyceride level D. BUN E. creatinine F. CBC with differential Answer: A, B, C Rationale: Healthcare providers use cholesterol, lipoprotein, and triglyceride levels to assess clients' risks for cardiac and vascular diseases. BUN and creatinine are reflective of kidney function. A CBC with differential does not give insight to cardiac and vascular disease risk.

Question format: Multiple Select Chapter 15: Nutrition Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 281 22. Which client's laboratory data indicates the need to include interventions in the nursing plan of care specifically aimed at cardiac and vascular disease?

A. total serum cholesterol of 200 mg/dL; HDL 50 mg/100 mg/dL

B. total serum cholesterol of 150 mg/dL; HDL 43 mg/100 mg/dL C. total serum cholesterol of 180 mg/dL; HDL 32 mg/100 mg/dL D. total serum cholesterol of 190 mg/dL; HDL 60 mg/100 mg/dL Answer: C Rationale: Cardiac risk can be estimated by dividing the total serum cholesterol level, which should be less than 200 mg/dL, by the HDL level. A result greater than 5 suggests that a client has a potential for coronary artery disease. Therefore, the client with total serum cholesterol of 180 mg/dL and HDL of 32 mg/100 me/dL requires interventions. The other findings do not require intervention.

Question format: Multiple Choice Chapter 15: Nutrition Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 281 23. A client is discussing vitamin and mineral intake with the nurse. Which client statement requires nursing intervention?

A. "I understand that my body does not manufacture vitamins."

B. "Eating raw vegetables is good, because cooking may alter the vitamin content in food."

C. "The milk I drink has calcium added to it."

D. "Taking megadoses of vitamins will help me increase muscle mass quickly."

Answer: D Rationale: Consuming megadoses of vitamins and minerals can be dangerous, so this statement requires intervention. The nurse should find out the type and dose of vitamins that the client takes. The other statements do not require intervention.

Question format: Multiple Choice Chapter 15: Nutrition Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 284 24. The nurse is teaching a parent of a toddler about healthy eating habits. Which practices will the nurse recommend? Select all that apply.

A. Establish patterns for meals.

B. Encourage healthy body image.

C. Educate self and family about nutrition.

D. Make time available for food preparation.

E. Promote food preferences in early childhood.

Answer: A, B, C, D Rationale: Establishing meal patterns, encouraging healthy body image, educating self and family about nutrition, making time for food preparation, and discouraging food preferences

by offering many types of foods in early childhood reflect healthy eating habits. Promoting food preferences in early childhood can inhibit healthy eating behaviors.

Question format: Multiple Select Chapter 15: Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 289 25. A nursing student is teaching healthy nutrition to a client who is vegetarian. Which statement by the nursing student requires the nursing instructor to intervene?

A. "Vegetarians have a lower incidence of colorectal cancer than people who eat high fat diets."

B. "Protein complementation is important so that you get the right amount and proportion of amino acids needed."

C. "Vegans consume plants sources for protein. " D. "Obesity is closely linked with vegetarianism."

Answer: D Rationale: Vegetarians have a lower incidence of colorectal cancer and fewer problems with obesity and diseases associated with a high-fat diet. Protein complementation involves eating a variety of incomplete plant proteins over the course of the day to provide adequate amounts and proportions of all the essential amino acids present in animal protein sources. Vegans rely solely on plant sources for protein; semi-vegetarians exclude only red meat from their diet.

Question format: Multiple Choice Chapter 15: Nutrition Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 286 26. The nurse is caring for a client who refuses most foods on the dietary tray. Which nursing intervention is appropriate?

A. Allow the client privacy during mealtime.

B. Delegate feeding assistance to the unlicensed assistive personnel.

C. Assess when client generally eats meals.

D. Contact the healthcare provider to prescribe an appetite stimulant.

Answer: C Rationale: There are many reasons a client may refuse food that is served. The nurse should assess for food preferences, when the client generally eats, whether the client has digestive concerns, and cultural beliefs about foods. Leaving the client alone to eat, or simply delegating feeding, does not encourage intake. The client does not need an appetite stimulant until a full assessment has been conducted and other interventions have been implemented.

Question format: Multiple Choice Chapter 15: Nutrition Cognitive Level: Apply

Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 286 27. The nurse is caring for a 70-year-old client with a body mass index (BMI) of 34.8. Which risk factor should the nurse discuss with this client?

A. Risk of infection B. Risk of osteoporosis C. Risk of heart disease D. Risk of low cholesterol Answer: C Rationale: A client with a BMI of 34.8 is obese and is at highest risk for heart disease, diabetes, and some types of cancer. Being underweight can increase the risk for infections, osteoporosis, and other health conditions.

Question format: Multiple Choice Chapter 15: Nutrition Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 281 28. A nurse is caring for a client with excessive abdominal fat. Which method should the nurse teach as the best strategy to use for healthy eating?

A. Reduce calories for fast weight loss to get off to a good start.

B. Reduce the number of meals to two per day.

C. Plan meals using ChooseMyPlate.

D. Replace sugar with non-caloric sweeteners.

Answer: C Rationale: The client should eat various foods that are high in nutrient value and low in saturated and trans fats, cholesterol, added sugars, and salt. Several small meals per day can help to offset blood sugar. Planning meals with ChooseMyPlate, a guide to portion size, is an effort to illustrate how to divide healthy food choices in a more easily understood way.

Limiting the amount of added sugar or non-caloric sweeteners is advised. A heathy diet should include the recommended daily allowance of vitamins and minerals. These should come from food, not just vitamin supplements. Reducing calories for fast weight loss is not sustainable and can cause rebound weight gain.

Question format: Multiple Choice Chapter 15: Nutrition Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 290 29. The nurse is educating a client taking furosemide for heart failure about eating foods that are rich in potassium. Which statement made by the client indicates that education was effective?

A. "When I take my medication, I will eat a banana or take it with a glass of orange juice."

B. "I am going to increase my intake of dairy products like milk and cheese."

C. "Because I am losing sodium with the medication, I need to increase my salt intake."

D. "It would be better to eat small frequent meals each day instead of three large meals."

Answer: A Rationale: The client demonstrates that the teaching was effective by identifying bananas and orange juice as foods rich in potassium. The desired effect of the medication is to excrete sodium to avoid the accumulation of fluid in the lungs. To increase the amount of salt in the diet would be counterproductive. Dairy products such as milk and cheese are not potassiumrich foods. Eating small frequent meals versus three meals per day is irrelevant in increasing potassium level.

Question format: Multiple Choice Chapter 15: Nutrition Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 282

Chapter 16 1. A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of: A. electrolytes.

B. nonelectrolytes.

C. colloid solution.

D. interstitial fluid.

Answer: A Rationale: The nurse knows that the client's electrolytes need to be restored. Rehydration after exercise can only be achieved if the electrolytes lost in sweat, as well as the lost water, are replaced. The client does not need to have nonelectrolytes, colloid solution, or interstitial fluid restored. Nonelectrolytes are chemical compounds that remain bound together when dissolved in a solution. Interstitial fluid is the fluid in the tissue space between and around cells. Colloids are substances that do not dissolve into a true solution and do not pass through a semipermeable membrane.

Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 303 2. A severely malnourished client has been admitted to a health care facility. The nurse is preparing to administer total parenteral nutrition (TPN) to the client. The nurse should administer the TPN solution in a: A. vein distant from the heart through peripheral veins.

B. peripheral vein in a lower limb.

C. peripheral vein with its tip terminating in the superior vena cava.

D. peripheral vein with its tip terminating in the jugular vein.

Answer: C Rationale: TPN solution should be administered through a catheter inserted into the subclavian or jugular vein; the tip terminates in the superior vena cava. Sometimes a peripherally inserted central catheter is used; this long catheter is inserted in a peripheral arm vein but its tip terminates in the superior vena cava as well. Total parenteral nutrition is a hypertonic solution of nutrients designed to meet almost all caloric and nutritional needs. It is preferred for clients who are severely malnourished or may not be able to consume food or liquids for a long period. A TPN solution is not infused in a peripheral vein with its tip terminating in the jugular vein.

Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Remember Client Needs Pn: Physiological Integrity: Pharmacological Therapies

Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 322 3. A nurse needs to select a venipuncture site to administer a prescribed amount of IV fluid to a client. The nurse looks for a large vein when using a needle with a large gauge. What explains the nurse's action?

A. to prevent pain and discomfort B. to prevent compromising circulation C. to reduce the potential for blood clots D. to avoid restriction of mobility Answer: B Rationale: The nurse looks for a large vein when using a needle with a large gauge to prevent compromising circulation. To reduce the potential for blood clots and restrict a client's mobility, the nurse does not use foot or leg veins. The nurse avoids using veins on the inner surface of the wrist to prevent pain and discomfort.

Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Remember Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 316 4. A client who was involved in an accident is bleeding very heavily. What would be required to replace the circulating blood?

A. colloid solution B. hypertonic solution C. hypotonic solution D. isotonic solution Answer: A Rationale: The nurse should use a colloid solution to replace the circulating blood in the client. Colloid solutions such as blood, blood products, and solutions known as plasma expanders are used to replace circulating blood volume because the suspended molecules pull fluid from other compartments. Hypertonic solution is not used very frequently except in extreme cases when it is necessary to reduce cerebral edema or to expand the circulatory volume rapidly. Hypotonic solution is administered to clients with fluid losses in excess of fluid intake, such as those who have diarrhea or vomiting. Isotonic solution is administered to maintain fluid balance in clients who may not be able to eat or drink for a short period. These solutions are not used to replace circulating blood.

Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Remember Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 311

5. A client has been brought to a health care facility with complaints of diarrhea and vomiting. The nurse caring for the client knows that the client should be administered: A. hypotonic solution.

B. isotonic solution.

C. hypertonic solution.

D. colloid solution.

Answer: A Rationale: Hypotonic solution should be administered to clients with fluid losses in excess of fluid intake, such as those who have diarrhea or vomiting. An isotonic solution generally is administered to maintain fluid balance in clients who may not be able to eat or drink for a short period. Hypertonic solution is not used very frequently except in extreme cases when it is necessary to reduce cerebral edema or to expand the circulatory volume rapidly. Colloid solutions are used to replace circulating blood volume because the suspended molecules pull fluid from other compartments.

Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Remember Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 311 6. A nurse needs to get an accurate fluid output assessment of a client with severe diarrhea.

Which action should the nurse perform?

A. Weigh the volume of IV fluid before instilling.

B. Weigh the client's wet linen or dressing.

C. Weigh the client without soiled incontinence pads.

D. Weigh the client before and after meals.

Answer: B Rationale: In cases in which accurate assessment is critical to a client's treatment, the nurse weighs wet linens, pads, or dressings and subtracts the weight of a similar dry item. The nurse does not weigh the client without soiled incontinence pads. The nurse does not weigh the client before and after meals to obtain an accurate assessment of the fluid output.

Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs Pn: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 307 7. During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible?

A. hypervolemia B. hypovolemia C. edema

D. circulatory overload Answer: B Rationale: The nurse should recognize that hypovolemia, also known as dehydration, may be responsible. Additional indicators of dehydration in older adults include mental status changes; increases in pulse and respiration rates; decrease in blood pressure; dark, concentrated urine with a high specific gravity; dry mucous membranes; warm skin; furrowed tongue; low urine output; hardened stools; and elevated hematocrit, hemoglobin, serum sodium, and blood urea nitrogen (BUN). Hypervolemia means a higher-than-normal volume of water in the intravascular fluid compartment and is another example of a fluid imbalance that would manifest itself with different signs and symptoms. Edema develops when excess fluid is distributed to the interstitial space.

Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Analyze Client Needs Pn: Physiological Integrity: Reduction of Risk Potential Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 308 8. A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV? A. Select a primary tubing of about 37 inches (94 cm) long.

B. Ensure that the prescribed solution is clear and transparent.

C. Use half-instilled IV solutions before infusing a new one.

D. Avoid replacing IV solutions every 24 hours.

Answer: B Rationale: Before preparing the solution, the nurse should inspect the container and determine that the solution is clear and transparent, the expiration date has not elapsed, no leaks are apparent, and a separate label is attached. The primary tubing should be approximately 110 inches (2.8 m) long and the secondary tubing should be about 37 inches (94 cm) long. To reduce the potential for infection, IV solutions are replaced every 24 hours even if the total volume has not been completely instilled.

Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Remember Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 312 9. A nurse needs to administer 250 mL of IV solution to a client. The IV solution is packaged in a rigid glass container. Which type of tubing should the nurse choose?

A. vented tubing B. nasogastric tubing C. unvented tubing D. primary tubing

Answer: A Rationale: Vented tubing is necessary for administering IV solutions packaged in rigid glass containers because when unvented tubing is inserted into a glass bottle, the solution does not leave the container. Primary tubing is used when the tubing must span the distance from a solution that hangs several feet above the infusion site. Nasogastric tubing is used to administer liquid foods to the client.

Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Remember Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 313 10. A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing?

A. 30 drops/mL B. 60 drops/mL C. 90 drops/mL D. 120 drops/mL Answer: B Rationale: Microdrip tubing, regardless of manufacturer, delivers a standard volume of 60 drops/mL. Macrodrip tubing manufacturers, however, have not been consistent in designing the size of the opening. Therefore, the nurse must read the package label to determine the drop factor (number of drops/mL).

Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Remember Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 313 11. A client with dehydration is being administered IV fluids. During rounds, the nurse noticed that the skin immediately surrounding the IV site was reddish in color and showing signs of inflammation. The nurse recognizes that what phenomenon is likely responsible?

A. phlebitis B. thrombus formation C. pulmonary embolus D. air embolism Answer: A Rationale: The nurse should record that the client has phlebitis, which is an inflammation of the vein. Thrombus formation is a situation in which there is a stationary blood clot.

Pulmonary embolus is a situation in which the blood clot travels to the lung. Air embolism is a bubble of air traveling within the vascular system.

Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 317 12. A nurse is caring for a client with phlebitis. The nurse notices that the client's forearm, which has the tubing, has become red and slightly warm. Which actions should the nurse perform to avoid further complications and provide relief to the client?

A. Administer oxygen.

B. Call for help.

C. Discontinue the IV promptly.

D. Elevate the affected arm.

Answer: C Rationale: When there is phlebitis, the nurse should discontinue the IV promptly and apply warm compresses to the affected site to provide immediate relief to the client. The nurse elevates the client's affected arm when there is infiltration. When there is pulmonary embolus, the nurse should call for help and administer oxygen.

Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Apply Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 318 13. A nurse is using an in-line filter when administering a prescribed dosage of IV fluid to a client. In which situation does the nurse know that an in-line filter is specifically used?

A. when administering solutions in rigid glass containers B. when infusing IV solutions to pediatric clients C. when the client is receiving intravenous antibiotics D. when administering nasogastric nutrition Answer: B Rationale: Filtered tubing is generally used when infusing IV solutions to pediatric clients, as it removes air bubbles as well as undissolved drugs, bacteria, and large substances. Vented tubing, not an in-line filter, is necessary when administering solutions in a rigid glass container. An in-line filter is used when the client is at high risk for infection and when administering blood and packed cells, and not when administering nasogastric nutrition to a client.

Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process

Reference: p. 313 14. When administering an IV solution, the nurse ensures that the solution is placed at least 18 to 24 in (45 to 60 cm) above the site of the infusion. For which reason should the nurse maintain this position for the IV solution?

A. to ensure that the IV tubing remains free of entanglements B. to match the pressure within the client's vein C. to infuse the solution into the client's vein slowly D. to overcome the pressure within the client's vein Answer: D Rationale: To overcome the pressure within the client's vein, which is higher than atmospheric pressure, the solution is elevated at least 18 to 24 in (45 to 60 cm) above the site of the infusion. The height of the solution affects the rate of flow: the higher the solution, the faster the solution infuses, and vice versa. Keeping the solution at such a height does not ensure that the IV tubing remains free of entanglements or help to match the pressure in the client's vein.

Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 314 15. A client with a diagnosis of type 1 diabetes has begun receiving subcutaneous injections of insulin. The nurse knows that insulin allows glucose to enter the body's cells. This is an example of what transport mechanism?

A. filtration B. passive diffusion C. facilitated diffusion D. active transport Answer: C Rationale: Facilitated diffusion is the process in which certain dissolved substances require the assistance of a carrier molecule to pass from one side of a semipermeable membrane to the other. An example is the role that insulin plays in transporting glucose into cells.

Filtration involves the movement of water and passive diffusion is dependent on a concentration gradient. Active transport requires an energy source, something which is not the case with insulin and glucose.

Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 305

16. An 81-year-old client has been admitted to the hospital during an exacerbation of chronic heart failure that has resulted in peripheral edema and hypervolemia. This client's fluid volume could be best reduced by which method?

A. performing therapeutic phlebotomy (removal of a quantity of blood) B. positioning the client with the limbs in a dependent position C. administering an IV solution that is rich in potassium D. administering drugs that increase urine production Answer: D Rationale: Diuresis is a common method of reducing fluid volume. This is not normally accomplished through phlebotomy. Potassium solutions and repositioning do not resolve hypervolemia.

Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 323 17. A client with anemia has been admitted to the emergency department and has had two units of packed red blood cells ordered. How will the intravenous administration of this blood product differ from the administration of other commonly used IV solutions?

A. The nurse must use Y-set tubing coupled with normal saline to administer the blood.

B. The nurse must administer the blood with an electronic IV pump and not by gravity.

C. The nurse must administer the blood cells at a rate of between 150 and 200 mL/hr.

D. The nurse must insert a 24- to 26-gauge IV catheter in order to administer the blood.

Answer: A Rationale: Blood is administered through tubing referred to as a Y-set. Two branches are at the top of the tubing; one is used to administer normal saline solution, the other to administer blood. An 18-gauge catheter is normally used and the rate is determined by the primary care provider. An electronic pump is not a necessity in all settings.

Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 320 18. A client began receiving a unit of blood about 5 minutes ago and states that the client feels "terribly itchy." The client's face is visibly flushed and there is a rash on the client's upper chest. However, the client's vital signs are within normal limits. What should the nurse do in response to this?

A. Stop the blood infusion and administer a bolus of normal saline.

B. Increase the rate of infusion to overcome the client's temporary response.

C. Slow the infusion rate and prepare an antihistamine.

D. Stop the infusion and administer an antiemetic.

Answer: C Rationale: The client's signs and symptoms are characteristic of an allergic reaction, which should prompt the nurse to slow the rate and possibly administer an antihistamine. It would be inappropriate to increase the rate of infusion or to administer an antiemetic. It is not normally necessary to stop the infusion.

Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 321 19. The nurse works at an agency that automatically places certain clients on intake and output (I&O). For which client will the nurse document all I&O? A. 23-year-old with ulnar and radial fracture B. 34-year-old whose urinary catheter was discontinued yesterday C. 48-year-old who has had a bowel movement after surgery D. 55-year-old with congestive heart failure on furosemide Answer: D Rationale: Agencies often specify the types of clients that are placed automatically on I&O. Generally, they include clients who have undergone surgery until they are eating, drinking, and voiding in sufficient quantities; those on IV fluids or receiving tube feedings; those with wound drainage or suction equipment; those with urinary catheters; and those on diuretic drug therapy. The client with congestive heart failure that is on a diuretic should have I&O documented. The other clients do not require the nurse to document all I&O. Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Analyze Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 306 20. An older adult client with dehydration repeatedly tells the nurse, "I am just not thirsty. I don't want anything to drink." Which nursing actions are appropriate? Select all that apply.

A. Identify fluid preferences.

B. Offer fluids at times other than meals.

C. Encourage caffeinated beverages.

D. Offer small amounts of preferred liquids frequently.

E. Initiate intravenous fluid replacement.

Answer: A, B, D Rationale: Older adults may need to be encouraged to drink fluids, even at times when they do not feel thirsty, because age-related changes may diminish the sensation of thirst. Rather than asking older adults if they would like a drink, it is important to identify their preferences and offer small amounts of their preferred liquids at frequent intervals. To maintain adequate consumption of nutrients, it is best to offer fluids to older adults at times other than meals.

Encourage older adults to drink noncaffeinated beverages because of the diuretic effect of caffeine or to replace the volume of caffeinated beverages by consuming the same volume of noncaffeinated fluids per day. The nurse should never initiate intravenous fluid replacement without an order.

Question format: Multiple Select Chapter 16: Fluid and Chemical Balance Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 306 21. The nurse is teaching a nursing student how to record strict I&O for a client who wears adult absorbent undergarments. Which nursing teaching is appropriate?

A. "Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)."

B. "We do not record fluids absorbed into undergarments."

C. "Estimate the amount of fluid that you think was excreted into the undergarment."

D. "You only record urine output in an adult undergarment; you do not record diarrhea output."

Answer: A Rationale: Fluid output is the sum of liquid eliminated from the body, including urine, emesis (vomitus), blood loss, diarrhea, wound or tube drainage, and aspirated irrigations. In cases in which an accurate assessment is critical to a client's treatment, the nurse weighs wet linens, pads, diapers, or dressings, and subtracts the weight of a similar dry item. An estimate of fluid loss is based on the equivalent: 1 lb (0.47 kg) = 1 pint (475 mL).

Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 307 22. The nurse is providing care to a client who has been experiencing emesis for 24 hours.

Which fluid should the nurse anticipate incorporating into the client's plan of care?

A. isotonic B. hypotonic C. hypertonic D. hypertonic, followed by isotonic Answer: B Rationale: A hypotonic solution contains fewer dissolved substances than normally found in plasma. It is administered to clients with fluid losses in excess of fluid intake, such as those who have diarrhea or vomiting. The other fluids are not appropriate to administer.

Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

Integrated Process: Nursing Process Reference: p. 311 23. The nurse is caring for a client who was in a motor vehicle accident and has severe cerebral edema. Which fluid does the nurse anticipate infusing?

A. isotonic B. hypotonic C. hypertonic D. hypotonic, followed by isotonic Answer: C Rationale: A hypertonic solution is more concentrated than body fluid and draws cellular and interstitial water into the intravascular compartment. This causes cells and tissue spaces to shrink. Hypertonic solutions are used infrequently, except in extreme cases when it is necessary to reduce cerebral edema or to expand the circulatory volume rapidly. The nurse does not anticipate using isotonic fluids.

Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 311 24. The nurse is preparing to perform venipuncture. Which items will the nurse plan to gather? Select all that apply.

A. clean gloves B. tourniquet C. antiseptic swabs D. transparent dressing E. adhesive tape F. antimicrobial ointment Answer: A, B, C, D, E Rationale: The nurse will gather clean gloves, a tourniquet, antiseptic swabs to cleanse the skin, a transparent dressing to cover the puncture site, and adhesive tape to secure the venipuncture device and tubing. Antibiotic and antimicrobial ointments should not be used at the site because these may promote fungal infections or antibiotic resistance.

Question format: Multiple Select Chapter 16: Fluid and Chemical Balance Cognitive Level: Remember Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 315 25. The nurse is caring for a client whose blood type is B negative. Which donor blood type does the nurse confirm as compatible for this client?

A. B positive B. O negative

C. A positive D. AB negative Answer: B Rationale: Type O blood is considered the universal donor because it lacks both A and B blood group markers on its cell membrane. Therefore, type O blood can be given to anyone because it will not trigger an incompatibility reaction when given to recipients with other blood types. B positive, A positive, and AB negative are not considered compatible in this scenario.

Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 319-320 26. The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. Which action should the nurse take?

A. Reassure the client that the feelings are associated with anxiety and will pass.

B. Confirm the shortness of breath by listening to the client's lungs.

C. Stop the transfusion and notify the health care provider.

D. Increase the rate of infusion to restore blood volume more quickly.

Answer: C Rationale: Life-threatening transfusion reactions generally occur within the first 5 to 15 minutes of the infusion. The nurse or someone designated by the nurse usually remains with the client during this critical time. Whenever a transfusion reaction is suspected or identified, the nurse's first step is to stop the transfusion, thereby limiting the amount of blood to which the client is exposed, and to notify the health care provider. Reassuring the client will not help if the client is experiencing a blood reaction. Increasing the rate of the administration will make the potential reaction worse if this is a transfusion reaction. Listening to the client's lungs is not the priority action.

Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 321 27. A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?

A. Allow nothing by mouth.

B. Give the client a glass of orange juice with added sugar.

C. Encourage fluid intake.

D. Start an IV of normal saline as prescribed.

Answer: D

Rationale: To treat a client with hypovolemia, the nurse should obtain an IV bag with normal saline (0.9% sodium chloride) as prescribed. Fluid intake by mouth will not provide fluid quickly enough for the desired effect but should be attempted if feasible, in addition to an IV. Orange juice with additional sugar may be given to a person with low blood sugar.

Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 308 28. The nurse is performing an assessment for an older adult client admitted with dehydration. When assessing the skin turgor of this client, which area of the body will be best for the nurse to assess?

A. sternum B. thigh C. hand D. abdomen Answer: A Rationale: The older adult client will most likely demonstrate a decrease in skin turgor when dehydrated and the best option for assessment is the sternum. The hand may normally tent when the skin is pulled up since older adult clients lose elasticity in that area first. The thigh and abdomen do not give the best information related to skin turgor when assessed due to the lack of elasticity in these areas of the older adult client.

Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 309 29. A client sustained severe trauma in a motor vehicle accident and has had 26 units of packed red blood cells infused since admission 2 days previously. What does the nurse predict will be prescribed to replace the clotting factors lost with the infusion of large amounts of packed red blood cells?

A. albumin B. plasma C. granulocytes D. normal saline solution Answer: B Rationale: The infusion of plasma helps restore and replace the clotting factors that are lost with the infusion of large amounts of packed red blood cells. Albumin pulls third-spaced fluid by increasing colloidal osmotic pressure but does not restore clotting factors. The infusion of granulocytes improves the ability of the body to overcome infection. Normal saline is an isotonic solution that replaces fluid loss but does not replace clotting factors.

Question format: Multiple Choice Chapter 16: Fluid and Chemical Balance Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 312

Chapter 17 1. A nurse is explaining the need for bathing to an elderly client who has been avoiding a daily bath. Which benefit of bathing should the nurse explain to the client?

A. Bathing maintains the body temperature.

B. Bathing prevents skin from peeling.

C. Bathing reduces the possibility of infection.

D. Bathing keeps mucous membranes soft and moist.

Answer: C Rationale: The nurse should explain to the elderly client that a daily bath reduces the possibility of infection. Although restoring cleanliness is the primary objective, bathing has several other benefits such as stimulating circulation, providing a refreshed and relaxed feeling, and improving self-image. Bathing does not prevent skin from peeling or maintain body temperature.

Question format: Multiple Choice Chapter 17: Hygiene Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 348 2. A nurse is preparing to help a client with a skin infection have a tub bath. In which way can the nurse ensure the client's safety?

A. Check that the bathroom has a nonskid floor.

B. Check that the grab bars are at shoulder level.

C. Give the client a damp towel for bathing.

D. Keep a bottle of bathing oil near the tub.

Answer: A Rationale: The nurse can ensure the client's safety by checking for nonskid strips on the floors of bathtubs and showers, along with strategically placed handles and grab bars that reduce the risk of falls for older adults when bathing. Grab bars should be placed not at shoulder level but at arm level and within reach of the dominant arm. As the client has a skin infection, providing him with a damp towel will add to his problem. Oils are not used in showers or bathtubs, as they increase the risk of falls.

Question format: Multiple Choice Chapter 17: Hygiene Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs Pn: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Caring Reference: p. 348 3. A nurse is caring for a client with a fractured arm. As part of hair care, what should the nurse do to increase circulation and distribution of sebum in the client's hair?

A. Use a wide-toothed comb.

B. Brush the client's hair slowly.

C. Apply a conditioner or alcohol.

D. Provide the client with a turban.

Answer: B Rationale: The nurse should brush the client's hair slowly so that it increases circulation and distributes oils. The nurse should start brushing the hair at the ends of the hair rather than from the crown downward if the hair is matted or tangled. Turbans or caps are given to clients who have hair loss from chemotherapy or other medical treatments.

Question format: Multiple Choice Chapter 17: Hygiene Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 354 4. A nurse is providing nail care to a client at a health care facility. Why is it important for the nurse to soak the client's hands in warm water prior to nail care?

A. to soften the keratin B. to loosen the nails C. to help the cuticles withdraw D. to loosen the skin near the nails Answer: A Rationale: The nurse needs to soak the client's hands or feet in warm water to soften the keratin and loosen trapped debris. A soft towel is used to help the cuticles withdraw. Warm water will not loosen the nails or the skin near the nails.

Question format: Multiple Choice Chapter 17: Hygiene Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 354 5. A middle-age client who wears glasses and has a slight hearing problem needs a hearing aid that is small and not too expensive. Which hearing aid device is best suited for the client?

A. behind-the-ear device B. body aid device C. infrared listening device D. in-the-ear device Answer: A Rationale: The best hearing device for this client is a behind-the-ear device, which consists of a microphone and amplifier worn behind the ear. The behind-the-ear device can be attached to an eyeglass frame as well. The in-the-ear device is small, self-contained, and fits within the

client's ear. The body aid device is not suitable, as the client does not have a severe hearing problem. Infrared listening devices (IRLDs) are expensive.

Question format: Multiple Choice Chapter 17: Hygiene Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 357 6. A child with a day-old fever is admitted to a health care facility. Which bath will be most appropriate for the client?

A. tub bath B. bed bath C. partial bath D. towel bath Answer: D Rationale: As the child has had a fever for approximately 1 day, he should be given a towel bath. A tub bath may aggravate the fever. A bed bath is not recommended for people with fever. A partial bath means washing only those body areas subject to greatest soiling or areas that are sources of body odor. Partial bathing is done at a sink or with a basin at the bedside.

Question format: Multiple Choice Chapter 17: Hygiene Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 350 7. A nurse is assessing a client with dental problems including irritation, inflammation, and bleeding gums. The nurse recognizes that what condition may be contributing to these signs and symptoms?

A. plaque B. sordes C. gingivitis D. periodontal disease Answer: C Rationale: The client has gingivitis, which develops when bacteria multiply and build up between teeth and gums, leading to irritation, inflammation, and bleeding. Bleeding gums are not a symptom of sordes, plaque, or periodontal disease. Sordes are dried crusts containing mucus and are common on the lips and teeth of unconscious clients. Plaque is a substance that supports the growth of mouth bacteria; it is composed of mucin and other gritty substances in saliva. Periodontal disease is a condition that results in the destruction of the tooth-supporting structures and jawbone.

Question format: Multiple Choice Chapter 17: Hygiene Cognitive Level: Remember Client Needs Pn: Physiological Integrity: Physiological Adaptation

Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 347-348 8. An elderly client is admitted to a health care facility for the treatment of frequent seizures.

What should the nurse use when attending to the personal hygiene of a client with seizures?

A. bed bath B. tub bath C. towel bath D. bag bath Answer: D Rationale: The nurse should give the client a bag bath because it will save time, which is important since seizures could occur at any time. A bag bath involves the use of a commercially packaged kit with eight to ten premoistened, disposable cloths in a plastic bag or container and is another form of a bed bath. The nurse should not give a bed bath, as it takes longer than the bag bath and requires assistance from the client. A towel bath is recommended for people who have fever. A tub bath is not recommended, as it can be dangerous for a client with seizures to be left alone in the bathroom.

Question format: Multiple Choice Chapter 17: Hygiene Cognitive Level: Remember Client Needs Pn: Physiological Integrity: Reduction of Risk Potential Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Caring Reference: p. 350 9. A client who has started using contact lenses visits a health care facility with an eye infection. The nurse observes that the client also has an eye abrasion. What could be the possible reason for the eye infection?

A. Contact lenses were not cleaned.

B. Contact lenses were new.

C. Contact lenses were rigid.

D. Contact lenses were colored.

Answer: A Rationale: The client likely did not clean the lenses properly. This likely caused both an infection and an abrasion in the eye. People who are not conscientious about following a routine for contact lens care are at risk for infection, eye abrasion, and permanent damage to the cornea. New, rigid, and colored contact lenses are not causes of eye infection. Any type of lenses should be cleaned properly and thoroughly.

Question format: Multiple Choice Chapter 17: Hygiene Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs Pn: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 355

10. A nurse is assessing a client during a health care camp. The nurse observes that the client has poor hygiene and an itchy, infected scalp. What should the nurse ask the client to do?

A. Wash hair daily.

B. Use dry shampoo.

C. Use oil-based shampoo.

D. Use antilice shampoo.

Answer: A Rationale: The client with a scalp infection should be advised to shampoo her hair daily with a mild shampoo. For occasional use, the nurse will use dry shampoos, which are applied to the hair as a powder. Other options include aerosol spray or foam. Antilice shampoos or oilbased shampoos are not used for fear of aggravating the infection.

Question format: Multiple Choice Chapter 17: Hygiene Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Client Needs Pn: Health Promotion and Maintenance Reference: p. 354 11. An elderly client has been admitted to a health care facility with a fractured arm and the nurse has to help the client change from a hospital gown into the client's clothing. How should the nurse ensure the client's comfort?

A. Clothes should be pulled on over the head.

B. Clothes should have front zippers.

C. Clothes should have front hooks.

D. Clothes should have small buttons.

Answer: B Rationale: The nurse should provide clothing with front zippers, Velcro closures, elastic waists, and oversized buttons and buttonholes to facilitate dressing for the client with a fracture or even just for the elderly client. This will help the client to dress and undress independently. A client with a fracture will find gowns that must be pulled over the head or gowns with hooks or small buttons very uncomfortable to put on or remove independently.

Question format: Multiple Choice Chapter 17: Hygiene Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Caring Reference: p. 359 12. The daughter of an elderly man who resides at a long-term care facility has confronted the nurse with the fact that her father has not been receiving full baths on a frequent basis and has instead been receiving partial baths. What is an acceptable rationale for providing partial baths rather than full baths to older adult clients?

A. Partial baths are more time-efficient than full baths.

B. Partial baths deplete less of the client's skin oils than a full bath.

C. Partial baths are less disruptive to a client's daily routine.

D. Partial baths remove more dead skin and debris than a full bath.

Answer: B Rationale: A daily bath or shower is not always necessary; for older adults, who perspire less than younger adults and are prone to dry skin, frequent washing with soap depletes oil from the skin. Partial baths take less time, but this consideration alone does not necessarily justify the practice. Partial baths do not remove more skin debris than a full bath nor do they necessarily disrupt the client's routine less than a full bath.

Question format: Multiple Choice Chapter 17: Hygiene Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Caring Reference: p. 349 13. A nurse is delegating some aspects of client hygiene to an unlicensed care provider and is ensuring the care provider has adequate knowledge to safely perform shaving. With which client would the use of a razor be contraindicated?

A. a man who had an unkempt beard and mustache upon admission B. a man who has a history of type 1 diabetes and who takes insulin daily C. a man who has a history of stroke and who takes oral anticoagulants D. a man who is the early stages of Alzheimer's disease Answer: C Rationale: Use of anticoagulants contraindicates shaving with a safety razor due to the consequent risk of bleeding. Unkempt beards, diabetes, and cognitive deficits do not necessarily contraindicate this practice.

Question format: Multiple Choice Chapter 17: Hygiene Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 351 14. A nurse is providing care for a client who is unconscious following a traumatic brain injury suffered in a motor vehicle accident. The nurse provides thorough oral care to the client on a regular basis. When providing this care, the nurse should take specific action to reduce the client's risk of what nursing diagnosis?

A. Risk for Impaired Skin Integrity B. Risk for Infection C. Risk for Imbalanced Fluid Volume D. Risk for Aspiration Answer: D Rationale: Unconscious clients are at a heightened risk for aspiration. Consequently, the nurse must ensure that liquids do not enter the client's airway during oral hygiene. Oral

hygiene does not constitute a specific risk for infection, fluid imbalance, or impaired skin integrity.

Question format: Multiple Choice Chapter 17: Hygiene Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 371 15. A nurse has noticed that an older adult's hearing aid frequently produces a shrill, highpitched noise. What possible solution should the nurse suggest to this problem with feedback?

A. Encourage the client to make sure the hearing aid is fully inserted in the ear canal.

B. Encourage the client to change the batteries in the hearing aid frequently.

C. Encourage the client to ensure that cerumen does not accumulate in the ears.

D. Encourage the client to clean their hearing aids frequently.

Answer: A Rationale: Failure to fully insert a hearing aid can result in feedback. This problem is not normally attributable to low batteries, cerumen accumulation, or dirty hearing aids.

Question format: Multiple Choice Chapter 17: Hygiene Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 358 16. An older adult client is trialing the use of an infrared listening device (IRLD). How does this device have the potential to increase the client's ability to hear?

A. The device directs sounds into one ear rather than into both ears.

B. The device increases the volume of foreground noises.

C. The device enhances the function of the auditory nerve.

D. The device converts light into an auditory stimulus.

Answer: D Rationale: An IRLD converts sound into infrared light and sends it through a wall- or ceilingmounted receiver to the person wearing the listening device. The light is converted back into an auditory stimulus. IRLDs do not direct sound into one ear, influence the function of the auditory nerve, or increase the volume of foreground noise.

Question format: Multiple Choice Chapter 17: Hygiene Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 359 17. A 71-year-old client is concerned about brown patches of skin on their face and forearm.

What is the appropriate nursing statement?

A. "Older people often have splotchy skin due to seborrheic keratoses."

B. "Those spots are senile lentigines and may be cancerous."

C. "Those spots are benign and are known as seborrheic keratoses."

D. "Those are senile lentigines and are common in older adults."

Answer: D Rationale: Benign skin lesions such as seborrheic keratoses (tan to black raised areas) and senile lentigines (brown, flat patches on the face, hands, and forearms) are common in older adults. Older people may have splotchy skin, but it is not attributed to seborrheic keratoses and this doesn't address the client's concern of brown patches on their face and arms.

Question format: Multiple Choice Chapter 17: Hygiene Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 345 18. The nurse has delegated oral care for an unconscious client to an unlicensed assistive personnel (UAP). Which UAP action requires immediate nursing intervention?

A. placing the client supine to perform mouth care B. moistening oral swabs before inserting them into the mouth C. mixing equal parts baking soda and table salt in warm water to be used to remove accumulated secretions D. applying petroleum jelly to lips Answer: A Rationale: The unconscious client is at risk for aspiration; the nurse must intervene to correct the UAP's positioning of the client. Moist oral swabs can be used to refresh the mouth, and petroleum jelly can be applied to the lips. Equal parts baking soda and table salt, mixed in warm water, can be used to remove accumulated secretions.

Question format: Multiple Choice Chapter 17: Hygiene Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 371 19. The nurse is teaching a nursing student about caring for a client with dentures. Which education will the nurse provide?

A. "Use your ungloved hands to remove an unconscious client's dentures."

B. "Clean dentures with hot water to eliminate bacteria."

C. "After brushing dentures, leave them out of the client's mouth overnight."

D. "Hold dentures over a plastic basin or towel when cleaning them."

Answer: D Rationale: Gloves should always be used to remove an unconscious client's dentures.

Dentures should be cleaned in cold or tepid water, and then replaced into the client's mouth

so the gum lines do not begin to change. Holding dentures over a plastic basin or towel when cleaning them is appropriate, so if dentures are dropped, they will not break.

Question format: Multiple Choice Chapter 17: Hygiene Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Caring Reference: p. 353-354 20. The nurse is caring for a client with diabetes who has thick toenails. What is the appropriate nursing intervention?

A. Clip the toenails with large clippers.

B. Contact a podiatrist to care for toenails.

C. Use a handheld electric rotary file to reduce the length of the toenails.

D. Clean under the toenails with a wooden orange stick.

Answer: B Rationale: Clients who have diabetes, impaired circulation, or thick nails are at risk for vascular complications secondary to trauma. The services of a podiatrist should be obtained.

It is not appropriate to clip the toenails with large clippers, use a handheld electric rotary file, or clean under the toenails with a wooden orange stick.

Question format: Multiple Choice Chapter 17: Hygiene Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 354 21. The nurse is caring for a client who has a large furuncle in the right axillae. What education will the nurse provide?

A. Squeeze the lesion to release pus.

B. Launder personal bath items in hot water and bleach.

C. This chronic skin disorder is noninfectious.

D. Nits may be present on hairs under the axillae.

Answer: B Rationale: A furuncle (boil) is a raised pustule, usually in the neck, axillary or groin area that feels hard and painful. The nurse will teach the client to keep hands away from the infection lesion, to use separate cloths and towels from the rest of the family, to wash hands thoroughly before and after applying medication, and to launder personal bath items in hot water and bleach to prevent the transmission of infection. The nurse will not teach the client to squeeze the lesion, nor will tell the client that the skin disorder is noninfectious or that nits may be present on hairs under the axillae.

Question format: Multiple Choice Chapter 17: Hygiene Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning

Reference: p. 346 22. A client with psoriasis tells the nurse, "I finally found a remedy online that will cure my psoriasis." What is the appropriate nursing response?

A. "Advertised remedies that promise a cure may be a scam."

B. "The medication your health care provider prescribed will cure psoriasis."

C. "This is great news; please let me know how this remedy works for you."

D. "I know you will feel much better after you have been cured of psoriasis."

Answer: A Rationale: Psoriasis is a noninfectious chronic skin disorder that appears as elevated silvery scales that shed over elbows, knees, trunk, and scalp. Acute episodes occur between periods of relief. The nurse will educate that the client should be wary of advertised remedies that promise a cure or quick relief, since this condition can be managed, but not cured. The nurse will not tell the client that the medication prescribed by the health care provider will be a cure, encourage the client to use the remedy, or provide false hope of the condition being cured.

Question format: Multiple Choice Chapter 17: Hygiene Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 346 23. The nurse is caring for a client who has a fungal infection in the groin. The client reports feeling sore and itchy. Upon assessment, the nurse notes a cluster of vesicles that are scaly and cracked. What tinea condition does the nurse anticipate?

A. capitis B. pedis C. corporis D. cruris Answer: D Rationale: Tinea cruris is a fungal infection of the groin and surrounding area. This condition appears as a ring or cluster of papules or vesicles that cause itching, and may be scaly, cracked, and sore. Tinea capitis is of the head; tinea pedis is of the feet; tinea corporis is of the body other than the head, feet, groin, or palms of hands.

Question format: Multiple Choice Chapter 17: Hygiene Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 346 24. The nurse manager notices that a nurse is wearing artificial fingernails. What is the appropriate nurse manager action? Select all that apply.

A. Remind the nurse that artificial fingernails can spread fungal infections.

B. Refer the nurse to the agency policy on artificial fingernails.

C. Provide the nurse with evidence that demonstrates outcomes of appropriate hand hygiene.

D. Demand that the nurse remove the artificial fingernails immediately.

E. Ask the nurse to use only fingernail polish instead of artificial fingernails.

Answer: A, B, C Rationale: Fungal nail infections can result from application of artificial fingernails if unsanitary application utensils are used. The nurse manager will educate the nurse on outcomes associated with use of artificial nails, refer the nurse to the agency policy on wearing artificial nails, and provide the nurse with literature that demonstrates outcomes of appropriate hand hygiene. Demanding that the nurse remove the artificial fingernails immediately does not educate the nurse and can contribute to a hostile working relationship.

The agency policy may prohibit nurses from wearing any fingernail treatment, so polish should not be recommended.

Question format: Multiple Select Chapter 17: Hygiene Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 346 25. The nurse is preparing to provide hygiene for a client who has a leg cast and activity restrictions. Which is the priority nursing intervention that will be performed to prepare for hygiene care?

A. Check the nursing care plan for hygiene directives.

B. Assess the client's level of consciousness.

C. Gather towels, washcloths, and soap.

D. Determine how to protect the cast with waterproof material.

Answer: A Rationale: The priority intervention is to check the plan of care for hygiene directives or orders. This ensures continuity of care. The other interventions can be carried out subsequent to this, after the nurse has determined if there are specific hygiene directives in place.

Question format: Multiple Choice Chapter 17: Hygiene Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 362 26. A nurse is providing nail care for feet to clients admitted to a health care facility. What should the nurse look for while performing nail care for a client with a long history of diabetes?

A. A bony bump on the joint at the base of the big toe B. Breaks in skin integrity and fungal nail infection C. Cold feet D. Redness and swelling in the joint of the big toe with reports of pain Answer: B

Rationale: Clients with diabetes will be more susceptible to infection from breaks in skin integrity and nail problems. People with diabetes are more susceptible to fungal toenails and foot injury because of poor circulation and lack of feeling. A bunion, a bony bump on the joint at the base of the big toe, is not specific to clients with diabetes and can be caused by wearing tight, narrow shoes. Cold feet can be caused by things other than diabetes, such as atherosclerosis. Red inflamed joint of the big toe with reports of pain can indicate the client is suffering from gout and may not be attributable to diabetes.

Question format: Multiple Choice Chapter 17: Hygiene Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 354 27. A nurse is caring for an adult client who has excess cerumen and has been prescribed carbamide peroxide. What information should the nurse teach the client about administering ear drops?

A. Instill ear drops on the side of the canal to allow the drops to flow in.

B. Straighten the canal by gently pulling the outer ear down and back.

C. Instill the ear drops directly into the center of the canal, and avoid having the drops touch the sides of the canal.

D. Straighten the canal by gently pulling the earlobe down and back.

Answer: A Rationale: Over-the-counter ear drops (such as carbamide peroxide) are used to prevent and treat excessive cerumen accumulation, a common cause of hearing loss. The client should straighten the canal for instillation by gently pulling the pinna up and back, the technique for older children and adults. Pulling the pinna down and back is used with infants and children younger than 3 years. The client should instill ear drops on the side of the canal and allow them to flow in. After instillation, the client should release the pinna and gently massage the tragus of the ear.

Question format: Multiple Choice Chapter 17: Hygiene Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 358 28. A client reports developing repeated furuncles in the groin area. What statement(s) made by the client indicates to the nurse that education about prevention will be required? Select all that apply.

A. "I ruptured the furuncle so that hydrogen peroxide and an antibiotic cream can be applied."

B. "I have aspirated the drainage with a needle to relieve the pressure and the pain."

C. "I use good hand hygiene before and after washing the area and applying the prescribed medication."

D. "I use a separate towel from other members of my household."

E. "All of the items that I use that touch the area are washed in hot water and bleach."

Answer: A, B Rationale: The client should be educated about not attempting to rupture or aspirate pus from the furuncle. Both of these actions may cause the furuncle to rupture underneath the skin and cause a widespread infection to the area and the development of cellulitis. The client demonstrates an understanding of hygienic practices that prevent the transmission of pathogens when discussing handwashing, using separate towels, and laundering items in bleach and hot water, and does not require further education.

Question format: Multiple Select Chapter 17: Hygiene Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 346

Chapter 18 1. A client diagnosed with impaired thermoregulation reports feeling uncomfortable due to excessive sweating. Which activity would help the nurse maintain the humidity of the environment?

A. using electrical fans B. using a dehumidifier C. air conditioning the room D. keeping the window open Answer: C Rationale: The nurse should have air conditioning on in the room to maintain the environmental humidity and make it more comfortable for the client. Electric fans and dehumidifiers are not always adequate substitutes, but they may be used if air conditioners are not available. Keeping the windows open is not an appropriate method.

Question format: Multiple Choice Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs Pn: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 375 2. A nurse is caring for a client who has started phototherapy for seasonal affective disorder.

Which instruction should the nurse give the client to prevent the recurrence of symptoms?

A. Take phototherapy for 2 to 6 hours.

B. Try to relax during the therapy.

C. Maintain good fluid intake during therapy.

D. Avoid abrupt discontinuation of the therapy.

Answer: D Rationale: The nurse should instruct the client to avoid abruptly discontinuing the therapy because doing so may lead to the recurrence of symptoms. Instructing the client to take phototherapy for 2 to 6 hours is for effectivity of the therapy and is not related to the recurrence of symptoms. Relaxing during the therapy and maintaining fluid intake are not related to the recurrence of symptoms.

Question format: Multiple Choice Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 385 3. A nurse is making a bed for a client confined to bed due to coma. Which position should the nurse place the client in to facilitate bedmaking?

A. lateral position

B. supine position C. prone position D. Fowler's position Answer: A Rationale: The nurse should place the client in a lateral position when making an occupied bed. This facilitates bedmaking from side to side. Placing the client in the supine, the prone, or Fowler's position may not be comfortable for the client and would not be convenient for the nurse to make the bed.

Question format: Multiple Choice Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 396 4. A nurse is caring for a client who is having difficulty breathing. Which bed accessory should the nurse use to provide a comfortable position to the client?

A. chair B. pillows C. side rails D. headboards Answer: B Rationale: The nurse should use pillows to provide a comfortable position to the client.

Pillows primarily are used for comfort, but they are also used to elevate a part of the body, relieve swelling, promote breathing, or help to maintain a therapeutic position. The client can be seated on a chair, but it does not provide comfort when the client is experiencing breathlessness. Side rails and headboards do not provide comfortable positions.

Question format: Multiple Choice Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 377 5. A nurse is caring for an older adult client confined to bed who reports an inability to sleep.

What activity should the nurse include in the client's plan of care to promote sleep?

A. sleeping about 1 to 2 hours during the day B. watching television before sleep C. performing chair exercises during the day D. going to bed in the early evening if the client feels fatigued Answer: C Rationale: The nurse should encourage the client to perform chair exercises during the day.

Exercise in a client confined to bed promotes sleep. Sleeping 1 to 2 hours during the day may interfere with nighttime sleep. Watching television before sleep may interfere with sleep

because it is stimulating in nature. The client is likely to have awakenings during the night if he goes to bed too early.

Question format: Multiple Choice Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 381 6. A nurse is caring for an older adult client who has been prescribed flurazepam by the physician. Which effect of flurazepam is a potential hazard for clients taking the medication?

A. drowsiness B. nausea and vomiting as a side effect C. excessive sleep due to cumulative effect D. risk of gastrointestinal upset Answer: A Rationale: Flurazepam is a hypnotic medication with a very long half-life. It tends to cause daytime drowsiness and increase the risk for falls. The nurse should, therefore, observe the client for falls and injury. Nausea and vomiting, excessive sleep, and gastrointestinal upset may be side effects but are not potential hazards.

Question format: Multiple Choice Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 382 7. A nurse is caring for an elderly client at a health care facility. What should the nurse do to provide an appropriate environment for the client?

A. Ensure that there are bright lights on during the night.

B. Ensure that the bed has raised side rails.

C. Ensure that the environment is warmer than normal.

D. Ensure that the client's belongings are in order.

Answer: C Rationale: The nurse should ensure that the environment is warmer than normal. Older adults tend to prefer warmer room temperatures because of decreased subcutaneous fat deposits.

Ensuring that bright lights are on during the night may interfere with good sleep. Raising side rails for safety may not be recommended. Ensuring that the client's belongings are in order is important, but is a secondary activity.

Question format: Multiple Choice Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 375

8. A nurse is supervising a nursing assistant who is preparing an occupied bed. What action by the nursing assistant indicates a need for further learning?

A. rolling the client to the far end of the bed B. pulling the draw sheet from below the client C. loosening the bed linen from one side of the bed D. wearing disposable gloves Answer: B Rationale: If the nursing assistant pulls the draw sheet from below the client, the assistant needs further instructions. Rolling the client to the far end of the bed, loosening the bed linen from one side, and wearing disposable gloves are the correct steps of bedmaking.

Question format: Multiple Choice Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Analyze Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 396 9. A nurse is caring for a client diagnosed with sleep apnea. What should the nurse do in order to promote sleep in the client?

A. Encourage the client to lose weight.

B. Avoid sedatives for sleeping.

C. Encourage deep breathing exercises.

D. Provide good ventilation in the room.

Answer: B Rationale: The nurse should avoid sedatives in the client because sedatives may depress respiration. The client with sleep apnea already has decreased ventilation and low blood oxygenation; the condition may become worse if the respiration is further depressed by sedatives. Losing weight is a long-term measure and is not applicable in this case.

Encouraging deep breathing exercises and providing good ventilation may help the client, but they are secondary measures.

Question format: Multiple Choice Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs Pn: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 384 10. A client visits a health care facility and reports that he falls asleep nearly immediately in the evening but often awakens between 4 and 5 a.m. The nurse should assess for: A. alcohol consumption.

B. regular exercise.

C. environmental stimulus.

D. recreational activities.

Answer: A

Rationale: The nurse should ask the client if he consumes alcohol before bedtime because alcohol reduces normal REM and deep sleep stages of NREM sleep. As alcohol is metabolized, stimulating chemicals that were blocked by the sedative effects of the alcohol surge forth from neurons, causing early awakening. Exercise, recreation, and environmental stimuli are unlikely to be the causes of this phenomenon.

Question format: Multiple Choice Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Reference: p. 382 11. A nurse is explaining to an insomniac client the effect of a prescribed medication and the different phases of sleep. Which statement is true for nonrapid eye movement (NREM) sleep?

A. It is called slow wave sleep.

B. It is called paradoxical sleep.

C. It is the deepest stage of sleep.

D. It is called active sleep.

Answer: A Rationale: Nonrapid eye movement sleep, which progresses through four stages, is also called slow wave sleep because during this phase, electroencephalographic (EEG) waves appear as progressively slower oscillations. The REM phase of sleep is referred to as paradoxical sleep because the EEG waves appear similar to those produced during periods of wakefulness, but it is the deepest stage of sleep. NREM sleep is characterized as quiet sleep and REM sleep as active sleep.

Question format: Multiple Choice Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 378 12. A nurse is caring for an older adult client with chronic back pain and a sleeping disorder.

The nurse suggests some relaxation techniques to be performed before bedtime. Which technique should the nurse suggest?

A. Drink a glass of milk.

B. Perform yoga.

C. Sit in a rocking chair.

D. Wear warm clothes.

Answer: C Rationale: The nurse should encourage older adult clients to use relaxation techniques before bedtime, such as chair rocking, imagery, meditation, deep breathing, progressive relaxation, soothing music, body or foot massage, reading nonstimulating materials, or watching nonstimulating television. Milk helps to induce sleep, but it is not a relaxation technique.

Likewise, warm clothes can make a person feel comfortable, but they are not a relaxation

technique. Asking older adult clients to perform yoga before bedtime may not be a good idea, as it could lead to indigestion and nausea.

Question format: Multiple Choice Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 388 13. A nurse suspects that an older adult's insomnia may be partially attributable to excessive daytime napping. The nurse has taught the client that the client may not need as much sleep as the client believes. The nurse should know that older adults typically require how much sleep in any given 24-hour period?

A. 5.5 to 7.5 hours B. 8 hours C. 7 to 9 hours D. 9 to 10 hours Answer: C Rationale: Although individuals vary in sleep needs considerably, most older adults require between 7 and 9 hours of sleep each day.

Question format: Multiple Choice Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 379 14. A 78-year-old resident of an assisted living facility has told the nurse of often feeling tired during the day but experiencing frequent awakenings during the night. The nurse is conducting a comprehensive sleep assessment. The nurse should be aware of what change in sleep characteristic that accompanies older age?

A. a gradual decrease in the amount of sleep required B. an increase in the proportion of REM sleep C. an absence of recognizable sleep cycles D. an increase in the intensity of dreams Answer: B Rationale: In older age, the percentage of time spent in REM sleep increases to 13% to 15%.

Sleep requirements are similar to those of younger adults. Dreams are not noted to intensify, and sleep cycles are present at all ages.

Question format: Multiple Choice Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 379

15. A female client has been admitted to the hospital with a diagnosis of pneumonia and admitted to a four-bed room. The client has found it difficult to sleep in this environment and explained this to the nurse. The nurse's first action in response to this client's complaint should be to: A. facilitate as many aspects of the client's sleep rituals as possible.

B. encourage the client to take naps during the day to reduce her nighttime sleep needs.

C. obtain a prescription for a benzodiazepine from the client's physician.

D. administer more of the client's medications in the morning rather than the evening.

Answer: A Rationale: Whenever possible, the nurse should facilitate a client's sleep rituals. This is preferable to using medications to produce sleep. It would be inappropriate, and likely ineffective, for the nurse to change the timing of the client's medications. Napping excessively may exacerbate rather than alleviate the problem.

Question format: Multiple Choice Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 381 16. A man with numerous comorbid health problems has presented to the clinic for a scheduled appointment. The man states that he has been awakening frequently during the night to void. The nurse should inquire about the time of day that the client is taking his prescribed: A. anticoagulant.

B. antihyperglycemic.

C. diuretic.

D. stool softener.

Answer: C Rationale: Diuretics should be taken in the morning to prevent nocturia. Anticoagulants, diabetes medications, and stool softeners do not have this effect.

Question format: Multiple Choice Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Analyze Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 381 17. A client reports to the nurse, "Sleep really isn't necessary." Which teaching by the nurse is appropriate? Select all that apply.

A. "Sleep helps your blood flow to the brain."

B. "Sleep can make your moods fluctuate over time."

C. "Sleep helps you to learn easier and remember more."

D. "Sleep takes time, which can be stressful for some people."

E. "Sleep helps your immune system to fight off infections."

Answer: A, C, E Rationale: In addition to promoting emotional well-being, sleep enhances various physiologic processes. Sleep is believed to play a role in the following: reducing fatigue, stabilizing mood, improving blood flow to the brain, increasing protein synthesis, maintaining the disease-fighting mechanisms of the immune system, promoting cellular growth and repair, and improving the capacity for learning and memory storage. It is not appropriate, nor accurate, to teach the client that sleep can be stressful or that sleep can cause mood fluctuations.

Question format: Multiple Select Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 378 18. The nurse is educating a client and spouse about sudden jerking that occurs during sleep.

What is the most appropriate nursing response?

A. "Sudden twitches that occur during the early phases of sleep are common."

B. "Those are hypnogogic twitches that happen during REM sleep."

C. "Sudden jerking movements can indicate vivid dreaming."

D. "When oxygen levels drop during sleep, muscles will jerk suddenly."

Answer: A Rationale: Nonrapid eye movement (NREM) is quiet sleep. NREM 1 sleep, which occurs at the onset of sleep and lasts about 10 minutes, is characterized as drowsiness and light sleep.

Sudden twitches, called hypnogogic jerks, are common. During this early stage of sleep, a person may be aware of sounds and conversations, but avoids arousal. Sudden jerking movements do not indicate vivid dreams and do not occur during REM sleep. A decreased oxygen level does not cause hypnogogic jerks.

Question format: Multiple Choice Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 378 19. An 82-year-old client is newly admitted to an assisted living facility. Which intervention promotes safety at night for the client?

A. using a night light in the bathroom B. leaving a bright light on in the bathroom C. administering diuretics at bedtime D. leaving the door open to the nursing hallway Answer: A Rationale: Using night lights rather than bright room lights is preferred if an older adult arises during the night. Bright lights stimulate the brain and interfere with efforts to resume sleep.

Administering a diuretic at night will cause nocturnal diuresis, causing the client to be up more at night. Leaving the door open to the nursing hallway does not promote safety.

Question format: Multiple Choice Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 381 20. A nursing student is changing the client's bed. Which action requires intervention from the nursing instructor?

A. placing the bed in a high position B. removing the call light attached to the bed sheet C. tossing soiled linen on the floor D. placing the clean linen on a dry bedside table Answer: C Rationale: Soiled linen should be placed directly into a pillow case or laundry hamper to prevent transferring microorganisms. Placing soiled linen on the floor requires intervention by the instructor to prevent the unnecessary spread of microorganisms. Placing the bed in a high position is appropriate, as it reduces back strain. Anything attached to the linens should be removed prior to changing the bed, and clean linen should be placed on a clean, dry surface, such as the bedside table or chair.

Question format: Multiple Choice Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 377 21. The nurse is caring for a client with narcolepsy. The client reports experiencing being unable to move upon awakening from sleep. The client's spouse states that the client makes sandwiches in the middle of the night, yet the client does not recall this behavior. How does the nurse document these concerns?

A. sleep paralysis and hypnogogic hallucinations B. cataplexy and hypnogogic hallucinations C. hypnogogic hallucinations and sleep paralysis D. sleep paralysis and automatic behavior Answer: D Rationale: Sleep paralysis occurs when the person cannot move for a few minutes just before falling asleep or awakening. Cataplexy occurs with a sudden loss of muscle tone triggered by an emotional change such as laughing or anger. Hypnogogic hallucinations are dream-like auditory or visual experiences while dozing or falling asleep. Automatic behavior is the performance of routine tasks without full awareness, or later memory, of having done them.

This client experiences sleep paralysis and automatic behavior.

Question format: Multiple Choice Chapter 18: Comfort, Rest, and Sleep

Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Communication and Documentation Reference: p. 385 22. The nurse is caring for a client on the acute care unit who experiences automatic behaviors associated with narcolepsy. What is the priority nursing intervention?

A. Contact the health care provider to consider prescribing a stimulant drug.

B. Educate the client about other symptoms that may be experienced, such as sleep paralysis.

C. Keep the client safe by monitoring ambulation on the unit.

D. Ask the client about willingness to explore taking an antidepressant to reduce symptoms associated with atypical REM sleep.

Answer: C Rationale: Safety is the priority factor in the client's care. Activity should be monitored in case sleep paralysis or sleep should occur while walking in or out of the client's room. A stimulant drug may be ordered but would not be the priority in the care of the client.

Antidepressants may exacerbate the disorder by increasing sleepiness.

Question format: Multiple Choice Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 385 23. The caregiver of a preschool-age child tells the nurse, "I am afraid my child sleeps too much," and reports that the child takes a daily 2-hour nap in addition to sleeping 12 hours at night. What is the appropriate nursing response?

A. "Your child should get 14-17 total hours of sleep time in a 24-hour period."

B. "Your child should get 12-15 total hours of sleep time in a 24-hour period."

C. "Your child should get 10-13 total hours of sleep time in a 24-hour period."

D. "Your child should get 9-11 total hours of sleep time in a 24-hour period."

Answer: C Rationale: Preschoolers, age 3-5, should get 10-13 total hours of sleep time in a 24-hour period. Newborns (0-3 months) require 14-17 total hours of sleep time in a 24-hour period.

Infants (4-11 months) require 12-15 total hours of sleep time in a 24-hour period. Schoolagers (6-13 years old) require 9-11 total hours of sleep time in a 24-hour period.

Question format: Multiple Choice Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 379 24. The nurse is teaching a client with seasonal affective disorder about proper use of a fullspectrum light. Which teaching will the nurse include?

A. Begin using the light in April or May.

B. Eyeglasses or contact lenses with ultraviolet filters should be used while using the light.

C. Sit within 3 ft (1 m) of the light for approximately 2 hours soon after awakening.

D. Do not engage in other activities while undergoing full-spectrum light therapy.

Answer: C Rationale: The client should sit within 3 ft (1 m) of the artificial light for approximately 2 hours soon after awakening from sleep. Light exposure should begin in October or November, not April or May. Eyeglasses and contact lenses with ultraviolet filters should be removed before using the light. Other activities may take place, such as reading or handiwork, while periodically glancing at the light.

Question format: Multiple Choice Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 385 25. A client taking a diuretic twice daily for treatment of hypertension reports being awakened often by a full bladder. What teaching regarding the diuretic will the nurse provide?

A. Take it immediately before going to sleep.

B. Take it before 6:00 p.m. at night.

C. Skip the bedtime dose of medication.

D. Take the second dose when awakening to urinate.

Answer: B Rationale: The client taking a diuretic may awaken at night with a full bladder. The nurse will teach the client to take the second dose of the medication before 6:00 p.m. at night so that urination is accomplished before going to sleep. The other options are not appropriate for the nurse to teach the client.

Question format: Multiple Choice Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 383 26. The nurse is caring for a client who reports insomnia. The client has recently moved from an area near a fire station in the inner city to the country. Which recommendation will the nurse make to facilitate sleep?

A. Enjoy the peace and quiet of the country.

B. Find a phone app that plays sounds of the city.

C. Avoid eating right before bedtime.

D. Ingest 1 ounce of liquor before going to sleep.

Answer: B

Rationale: Clients tend to adapt to the unique sounds where they live, such as traffic, trains, and the hum of appliance motors or furnaces. Unfamiliar sounds tend to interfere with the ability to fall or stay asleep. The nurse will recommend that the client find an app that plays sounds of the city, which mimics the sounds with which the client is most familiar. Ignoring the problem by telling the client to adapt to the new environment does not address the problem. Avoiding eating before bedtime could cause the client to wake up hungry in the middle of the night. The nurse does not recommend alcohol, a depressive drug, to clients.

Question format: Multiple Choice Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 384 27. A nurse is caring for a client with insomnia. Which teaching will the nurse provide to help the client improve sleep?

A. "Create a bedtime routine."

B. "Limit fluids in the evening."

C. "Eat a heavy meal for dinner."

D. "Watch television in bed before sleep."

Answer: A Rationale: Sleep is believed to play an important role in reducing fatigue, stabilizing mood, and improving blood flow to the brain, among other things. Creating a bedtime routine helps the client's mind and body know when it is time to sleep. The bed should not be used to watch television as this will confuse the bedtime routine. Insomnia is not known to be related to fluid intake in the evening, unless those fluids contain caffeine.

Question format: Multiple Choice Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 384 28. A nurse on the night shift notices that a client is grinding the teeth while sleeping. Which information will the nurse teach the client? Select all that apply.

A. Teeth grinding is called bruxism.

B. Teeth grinding can be caused by stress.

C. You should observe for damage to teeth.

D. With teeth grinding you should get regular dental care.

E. You should limit caffeine at night.

Answer: A, B, C, D, E Rationale: The nurse will share that bruxism is also known as teeth grinding. Teeth grinding can lead to damage of the teeth and regular dental care is recommended. Smoking tobacco, drinking caffeinated beverages or alcohol at night, or using recreational drugs may increase the risk of bruxism. Increased anxiety or stress can lead to teeth grinding. So can anger and frustration.

Question format: Multiple Select Chapter 18: Comfort, Rest, and Sleep Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 386

Chapter 19 1. A nurse in a psychiatric care unit finds that a client with psychosis has become violent and is actively trying to harm another client in the unit. What action should the nurse take?

A. Step in front of the client so that the other client will be protected.

B. Call for assistance to remove the client from the area.

C. Forcefully remove the client and place in four-point restraints.

D. Inject the client while being restrained with antipsychotic medication.

Answer: B Rationale: The nurse should attempt to redirect the client away from the other client with assistance prior to attempting to use force. Stepping in front of the client who is violent may result in the nurse or other personnel becoming injured. Restraints should be a last measure to keep the client under control and avoid injury to the client or others. Injecting a client without their consent is a form of chemical restraint.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs Pn: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 412 2. A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take?

A. Evacuate the unit.

B. Pull the fire alarm lever.

C. Confine the fire.

D. Extinguish the fire.

Answer: B Rationale: The nurse should pull the fire alarm lever. As per the RACE principle of fire management, the flow of activities should be rescue, alarm, confine, and extinguish. The client had already been evacuated by another nurse, so the next action should be to pull the fire alarm lever, followed by confinement of the fire and extinguishing.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs Pn: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 405 3. A nurse is caring for an older adult client at risk of injury due to confusion. The client has a stable gait. Which method of restraining should the nurse use?

A. waist restraint

B. locking lap tray chair C. alarm-activating bracelet D. vest restraint Answer: C Rationale: The nurse should use an alarm-activating bracelet for the client because the client has a stable gait. This prevents unnecessary confinement to bed, and the client can move freely without getting off the premises. Waist restraints, vest restraints, and chair restraints are restrictive, and their use should be minimal.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 413 4. A nurse is caring for a client who is receiving an intravenous therapy through an IV pump.

Which intervention should the nurse implement to ensure electrical safety?

A. Obtain a three-prong grounded plug adapter.

B. Use an extension cord to provide freedom of movement.

C. Tape the electrical cord of the pump to the floor.

D. Run the electrical cord of the pump under the carpet.

Answer: A Rationale: The nurse should obtain a three-prong grounded plug adapter, as it carries any stray electricity back to the ground. Using an extension cord may be an electrical hazard.

Taping the electrical cord to the ground and running the electrical cord under the carpet are not appropriate actions for electrical safety.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs Pn: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 409 5. In a nursing unit, a physician is about to defibrillate a client. What is an appropriate action when the physician says "clear"?

A. Shut off all the equipment.

B. Put the conductive gel pads in place.

C. Step away from the bed.

D. Shut off the IV fluid.

Answer: C Rationale: The nurse should step away from the bed when the physician says "clear" while defibrillating a client. The defibrillator discharges electricity, which can be conducted through the bed, and anybody in contact with the bed can be affected. The conductive gel

pads are put in place before defibrillation. Shutting off the IV line and the equipment are incorrect nursing actions in this case.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs Pn: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 409 6. A nurse is educating a mother about caring for a newborn baby. What should the nurse teach the client as a precautionary measure to protect the infant from burns?

A. Keep hot substances away from the baby.

B. Keep hot substances on the table.

C. Monitor the activities of the infant closely.

D. Keep the infant away from the kitchen.

Answer: A Rationale: The nurse should teach the client to keep hot substances away from the baby to prevent burns in the baby. Infants are not very mobile and depend on their parents for their care. Keeping hot substances on the table, monitoring the activities of the infant closely, and keeping the infant away from the kitchen are important but may not be appropriate, as the baby is not yet mobile.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 401 7. A nurse has rushed to the site of an accident where members of a family have suffered carbon monoxide poisoning. What is the priority action that must take place during carbon monoxide poisoning?

A. Treat with hyperbaric oxygen.

B. Remove the individual from the room.

C. Open the doors and windows of the room.

D. Give oxygen to the individual.

Answer: B Rationale: The first step in handling accidental carbon monoxide poisoning is to remove the individual from the site. If moving the person out of doors is impossible, rescuers should open windows and doors to reduce the level of toxic gas and promote the client's ventilation of air. Once emergency personnel arrive, they administer oxygen. In the case of extremely high blood levels of carbon monoxide, the victim may be treated with hyperbaric oxygen.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control

Client Needs Pn: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 407 8. A nurse is caring for a stable toddler diagnosed with accidental poisoning due to the ingestion of cleaning solution. What must be included in educating parents about how to protect a toddler from unintentional poisoning?

A. Closely monitor the toddler's activity.

B. Label poisonous solutions.

C. Keep cleaning solutions locked up.

D. Do not leave the toddler alone.

Answer: C Rationale: The parents should keep cleaning solutions locked up to protect the toddler from unintentional poisoning. Unintentional poisonings usually occur among toddlers and commonly involve substances located in bathrooms or kitchens. Labeling poisonous substances may not help, as toddlers are unable to read. Not leaving the child alone and closely monitoring the child are important, but not feasible all the time.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 409 9. A nurse on a home visit to a healthy elderly client finds that too much clutter has accumulated in the house. What is the most appropriate nursing diagnosis for the client?

A. Impaired home maintenance B. Disturbed sensory perception C. Impaired mobility D. Impaired walking Answer: A Rationale: The most appropriate nursing diagnosis for the client is Impaired home maintenance. Clutter may accumulate around the house if an older adult lacks the energy to clean or does not want to discard old items. Diagnoses of Disturbed sensory perception, Impaired mobility, or Impaired walking may not necessarily be applicable.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs Pn: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 414-415 10. A 17-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to: A. falls from beds.

B. automobile accidents.

C. play-related injuries.

D. falls from staircases.

Answer: B Rationale: Adolescents are prone to injuries related to activities that involve high risk, such as driving. Adolescents tend to be impulsive and take unnecessary risks as a result of peer pressure. Falling from the bed is common in infants. Play-related injuries are commonly seen in school-age children, and falling from staircases is a common injury among toddlers.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 402 11. A nurse finds that a fire has broken out in a client's room at the health care facility. Which intervention is the priority?

A. Extinguish the fire.

B. Evacuate the client.

C. Raise an alarm.

D. Confine the fire.

Answer: B Rationale: The first priority in case of fire is to evacuate the client. As per the RACE principle of fire management, the rescue of the client is the first step, followed by raising an alarm, confining the fire, and finally, extinguishing the fire.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 405 12. A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning?

A. Instruct the toddler not to go near the pool.

B. Avoid unattended baths for the toddler.

C. Monitor the activities of the toddler.

D. Allow the child to swim with friends.

Answer: B Rationale: The parents should not leave the toddler for an unattended bath. Toddlers are naturally inquisitive, and instructing them to stay away from the pool may make them more curious. Monitoring the activities of the toddler is not always feasible. Allowing the child to swim with friends does not ensure safety.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 408 13. A stable client is brought to the emergency department after ingesting too much prescribed medication. What is the priority nursing intervention?

A. Call family members.

B. Call the physician.

C. Administer antacids.

D. Induce vomiting.

Answer: D Rationale: The nurse should induce vomiting in the client if the client has ingested too much prescribed medication and is alert. Calling family members and the physician are not important immediately. Administering antacids is not an appropriate intervention.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 409 14. A nurse needs to restrain a client who may be harmful to himself. What is the priority nursing action when applying restraints?

A. Take a physician's order for restraining.

B. Administer chemical restraints first.

C. Put padding below the restraints.

D. Reassess the client's condition every 2 hours.

Answer: A Rationale: The nurse should get a physician's order for using restraints on the client.

Administering chemical restraints without a physician's order is illegal. Putting a pad below the restraints is important, but only after getting an order from the physician. Reassessing the client's condition should happen more often than every 2 hours.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 412 15. A nurse is preparing discharge teaching for a client being discharged with her newborn baby. What is the priority item that must be included in the teaching plan?

A. Lock all cabinets that contain cleaning supplies.

B. Keep all pots and pans in lower cabinets.

C. Give warm bottles of formula to the baby.

D. Restrain the baby in a car seat.

Answer: D Rationale: The client should restrain the baby in a car seat when driving. Infants are especially vulnerable to injuries resulting from falling off changing tables or being unrestrained in automobiles. Locking the cabinets and giving warm bottles of formula to the baby are secondary teachings.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 412-413 16. A nurse is caring for a client who is sensitive to latex. What is the simplest and most appropriate way to avoid exposing the client to latex?

A. Use nonlatex gloves for the client.

B. Collect the appropriate history of the allergy.

C. Wash hands before performing any procedure on the client.

D. Instruct the client to stay away from latex products.

Answer: A Rationale: The nurse should use nonlatex gloves when providing care to the client. The collection of an allergy history may not help in preventing latex exposure. Washing hands before any procedure on the client may not help if the gloves are made of latex. Instructing the client to stay away from latex products may not be helpful if the products around the client are made of latex.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 401-402 17. An unconscious client is brought to the emergency department after ingesting too much prescribed medication. What is the priority nursing intervention?

A. Call family members.

B. Establish IV access.

C. Administer antacids.

D. Establish a patent airway.

Answer: D Rationale: Initial treatment for a victim of suspected poisoning involves maintaining breathing and cardiac function. This is a priority over communication with the family, establishing IV access, or administering other medications.

Question format: Multiple Choice

Chapter 19: Safety Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 409 18. A nurse who is a member of a hospital's client safety committee is participating in an initiative to ensure that the institution meets the National Patient Safety Goals. What is the most important way in which this committee can meet these goals?

A. Institute measures to reduce clients' risks of death and injury while they are receiving care.

B. Enact guidelines for health promotion and primary disease prevention.

C. Educate caregivers about the appropriate use of standard infection control precautions.

D. Educate clients and families about actions they can take to protect their health while in the hospital.

Answer: A Rationale: The purpose of these goals is to help health care organizations obtain and retain their accreditation by demonstrating safe and effective care. The primary method of achieving this is by reducing the risk of adverse client outcomes. Health promotion, disease prevention, and the use of standard precautions all facilitate healthy outcomes, but these do not directly address the issue of safety.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 400 19. A nurse has entered the room of a resident at the care facility and discovered that the resident has lit some paper on fire in the trash can. What types of fire extinguisher are appropriate for putting out this fire? Select all that apply.

A. Class A B. Class B C. Class C D. Class D E. Class ABC Answer: A, E Rationale: Class A fire extinguishers are ideal for fires caused by burning paper, wood, or cloth. Class B and C extinguishers are intended for flammable liquids and electrical fires, respectively. There is no Class D of fire extinguishers. Class ABC extinguishers may be used on any type of fire.

Question format: Multiple Select Chapter 19: Safety Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 406

20. Public health nurses in a community are advocating for new community guidelines to enhance the safety of residents. Residents' risks of accidental asphyxiation can be reduced by which measure?

A. ensuring that open bodies of water and pools are fenced in B. enacting legislation to protect the air quality in the community C. teaching CPR to as many residents as possible D. teaching parents to keep cleaning products and chemicals in safe locations Answer: A Rationale: Drowning is a significant cause of accidental asphyxiation. Consequently, actions that prevent young children from falling into pools and water bodies may reduce this risk.

Asphyxiation does not result directly from poor environmental air quality. CPR skills can be used to treat asphyxiation emergencies but not to prevent them from occurring. Poisoning does not normally result in asphyxiation.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 405 21. A nurse has been commissioned to ensure that the policies and procedures at a large, multisite health care institution comply with the Nursing Home Reform Law. What trend initially prompted the enactment of this legislation?

A. the high incidence of accidental poisonings among older adults living in care facilities B. the widespread use of physical restraints in long-term care facilities C. increases in the number of falls among older adults and the deaths attributable to falls D. a series of fires that occurred in nursing homes in the 1980s Answer: B Rationale: After research studies revealed the widespread use of physical restraints in longterm care facilities, federal legislation known as the Nursing Home Reform Law was incorporated in the Omnibus Budget Reconciliation Act (OBRA) in 1987.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 413 22. A nurse who works with older adults is aware of the high incidence of falls among this population. Which individual exhibits a significant risk factor for falls?

A. a man who recently had surgery to repair a fractured humerus (upper arm) B. a man who has been recently diagnosed with type 2 diabetes C. a woman who takes anticoagulants because of her history of stroke D. a woman who is prone to episodes of low blood pressure

Answer: D Rationale: Low blood pressure can lead to loss of balance or loss of consciousness, leading to falls. Arm surgery, diabetes, and anticoagulants are not frequently implicated in older adults' falls.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 410 23. The nurse is teaching the caregiver of a 3-year-old about safety. Which teaching will the nurse include?

A. Supervise your child on the changing table.

B. Place all household cleaners out of reach.

C. Buy protective sporting equipment.

D. Peer pressure causes children of this age to take risks.

Answer: B Rationale: Household chemicals, which are associated with a risk for poisoning, should be placed out of the toddler's reach. Infants should be supervised on a changing table. Protective sporting gear should be purchased for school-age children who are physically active.

Adolescents tend to be impulsive and take risks as a result of peer pressure.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 409 24. The nurse is teaching the caregiver of an adolescent child about safety. Which teaching will the nurse include?

A. Supervise your child on the changing table.

B. Place all household cleaners out of reach.

C. Buy protective sporting equipment.

D. Peer pressure causes children of this age to take risks.

Answer: D Rationale: Adolescents tend to be impulsive and take risks as a result of peer pressure, so this is important for the nurse to teach the adolescent. Buying protective sporting equipment, placing household cleaners out of reach, and supervising the child on the changing table are not age-appropriate teachings to include.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning

Reference: p. 401 25. The nurse is caring for four clients. Which does the nurse anticipate may have a latex sensitivity?

A. 21-year-old who cannot eat bananas B. 30-year-old who is lactose intolerant C. 43-year-old who avoids nuts due to diverticulitis D. 55-year-old who does not drink orange juice due to gastroesophageal reflux disease (GERD) Answer: A Rationale: The molecular structure of latex is similar to avocados, bananas, almonds, peaches, kiwi, and tomatoes. The nurse will anticipate that the client who cannot eat bananas may have a latex sensitivity. The other options do not relate to latex sensitivity.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 401-402 26. The nurse is caring for a client with a latex allergy. Which nursing interventions are appropriate? Select all that apply.

A. Flag the chart and room door.

B. Apply an allergy-alert identification bracelet on the client.

C. Assign the client to a semi-private room so the roommate can report any reactions.

D. Communicate to the interdisciplinary health care team to use nonlatex equipment.

E. Remove blueberries from the client's dietary tray.

F. Teach the client to wear a Medic-Alert bracelet.

Answer: A, B, D, F Rationale: When caring for a client with a latex allergy, the chart and room should be flagged to reflect the client's status. The nurse will apply an allergy-alert identification bracelet and assign the client to a private room that can be kept free of latex equipment. Other members of the interdisciplinary team should be notified to use nonlatex equipment. Blueberries are not contraindicated for clients with a latex allergy. The nurse will teach the client to wear a Medic-Alert bracelet at all times for safety purposes.

Question format: Multiple Select Chapter 19: Safety Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 402 27. The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement requires immediate nursing intervention?

A. "I will rescue clients from harm before doing anything else."

B. "After clients are evacuated from the room with the fire, the alarm can be sounded."

C. "I will close the door to the room where the fire is after clients have been removed."

D. "Only certain members of the health care team can extinguish a fire."

Answer: D Rationale: All members of the health care team are educated about how to extinguish a fire.

Therefore, the UAP's statement about certain members being taught how to use the fire extinguisher requires correction. The other statements are appropriate.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 405 28. The telehealth nurse receives a call stating that upon entering a family member's home, two people have been found semi-conscious with a bright cherry red skin color. They are reporting nausea and headache, and are unable to move. Which initial direction will the nurse provide?

A. Open doors and windows.

B. Wait inside until emergency personnel arrive.

C. Allow emergency personnel to apply oxygen.

D. Recommend that carbon monoxide detectors be installed in the home.

Answer: A Rationale: Carbon monoxide (CO) is extremely lethal because it is colorless, odorless, and tasteless. The nurse recognizes symptoms of bright cherry red skin color, nausea, headache, and inability to move. The initial direction will be for the caller to open doors and windows to reduce the level of toxic gas and provide adequate ventilation. If, while waiting for emergency personnel to arrive, the family members gain the ability to move, they can evacuate outdoors. After having the caller open doors and windows, the nurse can then provide instructions about emergency personnel and further discuss CO detectors.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 407 29. The poison control nurse receives a call from the caregiver of a young school-age child who may have ingested a poisonous substance. Which is the priority response by the nurse?

A. "Check breathing and heart rate."

B. "What do you think that the child might have ingested?"

C. "At what time did the child ingest the substance?"

D. "Induce vomiting while you wait for emergency personnel to arrive."

Answer: A

Rationale: Initial treatment for a victim of suspected poisoning involves maintaining breathing and cardiac function. After that, rescuers attempt to identify what was ingested, how much, and when. Definitive treatment depends on the substance, the client's condition, and if the substance is still in the stomach.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 409 30. The nurse is caring for a client with Alzheimer's disease. A family member states, "I am afraid I will go to bed one night, and the next morning my loved one will be missing from wandering off." What is the appropriate nursing response?

A. "Clients with Alzheimer's disease often wander."

B. "Consider the Alzheimer's Association 'Safe Return' program."

C. "Adjust sleeping schedules so that you can monitor your loved one as they sleep."

D. "I know, my parent has Alzheimer's disease and I worry about that too."

Answer: B Rationale: The appropriate nursing response is to refer the client's family member to a program such as the Alzheimer's Association's "Safe Return" program. This validates the family member's concern and provides a resource. Validating that clients with this disorder wander does not provide a solution to the concern, and recommending that the family member adjust sleeping schedules is not realistic. The nurse should not verbalize his or her own concerns, but rather should focus on the needs of the client and family members.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 413 31. The nurse is caring for a client who has been placed in physical restraints. Which nursing action is appropriate? Select all that apply.

A. Obtain a physician order 2 hours after restraints are applied.

B. Communicate with the family regarding the need for restraints.

C. Check circulation and skin condition frequently and regularly.

D. Offer opportunities for toileting frequently and regularly.

E. Continue using the restraints until discharge.

Answer: B, C, D Rationale: An order for restraints from the licensed health care provider must be obtained within 1 hour after the restraint is initiated. The nurse must provide frequent and regular nursing assessments of the restrained client's vital signs; circulation; skin condition or signs of injury; psychological status and comfort; and readiness for discontinuing restraint. In addition, the nurse must offer regular toileting, nutrition, hydration, and range of motion opportunities while the client is restrained. The nurse promptly communicates with the

client's family regarding the need for restraints. When the assessment findings indicate that the client has improved, the nurse must legally and ethically remove the restraints. Restraints are not continued until discharge.

Question format: Multiple Select Chapter 19: Safety Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 412 32. The nursing instructor is observing a nursing student who is about to administer a medication. Which nursing student behavior concerning client identification does the nursing instructor validate as appropriate?

A. identifies client's last name and room number B. identifies client's date of birth and last name C. identifies client's full name and date of birth D. identifies client's room number and full name Answer: C Rationale: National Patient Safety Goals require that two methods for identification (e.g., the client's name and date of birth) be confirmed prior to administration of medications or treatments. Room numbers should not be used, since clients may be assigned to different rooms throughout a stay. Identifying a last name is not enough information to thoroughly confirm identification.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 401 33. A nurse visits an older adult client at home and assesses the safety of the client's environment. Multiple small rugs are located in the home. Which statement by the nurse is appropriate when addressing the client's safety?

A. "Your home needs to be a safe environment as older adults have a tendency to fall."

B. "I think you should replace your small rugs with skid-resistant rugs on the floor."

C. "I am concerned that the small rugs in your home can be a tripping hazard."

D. "You need to remove the small rugs from your house or you will fall."

Answer: C Rationale: The nurse can open up the conversation by stating concern about the small rugs.

The conversation provides education through problem-solving. If the nurse demands or states generalities, the nurse will not gain the needed cooperation from the client. The older adult client should remove all area rugs, even if skid resistant, to prevent accidental injury.

Question format: Multiple Choice Chapter 19: Safety Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Safety and Infection Control

Integrated Process: Teaching/Learning Reference: p. 411

Chapter 20 1. A nurse is caring for a client with cancer who is experiencing pain. What would be the most appropriate assessment of the client's pain?

A. the client's recent responses to pain and to pain medication B. nonverbal cues of the client C. the nurse's impression of the client's pain D. the client's pain based on a pain rating Answer: D Rationale: The client's assessment of pain, based on a pain rating, is the most appropriate assessment data. The pain is rated on a 0 to 10 scale and nursing actions are then implemented to reduce the pain. The nurse's impression of pain and nonverbal clues are subjective data which should be considered, but which are not more important than the pain rating. Pain relief after nursing intervention is appropriate, but is a part of evaluation.

Question format: Multiple Choice Chapter 20: Pain Management Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs Pn: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 428 2. A nurse is caring for a client who was administered opioid narcotics. The client reports constipation. What is another potential side effect of opioid narcotics?

A. sedation B. anxiety C. diarrhea D. insomnia Answer: A Rationale: Opioids and opiates can cause sedation, nausea, and constipation. They also can cause respiratory depression, which is the main side effect to watch for with narcotics.

Opioids and opiates do not lead to anxiety, diarrhea, or insomnia in clients.

Question format: Multiple Choice Chapter 20: Pain Management Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 430 3. A nurse is caring for a client who has undergone a surgical intervention in which the pain pathways in the spinal cord have been interrupted to control pain in his back. The nurse knows that the client has undergone which treatment?

A. cordotomy

B. tubectomy C. rhizotomy D. osteotomy Answer: A Rationale: The client has undergone a cordotomy, which is the surgical interruption of pain pathways in the spinal cord to control pain. A tubectomy, in general terms, means the cutting of the fallopian tubes. A rhizotomy is the surgical sectioning of a nerve root close to the spinal cord. It prevents sensory impulses from entering the spinal cord and traveling to the brain. An osteotomy is a surgical operation whereby a bone is cut to shorten, lengthen, or change its alignment.

Question format: Multiple Choice Chapter 20: Pain Management Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 433 4. A nurse is caring for a middle-aged client with acute abdominal pain at a health care facility. The physician has asked the nurse to administer a prescribed dosage of narcotics to the client to relieve the pain. The client has a throat infection and is unable to take the medication orally. What other delivery route might the physician prescribe?

A. sublingual route B. intramuscular route C. dermal route D. transdermal route Answer: D Rationale: The nurse can administer the prescribed dosage of narcotics to the client by the transdermal, oral, rectal, or parenteral route. The nurse should avoid the sublingual, dermal, and intramuscular routes. Administration of the drug through the intramuscular route could result in slower absorption, leading to delayed onset of action, prolonged duration, and altered absorption with potential for toxicity.

Question format: Multiple Choice Chapter 20: Pain Management Cognitive Level: Remember Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 430 5. A nurse is caring for a client with dull ache in her abdomen. On the way to the health care facility, the client vomits and shows symptoms of pallor. What kind of pain is the client experiencing?

A. visceral pain B. cutaneous pain C. somatic pain D. neuropathic pain

Answer: A Rationale: The client is experiencing visceral pain, which is associated with disease or injury.

It is sometimes poorly localized as it is not experienced in the exact site where an organ is located. In cutaneous pain, the discomfort originates at the skin level and is a commonly experienced sensation resulting from some form of trauma. Somatic pain develops from injury to structures such as muscles, tendons, and joints. Neuropathic pain is experienced days, weeks, or even months after the source of the pain has been treated and resolved.

Question format: Multiple Choice Chapter 20: Pain Management Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 425 6. A middle-age client with cancer has been prescribed patient-controlled analgesia (PCA).

The nurse caring for the client explains the functioning of PCA. What is the main advantage of PCA? A. The client obtains pain relief slowly and steadily.

B. The client requires less nursing care.

C. The client is able to have long hours of rest.

D. The client is actively involved in pain management.

Answer: D Rationale: Patient-controlled analgesia (PCA) gives the client the advantage of playing an active role in pain management, as the client is allowed to self-administer medication. Pain relief is rapid, not slow and steady, because the drug is delivered intravenously. PCA does not replace nursing care or reduce the amount of care that the client requires.

Question format: Multiple Choice Chapter 20: Pain Management Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 430-431 7. A physician is explaining to the client the role of endogenous opioids in the transmission of pain. What happens when endogenous opioids are released?

A. They bind to sites on the nerve cell's membrane.

B. They react with acetylcholine and serotonin.

C. They occupy cell receptors for neurotransmitters.

D. They block glutamate receptors and peptides.

Answer: A Rationale: When endogenous opioids are released, they are thought to bind to sites on the nerve cell's membrane that block the transmission of pain-conducting neurotransmitters such as substance P and prostaglandins. Endogenous opioids do not occupy cell receptors for

neurotransmitters like acetylcholine and serotonin, but efforts are being made to develop pain-modulating drugs that will do so and will also block glutamate receptors and peptides.

Question format: Multiple Choice Chapter 20: Pain Management Cognitive Level: Remember Client Needs Pn: Physiological Integrity: Physiological Adaptation Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 425 8. A client having acute pain tells the nurse that her pain has gradually reduced, but that she fears it could recur and become chronic. What is a characteristic of chronic pain?

A. Chronic pain will lead to psychological imbalance.

B. Chronic pain has far-reaching effects on the client.

C. Chronic pain can be severe in its initial stages.

D. Chronic pain eases with healing and eventually disappears.

Answer: B Rationale: Chronic pain has far-reaching effects on the client because the discomfort lasts longer than 6 months. Chronic pain is not as severe in the initial stage as acute pain, but does not disappear eventually with pain medication. Chronic pain need not always lead to psychological imbalance.

Question format: Multiple Choice Chapter 20: Pain Management Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 426 9. A nurse is assessing a mentally challenged adult client who is in pain after a fall from a staircase. Which scale should the nurse use to assess the client's pain?

A. numeric scale B. word scale C. linear scale D. FACES scale Answer: D Rationale: The nurse should use the Wong-Baker FACES scale, which is best for children and clients who are culturally diverse or mentally challenged. Nurses generally use a numeric scale, a word scale, or a linear scale to quantify the pain intensity of adult clients who can express their pain intensity in words, numbers, or linear fashion.

Question format: Multiple Choice Chapter 20: Pain Management Cognitive Level: Analyze Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 428

10. A neurosurgeon has performed a cordotomy on a client having intractable pain. Which procedure is involved in a cordotomy?

A. surgical sectioning of a nerve root close to the spinal cord B. delivering bursts of electricity to the skin and underlying nerves C. surgical interruption of pain pathways in the spinal cord D. connecting electromyography machine to control pain Answer: C Rationale: In cordotomy surgery, the neurosurgeon surgically interrupts the pain pathways in the spinal cord by cutting bundles of nerves. A rhizotomy involves the surgical sectioning of a nerve root close to the spinal cord. In TENS, the client is given bursts of electricity to the skin and underlying nerves, whereas in biofeedback, the client is connected to an electromyography machine to control pain.

Question format: Multiple Choice Chapter 20: Pain Management Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 433 11. A nurse is caring for a client with neck pain. The nurse is explaining neck pain and some basic methods for pain management to the client. Which pain-management facts should the nurse mention to the client and the client's family?

A. Take pain-relieving medication before physical activity.

B. Avoid performing abdominal breathing techniques.

C. Apply cold and hot packs to enhance pain control.

D. Discuss pain-control methods with the physician.

Answer: D Rationale: The nurse should explain to the client the importance of discussing pain-control methods that have been effective and not effective with the physician. The nurse should ask the client to perform simple techniques such as abdominal breathing and jaw relaxation to increase comfort. The client should not take pain-relieving medication on his or her own before any physical activity. Instead, the client should ask for or take pain-relieving drugs when pain begins or before an activity that causes pain. The client should consult with the doctor or nurses about using cold or hot packs or any other nondrug technique to enhance pain control.

Question format: Multiple Choice Chapter 20: Pain Management Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs Pn: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 429 12. A nurse is assessing a client with severe pain in the lower back. The client's breathing becomes shallow when the client is in pain. Which autonomic nervous system responses should the nurse look for in the client?

A. headache B. lethargy C. dilated pupils D. irritation Answer: C Rationale: When dealing with clients whose pain is poorly controlled, the nurse should look for autonomic nervous system responses such as tachycardia, hypertension, dilated pupils, perspiration, pallor, rapid and shallow breathing, urinary retention, reduced bowel motility, and elevated blood glucose levels. Headaches, lethargy, and irritation are not autonomic nervous system responses that the client will show.

Question format: Multiple Choice Chapter 20: Pain Management Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 427 13. A nurse is caring for a client with an amputated limb. The client tells the nurse that he has a burning sensation in his amputated limb. How should the nurse document this pain?

A. referred pain B. phantom pain C. visceral pain D. cutaneous pain Answer: B Rationale: The nurse should document the pain as phantom pain, a type of neuropathic pain that is often experienced days, weeks, or even months after the source of the pain has been treated and resolved. The client perceives that the amputated limb still exists and feels burning, itching, and deep pain in tissues that have been surgically removed. The client is not experiencing referred pain, visceral pain, or cutaneous pain. Visceral pain is associated with disease or injury. Referred pain is not experienced in the exact site where an organ is located.

Cutaneous pain originates at the skin level, and is a commonly experienced sensation resulting from some form of trauma.

Question format: Multiple Choice Chapter 20: Pain Management Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 425 14. As per the physician's orders, a nurse is placing two electrodes on a client's lower back to perform transcutaneous electrical nerve stimulation (TENS). The nurse spaces the electrodes at least the width of one from the other on the client's skin. What explains the nurse's action?

A. prevents the potential for burning the skin B. promotes the integrity of the skin C. prevents premature stimulation of the skin D. provides wider and deeper stimulation

Answer: A Rationale: When performing TENS, the nurse spaces the electrodes at least the width of one from the other in order to limit the potential for burning caused by close proximity of the electrodes. To promote skin integrity, the nurse changes the position of the electrodes slightly if skin irritation develops. To prevent premature stimulation of the skin, the nurse ensures the TENS unit is set to "off." To provide wider and deeper stimulation as the pulse width increases, the nurse should set the pulse width of the TENS. Question format: Multiple Choice Chapter 20: Pain Management Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs Pn: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 435 15. A nurse is caring for a client with acute back pain. When should the nurse assess the client's pain?

A. six hours after administering a prescribed analgesic B. after the client is discharged from the health care facility C. once per day when the pain is a potential problem D. whenever the vital signs are measured and documented Answer: D Rationale: The nurse should assess the client's pain whenever the nurse measures and documents vital signs. When administering a prescribed analgesic, the nurse should assess pain before implementing a pain-management intervention, and again 30 minutes later. The nurse should assess the client's pain when the client is admitted to, not discharged from, the health care facility. Similarly, the nurse should assess pain once per shift when pain is an actual or potential problem.

Question format: Multiple Choice Chapter 20: Pain Management Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 426-427 16. A middle-age client tells the nurse that the client's neck pain reduced considerably after the client underwent a treatment in which thin needles were inserted into the skin. What kind of pain relief treatment did the client undergo?

A. transcutaneous electrical nerve stimulation B. rhizotomy C. acupuncture D. biofeedback Answer: C

Rationale: The client underwent acupuncture. Acupuncture is a pain-management technique in which long, thin needles are inserted into the skin. Transcutaneous electrical nerve stimulation (TENS) and biofeedback are nonsurgical and nondrug procedures used to treat pain. TENS is a medically prescribed pain-management technique that delivers bursts of electricity to the skin and underlying nerves. In biofeedback, a client learns to control or alter a physiologic phenomenon. Rhizotomy involves the surgical sectioning of a nerve root close to the spinal cord.

Question format: Multiple Choice Chapter 20: Pain Management Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 435 17. A nurse who works in a high-acuity setting is conscious of ensuring that clients' pain assessments and pain control regimens are highly individualized. Which statement about pain threshold is most accurate?

A. Pain thresholds are culturally bound concepts that vary geographically.

B. Pain thresholds are significantly higher among females than males.

C. Pain thresholds tend to be highest among older adults.

D. Pain thresholds tend to be the same among healthy people.

Answer: D Rationale: Pain thresholds tend to be the same among healthy people, but each person tolerates or bears the sensation of pain differently. Pain tolerance, however, is more subjective and variable between groups and individuals.

Question format: Multiple Choice Chapter 20: Pain Management Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 424 18. A client who experienced domestic violence for years states to the nurse, "I know I should not feel this way, but every time I think of my former spouse, I get a horrible headache and have to go lie down." Which nursing intervention reflects practice according to the Neuromatrix Theory?

A. asking client how sensory stimuli produces pain B. administering backrub when client's head hurts C. removing items from the room that remind client of former spouse D. requesting health care provider to order the client's opioid medication Answer: C Rationale: Removing items that remind the client of a former spouse reflects the Neuromatrix Theory. Administering a backrub reflects the Gate Control Theory. Asking the client how sensory stimuli produces pain reflects the Pattern Theory. Having the health care provide order the client's opioid medication reflects the endogenous opioid theory.

Question format: Multiple Choice

Chapter 20: Pain Management Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 425 19. A client who was a victim of domestic violence for years states to the nurse, "I know I should not feel this way, but every time I think of my former spouse, I get a horrible headache and have to go lie down." Which nursing intervention reflects practice according to the Pattern Theory?

A. asking client how sensory stimuli produces pain B. administering backrub when client's head hurts C. removing items from the room that remind client of former spouse D. requesting health care provider to order the client's opioid medication Answer: A Rationale: Asking the client how sensory stimuli produces pain reflects the Pattern Theory.

Administering a backrub reflects the Gate Control Theory. Removing items from the room that remind the client of the client's former spouse reflects the Neuromatrix Theory. The endogenous opioid theory is based on the fact that nociceptors contain receptors that can bind with neurotransmitters called endogenous opioids - endorphins, dynorphins, and enkephalins that modulate pain; therefore, giving opioids reflects this theory.

Question format: Multiple Choice Chapter 20: Pain Management Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 424 20. A client who was a victim of domestic violence for years states to the nurse, "I know I should not feel this way, but every time I think of my former spouse, I get a horrible headache and have to go lie down." Which nursing intervention reflects practice according to the Gate-Control Theory?

A. asking client how sensory stimuli produces pain B. administering backrub when client's head hurts C. removing items from the room that remind client of former spouse D. requesting health care provider to order the client's opioid medication Answer: B Rationale: Administering a backrub reflects the Gate Control Theory. Asking the client how sensory stimuli produces pain reflects the Pattern Theory. Removing items that remind the client of a former spouse reflects the Neuromatrix Theory. Having the health care provide order the client's opioid medication reflects the endogenous opioid theory.

Question format: Multiple Choice Chapter 20: Pain Management Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process

Reference: p. 424 21. While caring for a client with chronic pain, the nurse talks with a family member. Which family member statement does the nurse identify as consistent with caregiver role strain?

A. "I feel badly because my loved one is in pain all of the time."

B. "Sometimes it seems like I can never get a moment to myself."

C. "Even when I do extra tasks around the house, I'm glad to help my loved one."

D. "Our insurance company finally found a way to cover my loved one's care."

Answer: B Rationale: Caregiver role strain may be exhibited by statements of exhaustion, frustration, or seeming overwhelmed. If the client states that time to themselves is rare, he or she may be feeling consumed with care for the client with chronic pain. Feeling badly regarding a loved one's pain, discussing insurance coverage, and helping the loved one by doing household tasks do not indicate caregiver role strain.

Question format: Multiple Choice Chapter 20: Pain Management Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 426 22. The nurse is caring for a client who has experienced significant pain following a surgical procedure. Which nursing interventions are appropriate? Select all that apply.

A. Delegate pain assessment to the UAP. B. Assess for pain control 30 minutes after administering an analgesic.

C. Consider cultural implications of the perception of pain.

D. Infer that the client who does not complain has no pain.

E. Provide pain medication before activity that may increase pain.

Answer: B, C, E Rationale: Pain assessment should never be delegated to a UAP. Pain medication should be given in advance of an activity that may increase pain. The nurse should consider cultural implications associated with pain and assess for pain control after medication is given.

Assumptions should not be made about pain.

Question format: Multiple Select Chapter 20: Pain Management Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 426-427 23. The nurse is conducting an admission assessment, and asks the client what medication is taken for pain. The client responds, "I take a little white pill to control my pain, but I don't know the name of it," and presents the nurse with a plastic baggie full of white pills. What is the priority nursing intervention?

A. Document what the client states.

B. Tell the healthcare provider that the client is unsure of the pain medication taken.

C. Ask the client if he or she has the bottle the drug was dispensed in from the pharmacy.

D. Call the pharmacy to attempt to identify the pill.

Answer: C Rationale: The priority nursing intervention is to ask the client for the original bottle that the drug was dispensed into from the pharmacy. This will provide the most accurate identification of the medication. Other interventions can subsequently be implemented.

Question format: Multiple Choice Chapter 20: Pain Management Cognitive Level: Analyze Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 427 24. The nurse manager hears a nurse and a nurse aide talking about a female client who reports pain of 8 out of 10 on a 1-10 scale after a Caesarean birth to deliver twins. The nurse states, "I don't believe this client has any pain at all. I'm sure she is just drug seeking." What is the appropriate nurse manager action?

A. Continue listening to the conversation before intervening.

B. Ask the nurse to speak privately for a moment, and educate about bias in pain treatment.

C. Enter the conversation and tell the nurse and UAP that this type of discussion will not be tolerated.

D. Write the nurse up for disciplinary action.

Answer: B Rationale: Research has shown that treatment bias may delay pain-relieving measures. The nurse manager should privately and professionally educate the nurse, and then subsequently educate the nurse aide. Addressing the concern quickly is important so the client can receive appropriate care and pain management. Entering the conversation is not the best action to educate the nurse and disciplinary action doesn't help to immediately address the current situation.

Question format: Multiple Choice Chapter 20: Pain Management Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 429 25. The nurse is caring for a client who has had unrelieved back pain for 3 years. How will the nurse document this type of pain? Select all that apply.

A. somatic B. visceral C. neuropathic D. acute E. chronic Answer: A, E

Rationale: Chronic pain is discomfort that lasts longer than 6 months. Somatic pain develops from injury to structures such as muscles, tendons, and joints. Therefore, the nurse appropriately documents this client's pain as somatic and chronic. Cutaneous, visceral, referred, neuropathic, and acute pain are not being depicted in this scenario.

Question format: Multiple Select Chapter 20: Pain Management Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 425-426 26. The nurse is caring for a client who reports nausea and vomiting for 1 week. How will the nurse document this type of pain? Select all that apply.

A. visceral B. referred C. neuropathic D. acute E. chronic Answer: A, D Rationale: Visceral pain is associated with disease or injury. Acute pain lasts for a few seconds to less than 6 months. Therefore, the nurse in the scenario documents the client's pain as visceral and acute. Cutaneous, somatic, referred, neuropathic, and chronic pain are not represented in this scenario.

Question format: Multiple Select Chapter 20: Pain Management Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 425 27. The nurse is caring for a client who reports muscular and joint pain after an ankle sprain when playing soccer last week. How will the nurse document this type of pain? Select all that apply.

A. cutaneous B. somatic C. visceral D. referred E. acute Answer: B, E Rationale: Based on the information about the client, the nurse documents the pain as somatic, acute pain. Somatic pain develops from injury to structures such as muscles, tendons, and joints. Cutaneous, visceral, referred, chronic, and neuropathic pain are not reflected in this scenario.

Question format: Multiple Select Chapter 20: Pain Management Cognitive Level: Apply

Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 425 28. The nurse is caring for a client who has a long history of using opioid pain medication.

Which action will the nurse take to further assess the client's pain and provide pain relief?

A. Acknowledge the pain as the client reports it and administer pain medication as prescribed.

B. Observe the client's behavior when the nurse is not with the client.

C. Take the client's vital signs often to observe for changes that may indicate pain.

D. Report the client to the health care provider for seeking drugs.

Answer: A Rationale: Pain is subjective and the nurse must acknowledge pain as the client reports it.

Observing the client's behavior is not an appropriate nursing intervention, as pain is a selfreported finding. Taking the client's vital signs would help in administering pain medications, as pain medicine can lower a client's blood pressure and heart rate. The nurse will not report the client to the health care provider; this is making assumptions about the client.

Question format: Multiple Choice Chapter 20: Pain Management Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 430

Chapter 21 1. A physician has ordered an arterial blood gas test for a client with a respiratory disorder.

What is the most common role of the nurse in performing the arterial blood gas test?

A. Measure the partial pressure of oxygen dissolved in plasma.

B. Perform the arterial puncture to obtain the specimen.

C. Implement measures to prevent complications after arterial puncture.

D. Measure the percentage of hemoglobin saturated with oxygen.

Answer: C Rationale: During the arterial blood gas test, the nurse should implement measures to prevent complications after the arterial puncture. The nurse would not be involved in measuring the partial pressure of oxygen dissolved in plasma or the percentage of hemoglobin saturated with oxygen. Intensive care nurses commonly obtain arterial blood gases.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Reduction of Risk Potential Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 448 2. During the physical assessment of a client who has been inactive due to a leg injury, the nurse notes that the client tends to breathe very shallowly. What technique should the nurse teach the client in order to breathe more efficiently?

A. deep breathing B. pursed-lip breathing C. diaphragmatic breathing D. incentive spirometry Answer: A Rationale: The nurse should teach deep breathing techniques to the client who tends to breathe shallowly in order to help the client breathe more efficiently. Deep breathing is a technique for maximizing ventilation. Taking in a large volume of air fills alveoli to a greater capacity, thus improving gas exchange. Pursed-lip breathing is a form of controlled ventilation in which the client consciously prolongs the expiration phase of breathing, which helps clients to eliminate more than the usual carbon dioxide from the lungs. It is used to increase the volume of air exchanged during inspiration and expiration. Incentive spirometry, a technique for deep breathing using a calibrated device, encourages clients to reach a goaldirected volume of inspired air. Diaphragmatic breathing is breathing that promotes the use of the diaphragm rather than the upper chest muscles. It is used to increase the volume of air exchanged during inspiration and expiration.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Apply Client Needs: Health Promotion and Maintenance

Integrated Process: Teaching/Learning Reference: p. 449 3. A nurse is caring for a client who is being administered oxygen through a liquid oxygen unit. What is the most common potential problem the nurse may face when using a liquid oxygen unit to administer oxygen?

A. It increases the client's electric bill.

B. It produces an unpleasant odor.

C. It requires a secondary source of oxygen.

D. It leaks during warm weather.

Answer: D Rationale: The most common potential problem that the nurse may face when administering oxygen using a liquid oxygen unit is that the unit may leak during warm weather. An oxygen concentrator increases the client's electric bill and produces an unpleasant odor or taste if the filter is not cleaned weekly. An oxygen concentrator also requires a secondary oxygen device in case of a power failure.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 453 4. During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered?

A. flow meter B. oxygen analyzer C. humidifier D. nasal cannula Answer: A Rationale: In order to regulate the amount of oxygen delivered to the client, the nurse should use a flow meter. A flow meter is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. A humidifier is a device that produces small water droplets and may be used during oxygen administration because oxygen dries the mucous membranes. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It provides a means for administering a low concentration of oxygen.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 453 5. A nurse is caring for a client with influenza who requires an external source of oxygen in order to breathe efficiently. In which situation is oxygen humidified?

A. when more than 2 L/min of oxygen is administered for an extended period B. when more than 2 L/min but less than 3 L/min oxygen is administered C. when more than 4 L/min of oxygen is administered for an extended period D. when more than 5 L/min of oxygen is administered intermittently Answer: C Rationale: When administering oxygen to a client using an external source of oxygen, the nurse should remember that oxygen is humidified when more than 4 L/min of oxygen is administered for an extended period. Oxygen need not be humidified if less than 4 L/min of oxygen has been administered to the client. Oxygen administered over an extended period of time, not intermittently, is humidified.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 454 6. A nurse is caring for an asthmatic client who requires a low concentration of oxygen.

Which delivery device should the nurse use in order to administer oxygen to the client?

A. simple mask B. nasal cannula C. face tent D. nonrebreather mask Answer: B Rationale: The nurse should use a nasal cannula to administer oxygen to an asthmatic client who requires a low concentration of oxygen. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It is used for administering a low concentration of oxygen to clients who are not extremely hypoxic and are diagnosed with chronic lung disease. A simple mask allows the administration of higher levels of oxygen than a cannula.

A face tent is used for clients with facial trauma and burns. Nonrebreather masks are used for clients requiring a high concentration of oxygen and who are critically ill.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 454 7. A nurse is caring for a client who is being administered oxygen through a transtracheal catheter. Which device should the nurse use to administer oxygen when cleaning the opening and the tube?

A. simple mask B. face tent C. nasal cannula D. Venturi mask

Answer: C Rationale: The nurse should use a nasal cannula to administer oxygen when cleaning the opening and the tube of the transtracheal catheter. A transtracheal catheter, which is a hollow tube inserted within the trachea to deliver oxygen, is used to administer oxygen to a client who requires long-term oxygen therapy. During the cleaning of the catheter, the client takes in oxygen through a nasal cannula. The nurse may not use a simple mask, face tent, or a Venturi mask to administer oxygen to the client.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 454 8. A nurse is caring for a critically ill client who is receiving oxygen through a nonrebreather mask. The nurse should remember that which situation could lead to oxygen toxicity in the client?

A. oxygen concentration of more than 25% given for longer than 24 hours B. oxygen concentration of more than 30% given for longer than 48 hours C. oxygen concentration of more than 25% given for longer than 36 hours D. oxygen concentration of more than 50% given for longer than 48 hours Answer: D Rationale: When administering oxygen to a critically ill client using a nonrebreather mask, the nurse should remember that an oxygen concentration of more than 50% given for longer than 48 hours can cause oxygen toxicity in the client. Oxygen toxicity refers to lung damage that develops when oxygen concentrations of more than 50% are administered for longer than 48 to 72 hours. The best way to prevent oxygen toxicity is to administer the lowest FiO2 possible for the shortest amount of time.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 458 9. A physician prescribes the use of water-seal chest tube drainage for a client at a health care facility. What should the nurse ensure when using the water-seal chest tube drainage?

A. Filters need to be cleaned regularly to avoid unpleasant taste or smell.

B. The chest tube should not be separated from the drainage system unless clamped.

C. A nasal cannula should be used to administer oxygen when cleaning the opening.

D. A secondary source of oxygen should be available in case of power failure.

Answer: B Rationale: When using water-seal chest tube drainage, the nurse should never separate the chest tube from the drainage system unless clamped. Even then, the tube should be clamped only briefly. When using an oxygen concentrator as a source of oxygen, the nurse should

clean the filter regularly to avoid an unpleasant taste or smell. A secondary source of oxygen should also be available in case of a power failure. When cleaning a transtracheal catheter, oxygen needs to be administered with a nasal cannula.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 460 10. A nurse is caring for a client who was involved in a deep-sea diving accident. The client has been put on hyperbaric oxygen therapy by the health care provider for decompression.

How could the nurse avoid oxygen toxicity for this client?

A. by delivering 100% oxygen at two times normal atmospheric pressure B. by reducing the treatment time from 90 minutes to 30 minutes C. by providing brief periods of breathing room air D. by performing the therapy once in 2 weeks Answer: C Rationale: The nurse can prevent oxygen toxicity from occurring in a client on hyperbaric oxygen therapy by providing the client with brief periods of breathing room air. Hyperbaric oxygen therapy (HBOT) consists of the delivery of 100% oxygen at three times the normal atmospheric pressure within an airtight chamber. Treatments, which last approximately 90 minutes, are repeated over days, weeks, or months of therapy. Reducing the amount of time oxygen is delivered over the atmospheric pressure, reducing the treatment time, or performing the therapy once in 2 weeks would not help to prevent oxygen toxicity in a client.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 460 11. A nurse uses a simple mask to administer oxygen to a client with nasal trauma who breathes through the mouth. What is the minimum amount of oxygen delivered to the client using a simple mask?

A. 5 L/min B. 4 L/min C. 3 L/min D. 2 L/min Answer: A Rationale: When a simple mask is used for a client with nasal trauma who breathes through the mouth, oxygen is delivered at no less than 5 L/min. A simple mask, like other types of masks, allows the administration of higher levels of oxygen than are possible with a cannula.

A simple mask is sometimes substituted for a cannula when a client has nasal trauma or breathes through the mouth.

Question format: Multiple Choice

Chapter 21: Oxygenation Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 454 12. When caring for older adults with respiratory ailments, why is it imperative that the nurse carefully assess a client who demonstrates restlessness or confusion?

A. to provide the physician or respiratory therapist with as much data as possible B. to select the oxygenation techniques that could be used C. to calculate the amount of oxygen that needs to be administered D. to differentiate signs of inadequate oxygenation from early signs of delirium Answer: D Rationale: In elderly clients, the signs of inadequate oxygenation, such as restlessness or confusion, can resemble the early signs of delirium. Therefore, it is important for the nurse to carefully assess clients demonstrating these symptoms. Determining the cause of inadequate oxygenation, selecting an oxygenation technique, and calculating the amount of oxygen that needs to be administered are of secondary importance.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Physiological Adaptation Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 447 13. A nurse uses a nasal cannula to deliver oxygen to a client who is extremely hypoxic and has been diagnosed with chronic lung disease. What is the most important thing to remember when using a nasal cannula?

A. It can cause the nasal mucosa to dry in case of high flow.

B. It can cause anxiety in clients who are claustrophobic.

C. It can create a risk of suffocation.

D. It can result in an inconsistent amount of oxygen.

Answer: A Rationale: When using a nasal cannula to deliver oxygen to a client, the nurse should remember that the nasal cannula can cause the nasal mucosa to dry in case of high oxygen flow. A simple mask can cause anxiety in clients who are claustrophobic. Clients using a partial rebreather mask are at risk of suffocation. A face tent may deliver an inconsistent amount of oxygen, depending on environmental loss.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 455

14. A nurse is conducting a physical assessment of a client who is being treated for pleural effusion at a health care facility. The nurse needs the client to exhale additional air, which will allow the nurse to check the quality of the client's oxygenation. What instruction should the nurse give the client?

A. Expand the thoracic cavity.

B. Relax the respiratory muscles.

C. Contract the abdominal muscles.

D. Elevate the ribs and sternum.

Answer: C Rationale: The nurse should instruct the client to contract the abdominal muscles to exhale additional air. A person can forcibly exhale additional air by contracting abdominal muscles such as the rectus abdominis, transverse abdominis, and external and internal obliques. The client elevates the ribs and sternum and expands the thoracic cavity during inspiration. The client relaxes the respiratory muscles during normal expiration.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Apply Client Needs Pn: Physiological Integrity: Physiological Adaptation Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 451 15. A nurse is caring for a client who is unable to breathe efficiently by himself. The physician has directed the nurse to put the client on oxygen therapy. The client is receiving a high concentration of oxygen. At what level should a nurse use a humidifier for the client?

A. 1 L/min B. 2 L/min C. 3 L/min D. 4 L/min Answer: D Rationale: The nurse should use a humidifier when the client has been receiving more than 4 L/min of oxygen over an extended period. A humidifier is a device that produces small water droplets and may be used during oxygen administration because oxygen dries the mucous membranes. In most cases, oxygen is humidified only when more than 4 L/min is administered for an extended period. When humidification is desired, a bottle is filled with distilled water and attached to the flow meter.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 454 16. During oxygen administration to the client, which piece of equipment would enable the nurse to regulate the quantity of oxygen delivered from the wall-mounted oxygen supply?

A. flowmeter

B. oxygen analyzer C. humidifier D. nasal cannula Answer: A Rationale: To regulate the amount of oxygen delivered to the client, the nurse should use a flowmeter. A flowmeter is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine whether the client is receiving the amount prescribed by the physician. A humidifier is a device that produces small water droplets and may be used during oxygen administration because oxygen dries the mucous membranes. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It provides a means for administering a low concentration of oxygen.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 453 17. Which is a disadvantage of using a face tent to administer oxygen to a client with facial trauma?

A. delivers an inconsistent amount of oxygen B. creates a risk of suffocation C. dries nasal mucosa at a higher flow D. permits condensation to form in the tubing Answer: A Rationale: When using a face tent to administer oxygen to a client with facial trauma, the nurse should remember that the amount of oxygen the client actually receives may be inconsistent with what is prescribed because of environmental losses. A partial rebreather mask creates a risk of suffocation. A nasal cannula dries the nasal mucosa at a higher flow. A Venturi mask permits condensation to form in the tubing, which diminishes the flow of oxygen.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 456 18. A nurse is caring for a critically ill client who is receiving oxygen through a nonrebreather mask. The nurse should remember that the client becomes at risk of oxygen toxicity at what concentration and length of administration?

A. oxygen concentration of more than 25% given for longer than 24 hours B. oxygen concentration of more than 30% given for longer than 48 hours C. oxygen concentration of more than 25% given for longer than 36 hours D. oxygen concentration of more than 50% given for longer than 48 hours

Answer: D Rationale: When administering oxygen to a critically ill client using a nonrebreather mask, the nurse should remember that an oxygen concentration of more than 50% given for longer than 48 hours can cause oxygen toxicity in the client. Oxygen toxicity means lung damage that develops when oxygen concentrations of more than 50% are administered for longer than 48 to 72 hours. The best way to prevent oxygen toxicity is to administer the lowest FiO2 possible for the shortest amount of time.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 458 19. A nurse is conducting a focused respiratory assessment of a 21-year-old client who has been admitted to the hospital with a pneumothorax (collapsed lung). The nurse is aware that this client's diagnosis affects multiple aspects of the respiratory function, including external respiration. In what anatomical location does the external respiration take place?

A. the bronchi B. the alveoli C. the surface of red blood cells D. arterial vessel walls Answer: B Rationale: External respiration takes place at the most distal point in the airway between the alveolar–capillary membranes. Internal respiration occurs at the cellular level by means of hemoglobin and body cells.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 458 20. The daughter of a client who is being treated for pneumonia has told the nurse that her father had his blood checked for its oxygen level during a previous bout with pneumonia.

What disadvantage of arterial blood gas measurement should the client's nurse be aware of?

A. The procedure is invasive and painful.

B. ABGs are less accurate than pulse oximetry.

C. ABGs are not accurate if the client has been receiving supplementary oxygen.

D. The procedure is normally conducted on an outpatient basis.

Answer: A Rationale: Having ABGs drawn is invasive and painful. ABGs are more accurate than pulse oximetry and are not invalidated by the use of supplementary oxygen. ABGs are usually performed on acutely ill clients on an inpatient basis.

Question format: Multiple Choice

Chapter 21: Oxygenation Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 447 21. A hospital client has illuminated the call light and told the nurse, "I can't quite seem to catch my breath." The client appears to be in no visible distress. What is the first intervention that the nurse should perform?

A. Place the client in the recovery position, side-lying with one knee bent.

B. Apply oxygen at 8 L/min by nasal cannula.

C. Apply supplementary oxygen using a Venturi mask.

D. Raise the head of the client's bed and put the client in the high Fowler position.

Answer: D Rationale: Repositioning in a high Fowler position can facilitate oxygenation in clients who are experiencing shortness of breath. A Venturi mask is used to deliver a precise mixture of oxygen and air to an acutely ill client. Oxygen by nasal cannula should not exceed 6 L/min. A side-lying position does not facilitate oxygenation.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 449 22. A client with a diagnosis of vascular dementia is unable to communicate clearly because of a cognitive deficit. The client has developed influenza with extensive respiratory involvement. The nurse should assess the client for what sign of inadequate oxygenation?

A. flushed skin B. uncharacteristic restlessness C. wincing, grimacing, or guarding D. decreased respiratory rate Answer: B Rationale: Restlessness can be a sign of inadequate oxygenation. Pallor and increased respirations also accompany the problem, rather than flushed skin and decreased respiratory rate. Impaired oxygenation does not normally result in wincing, grimacing, or guarding.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 447 23. The nurse observes that the client's pulse oximetry is 89%. What is the priority nursing action?

A. Document hypoxemia.

B. Report pulse oximetry to the health care provider.

C. Perform respiratory assessment.

D. Check the placement of the pulse oximeter.

Answer: C Rationale: As the nurse enters the room, the respiratory assessment immediately begins by visualizing the client's skin color, observing chest symmetry, vocalization, and auditory adventitious lung sounds. The nurse can then proceed to check the placement of the pulse oximeter, report findings to the health care provider, and document.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 447 24. The nurse is preparing discharge teaching for a client with a history of recurrent pneumonia. What deep breathing techniques will the nurse plan to teach?

A. "Take in a small amount of air and exhale quickly."

B. "Take in as much air as possible, hold your breath briefly, and exhale slowly."

C. "Take in a large volume of air and hold your breath as long as you can."

D. "Take in a little air, hold your breath 15 seconds, and exhale slowly."

Answer: B Rationale: This technique maximizes ventilation taking in a large volume of air fills alveoli to a greater capacity, which improves gas exchange. Deep breathing is useful for client's who has been inactive or in pain as associated with pneumonia. The other techniques do not promote improved gas exchange.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 451 25. Which breathing technique(s) will the nurse teach to the client who has hypoxemia and hypercarbia? Select all that apply.

A. deep breathing B. incentive spirometry C. pursed-lip breathing D. diaphragmatic breathing E. apply nasal strips Answer: C, D Rationale: Pursed-lip breathing and diaphragmatic breathing are helpful for clients who have excessive levels of carbon dioxide in the blood. Deep breathing, incentive spirometry, and use of nasal strips does not eliminate as much carbon dioxide from the blood.

Question format: Multiple Select Chapter 21: Oxygenation Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 451 26. An older adult client was recently placed on home oxygen. The client's caregiver reports that the client now refuses to leave the house. What teaching will the nurse provide the caregiver? Select all that apply.

A. "Continued socialization with others is important."

B. "Discuss with the client switching to a portable oxygen device."

C. "Give the client time to adjust."

D. "Invite friends and family to the client's house."

E. "Remove the oxygen for times when the client wants to leave the house."

Answer: A, B, D Rationale: Socialization is important for older adults. Having a portable oxygen device increases functional mobility. Inviting friends and family provides socialization and may help the client feel more at ease with oxygen use. The nurse should not suggest that the caregiver ignore the issue or remove the oxygen are inappropriate; these are inappropriate actions.

Question format: Multiple Select Chapter 21: Oxygenation Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 453 27. The nurse is demonstrating oxygen administration to a client. What teaching will the nurse include about the flowmeter?

A. "This is a gauge used to regulate the amount of oxygen that a client receives."

B. "The flowmeter prescribes the concentration of oxygen."

C. "It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed."

D. "Small water droplets come from this, thus preventing dry mucous membranes."

Answer: A Rationale: The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The healthcare provider prescribed the concentration of oxygen. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The humidifier produces small water droplets, which are delivered during oxygen administration to prevent or decrease dry mucous membranes.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 453

28. The nurse is caring for a client with facial burns who also is prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client?

A. simple mask B. tracheostomy collar C. nasal cannula D. face tent Answer: D Rationale: A face tent is used without a mask; it is open and loose around the face and is often used for patients with facial trauma or burns. This device is most appropriate for a client with facial burns. All other methods of delivery would irritate the facial skin.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 456 29. The nurse is caring for a client who has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client?

A. simple mask B. tracheostomy collar C. nasal cannula D. face tent Answer: B Rationale: A tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT. All other devices are less appropriate for this client.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 457 30. The nurse is caring for a 3-year-old client who experienced smoke inhalation during a house fire, and now requires oxygen. What delivery device will the nurse select that is most appropriate for this client?

A. nasal catheter B. oxygen tent C. Venturi mask D. nonrebreather mask Answer: B

Rationale: An oxygen tent is often used when caring for active toddlers who require oxygen because they are less likely to keep a mask on. Nasal catheters and masks are inappropriate, as the child will attempt to remove them and not receive the benefit of oxygen therapy.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 458 31. A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention?

A. Ask the client what factors contribute to nonadherence.

B. Contact the health care provider to report the client's current status.

C. Explain the use of a BiPAP mask instead of a CPAP mask.

D. Document outcomes of modifications in care.

Answer: A Rationale: The nurse must first assess the reasons that contribute to nonadherence; interventions cannot be determined without a thorough assessment. Then, the nurse can work with the health care provider to find alternate treatment options if necessary, and then document the care.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 458 32. A nurse is conducting a morning assessment of an elderly client who is being rehabilitated after orthopedic surgery. In addition to vital signs, the nurse assesses the client's oxygenation by pulse oximetry. At what SpO2 reading should the nurse begin to consider additional respiratory assessments and interventions?

A. SpO2 96% (0.96) B. SpO2 93% (0.93) C. SpO2 86% (0.86) D. SpO2 90% (0.90) Answer: C Rationale: In general, the nurse should consider additional assessments and interventions if a client's oxygen level is below 90% (0.90). The normal range is 95% to 100% (0.95 to 1.00).

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 462

33. A client who utilizes a portable oxygen device reports planning to attend an upcoming bonfire on the beach. What is the appropriate nursing response?

A. "Have an enjoyable time."

B. "You should not leave the house with portable oxygen."

C. "When using portable oxygen, you should avoid any fire."

D. "Saltwater can increase the potential for oxygen toxicity."

Answer: C Rationale: Although freedom to move about comes with portable oxygen, the client should be educated about the dangers of oxygen near fire; therefore, fires and anyone smoking should be avoided. Saltwater does not increase the potential for oxygen toxicity.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 458 34. A client is diagnosed with hypoxia related to emphysema. The client's adult child will be assisting the client with daily hygiene. How will the nurse explain positioning of the client to the caregiver?

A. "Place your parent at the sink to allow teeth brushing and stand outside of the shower to help if needed."

B. "Whichever position helps your parent feel most comfortable and will allow you to help with hygiene is fine."

C. "A standing position works best to allow your parent to move around in the bathroom and to allow you to help your parent in and out of the shower."

D. "An upright, sitting position is the best for daily hygiene so a lightweight chair that can be used in and out of the shower works best to help your parent breathe easier and allow you to assist."

Answer: D Rationale: The best way to explain caregiving is to describe the specific position and type of chair to use as well as teach the caregiver why it is the best position and device. Teaching the caregiver to place the parent at the sink and then stand outside the shower does not provide the best position nor the device to obtain, plus it does not address the facts that the parent standing in the shower may not be possible due to hypoxia and is not safe. Teaching the caregiver to use whichever position is most comfortable for the parent does not address the safest position for the client nor the position that provides easiest breathing and energy conservation. Standing for the period of time it may take to complete daily hygiene is not feasible or safe for the client and should not be recommended by the nurse.

Question format: Multiple Choice Chapter 21: Oxygenation Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 451

Chapter 22 1. A nurse is administering prescribed tuberculosis (TB) drugs to a client with HIV. The client's recovery chart, however, shows that the microorganisms have developed drugresistant strains. What other infectious disease has developed drug-resistant strains?

A. malaria B. sinusitis C. cancer D. gonorrhea Answer: D Rationale: Microorganisms that cause tuberculosis, gonorrhea, and some forms of wounds and respiratory infections have developed drug-resistant strains. Sinusitis and cancer are not infectious diseases. Malaria is usually transmitted to humans by the bite of an infected female mosquito. Cancer is a disease characterized by disorderly division of cells. Sinusitis is an inflammation of the paranasal sinuses, which may or may not be a result of infection.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 475 2. A nurse is collecting contaminated items and depositing the bag in a second bag, held by another nurse, outside the client's room. Which infection control measures are the nurses performing?

A. double-bagging B. airborne precautions C. personal protection D. droplet precautions Answer: A Rationale: The nurses are performing the double-bagging infection control measure, in which one bag of contaminated items, such as trash or laundry, is placed within another. Personal protection, airborne precautions, and droplet precautions are important infection control measures that block pathogens within air and moist droplets larger than 5 microns, respectively.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 484

3. A nurse needs to fix a respirator mask on a client who was exposed to hazardous chemicals at a factory site. Which of the following respirator masks should the nurse carry in the ambulance to fix on the client?

A. powered air purifying respirator B. N95 respirator C. cuirass respirator D. Drinker respirator Answer: A Rationale: The nurse should use a powered air purifying respirator (PAPR) when rescuing victims exposed to hazardous chemicals or bioterrorist substances, as compared to an N95 respirator, which is individually fitted for each caregiver. A cuirass respirator is not suitable for victims exposed to hazardous chemicals, as it is used specifically to produce alternate negative pressure about the thoracic cage. A Drinker respirator is a mechanical respirator in which the entire body, except the head, is encased within a metal tank.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 481 4. A nurse needs to check the vital signs of a client with an infectious disease who is receiving intravenous therapy through an IV pump. Before entering the client's room, the nurse follows airborne and contact precautions. Which infectious disease does the client have?

A. SARS B. polio C. HIV D. measles Answer: A Rationale: The client has severe acute respiratory syndrome (SARS). Infectious diseases like chickenpox (varicella) and SARS require both airborne and contact precautions. Measles is an acute exanthematous disease caused by measles virus, and polio is caused by poliovirus.

Polio is transmitted primarily through the ingestion of material contaminated with a virus found in stool. Infection with HIV occurs through the transfer of blood, semen, vaginal fluid, pre-ejaculate, or breast milk.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 482 5. A nurse has cleansed the infected wound of a middle-aged client. What is the first step nurses take in the orderly sequence for removing their garments?

A. wiping the soiled surface of the gown with a disinfectant

B. removing the garments that are most contaminated first C. washing hands before removing the contaminated gown D. folding the soiled side of the gown to the inside before removing Answer: B Rationale: Nurses remove the garments that are most contaminated first, preserving the clean uniform underneath. Regardless of which garments they wear, nurses follow an orderly sequence for removing them. Washing hands before removing the contaminated gown or wiping the soiled surface of the gown is not part of the sequence of removing garments.

Folding the soiled side of the gown to the inside before removing is not the first step in the orderly sequence.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs Pn: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 484 6. A nurse is taking care of a client with tuberculosis who has developed resistance to the ordered antibiotic. Which type of client is most likely at increased risk for infection?

A. adult B. child C. older adult D. pregnant woman Answer: C Rationale: Long-term care residents and older adult hospitalized clients are at increased risk for antibiotic-resistant infections. Pneumonia, influenza, urinary tract and skin infections, and TB are common in older people, especially residents of long-term care facilities. These infectious diseases are not commonly seen in young adults, children, or pregnant women admitted to health care facilities.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs Pn: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 476 7. A nurse is caring for a client with acute influenza. The nurse has taken precautions to reduce pathogen transmission. Which method is the most likely way for the influenza virus to be transmitted from one host to another?

A. talking B. blood transfusion C. touching the eyes D. walking

Answer: A Rationale: Microorganisms carried on droplets commonly exit the body during coughing, sneezing, talking, and procedures such as airway suctioning and bronchoscopy. Despite this, direct physical contact is still a more likely method of transmission.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs Pn: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 482 8. A nurse has collected the blood, urine, and stool specimens of a client with meningococcal meningitis. Which precaution should the nurse take when transporting the specimens?

A. wear gloves and a gown when transporting the specimen B. place each of the three sealed specimens in a separate paper bag C. place the specimens into plastic biohazard bags D. swab the outside of each specimen container with alcohol prior to transport Answer: C Rationale: Specimens should be placed in sealed plastic bags to prevent them from becoming contaminated or causing the transmission of infective microorganisms. Paper bags are not used for this purpose, and it is not customary to swab the outsides of specimen containers.

Standard precautions should be implemented, but this does not necessitate the use of a gown in all cases.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs Pn: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 485 9. A nurse is taking stock of the equipment and supplies kept in an infection control room that can be reused for other clients. Which piece of equipment should the nurse avoid taking outside the infection control room to prevent infection among the non-infected clients?

A. catheter B. tympanic thermometer C. soap dispenser D. sphygmomanometer Answer: D Rationale: Equipment that personnel would ordinarily use for several non-infected clients, such as a stethoscope and sphygmomanometer, are usually kept in the client's infectioncontrolled room whenever possible and not taken out. This prevents the need to clean and disinfect the items each time they are removed. Disposable thermometers are preferred to tympanic thermometers. Catheters are not reused for the next client, whereas liquid soap

dispensers are usually washed and reused. In the case of infectious clients, however, it is better to keep the soap dispensers in the room as well.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 482 10. A nurse is caring for a client who is admitted to the infection control room of a health care facility with AIDS and acute diarrhea. Which isolation measure is taken in the infection control room?

A. The door to the room is kept open for cross-ventilation.

B. The sink is located outside the room for handwashing.

C. A private bathroom is provided for flushing of contaminated liquids.

D. Housekeeping personnel clean the infection control room first.

Answer: C Rationale: The infection control room has a private bathroom so that personnel can flush contaminated liquids and biodegradable solids. Infection control personnel keep the door to the room closed to control air currents and the circulation of dust particles. A sink is also located in the room for hand washing. The housekeeping personnel should clean the infection control room last to avoid transferring organisms on the wet mop to other client areas.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs Pn: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 482 11. A nurse is cleaning the room of a client with tuberculosis. Which item can the nurse dispose of as biodegradable trash?

A. urine sample B. soiled linen C. plastic bedpans D. specimen containers Answer: A Rationale: Urine is biodegradable trash that can be flushed down the toilet in the client's room. It will decompose naturally into less complex compounds. Soiled linen and specimen containers are bulkier items that are incinerated or autoclaved, whereas plastic bedpans are sterilized with heat or chemicals.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process

Reference: p. 486 12. A nurse is spraying disinfectant on the equipment in the room of an older adult client.

Which piece of equipment has the highest risk of transmitting infection to an older adult client?

A. bath blanket B. face shield C. gloves D. humidifier Answer: D Rationale: Infections are often transmitted to older adult clients through equipment reservoirs such as indwelling urinary catheters, humidifiers, and oxygen equipment, or through incisional sites, such as those for intravenous tubing, parenteral nutrition, or tube feedings.

Use of proper aseptic techniques is essential to prevent the introduction of microorganisms.

Bath blankets, face shields, and gloves are not part of the equipment reservoir that transmits infections to older adult clients.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 477 13. A nurse who is taking the vital signs of a client with acute diarrhea is ordered to attend to another client. What is the priority nursing action the nurse must perform before leaving the client's room?

A. thorough handwashing B. spraying of disinfectant C. placing one bag of contaminated items within another D. removing personal protective equipment that is most contaminated first Answer: A Rationale: Since the client has an infectious disease, the most important nursing action is to perform thorough handwashing before leaving the client's room and before touching any other client, personnel, environmental surface, or client care item. Spraying a disinfectant before leaving the client's room, or placing one bag of contaminated items in another, is not the most important nursing action in this case. Regardless of which garments they wear, nurses follow an orderly sequence for removing them. Nurses remove the personal protective equipment that is most contaminated first to preserve the clean uniform underneath.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs Pn: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 477

14. A nurse is transporting a client with pulmonary tuberculosis to the x-ray unit. Which precaution is the priority for the nurse to take to prevent the spread of pathogens?

A. Take standard precautions when transporting the client.

B. Wear personal protective equipment when transporting the client.

C. Ask the personnel at the x-ray department to wear masks.

D. Wash the transport vehicle with disinfectant after use.

Answer: B Rationale: The nurse having direct contact with the client should use personal protective equipment similar to that used in client care. The client wears a mask or particulate air filter respirator if the pathogen is transmitted by an airborne or droplet route. Some agencies also spray or wash the transport vehicle with disinfectant after use. Informing the x-ray department personnel to wear masks is not such a good idea, because they also adhere to standard precautions when assisting clients with infectious diseases.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs Pn: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 483 15. A nurse is changing the bed linen of a client admitted to the health care facility. Which isolation precautions should the nurse follow?

A. standard precautions B. droplet precautions C. contact precautions D. airborne precautions Answer: A Rationale: Health care personnel follow standard precautions whenever there is the potential for contact with the client's blood; body fluids except sweat, regardless of whether they contain visible blood; non-intact skin; and mucous membranes. Standard precautions are measures for reducing the risk of microorganism transmission from both recognized and unrecognized sources of infection. The other three precautions are transmission-based precautions, which are measures for controlling the spread of infectious agents from clients known to be, or suspected of being, infected with highly transmissible or epidemiologically important pathogens.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 477 16. A nurse is helping another nurse fasten the knot of a cover gown before assisting a colleague with a dressing change. Which advantage does a cover gown offer?

A. It decomposes easily with other biodegradable items.

B. Its snug-fitting wristbands avoid contamination of the forearms.

C. Its loose-fitting waist straps avoid contamination of the waist.

D. It is durable enough to be used for the duration of the nurse's shift.

Answer: B Rationale: The advantage of a cover gown is that its close-fitting wristbands help avoid contamination of the forearms. Cover gowns are not biodegradable; after use, they are laundered or incinerated. Cover gowns are never loose-fitting; instead, fasteners at the neck and waist keep the gown securely closed, thus covering all the wearer's clothing. A cover gown is never worn for the duration of the shift; it is changed between clients.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 483 17. A health care facility has experienced a recent outbreak of infection that is attributable to an antibiotic-resistant microorganism. Which type of client is most likely at increased risk for infection?

A. adult B. child C. elderly D. pregnant Answer: C Rationale: Long-term care residents and elderly hospitalized clients are at increased risk for antibiotic-resistant infections. Pneumonia, influenza, urinary tract and skin infections, and TB are common in older people, especially residents of long-term care facilities. The incidence is not as high in young adults, children, or pregnant women admitted to health care facilities.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 475 18. A nurse has collected the blood, urine, and stool specimens of a client with meningococcal meningitis. What will be done with these specimens after the testing is complete?

A. The specimens will be bagged and put in a landfill.

B. The specimens will be flushed and the containers incinerated.

C. The specimens will be emptied into a plastic biohazard bag.

D. The specimens will be flushed and the sealed containers will be washed.

Answer: B

Rationale: When testing is complete, most specimens are flushed, incinerated, or sterilized.

Specimens are not emptied into plastic biohazard bags or labeled and buried in a landfill.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 485 19. A nurse is caring for a client with urinary incontinence and diarrhea. What is the priority nursing diagnosis for this client?

A. risk of infection B. social isolation C. impaired walking D. risk of loneliness Answer: A Rationale: Risk of infection is an appropriate nursing diagnosis for this client. Delay in providing personal care for the client, as and when required, puts the client at risk of developing infectious diseases like pneumonia and urinary tract infection, among others. Risk of loneliness, social isolation, and impaired walking may or may not be applicable.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 482 20. A client has been swabbed for an antibiotic-resistant microorganism upon admission to the hospital, and the results reveal that she has been colonized. What are the implications of this assessment finding?

A. The client will be admitted and treated for sepsis.

B. The microorganism will multiply but is incapable of causing an infection.

C. The client will require a prophylactic course of antibiotics while in the hospital.

D. The microorganism is present on the client but is not making her sick.

Answer: D Rationale: Colonization is a condition that exists when microorganisms are present but the host does not manifest any signs or symptoms of infection. Active treatment is not normally necessary, but the microorganism is capable of causing infection if favorable circumstances exist.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Create Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 477

21. An individual has come into contact with a coworker who has influenza. The person is now in the incubation stage of infection. What is true of this stage of infection?

A. The person is likely experiencing vague, nonspecific effects of influenza.

B. The person's immune system is successfully destroying the influenza virus.

C. The person is currently not experiencing symptoms of the flu.

D. Viral levels in the person's blood are at a peak.

Answer: C Rationale: During the incubation period, the infectious agent reproduces, but there are no recognizable symptoms. The immune system has not overcome the organism in this stage, and blood levels are low but rising.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 480 22. A client has been receiving care in an isolation room in the hospital for several days and is on contact and droplet precautions. How can the nurse best minimize the psychological effects of this client's illness experience?

A. reassure the client about the certainty of recovery B. plan to have frequent interaction with the client C. provide varied and plentiful reading material to the client D. assess the client for depression on a regular basis Answer: B Rationale: When transmission-based precautions are in effect, it is important to plan frequent contact with the client in order to reduce social isolation. It is inappropriate to guarantee recovery to the client. Reading material may be helpful but does not reduce the isolation effects of being on precautions. Assessment for depression may be warranted, but assessment alone does not minimize the psychological effects of this form of treatment.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 485 23. An immunocompromised client will soon be discharged home following a kidney transplant. To reduce the client's risk of infection, what should the nurse teach the client's family to do? (Select all that apply.)

A. ensure that their immunizations are up to date B. disinfect hard surfaces with a saline solution C. bathe daily and attend to hygiene carefully D. perform frequent thorough hand washing E. plan nutritious meals

Answer: A, C, D, E Rationale: Nutrition, immunizations, and thorough hygiene and handwashing can protect a susceptible individual from infection. Saline solution is not an effective disinfectant; diluted bleach should be used.

Question format: Multiple Select Chapter 22: Infection Control Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 486 24. The CDC has identified three new standard precautions for infection control. Which clinical situation is addressed by these new precautions?

A. A client is scheduled for a lumbar puncture to assess for meningitis.

B. A client will undergo a screening colonoscopy for colorectal cancer.

C. A client will be placed in a room that will be shared with other clients.

D. A client will have the appendix removed laparoscopically (without a linear incision).

Answer: A Rationale: The CDC's three new standard precautions for infection control address Respiratory Hygiene/Cough Etiquette, Safe Injection Practices, and Practices for Special Lumbar Puncture Procedures. These particular precautions do not address surgery, endoscopies, or room-sharing.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 479 25. A pediatric client's caregiver states, "I will never give my child vaccinations." What is the priority nursing response?

A. "Vaccinations prevent disease."

B. "Help me understand your thoughts about vaccinations."

C. "Has your child received any previous vaccinations?"

D. "Transmission of certain diseases is halted with vaccination."

Answer: B Rationale: Seeking to understand the caregiver's perspective helps the nurse to collect assessment data and create a therapeutic relationship of trust. The nurse could then collect assessment data regarding past vaccines and provide appropriate teaching.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 487

26. The nurse is providing an in-service educational program for the interprofessional health care team about infection control precautions. What teaching will the nurse include? Select all that apply.

A. Wear personal protective equipment (PPE).

B. Practice hand hygiene.

C. Use standard precautions only for clients with infection.

D. Use equipment repeatedly on clients with similar conditions.

E. Keep client's environment clean.

Answer: A, B, E Rationale: Wearing PPE, practicing hand hygiene, and keeping the client's environment clean interfere with the chain of infection. Standard precautions should be used for all clients, and equipment should be cleaned, disinfected, or sterilized between uses.

Question format: Multiple Select Chapter 22: Infection Control Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 483 27. The nurse is caring for a client with tuberculosis. Which precautions will the nurse select for this client?

A. standard B. airborne C. droplet D. contact Answer: B Rationale: Tuberculosis is transmitted via the air. Therefore, airborne precautions are required. Standard, droplet, and contact precautions will not be selected by the nurse for a client who has tuberculosis.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 481 28. The nurse is caring for a client who has been placed in strict isolation. Which nursing action is appropriate?

A. Allow many family members to visit at once.

B. Deliver flowers and balloons to the room.

C. Remove fresh fruit from the room.

D. No special precautions are required.

Answer: C

Rationale: Fresh fruit and flowers can carry pathogens and chemicals to which the client should not be exposed. The number of visitors should be controlled to prevent exposure to multiple infection opportunities.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 477 29. The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. How will the nurse listen to the client's heart?

A. stethoscope belonging to the nurse B. stethoscope that remains in the client's room C. stethoscope that hangs outside the client's room D. stethoscope that has been purchased by the client Answer: B Rationale: A dedicated stethoscope and blood pressure cuff should remain in the client's room when a client has been placed in contact isolation. Therefore, the nurse would not use a personal stethoscope, one that hangs outside the client's room, nor one that was purchased by the client.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 482 30. The nurse is preparing a client who is in droplet isolation for transport to radiology. What is the appropriate nursing intervention(s)? Select all that apply.

A. facilitating interdepartmental coordination about the transport B. removing the client's mask for transport C. placing a clean sheet on the stretcher that the client will be transported upon D. ensuring that the client has a mask on E. reminding transporter to utilize droplet precautions Answer: A, C, D, E Rationale: The nurse will provide interdepartmental coordination, use methods to prevent the spread of pathogens (such as lining the surface of the stretcher with a sheet to protect the surface from direct contact), and ensure that the client is wearing a mask before being transported. The nurse will not remove the client's mask for transport.

Question format: Multiple Select Chapter 22: Infection Control Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 482

31. The nurse has worn a gown and gloves while caring for a client in contact isolation. How will the nurse appropriately remove this personal protective equipment (PPE)?

A. remove gloves, wash hands, remove gown B. remove gown, wash hands, remove gloves C. remove gloves, remove gown, wash hands D. remove gown, remove gloves, wash hands Answer: C Rationale: The nurse will remove and dispose of the most contaminated items first, then dispose of other items, and then wash hands. Gloves should be first removed, then the gown.

Then, hands are washed. The other answers are incorrect.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 484 32. The nurse is educating a client with human immunodeficiency virus (HIV) about ways the virus can be transmitted. Which statements made by the client demonstrates the education provided was effective? Select all that apply.

A. "If someone is exposed to my blood, I may transmit the virus to him or her."

B. "I may transmit the virus to my child during pregnancy and childbirth."

C. "I may transmit the virus if I share needles with another person."

D. "If I sweat at the gym and someone touches me, he or she can contract the virus."

E. "If someone uses the bathroom after I have been on the toilet, he or she can catch the virus."

Answer: A, B, C Rationale: The client has demonstrated that an understanding of the transmission of the virus may occur through exposure to blood, during pregnancy and childbirth, and through sharing of needles. Transmission of the virus does not occur through sweat or by exposure on a toilet seat. The virus is fragile and does not live on inanimate objects.

Question format: Multiple Select Chapter 22: Infection Control Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 476 33. A nursing is caring for an older adult client with an indwelling urinary catheter. Which measure is the priority for the nurse to take to prevent urinary tract infections (UTIs)?

A. placing catheter tubing lower than the client's bladder B. lightly cleansing the urinary area toward the rectal area C. performing bladder training while the catheter is in situ D. using lubricant jelly when inserting the catheter

Answer: A Rationale: When an indwelling catheter is absolutely necessary, the tubing should be placed lower than the client's bladder to prevent any backflow of urine into the bladder. Indwelling catheters should be avoided, because elderly clients have increased susceptibility to UTIs. In women, thorough cleansing should always be done from the urinary area toward the rectal area to prevent organisms in the stool from entering the bladder, but in this case it is a secondary measure. Bladder training is much more desirable, but it is not undertaken while the catheter is in place. A single-use packet of lubricant jelly should be used for catheter insertion, as it helps to reduce pain, but it is not related to UTI prevention.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 479 34. Several family members are visiting a client with an antibiotic-resistant infection who has been placed on contact precautions. When the nurse teaches the visitors about wearing gloves and gowns, a family member states, "I don't want to wear those. I can't catch anything just by holding my loved one's hand." What is the best response to educate the family about infection transmission?

A. "I understand; wearing these items is not pleasant but it really isn't optional."

B. "If you don't come into contact with anything with your body, you may wear gloves only, as long as you wash your hands after removing the gloves."

C. "These barriers help prevent the transmission of infection to you or other people."

D. "Wearing the gloves and gown prevents sharing additional microorganisms with the client."

Answer: C Rationale: Contact precautions block transmission of pathogens by direct or indirect contact Wearing a gown and gloves decreases the chance of the contaminating organism to be spread to the visitors via hands or clothing or even to others the visitors may come in contact with.

While wearing gloves and gown may prevent sharing additional microorganisms with the client, that is not the reason for contact precautions. Agreeing that wearing the gown and gloves is not pleasant doesn't educate the family member.

Question format: Multiple Choice Chapter 22: Infection Control Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 487

Chapter 23 1. A nurse needs to give a bath to a client with chronic back pain. Which ergonomic hazard is the nurse likely to face when caring for the client?

A. assisting with dressing B. lifting heavy loads C. carrying medical equipment D. administering physiotherapy Answer: B Rationale: The nurse is vulnerable to the ergonomic hazard of lifting a heavy load. Other ergonomic hazards include reaching and lifting loads far from the body, twisting while lifting, and unexpected changes in load demand during a lift. A nurse is not likely to face an ergonomic hazard when assisting the client with dressing, carrying medical equipment, or administering physiotherapy.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 499 2. A nurse is caring for a client with muscle spasms due to bad sitting posture. The nurse wants to teach the client correct sitting posture. Which sitting position is good for the client?

A. The upper thighs should rest on the chair.

B. Both the feet should be slightly above the floor.

C. The knees should extend straight from the edge of the chair.

D. The buttocks and upper thighs should become the base of support.

Answer: D Rationale: In a good sitting position, the buttocks and upper thighs become the base of support. Both feet rest on the floor. The knees are bent, with the posterior of the knee free from the edge of the chair to avoid interference with distal circulation.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 498 3. A nurse needs to change the soiled linen and body position of a client who is confined to bed and has developed bedsores. Which general principle of positioning should the nurse follow?

A. fasten drainage tubes to the bed linen B. tuck in pillows and positioning devices C. raise the bed to the height of the caregiver's elbow

D. change the client's position every half hour Answer: C Rationale: When caring for clients, the nurse should raise the bed to the height of the caregiver's elbow. The nurse should also change the position of a client who is confined to bed at least every 2 hours, ask for the assistance of at least one other caregiver, remove pillows and positioning devices, unfasten drainage tubes from the bed linen, and use a lowfriction fabric or gel-filled plastic sheet, among other things.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 500 4. A nurse is caring for a client with severe back pain. The client has been lying flat on his back in bed for a long time. Which body position has the highest potential for causing foot drop in a bedridden client?

A. supine B. prone C. lateral D. Sims Answer: A Rationale: The supine position, in which a person lies on the back, creates the potential for foot drop. Foot drop makes the client drag the toes on the ground during walking unless a steppage gait is used. The lateral, prone, and Sims positions do not have the potential to create foot drop. In the lateral position, the client lies on their side; in the prone position, the client lies on the abdomen; in the Sims position, the client lies on the left side with the right knee drawn up toward the chest.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 500 5. A nurse needs to transfer a client who has polio but has strong arms and upper body muscles to the x-ray unit. Which transfer device will be most suitable for the client?

A. transfer belt B. transfer board C. transfer handle D. transfer bed Answer: B Rationale: Some clients with strong arm and upper body muscles can use a transfer board independently. Transfer boards are positioned in such a way that the client's buttocks or body

can slide across what would otherwise be an open space or a gap in height between two surfaces. A transfer handle, transfer belt, or transfer bed would not be suitable in this case because the client has polio and his lower body is not active. A transfer belt is used as a walking belt to provide safety and security while assisting a client with ambulation. A transfer handle supports the client's weight when exiting and returning to bed, but in this case, the client is unable to walk independently.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 509 6. A nurse is caring for a client with severe burns. The client's bed has a cradle. Which feature does a cradle offer?

A. It forms a shell over the person's lower legs to keep bed linen off the feet.

B. It supports the body and equalizes the pressure per square inch over its surface.

C. It creates wavelike redistribution of air, which relieves pressure over bony prominences.

D. Its buoyant surface distributes the pressure on the client's underlying tissue.

Answer: A Rationale: A cradle forms a shell over the client's lower legs to keep bed linen off the feet or legs. It is often used for clients with burns, painful joint disease, and fractures of the leg. A water mattress supports the body and equalizes the pressure per square inch over its surface.

An alternating air mattress creates wavelike redistribution of air, cyclically relieving pressure over bony prominences. A static air pressure mattress suspends the client on a buoyant surface, distributing the pressure on the underlying tissue.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 506 7. A nurse is caring for a client who is recovering from acute back pain. Which device will allow the bedridden client to maintain as much independence as possible?

A. bed cradle B. bed board C. trapeze D. side rails Answer: C Rationale: An overbed trapeze is an excellent device for helping a bedridden client increase activity. It is a triangular piece of metal hung by a chain over the head of the bed that the client can grasp to lift the body and move about in bed. Side rails help clients in changing their positions. A bed cradle is used for clients with burns and painful joint diseases. A bed board provides additional skeletal support to the client.

Question format: Multiple Choice

Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 505 8. A nurse instructs a client with cognitive impairment to get into Sims position, but the client, whose word recall is diminished, is unable to understand the instruction. What should the nurse do when instructing clients with cognitive impairment?

A. use illustrations of the desired action to the client B. demonstrate the position to convey the message C. use simple and clear words when giving instructions D. ask the client to use the side rails when moving Answer: B Rationale: Since the client's word recall is diminished, the nurse should demonstrate the position to convey the message. Using illustrations, photographs, or simple and clear words to convey the message would also help but would not be relevant for a client with reduced word recall.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Communication and Documentation Reference: p. 500 9. A nurse is showing a group of clients the correct way to move their body parts during their daily exercise regimen at a health care facility. Which effect occurs when a person adheres to proper body mechanics?

A. reduced skin breakdown B. reduced trauma C. reduced muscle injuries D. increased muscle effectiveness Answer: D Rationale: The use of proper body mechanics increases muscle effectiveness, reduces fatigue, and helps avoid repetitive strain injuries or disorders that result from cumulative trauma to musculoskeletal structures. Basic principles of body mechanics are important regardless of a person's occupation or daily activities. Proper body mechanics alone will not necessarily reduce musculoskeletal injuries or skin breakdown.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 498

10. A nurse needs to document client data in the computer of a health care facility. Which ergonomic recommendation should the nurse follow when working at a computer?

A. Use assistive devices to avoid twisting the trunk or neck.

B. Keep the elbows flexed no more than 100° to 110°.

C. Use alternative equipment for repetitive motions.

D. Take frequent breaks and crane the neck sideways.

Answer: B Rationale: The nurse should keep the elbows flexed no more than 100° to 110° or use wrist rests to keep the wrists in a neutral position when working at a computer. The nurse should also work under non-glare lighting to avoid eye strain. Using assistive devices or alternative equipment will not help, because alternative equipment is used for tasks that require repetitive motion—for instance, headsets or automatic staplers—and assistive devices are used to lift or transport heavy items or clients. Taking breaks and craning the neck sideways are not ergonomic recommendations.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 499 11. A nurse is assessing the home environment of an elderly client with limited mobility.

What recommendation by the nurse would most likely increase the client's confidence in ambulation in the home environment?

A. placement of furniture around the room B. placement of trapeze handles on pathway C. installation of non-glare lighting in the pathway D. strategically placed handrails Answer: D Rationale: Strategically placed handrails promote confidence in ambulation. Placement of furniture around the room would cause the client to fumble while walking (although placing chairs near a frequent pathway allows the client to take rest stops, thus increasing confidence in ambulation). A trapeze is a triangular piece of metal hung by a chain over the head of the bed. It is more useful for bedridden clients.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 503 12. A nurse is caring for a client with cardiac dyspnea. The nurse assists the client into Fowler position. Which advantage does Fowler's position offer a client with dyspnea?

A. It makes it easier for the client to eat, talk, and look around.

B. It relieves pressure on the diaphragm, allowing easy breathing.

C. It reduces the possibility of developing foot drop.

D. It provides good drainage from bronchioles.

Answer: B Rationale: Fowler position is especially helpful for clients with dyspnea because it causes the abdominal organs to drop away from the diaphragm. Relieving pressure on the diaphragm allows the exchange of a greater volume of air. The lateral position reduces the possibility of foot drop. The prone position provides good drainage from bronchioles, stretches the trunk and extremities, and keeps the hips in an extended position.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 506 13. A nurse is observing a client who is lying on an oscillating bed. Which pressure-relieving action does an oscillating bed offer?

A. maintains capillary pressure B. prevents skin irritation and maceration C. promotes a sense of control D. relieves skin pressure Answer: D Rationale: An oscillating bed relieves skin pressure and helps mobilize respiratory secretions.

A circular bed promotes a sense of control among otherwise dependent clients. An airfluidized bed allows the client to "float" and prevents skin irritation and maceration from moisture. A low–air-loss bed maintains capillary pressure well below that which can interfere with blood flow.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 508 14. A wheelchair-bound client reports the "hammock effect" each time the client sits in the wheelchair. Which device should the nurse place in the wheelchair to prevent the hammock effect?

A. waffle-shaped foam mattresses B. foam and latex cushions C. gel and foam cushions D. egg-crate foam mattresses Answer: C Rationale: The nurse should place gel and foam cushions in the wheelchair to prevent the "hammock effect," the posterior and lateral compression, that occurs when sitting in a slinglike seat. Gel is an alternative substance used to fill cushions and mattresses. It differs

from foam in that it suspends and supports the body part. Placing foam and latex cushions, egg-crate foam mattresses, or waffle-shaped foam mattresses in the wheelchair would not reduce the hammock effect.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 506 15. A client with a fractured leg and arm needs to be transferred to the x-ray unit. Which nursing guideline should be followed during client transfer?

A. Assess the client's strength and mobility.

B. Tell the client about the time to get out of bed.

C. Arrange the stretcher next to the client's weaker side.

D. Unlock the wheels of the bed, wheelchair, or stretcher.

Answer: A Rationale: The nurse should assess the client's strength and mobility, because doing so helps determine the need for additional personnel or a mechanical lifting device. Consult with the client on the preferred time for getting out of bed so that the client participates in decision making. Arrange the chair or stretcher next to or close to the bed on the client's stronger side, if there is one, to ensure safety. Locking the wheels of the bed, wheelchair, or stretcher prevents rolling and ensures safety.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 518 16. A nurse is caring for a client who had a stroke. The client is lying in a supine position and is unable to reach the foot board. What should the nurse do to prevent foot drop in the client?

A. use an adjustable bed B. use a water mattress C. give a foot massage D. use a foot splint Answer: D Rationale: If the client is unable to reach the foot board, a foot splint is used. A foot splint allows more variety in body positioning while maintaining the foot in a functional position. If a foot splint or foot board is not available, the nurse can use a pillow and a large sheet.

Giving a foot massage or using an adjustable bed or water mattress will not prevent foot drop.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process

Reference: p. 504 17. A nurse is caring for a client with impaired mobility. What is the purpose of the trochanter roll?

A. to prevent the legs from turning outward B. to preserve the functional ability to grasp C. to prevent skin breakdown and wrinkles D. to prevent unnatural curvature of the spine Answer: A Rationale: Trochanter rolls prevent the legs from turning outward. The trochanters are the bony protrusions at the heads of the femurs, near the hips. Placing a positioning device at the trochanters helps prevent the leg from rotating outward. Hand rolls are devices that preserve the client's functional ability to grasp and pick up objects. A roller sheet is a helpful positioning device that prevents skin breakdown. A firm and comfortable mattress is used to permit good body alignment and prevent unnatural curvature of the spine.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 504 18. A nurse is using a mechanical lift to assist an obese client with limited mobility. Which client will benefit the most from a mechanical lift?

A. infant B. elderly C. heavy D. pregnant Answer: C Rationale: A mechanical lift is best for heavy clients or those with limited mobility. A mechanical lift or repositioning sling is recommended when major repositioning is required.

A mechanical lift can also be used to lift elderly clients, infants, or pregnant women.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 510 19. A nurse is caring for a client with chronic back pain. The client attributes the pain to the client's teaching job, which involves long hours of standing in the classroom. Which position can contribute to a good standing posture and relieve the pain?

A. keeping the knees straight B. maintaining the hips at an uneven level C. holding the chest slightly backward D. distributing weight equally between the feet

Answer: D Rationale: Distributing weight equally between the feet provides a broad base of support.

Maintain the hips at an even level. Bend the knees slightly to avoid straining the joints. Hold the chest up and slightly forward, and extend or stretch the waist to give internal organs more space and maintain good alignment of the spine.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 497 20. A nurse needs to examine the rectum of a constipated client for the presence of stool. The nurse should instruct the client to lie in which position?

A. on the back with legs slightly stretched on the bed B. flat on the stomach with legs slightly stretched to the sides C. on the left side with the right knee drawn up toward the chest D. flat on the abdomen with slightly outstretched arms Answer: C Rationale: In the Sims position, the client lies on the left side with the right knee drawn up toward the chest. This position is used for conducting examinations and procedures involving the rectum and vagina. Prone and supine positions are not typically used for a rectal examination.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 501 21. A public health nurse has been asked to participate in an initiative that is aimed at promoting the use of ergonomics. What is the most likely goal of this initiative?

A. to promote rehabilitation among postsurgical clients B. to promote comfort and health in workplace settings C. to reduce the health consequences of chronic disease D. to increase older adults' awareness of the importance of mobility Answer: B Rationale: Ergonomics is defined as the field of engineering science devoted to promoting comfort, performance, and health in the workplace. The principles are certainly consistent with the other health goals that are listed, but the primary focus is on the workplace.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Understand Client Needs: Health Promotion and Maintenance

Integrated Process: Nursing Process Reference: p. 498 22. A nurse is working with an elderly client who possesses numerous risk factors for disuse syndrome. When assessing this client for disuse syndrome, what assessments should the nurse prioritize? Select all that apply.

A. assess the client's cognition B. assess the client's bowel elimination patterns C. assess the client's temperature and blood pressure D. assess the client's current level of mobility E. assess the client's skin integrity Answer: A, B, D, E Rationale: A potential for disuse syndrome necessitates a comprehensive assessment that includes such elements as cognition, skin integrity, mobility, and bowel elimination.

Temperature and blood pressure may be relevant, but they are less directly related to the signs and symptoms of this syndrome.

Question format: Multiple Select Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 512 23. An 80-year-old client has been transferred from the neurological unit to a rehabilitative unit during the client's recovery from a stroke. The client's nursing care plan includes Risk for Disuse syndrome. What intervention should be performed to address this risk?

A. using a pressure-reducing device on the client's bed B. encouraging the client to limit mobility in order to conserve energy C. providing the client with a low-fat, high-protein diet D. teaching the client to limit fluid intake to reduce edema Answer: A Rationale: Pressure reduction is an important component of preventing disuse syndrome.

Mobility should be encouraged, not limited. Fluid restriction and a low-fat diet are not necessarily indicated.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 506 24. A roller sheet has been placed under an elderly client who is receiving treatment for failure to thrive. When using a roller sheet in a client's care, the nurse must: A. keep the siderails raised to prevent the client from rolling off the side of the bed.

B. ensure that the roller sheet is kept dry and wrinkle-free.

C. first ensure that the client is able to roll from side to side independently.

D. insert an indwelling urinary catheter to protect the roller sheet from urine.

Answer: B Rationale: Nurses use the roller sheet to change the client to an alternate position while avoiding any stooping, reaching, or twisting. The sheet is removed after being used or kept dry and free of wrinkles to prevent skin breakdown. It does not require that the siderails be raised, and a client who can move independently is unlikely to require a roller sheet. The sheet must be kept dry, but a urinary catheter should not be inserted for this sole reason.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 512 25. A client's plan of care specifies that the client should spend the majority of time in a high Fowler position. When following this guideline, the nurse would elevate the client's head at: A. 45°.

B. 55°.

C. 60° to 90°.

D. 75° to 105°.

Answer: C Rationale: A high Fowler position is an elevation of 60° to 90°.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 502 26. The occupational nurse is teaching employees about maintaining good posture. Which teaching will the nurse include? (Select all that apply.)

A. Alternate placing weight on one foot versus the other.

B. Bend the knees slightly to avoid straining joints.

C. Maintain the hips at an even level.

D. Push the buttocks out and hold the abdomen up to properly align the spine.

E. Keep the shoulders even and centered above the hips.

Answer: B, C, E Rationale: Proper posture includes distributing weight equally on both feet to provide a broad base of support, bending the knees slightly to avoid straining joints, maintaining the hips at an even level and keeping the shoulders even and centered above the hips, and pulling the buttocks in and holding the abdomen up to properly align the spine. Alternating the weight on one foot at a time and pushing the buttocks out can lead to injury.

Question format: Multiple Select

Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 497 27. The nurse is teaching a client about good posture when lying down to go to sleep. Which teaching will the nurse include?

A. "Picture yourself with good posture standing; that is how good lying posture works."

B. "Keep knees and legs very straight."

C. "Your feet should be at 45-degree angles from the legs."

D. "Sleep with your head tilted to one side to take pressure off your neck."

Answer: A Rationale: The best posture lying down will be the same as standing posture, except the client is horizontal. Knees should be slightly flexed; feet should be at a right angle from the legs; the head and neck muscles should be in a neutral position, centered between the shoulders. It is not correct to say to keep the knees and legs very straight, to position feet at a 45-degree angle from the legs, or to sleep with the head tilted to one side.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 497 28. The nurse manager is assessing the unit for proper work ergonomics. Which finding will require immediate intervention by the nurse manager?

A. Equipment is positioned 25 degrees away.

B. Chairs have firm back support.

C. Nonglare lighting is present.

D. Nurses and unit assistants use telephones with handsets.

Answer: D Rationale: Proper ergonomics promote comfort, performance, and health in the workplace.

All findings support proper ergonomics, with the exception of the use of handsets. Telephone headsets should be considered to allow hands-free communication.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 498 29. The nurse has completed proper body mechanic education for a group of unlicensed assistive personnel (UAP). Which UAP statement requires the nurse to intervene?

A. "I will ask another UAP to assist with lifting heavy loads."

B. "It is easier to twist my back when moving objects from side to side."

C. "We should report to our manager if items we need are located on shelves that are too high to reach."

D. "When moving a client, we need to plan ahead for the distance we will be going."

Answer: B Rationale: Twisting while lifting is an ergonomic hazard; therefore the nurse will intervene to clarify that the UAPs should not twist their backs while moving objects. The other statements reflect appropriate body mechanics and ergonomic principles.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 506 30. The nurse is delegating inactive client positioning to a UAP. What directions will the nurse include?

A. helping the client change positions every 4 hours B. placing the client in good alignment with joints slightly flexed C. providing skin care before repositioning D. using a sheet to drag and lift the client Answer: B Rationale: The inactive client should be repositioned every 2 hours with the use of a lowfriction fabric or gel-filled plastic sheet and then placed in good alignment with joints slightly flexed. Skin care should be provided after repositioning.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 500 31. The nurse is caring for a client with multiple areas of skin breakdown on the back. In which position will the nurse choose to place the client to improve arterial oxygenation?

A. supine B. prone C. Sims' D. Fowler's Answer: B Rationale: Placing the client in prone position allows for better arterial oxygenation, which may assist in healing of skin breakdown. The other positions place pressure on the areas of skin breakdown and are therefore incorrect.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Apply

Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 501 32. A client who has been lying prone reports shortness of breath and a sensation of choking.

Into which position will the nurse place the client?

A. supine B. prone C. Sims' D. Fowler's Answer: D Rationale: Fowler's position, a semi-sitting position, will assist the client with dyspnea because this position allows the abdominal organs to drop away from the diaphragm. The other position choices do not promote oxygenation.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 502 33. A student nurse asks the nurse what trochanter rolls are used for when providing client care. What is the appropriate nursing response?

A. "To preserve the client's functional ability to grasp and pick up objects."

B. "To prevent foot drop."

C. "To avoid contractures."

D. "To prevent the legs from rotating outward."

Answer: D Rationale: Trochanter rolls prevent the legs from rotating outward. The other statements do not describe trochanter rolls. Hand rolls preserve the client's functional ability to grasp and pick up objects and help the client avoid contractures. Foot boards prevent foot drop.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 504 34. The nurse is caring for a client with incontinence who has been neglected in supine position at home for more than a week. Which priority nursing diagnosis will the nurse select?

A. risk for disuse syndrome B. impaired transfer ability C. impaired physical mobility D. risk for impaired skin integrity

Answer: D Rationale: Although the client may have or be at risk for any of these nursing diagnoses, risk for impaired skin integrity is the priority, as the client has incontinence and has been left in a supine position, which could facilitate skin breakdown. Therefore the other nursing diagnoses are not the priority.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 511 35. The nurse cares for an older adult client who reports feeling dizzy when moving from sitting to standing. Which response by the nurse is most appropriate in addressing the physiological causes of the situation the client is experiencing?

A. Wearing compression stockings can help by limiting how much blood can pool in your legs if you often sit for a long time.

B. Dehydration is a common cause of low blood pressure that causes dizziness, so drinking 1 to 2 glasses of water before standing may be helpful.

C. Sometimes after periods of inactivity the blood vessels do not constrict quickly and a drop in your blood pressure occurs when you stand.

D. When you move from sitting to standing, hold onto the chair for a few minutes, and look straight ahead and take a couple of deep breaths before slowly starting to walk.

Answer: C Rationale: The most appropriate response by the nurse addresses the physiological causes of the situation the client is experiencing. Sometimes, after periods of inactivity the blood vessels do not constrict quickly and a drop in blood pressure occurs when a person stands.

Although the other responses—wearing compression stockings; drinking 1 to 2 glasses of water before standing; and holding onto the chair for a few minutes, looking straight ahead, and taking a couple of deep breaths—are correct actions for a client with this condition, these responses only provide recommendations regarding how to manage the dizziness. They do not provide education on the physiological causes of the situation the client is experiencing.

Question format: Multiple Choice Chapter 23: Body Mechanics, Positioning, and Moving Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 503

Chapter 24 1. A nurse needs to administer the prescribed fitness test of a client who has had prior cardiac-related symptoms. Which fitness test method is most suitable for the client?

A. cross-trainer fitness test B. submaximal fitness test C. ambulatory electrocardiogram D. stress electrocardiogram Answer: C Rationale: An ambulatory electrocardiogram is used when the person has had prior cardiacrelated symptoms, such as chest pain, or has major health risks that contraindicate a stress electrocardiogram. It is a less taxing version of a stress electrocardiogram. A stress electrocardiogram tests electrical conduction through the heart during maximal activity and is performed in an acute care facility or outpatient clinic. A cross-trainer fitness test is a normal fitness test done on a cross-trainer fitness machine. Submaximal fitness tests, such as a step test and a walk-a-mile test, do not stress a person to exhaustion.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 524 2. A nurse is assessing the body mass index of a client when determining his body composition. Which factor contributes to the determination of body composition?

A. skin thickness B. pulse rate C. blood pressure D. body temperature Answer: A Rationale: Factors that determine body composition include anthropometric measurements such as height, weight, body mass index, skinfold thickness, and mid-arm muscle circumference. Body composition is the amount of body tissue that is lean versus the amount that is fat. Pulse rate, blood pressure, and temperature do not determine body composition, but rather a person's vital signs and physical status.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Remember Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 523

3. A nurse is examining and documenting the physical condition of a client who is undergoing a prescribed stress electrocardiogram test at a health care facility. Which client observation should the nurse document?

A. breathing pattern B. endurance level C. running speed D. muscle reflexes Answer: A Rationale: During a stress electrocardiogram test, the nurse or the examiner notes the client's breathing pattern, heart rate and rhythm, blood pressure, and symptoms such as dizziness and chest pain. The client's endurance level, running speed, and muscle reflexes are part of the maximal activity performed by the client during the test.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Remember Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 524 4. A client is wearing a Holter monitor in order to undergo a prescribed ambulatory electrocardiogram. Which precaution should the client take during an ambulatory electrocardiography test?

A. Insulate all metal detectors.

B. Avoid a sponge bath.

C. Avoid a shower or swim.

D. Use an electric blanket.

Answer: C Rationale: During a prescribed ambulatory electrocardiography test, the client should not shower or swim; a sponge bath is permitted as long as the monitor does not get wet. The client also should avoid magnets, metal detectors, electric blankets, and high-voltage areas that may cause artifacts on the recordings that interfere with an accurate interpretation of the test results.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Remember Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 524 5. A client has been ordered to undergo a step test. Which arrangement is of greatest importance during a step test?

A. Reduce the height of the step test machine platform.

B. Make arrangements for a metronome and a stopwatch.

C. Shorten the test time when the client's heart rate is rapid.

D. Make arrangements for cardiopulmonary resuscitation personnel.

Answer: D Rationale: The most important arrangement that a nurse should make during a step test is to ask for the assistance of personnel certified in cardiopulmonary resuscitation and the use of an automatic cardiac defibrillator if there is an adverse cardiac event. The step test is used with caution; hence, test time is shortened if the client develops discomfort. The examiner uses a metronome and a stopwatch to keep track of the rate and the time, but this is not the most important arrangement. The height of the step test machine platform is prescribed as per the client.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 525 6. A nurse is calculating the maximum heart rate of a 20-year-old client who has undergone a prescribed fitness level test. What should this client's heart rate be?

A. 120 beats per minute B. 150 beats per minute C. 170 beats per minute D. 200 beats per minute Answer: D Rationale: Maximum heart rate is calculated by subtracting a person's age from 220. Thus, a 20-year-old's maximum heart rate is 200 beats per minute (bpm), whereas a 50-year-old client's maximum heart rate is 170 bpm. The target heart rate is 60% to 90% of the maximum heart rate. Beginners should not exceed 60%, intermediates can exercise at 70% to 75%, and competitive athletes can tolerate 80% to 90% of their maximum heart rate.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 526 7. A physician has ordered an obese client to join an aerobic exercise class to promote cardiorespiratory conditioning. Which of the following fitness exercises is most suitable for the client?

A. active exercise B. isometric exercise C. isotonic exercise D. therapeutic exercise Answer: C Rationale: Isotonic exercise is most suitable for an obese client, as it involves movement and work. The prime example is aerobic exercise, which involves moving all body parts at a moderate-to-slow speed without hindering the ability to breathe. To promote

cardiorespiratory conditioning, a person should perform isotonic exercise at his target heart rate. Isometric exercise does not promote cardiorespiratory conditioning; in fact, strenuous isometric exercise elevates blood pressure temporarily. Therapeutic exercise is performed by people with health risks or those who are being treated for an existing health problem. In contrast, active exercise is therapeutic activity that the client performs independently, after proper instruction.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 527 8. A nurse is observing the prescribed therapeutic activity of a middle-aged client who underwent a mastectomy to control her breast cancer. Which active exercises or therapeutic activities should the client perform?

A. Learn to comb her hair independently with the arm on the surgical side.

B. Learn to hop on the floor independently with the leg on the surgical side.

C. Learn to perform isometric exercise independently with all body parts.

D. Learn to perform exercises that maintain muscle tone and flexible joints.

Answer: A Rationale: Clients who have undergone a mastectomy learn to exercise the arm on the surgical side by combing their hair, squeezing a soft ball, finger-climbing the vertical surface of a wall, and swinging a rope attached to a doorknob. Active exercise is therapeutic activity that the client performs independently after proper instruction. Active therapeutic exercise is often limited to a particular part of the body that is in a weakened condition; consequently, hopping on the floor or performing isometric exercises is not feasible. Performing exercises that maintain muscle tone and flexible joints with assistance is part of passive exercise, not active exercise.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 431 9. A nurse at a health care facility is assisting a client during a prescribed passive therapeutic exercise. Passive exercise is most suitable for clients who: A. have undergone mastectomy surgery.

B. are paralyzed from a stroke or spinal injury.

C. have cardiorespiratory conditioning.

D. have had prior cardiac-related symptoms.

Answer: B Rationale: Passive exercise is most suitable for clients who are comatose or paralyzed from a stroke or spinal injury. Nurses perform exercises that maintain muscle tone and flexible joints. Active exercise is performed independently by clients who have undergone

mastectomy surgery in order to exercise the arm on the surgical side. Isotonic exercise is activity performed by clients to promote cardiorespiratory conditioning and increase lean muscle. Clients who have had prior cardiac-related symptoms, such as chest pain, or have major health risks use a stress electrocardiogram to assess their heart response to physical activity.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 529 10. A nurse is caring for a 65-year-old client who has been paralyzed from the waist down.

The physiotherapist has prescribed ambulatory exercise, for which the nurse needs to monitor and assist the client. What would be an indication to the nurse that the activity is beyond the tolerance level of the client?

A. increased heart rate B. decreased pulse rate C. increased body temperature D. decreased blood pressure Answer: A Rationale: An increased heart rate in a client is an indication to the nurse that the activity is beyond the client's level of tolerance. Older adults, especially those who are disabled, need to balance periods of physical activity with periods of rest. Shortness of breath or increased heart rate indicate that the level of activity is beyond the client's tolerance. Since an increased heart rate is an indicator that the activity is beyond the client's tolerance level, an increased pulse rate—not a decreased pulse rate—would be a suitable indicator. A client's temperature may increase or blood pressure may decrease during the activity, but these are not very good indicators, as they are not observable when the activity is being performed.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 530 11. A nurse is caring for a client at a health care facility who has been prescribed physical exercise by the physiotherapist. Which of the following beverages should the nurse eliminate for older adults before or during physical activity?

A. mineral water B. glucose C. fruit juice D. tea Answer: D Rationale: The nurse should eliminate tea from the diet of older adults before or during physical activity. Older adults need to eliminate their intake of caffeinated and alcoholic

beverages before and during physical activity to avoid depleting fluid volume. Water is the preferred drink for fluid replacement, and thus the client is permitted to drink mineral water.

Fruit juices and glucose do not contain caffeine or alcohol and therefore can be permitted by the nurse.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 530 12. A nurse suggests that an elderly client perform exercises in water. What is a benefit for older adults of performing exercises in water?

A. It reduces stress on the joints.

B. It keeps the body cool.

C. It reduces blood pressure.

D. It keeps the heart rate low.

Answer: A Rationale: Performing exercises in water reduces stress on the joints. Swimming or exercising in water puts less stress on joints and is beneficial for older adults. Exercising in water may help to keep the body cool, but it is not necessary in this case. There is no indication that performing exercises in water reduces blood pressure. The heart rate is more likely to increase when performing physical activities or exercises, even if the client is performing them in water.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Reference: p. 530 13. A nurse is caring for client at a health care facility whose treatment includes exercise.

Which nursing diagnosis is most likely for this client?

A. ineffective breathing pattern B. perioperative-positioning injury C. impaired social interaction D. delayed surgical recovery Answer: D Rationale: The nursing diagnosis of delayed surgical recovery should be treated with exercise. Some of the other nursing diagnoses that need to be treated with exercise are impaired physical mobility, disuse syndrome, unilateral neglect, and activity intolerance. The nursing diagnoses of ineffective breathing pattern, perioperative-positioning injury, or impaired social interaction do not require treatment with exercise.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Remember Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

Integrated Process: Nursing Process Reference: p. 530 14. A physician has directed a nurse to assist a client to perform exercises in order to prevent ankylosis. What type of exercise should the nurse assist the client with in this case?

A. range-of-motion exercises B. continuous passive motion (CPM) machine exercises C. active exercises D. aerobic exercises Answer: A Rationale: The nurse should assist the client to perform range-of-motion exercises in order to prevent ankylosis. Range-of-motion (ROM) exercises are therapeutic activities that move the joints. They are performed to assess joint flexibility before initiating an exercise program, maintain joint mobility and flexibility in inactive clients, prevent ankylosis (permanent loss of joint movement), stretch joints before performing more strenuous activities, and evaluate the client's response to a therapeutic exercise program. A continuous passive motion (CPM) machine is an electrical device that is used as a supplement or substitute for manual ROM exercise. Active exercises are therapeutic activities that the client performs independently after proper instruction. Aerobic exercises are isotonic exercises that promote cardiorespiratory conditioning and increase lean muscle mass.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 530 15. A comatose client is being treated in the intensive care unit of a health care facility. What type of exercise should the nurse assist this client to perform in order to maintain the muscle tone and flexibility of the client's joints?

A. isotonic exercise B. isometric exercise C. passive exercise D. active exercise Answer: C Rationale: The nurse should assist the comatose client in performing passive exercise in order to maintain muscle tone and flexibility. Passive exercise is a therapeutic activity that the client performs with assistance and is provided when a client cannot move one or more parts of the body. An isotonic exercise is an activity that involves movement and work. Isometric exercise consists of stationary exercises generally performed against a resistive force. Active exercise is therapeutic activity that the client performs independently after proper instruction.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process

Reference: p. 529 16. A nurse at a health care facility is suggesting the use of isometric exercise to a client.

What is the major purpose of isometric exercise?

A. to prevent ankylosis B. to promote cardiorespiratory conditioning C. to increase lean muscle mass D. to maintain flexible joints Answer: C Rationale: Isometric exercise consists of stationary exercises generally performed against a resistive force. Isometric exercises increase muscle mass, strength, and tone, and define muscle groups. Although they improve blood circulation, they do not promote cardiorespiratory function. The nurse should suggest isotonic exercises in order to maintain cardiorespiratory conditioning. Passive exercises help to maintain flexible joints. Isometric exercise is not primarily intended to prevent ankylosis.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 527 17. A nurse is caring for a client who recently underwent hip replacement surgery. What type of exercise should the nurse suggest for this client in order to restore muscle and joint functioning?

A. active exercises B. continuous passive motion machine exercises C. isometric exercises D. isotonic exercises Answer: B Rationale: The nurse should suggest a continuous passive motion machine to the client who recently underwent hip surgery. A continuous passive motion machine is an electrical device used as a supplement or substitute for manual ROM exercises. Machine-assisted ROM sometimes is preferred during the rehabilitation of clients who have experienced burns or have had knee or hip replacement surgery because the machine precisely controls the degree of joint movement and can increase it in specific increments throughout recovery. Active exercise is therapeutic activity that the client performs independently after proper instruction.

Isotonic exercise is activity that involves movement and work used to promote cardiorespiratory conditioning and increase lean muscle mass. Isometric exercises increase muscle mass, strength, and tone, and define muscle groups. The nurse, however, would not suggest these exercises for the client.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning

Reference: p. 529 18. During discharge teaching with a client who has been treated for a hernia, the nurse has discussed the benefits of a regular regime of physical exercise. What benefits of regular exercise should the nurse cite? Select all that apply.

A. decreased low-density blood lipids B. reduced blood pressure C. reduced blood glucose levels D. improved bowel function E. increased urine concentration Answer: A, B, C, D Rationale: There are multiple benefits of regular exercise, including cholesterol reduction, decreased blood pressure, reduced blood glucose, and regularity of bowel function. Increased urine concentration, however, is not a noted benefit of physical activity.

Question format: Multiple Select Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Reference: p. 524 19. A nurse is conducting an admission assessment of a client who has presented to the hospital with complications of pregnancy. The nurse has asked the client to rate their perceived level of fitness. The nurse should be aware that fitness is defined as: A. resistance to physical injury.

B. ability to weight bear.

C. objective evidence of cardiac output.

D. capacity to exercise.

Answer: D Rationale: Fitness means capacity to exercise. Weight-bearing and resistance to injury may be outcomes of fitness, but they are not synonymous with it. Increased cardiac output facilitates fitness and is influenced by fitness but is not definitive of the term.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 532 20. After being diagnosed with type 2 diabetes, a client has expressed an intention to "turn over a new leaf" and commit to a vigorous exercise regime. The nurse has emphasized the importance of having the client's fitness level assessed before beginning the exercise program. What is the primary rationale for the nurse's advice?

A. Provide a baseline against which to compare improvements.

B. Determine if the client's fitness matches norms for age and gender.

C. Identify any risks for injury that might be posed by an exercise program.

D. Ensure that the client understands how to carry out the necessary exercises.

Answer: C Rationale: Existing health problems can result in injury during exercise. Therefore, before a client begins an exercise program, assessment of the client's fitness level is necessary. This safety measure is more important than establishing baselines or teaching the correct techniques, though these may also be addressed.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 523 21. An obese client has been advised to begin a program of fitness exercise. In preparation for the program, the nurse has taught the client the concept of metabolic energy equivalents (METs). An understanding of METs allows the client to: A. compare the relative intensity of different forms of activity.

B. match glucose intake to energy needs while exercising.

C. understand the energy needs of the body cells and heart.

D. perform exercise at the time of day when it will have maximum benefit.

Answer: A Rationale: METs allow a comparison of the relative energy demands of different activities; activities assigned higher METs consume more energy and are more vigorous. METs do not directly address glucose needs, cellular metabolism, or the timing of exercise.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 526 22. An adult client and the nurse have collaboratively calculated the client's maximum heart rate for the client's age. The client has no major health problems but has very minimal experience with performing fitness exercise. The client's target heart rate during exercise should be no more than what approximate percentage of the maximum heart rate?

A. 35% B. 50% C. 65% D. 80% Answer: B Rationale: Beginners should not exceed 50% of maximum heart rate.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Remember Client Needs: Health Promotion and Maintenance

Integrated Process: Nursing Process Reference: p. 526 23. The nurse is teaching a 37-year-old client about factors that impair fitness and stamina.

Which factors will the nurse identify? Select all that apply.

A. obesity B. health problems C. smoking D. age E. optimal muscle and skeletal function Answer: A, B, C, D Rationale: Obesity, health problems, smoking, and age (particularly advanced age) can impair a client's fitness and stamina. Optimal muscle and skeletal function do not impair fitness and stamina, yet compromised muscle and skeletal function does.

Question format: Multiple Select Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 523 24. The occupational nurse is assessing an employee's vital signs at rest. Which finding requires nursing intervention?

A. blood pressure 140/90 mmHg B. respirations 18 per minute C. pulse rate 88 beats per minute D. temperature 98.8ºF Answer: A Rationale: Elevated blood pressure, pulse rate, and/or respiratory rate while resting may indicate a life-threatening cardiovascular concern. The nurse should intervene when the client's resting blood pressure is high. All other vital signs are normal.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 524 25. The nurse is preparing a client for a stress electrocardiogram. Which client statement requires further nursing teaching?

A. "I will keep walking, even if I feel exhausted."

B. "You will monitor my heart rate and rhythm while I walk."

C. "The speed and incline of the treadmill will increase as the test goes on."

D. "I will wear a pulse oximeter to measure my level of oxygenation."

Answer: A

Rationale: A stress electrocardiogram will be stopped if the client develops an abnormal heart rhythm, cardiac ischemia, elevated blood pressure, or exhaustion. All other client statements are accurate.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 524 26. The nurse is teaching a client about ambulatory electrocardiogram. Which client statement requires further nursing teaching? Select all that apply.

A. "I will wear this device for 24 hours."

B. "This procedure will assess how my heart reacts to normal activity."

C. "I can take a sponge bath while wearing this device."

D. "It is acceptable for me to go through the metal detector at the airport."

E. "This will help me understand how my heart performs when I swim."

Answer: D, E Rationale: Magnets, metal detectors, electric blankets, and high-voltage areas should be avoided when wearing a Holter monitor because these can cause artifacts. The client should not shower or swim because the device could get wet. All other client statements are acceptable and do not require further teaching.

Question format: Multiple Select Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 524 27. The nurse is calculating the maximum heart rate for a 60-year-old client. Which accurately reflects the client's maximum heart rate?

A. 120 beats per minute B. 140 beats per minute C. 160 beats per minute D. 180 beats per minute Answer: C Rationale: Maximum heart rate is calculated by subtracting the client's age from 220. For a 60-year-old client, 220 minus 60 equals 160. The other values are too low or too high.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 526

28. The nurse is calculating the maximum heart rate for a 28-year-old client. Which accurately reflects the client's maximum heart rate?

A. 132 beats per minute B. 152 beats per minute C. 172 beats per minute D. 192 beats per minute Answer: D Rationale: Maximum heart rate is calculated by subtracting the client's age from 220. For a 28-year-old client, 220 minus 28 equals 192. The other values are too low.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 526 29. The nurse is caring for a client who has undergone a mastectomy. Which example(s) of active exercise will the nurse emphasize? Select all that apply.

A. performing range-of-motion exercise for the arm on the opposite side of the surgery B. having the UAP perform gentle ankle rotation until the client regularly ambulates C. having the client comb her hair with the arm on the surgical side D. asking the client to squeeze a soft ball E. instructing the client to swing a rope attached to a doorknob Answer: C, D, E Rationale: Active exercise involves the client doing something, such as combing hair, squeezing a ball, or swinging a rope. Performance of range-of-motion or rotation exercises by another individual reflects passive exercise.

Question format: Multiple Select Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 529 30. An older adult client tells the nurse, "I don't bother exercising because I get too tired very quickly." What is the appropriate nursing response?

A. "Try drinking some coffee first, and you will have more energy."

B. "Alternate periods of activity with periods of rest."

C. "Exercise must be done standing; do not try to exercise sitting down."

D. "If you'd just get started, you'd want to continue exercising."

Answer: B Rationale: Older adults may need to balance periods of activity with periods of rest. Small increments of each can be beneficial in helping the older adult establish a workable exercise routine. Coffee and alcoholic beverages should be avoided, and water should be consumed

when exercising. Some exercises can be done sitting or lying down if the client has balance concerns. Telling the client to get started exercising does not address the primary concern.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Reference: p. 530 31. The nurse is teaching a client about moving joints into positions of pronation and supination. Which client action does the nurse identify that appropriately reflects these movements?

A. turns the arms downward and then upward B. moves the legs away from the midline and then toward the midline C. tilts the chin down to touch the chest and then stretches the head back as far as it will go D. turns the sole of the foot toward the midline and then away from the midline Answer: A Rationale: Pronation and supination involve turning downward and then upward. Moving the legs away from the midline and then toward the midline is reflective of abduction and adduction. Tilting the chin downward and then stretching the head backward comfortably reflects flexion and extension. Turning the sole of the foot toward and then away from the midline is reflective of inversion and eversion.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 538 32. The nurse is providing education to a community about creation of a safe exercise program. Which teaching will the nurse include? Select all that apply.

A. See a health care provider prior to starting an exercise program.

B. Plan at least 300 minutes of moderate-intensity exercise weekly, divided into no less than 10 minutes or longer over multiple days.

C. Build up to 30 minutes or more of moderate-intensity physical activity on most days.

D. Exercise alone if you are embarrassed to get started.

E. Dress in layers according to temperature.

F. Wear supportive shoes.

G. Eat proteins before exercising.

Answer: A, C, E, F Rationale: Participants should see a health care provider before starting an exercise program and build up to 30 minutes or more of moderate-intensity physical activity on most days. It is appropriate to dress in layers according to the temperature and wear supportive shoes.

Individuals should plan for at least 150 minutes of moderate-intensity exercise weekly, divided into no less than 10 minutes or longer over multiple days. Exercising with a partner

promotes safety and motivation. Complex carbohydrates should be consumed before exercising.

Question format: Multiple Select Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 528 33. A nurse is assisting a client in performing prescribed range-of-motion exercises. What is one of the reasons why these exercises are being performed?

A. to maintain joint mobility and flexibility in active clients B. to stretch muscles before performing more strenuous activities C. to promote cardiorespiratory function and reduce body fat D. to test a client's ability to bear weight Answer: A Rationale: Range-of-motion (ROM) exercises are therapeutic activities that move the joints.

They are performed to assess joint flexibility before initiating an exercise program, maintain joint mobility and flexibility in inactive clients, prevent ankylosis or permanent loss of joint movement, stretch joints before performing more strenuous activities, and evaluate the client's response to a therapeutic exercise program. In unconscious clients, ROM exercises prevent contractures and promote circulation but do not build muscle strength.

Question format: Multiple Choice Chapter 24: Fitness and Therapeutic Exercise Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 529

Chapter 25 1. A nurse is assisting a physician in applying an emergency splint on the injured leg of a client. Which action should the nurse remember when applying an emergency splint?

A. Avoid changing the position of the injured part.

B. Remove the high-top shoe in case of ankle injury.

C. Avoid covering any open wound.

D. Select a flexible splinting material.

Answer: A Rationale: When applying an emergency splint, the nurse should avoid changing the position of the injured part to prevent additional injuries. The nurse should leave a high-top shoe in place in case of ankle injury to reduce pain and swelling. Open wounds should not be left open but rather should be covered with a clean dressing to prevent dirt and pathogens from entering. The nurse should select rigid splinting material such as a flat board or a broom handle to provide support while restricting movement.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Analyze Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 543 2. A nurse is cleansing the skin and tissue around the pin site of a client. Which sign confirms the need to obtain a wound culture?

A. pain B. temperature C. swelling D. purulent drainage Answer: D Rationale: The presence of purulent drainage at the pin site indicates the need to obtain a wound culture. Redness, swelling, and increased tenderness around the pin site are also signs that provide data for current and future comparisons. The nurse should also check if the client has a temperature and pain as it indicates the possibility of infection.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 566 3. A nurse is applying a fiberglass cast to a client. What is a feature of a fiberglass cast as compared to a plaster of paris cast?

A. inexpensive B. easy to apply

C. durable D. nonporous Answer: C Rationale: A fiberglass cast is durable, lightweight, porous, allows immediate weight bearing, and is unaffected by water. It is expensive compared to a plaster of paris (POP) cast, which is inexpensive. A POP cast is easy to apply but heavy and is prone to cracking and crumbling.

Although fiberglass is porous, it is not recommended for severe injuries or those accompanied by excessive swelling.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 547 4. A nurse is caring for a client with pin insertions in the left thigh. Which action should the nurse perform to prevent infection to the pin site?

A. Avoid removing crusted secretions.

B. Avoid applying ointment to pin sites.

C. Teach the client to cleanse the pin sites.

D. Cleanse the skin at the pin sites moving inward.

Answer: B Rationale: In order to prevent infection to the pin site, the nurse should avoid applying ointment to pin sites unless prescribed because it reduces moisture at the site and occludes drainage. The nurse should gently remove crusted secretions because it helps in removing debris that supports the growth of microorganisms. The nurse should teach the client not to touch the pin sites in order to prevent the transmission of pathogens. The nurse should cleanse the skin at the pin sites moving outward in a circular manner to prevent microorganisms from moving toward the areas of open skin.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 566 5. A nurse is caring for a client in Buck's skin traction. What indicates a need for corrective action?

A. The traction weights are touching the floor.

B. The traction is being applied continuously.

C. The countertraction is opposite to the pull of traction.

D. The client's position is limited.

Answer: A

Rationale: To maintain an effective traction, the traction weight should be suspended without interference and not touching the floor. The nurse should keep the traction applied continuously to get the desired effect unless there are medical orders otherwise. The countertraction must be maintained in a direction opposite to the pull of traction for effective traction. The client's position is limited as per the standards of care to avoid any interference in the traction pull and counterpull action.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Analyze Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 550 6. A nurse is caring for an elderly client with an upper extremity fracture. Which therapy can be given to elderly clients to treat fractures of the upper extremities?

A. traction B. an external fixator C. immobilization D. acupressure Answer: C Rationale: Some fractures, particularly of the upper extremities, are treated nonsurgically with immobilization. Occupational and physical therapists are helpful in assisting older adults to regain function and range of motion following any period of immobilization in order to prevent a decrease in or permanent loss of function. An external fixator is a metal device surgically inserted into and through the broken bones of a client to stabilize fragments during healing. Traction is a treatment measure for musculoskeletal trauma and disorders.

Acupressure and massage may not be suitable to treat fractures of the upper extremities among elderly clients as they may lead to further complication and injury. Both acupressure and massage involve exertion of physical pressure on the different parts of the body by hand, elbow, or with the aid of various devices.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 542 7. A nurse is assessing the neck injury of a client who has been wearing a cervical collar for over 2 weeks. What could occur if the client wears the cervical collar for a prolonged period?

A. restricted movement and activity B. quick recovery C. permanent neck stiffness D. faster revascularization Answer: C Rationale: Wearing a cervical collar for a prolonged period can lead to permanent stiffness in the neck. Clients are required to wear cervical collars almost continuously, even while

sleeping, for 10 days to 2 weeks. They remove them to do gentle range of motion neck exercises. The sooner a client performs exercise, the faster the revascularization and recovery occurs. A cervical collar does not restrict a person's movement and activity, but hip spica casts do.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 544 8. A nurse is caring for a client with a fractured wrist in a cylinder cast. Which action should the nurse perform to identify the neuromuscular function of the client?

A. Monitor the mobility of the fingers.

B. Assess the sensation in the exposed fingers.

C. Observe the color of the client's nail beds.

D. Show the objects used to check stimulation.

Answer: A Rationale: To identify the neuromuscular function of the client, the nurse should monitor the mobility of the fingers. Assessing the sensation in the exposed fingers provides data about neurovascular complications. The nurse can observe the color of the nail beds only if the nurse compresses them and determines the time for the color to return following blanching.

The nurse touches the client's extremities with sharp, dull, and warm objects to check if the client can differentiate stimuli without actually seeing it.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 561 9. A nurse is caring for a client with lower back pain due to contracted muscles. Which splint is most suitable for pulling contracted muscles?

A. emergency splint B. immobilizer C. inflatable splint D. traction splint Answer: D Rationale: Traction splints are metal devices that immobilize and pull on contracted muscles.

Immobilizers are more suitable for injuries to the neck and knee. Inflatable splints are used to limit motion and reduce swelling and blood flow. Emergency splints are basically applied as a first-aid measure with materials such as a board, a broom handle, or a golf club, among other things.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Remember

Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 544 10. A nurse has used a commercial arm sling to support a client's arm. Which function does a sling perform?

A. reduces muscle spasms B. reduces transmission of pathogens C. provides elevation to body parts D. encloses the client's forearm Answer: C Rationale: A sling is a cloth device used to elevate, cradle, and support parts of the body. A sling does not reduce transmission of pathogens, but washing hands thoroughly does.

Traction is used to reduce muscle spasms with its pulling effect on the affected part of the skeletal system. The sling not only encloses the client's forearm but also the wrist.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 543 11. A nurse needs to bathe and clean the fractured arm of a client with a bivalved cast. Which action is most suitable when removing a bivalved cast?

A. Remove both the casts simultaneously.

B. Remove the anterior half of the shell.

C. Obtain a sharp x-ray of the arm.

D. Assess the fingers for blood circulation.

Answer: B Rationale: The most important action when removing a bivalved cast is to remove the anterior half of the shell temporarily for hygiene and assist the client to a prone position when removing the posterior half of the cast. Removing both the casts simultaneously can lead to further injury. A sharp x-ray is obtained when the bivalved cast is created, not when it is removed temporarily. It is important to assess the client's fingers for blood circulation if a cylindrical cast has been applied.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 560 12. A nurse is fitting a custom-made brace to a client with weak knees in order to provide stability when ambulating. Which support device is most suitable for the client?

A. Invisalign braces B. prophylactic braces

C. functional braces D. rehabilitative braces Answer: C Rationale: Functional braces are most suitable for the client because they can provide stability for an unstable joint. Braces are custom-made or custom-fitted devices designed to support weakened structures. Prophylactic braces are not suitable because they are used to prevent or reduce the severity of a joint injury. Rehabilitative braces allow protected motion of an injured joint that has been treated operatively. Invisalign braces are a type of orthodontic braces which are used to correct the alignment of teeth and their position with regard to bite.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 545 13. A nurse is trimming the cast applied to the fractured leg of a client since the leg is healing. The cast was applied in such a way that the toes were exposed. Which cast was applied to the client?

A. cylinder cast B. spica cast C. bivalved cast D. body cast Answer: A Rationale: A cylinder cast was applied to the client. A cylinder cast encircles an arm or leg and leaves the toes or fingers exposed. The cast extends from the joints above and below the affected bone in order to prevent movement and maintain correct alignment during healing. A spica cast is not the correct response because it cannot be trimmed, and is heavy and uncomfortable. A bivalved cast is not the correct response because it is usually used for upper extremities. A body cast is used to encircle the trunk of the body instead of an extremity.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Analyze Client Needs: Physiological Integrity: Basic Care and Comfort Reference: p. 546 14. A nurse is assisting a physician who is placing a client's dislocated arm in its original position. Which type of traction is being applied to the client?

A. skin traction B. manual traction C. skeletal traction D. electric traction Answer: B

Rationale: Manual traction is used to realign a broken bone or replace a dislocated bone into its original position within a joint. Electric traction is done by using alternating current and direct current. Skin traction is a pulling effect on the skeletal system done by applying devices. Skeletal traction is the pull exerted directly on the skeletal system by attaching wires, pins, or tongs into or through a bone.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 549 15. A nurse is removing the leg cast of a client. Which precaution should the nurse take when removing a cast?

A. Bivalve the cast with an electric cutter.

B. Cut the padding with the electric cutter.

C. Use a knife or sharp object to split the cast.

D. Soak the cast in water before cutting.

Answer: A Rationale: Most casts are removed with an electric cast cutter, an instrument that looks like a circular saw. The proper use of an electric cast cutter leaves the skin intact. Padding should be cut manually with clean scissors. A blunt knife or forceps should be used to split open the cut cast. A cast is not soaked in water before being cut.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 547 16. A nurse is caring for a client with a cast on the left leg. Which nursing intervention should the nurse perform to prevent the client from being at risk of peripheral neurovascular dysfunction?

A. Elevate the affected leg higher than the client's heart.

B. Avoid applying ice packs on the affected area.

C. Tell the client to avoid wiggling the toes.

D. Encourage the client to eat a diet rich in proteins and calcium.

Answer: A Rationale: Elevating the casted leg higher than the client's heart facilitates venous return of blood from distal areas to the heart. Applying ice packs on the cast over the area of injury and refilling the ice bag every 20 minutes helps to reduce swelling and pain. The nurse should ask the client to wiggle the toes of the affected leg every 15 minutes when awake to avoid stiffening. Exercising the toes also contracts the skeletal muscles, thereby compressing the capillaries and veins, which propels venous blood toward the heart. Encouraging the client to eat a healthy diet is important, but not a priority at this stage.

Question format: Multiple Choice

Chapter 25: Mechanical Immobilization Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 552 17. A client with a severe muscle spasm in the lower back has been prescribed traction.

Which aspect of the equipment should the nurse check before applying traction to the client?

A. number of pulleys B. availability of gloves C. prescribed amount of weight D. infrared heat of the lamp Answer: C Rationale: The nurse should check the prescribed amount of weight that needs to be applied to create the necessary pulling effect on the affected body part. The number of pulleys does not matter as long as the rope moves freely through each pulley. Using fresh gloves is a good practice but is not important when applying traction. Applying infrared heat with a lamp is used to treat pain, but it is not part of traction.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 551 18. To check if a client has recovered from a slipped disc, a nurse is assessing the client's neuromuscular status by having the client perform movements that correlate with muscular functions controlled by the cervical spine and peripheral nerve roots. What was applied to the client?

A. cervical collar B. pelvic belt C. molded splint D. bivalved cast Answer: A Rationale: During recovery from a slipped disc, the nurse assesses the client's neuromuscular status by having the client wear a cervical collar. The nurse also performs movements that correlate with muscular functions controlled by the cervical spine and peripheral nerve roots.

A pelvic belt is a part of skin traction, which is applied to the skeletal system with devices. A molded splint is used for chronic injuries or diseases. A bivalved cast is usually applied to clients with arthritis.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Remember Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 544

19. A client has had a cylinder cast applied to the tibia after suffering a fracture during a soccer game. The primary purpose of a cast is to: A. maintain constant tension on injured bones to promote healing.

B. temporarily reduce the weight-bearing ability of the injured limb.

C. preserve the neurovascular function of the injured limb.

D. immobilize injured bones to facilitate reunion.

Answer: D Rationale: The purpose of the cast is to immobilize the injured structure. Casts do not provide tension. Maintaining neurovascular function is imperative when a client has a cast in place, but this is not the purpose of the cast itself. Similarly, reduction of weight-bearing undoubtedly occurs, but this is not the central purpose of a cast.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 553 20. A nurse on an orthopedic trauma unit is providing care for a client who has had Buck's traction applied after suffering multiple trauma in a motorcycle accident. The essential characteristic of all types of traction is the application of: A. pulling force to aid healing or relieve symptoms.

B. twisting force to prevent complications of immobility.

C. therapeutic pressure on an injured body part.

D. pushing injured bones together to promote reunion.

Answer: A Rationale: There are several different types of traction, but each involves the therapeutic application of pulling force. Twisting, pressure, and pushing are not main components of traction.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 552 21. A middle-aged male client suffered multiple lower leg injuries after being struck by a vehicle while cycling. The client has had external fixation applied to his left leg as part of his treatment regimen. What client education should the nurse provide to this man?

A. "The most important thing is to always make sure that the weights are hanging freely."

B. "Together, we'll work on ways to maximize your mobility while you have the device in place."

C. "I'll teach you exercises to maintain your strength and circulation while you're restricted to bed."

D. "Your fixators will feel intrusive and restrictive at first, but you'll get used to them over the next several months."

Answer: B Rationale: Although the external fixator immobilizes the area of injury, the client is encouraged to be active and mobile. External fixation does not use weights and the fixators are not left in place for several months.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 542 22. After having a consultation with the orthopedic surgeon, a nurse has learned that a client's fracture will be treated with external fixation rather than with a cast. The nurse should recognize that this chosen treatment heightens the client's risk of what nursing diagnosis?

A. risk for infection B. ineffective coping C. sleep deprivation D. risk for trauma Answer: A Rationale: Because external fixators involve a potential portal of entry for microorganisms, there is an increased risk of infection. External fixators do not have an increased risk of ineffective coping or sleep disturbance when compared to casting. Risk for trauma is present any time that a client is being treated for a fracture.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 563 23. The nurse is providing pin site care for a client who is in traction. Which assessment finding requires the nurse to intervene?

A. Client requests pain medication every 4 hours.

B. Crusted secretions must be removed.

C. Mild amount of serosanguineous draining is present.

D. White blood cell count of 13,000/mL (13 ×109/L).

Answer: D Rationale: A white blood cell count of over 10,000/mL (10 ×109/L) could indicate the presence of infection; this requires the nurse to intervene. All other findings are normal.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Analyze

Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 565 24. The nurse is assessing a client who had a plaster cast applied after surgery to the right ankle 3 hours ago. Which finding requires immediate nursing intervention?

A. Cast appears to change shape after the client moved.

B. Skin above and below cast is pink and warm to touch.

C. Toes are cool and dry.

D. Client reports pain of "4" on 1-10 scale.

Answer: C Rationale: Neurovascular complications are most likely to occur in the early hours after initial casting; cool toes may be an indication that circulation is impaired. All other findings are normal.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 562 25. The nurse is caring for a client with a dislocated fracture who will undergo reduction and casting. When will the nurse plan to administer an opioid pain medication?

A. 1 hour before reduction B. 15 minutes before reduction C. during casting process D. 30 minutes after casting is completed Answer: B Rationale: The client should be given pain medication prior to the reduction and casting process so that it has time to take effect. Onset of opioid pain medication is quick; therefore, 15 minutes before reduction is appropriate. It is not appropriate to administer the medication 1 hour before.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 559 26. The nurse has applied a sling to a client who has an arm injury. Which assessment finding requires the nurse to further intervene?

A. Client reports arm pain of "3" on scale of 1-10.

B. Capillary refill time is 4 seconds.

C. Skin temperature is warm to touch.

D. No edema noted.

Answer: B Rationale: Capillary refill should be 2 seconds or less. If it is greater than 2 seconds, circulation may be impaired, which requires nursing intervention. All other findings are normal.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 557 27. The telehealth nurse is speaking with a parent whose child jumped from a swing set and now reports forearm pain. How will the nurse explain splinting? Select all that apply.

A. "Apply the splinting device from the joint above the injured area to the joint below the injured area."

B. "Use a flexible splinting material."

C. "Secure the splint with duct tape."

D. "Tie the splint securely until fingers are cool and pale."

E. "Pad the elbow with soft material under the splint."

Answer: A, C, E Rationale: The splint should be rigid, tied securely with wide tape or fabric, and span from the joint above the injury to the joint below the injury. If fingers are pale, blue, or cold, the splint is tied too tightly and should be loosened. The elbow, a bony prominence, can be padded with soft material under the splint.

Question format: Multiple Select Chapter 25: Mechanical Immobilization Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 543 28. The nurse is caring for a client with bilateral leg fractures who will be in skeletal traction for an extended period of time. Which nursing intervention will best address the client's selfcare deficit?

A. Delegate bathing to UAP. B. Assess skin integrity every shift.

C. Provide client with washcloth to clean face.

D. Perform range of motion for joints.

Answer: C Rationale: The client who is in traction for an extended period of time may not be able to perform many ADLs. However, allowing the client to perform simple self-care, such as washing the face, may address self-care deficit. Bathing, assessment of skin integrity, and performance of range-of-motion exercises done by others does not address the client's selfcare needs.

Question format: Multiple Choice

Chapter 25: Mechanical Immobilization Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 564 29. Immediately following cast removal, a client anxiously tells the nurse, "My arm looks so small and feels weak. I thought I would be healed by now." What is the appropriate nursing response?

A. "Let me immediately notify the health care provider."

B. "The unexercised muscle usually does appear smaller and weaker."

C. "That is a very unusual reaction."

D. "Are you concerned about the way your arm looks?"

Answer: B Rationale: When a cast is removed, the unexercised muscle may appear smaller and weaker; this is a normal finding which should be conveyed to the client. The other responses are inappropriate.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 549 30. The nurse is caring for a client whose cast will be removed later in the day. What information will the nurse provide? Select all that apply.

A. "The health care provider will remove the cast by cutting it with a cast cutter."

B. "The cast cutter looks like a circular saw."

C. "I will stay with you while the cast is removed."

D. "You will not be able to put lotion on your skin for several weeks."

E. "If there is residual dead skin on your arm, we can scrub it off."

Answer: A, B, C Rationale: The nurse will prepare the client for cast removal by explaining how the cast will be removed, and what it may sound like. It is also appropriate for the nurse to stay with the client while the cast is removed. Lotion can be applied to the skin to add moisture. The skin will not be scrubbed, but can be washed with soapy warm water.

Question format: Multiple Select Chapter 25: Mechanical Immobilization Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 548 31. The nurse is caring for a 19-year-old client who sustained a knee sprain while playing college sports. Which type of splint does the nurse anticipate will be ordered to support the knee while it heals?

A. inflatable B. traction C. immobilizer D. molded Answer: C Rationale: Immobilizers limit motion in the area of a painful, but healing, injury. Therefore, the nurse anticipates an immobilizer splint to be ordered for the client. Inflatable splints become rigid when filled with air, and would not be appropriate for this type of injury.

Traction splints are metal devices that immobilize, and are not appropriate for this type of injury. A molded splint is an orthotic device made of rigid materials that is used for treatment of chronic injuries accompanied by inflammation.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Reference: p. 543 32. The nurse is caring for an older adult client whose lower legs are casted. Which nursing interventions are appropriate? Select all that apply.

A. Assist to change positions every 4 hours.

B. Assess skin daily for signs of redness or pressure.

C. Encourage partnering with the physical therapist to promote range of motion.

D. Assure that pain is normal, and medication will be given if pain becomes unbearable.

E. Work with the occupational therapist to promote independent function with select ADLs. Answer: B, C, E Rationale: The client should reposition, or be repositioned, every 2 hours to relieve pressure.

Skin should be assessed daily for redness or signs of pressure. Working with the physical therapist and occupational therapist, the client can regain or maintain a certain range of motion and be independent in select ADLs, such as combing hair and brushing teeth. The client's pain should be continually monitored, and medication should be provided well before the client identifies the pain as unbearable.

Question format: Multiple Select Chapter 25: Mechanical Immobilization Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 555 33. The telehealth nurse has received a call from the caretaker of a client who fell from a ladder. The caretaker reports that the client's right leg and ankle appear deformed, and there is bleeding coming from an open wound. What teaching will the telehealth nurse provide?

Select all that apply.

A. "Leave high-top boots in place to minimize swelling."

B. "Attempt to place the leg back into proper alignment."

C. "Cover the wound with a clean towel."

D. "Keep the client warm and safe until emergency workers arrive."

E. "Transport the client immediately to an emergency department."

Answer: A, C, D Rationale: A client with this type of injury should be kept warm and safe until emergency services can arrive. The caretaker should not attempt to move the client personally. High-top boots should be left in place to limit movement of the joint and reduce pain and swelling. The injured part should be left as it is to prevent additional injuries. Wounds should be covered with clean material to absorb blood while preventing pathogens from entering.

Question format: Multiple Select Chapter 25: Mechanical Immobilization Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 543 34. A nurse is applying a fiberglass cast to a client's hand. Which procedure should the nurse follow when applying premoistened rolls of fiberglass?

A. Wash the client's skin with soap and dry it well.

B. Cover the skin with a protective padding.

C. Administer a pain-relief medication.

D. Open all the foil packets one at a time.

Answer: D Rationale: When using premoistened rolls of fiberglass, the nurse should open the foil packets one at a time to reduce the risk of the material rapidly drying and becoming unfit for use. Regardless of whether the nurse applies a plaster cast or premoistened rolls of fiberglass, the nurse washes the client's skin with soap, dries it well, and covers the skin with a protective padding. The nurse should administer pain-relief medication to the client only if it is prescribed by the physician.

Question format: Multiple Choice Chapter 25: Mechanical Immobilization Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 558

Chapter 26 1. A nurse at a health care facility has been assigned the care of an elderly client. For which reason would the nurse use a tilt table when preparing this client for ambulation?

A. to promote muscle tone and strength B. to improve upper arm strength C. to normalize blood pressure D. to help the client bear weight on the feet Answer: D Rationale: The nurse would use a tilt table to help the client bear weight on the feet. A tilt table is a device that raises the client from a supine to a standing position. It helps clients adjust to being upright and bearing weight on their feet. Dangling helps normalize a client's blood pressure, which may drop when the client rises from a reclining position. The client should perform isometric exercises to improve muscle tone and strength. Isotonic exercise would help the client to improve upper arm strength.

Question format: Multiple Choice Chapter 26: Ambulatory Aids Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 567 2. A nurse is caring for a client whose fractured ankle is in a cast. The client needs crutches to ambulate. What would help prepare this client for ambulation?

A. modified hand push-ups B. isometric exercises C. parallel bars D. tilt table Answer: A Rationale: Modified hand push-ups strengthen the upper arms, thus helping the client to ambulate using crutches. An exercise regimen to strengthen the upper arms typically includes flexion and extension of the arms and wrists, raising and lowering weights with the hands, squeezing a ball or spring grip, and performing modified hand push-ups in bed. Isometric exercises are used to promote muscle tone and strength, which are inherent in maintaining mobility. Clients use parallel bars as handrails to gain practice in ambulating. A tilt table is a device that helps clients adjust to being upright and bearing weight on their feet.

Question format: Multiple Choice Chapter 26: Ambulatory Aids Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 568

3. A nurse is caring for a client with a strained gluteal muscle at a health care facility. The nurse should understand that the function of the gluteal muscles is to aid: A. in supporting body weight.

B. in extending the legs.

C. the client in standing.

D. in strengthening the upper arms.

Answer: B Rationale: The gluteal muscles aid the client in extending the legs. As a group, the gluteal muscles in the buttocks aid in extending, abducting, and rotating the legs; these functions are essential to walking. Exercising the quadriceps enables clients to stand and support their body weight. Exercises such as modified hand push-ups help in strengthening the upper arms.

Question format: Multiple Choice Chapter 26: Ambulatory Aids Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 568 4. A client who tore his quadriceps muscle during a soccer match has been prescribed exercise for the quadriceps muscles. How should the client perform quadriceps-setting exercises?

A. by alternatively tensing and relaxing the muscles B. by performing modified hand push-ups in bed C. by performing deep knee bends D. by slowly lifting then lowering the foot and lower leg Answer: A Rationale: The client performs quadriceps-setting exercises by alternately tensing and relaxing the quadriceps muscles without moving or bending the legs. Modified hand push-ups in bed would enable the client to strengthen the upper arms.

Question format: Multiple Choice Chapter 26: Ambulatory Aids Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 568 5. A nurse is assisting a client at a health care facility dangle his legs before he ambulates.

The nurse places the client in Fowler's position for a few minutes. What is a possible reason for this action?

A. to give the client time to mentally focus on the task B. to allow the client to use the floor for support C. to maintain safety should the client become dizzy or faint D. to help the client's heart rate stabilize Answer: C

Rationale: The nurse places the client in Fowler's position for a few minutes before dangling to maintain safety should the client feel dizzy or faint due to postural hypotension. The nurse lowers the height of the bed so that the client can use the floor for support. The nurse provides the client with a robe and slippers to maintain warmth and show respect for the client's modesty. The nurse helps the client pivot a quarter of a turn to swing the legs over the side and sit on the edge of the bed, which helps the client adjust to a sitting position.

Question format: Multiple Choice Chapter 26: Ambulatory Aids Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 569 6. When assisting a client with ambulation by using an assistive device such as parallel bars or a walking belt, what should the nurse observe the client for?

A. walking gait B. pallor, weakness, or dizziness C. upper-arm strength D. tone and strength of the muscles Answer: B Rationale: When assisting a client with ambulation by using an assistive device such as parallel bars or a walking belt, the nurse should observe the client for pallor, weakness, or dizziness. Observing the client's walking gait would not be an appropriate action in this case.

The nurse should preferably observe the walking gait of clients who ambulate with crutches, walkers, or canes. The nurse need not observe the upper-arm strength of the client nor the tone and strength of the client's muscles. Upper-arm strength and muscle tone/strength need to develop before the client begins to ambulate.

Question format: Multiple Choice Chapter 26: Ambulatory Aids Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 569 7. A nurse at a health care facility suggests the use of parallel bars for a client who has recently been fitted with a prosthetic limb. How would parallel bars help this client?

A. providing support if the client loses balance B. improving the client's upper arm strength C. helping the client to practice ambulating D. enabling the client to stand and support body weight Answer: C Rationale: Using parallel bars as handrails helps the client gain practice when ambulating.

Some clients still need assistance to ambulate independently even after performing strengthening exercises. Two devices used to provide support and assistance with walking are parallel bars and a walking belt. Sometimes a tilt table is positioned just in front of the parallel bars so that the client can progress from being upright to actually walking again. A

walking belt provides support if the client loses balance. Isometric exercises, like modified hand push-ups in bed, help the client to improve upper arm strength. Exercising the quadriceps muscles enables clients to stand and support their body weight.

Question format: Multiple Choice Chapter 26: Ambulatory Aids Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 569 8. Which ambulatory aid could a nurse suggest to assist a client who has weakness in one side of his body?

A. cane B. walker C. axillary crutch D. forearm crutch Answer: A Rationale: The nurse could suggest the use of a cane to a client who has weakness in one side of his body in order to aid ambulation. Canes are hand-held ambulatory devices made of wood or aluminum. A walker is used by clients who require considerable assistance with balance. Clients who need brief, temporary assistance with ambulation are likely to use axillary crutches. Forearm crutches generally are used by experienced clients who need permanent assistance with walking.

Question format: Multiple Choice Chapter 26: Ambulatory Aids Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 570 9. A client at a health care facility is to undergo amputation of the left leg due to gangrene.

The client will be fitted with an immediate post-operative prosthesis (IPOP) after the surgery.

What is the function of the IPOP? A. stabilizes the size of the stump B. promotes intact body image C. promotes quicker healing D. helps to compress the vein walls Answer: B Rationale: An immediate postoperative prosthesis (IPOP) facilitates early ambulation, promotes intact body image, and controls stump swelling in clients who have undergone surgery for amputation. An IPOP may not stabilize the size of the stump or promote quicker healing, but it does control swelling. A permanent prosthetic leg is constructed when the stump size is stabilized and the wound is healed. The nurse applies an elastic stocking when using a tilt table to help compress the vein walls.

Question format: Multiple Choice Chapter 26: Ambulatory Aids

Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 574 10. A nurse is a caring for a diabetic client whose right leg had to be amputated due to the development of gangrene. The client uses crutches to ambulate and is waiting to be fitted with a prosthetic leg. What gait should the nurse observe in this client?

A. swing-through B. three-point partial weight-bearing C. three-point non–weightbearing D. two-point Answer: A Rationale: The nurse should observe a swing-through gait in a diabetic client whose leg had to be amputated due to gangrene and who is waiting to be fitted with a prosthetic leg. A three-point partial weight-bearing gait is observed in amputees learning to use a prosthesis, clients with minor injuries to one leg, or clients with previous injuries showing signs of healing. A three-point non–weightbearing gait can be observed in clients with one amputated, injured, or disabled extremity. A two-point gait is observed in clients who have more strength, coordination, and balance.

Question format: Multiple Choice Chapter 26: Ambulatory Aids Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 578 11. A nurse at a health care facility is caring for clients who are using crutches to ambulate.

In which client would the nurse observe a four-point walking gait?

A. clients with disabilities such as arthritis or cerebral palsy B. clients who have more coordination and balance C. clients with one amputated, injured, or disabled extremity D. clients with amputated limbs who are learning to use prosthetic limbs Answer: A Rationale: The nurse would observe a four-point gait in clients with disabilities such as arthritis or cerebral palsy who are using crutches to ambulate. Clients who have more coordination and balance are more likely to have a two-point gait. A three-point nonweightbearing gait can be observed in clients with one amputated, injured, or disabled extremity. A client with an amputated limb learning to use a prosthesis would have a threepoint partial weight-bearing gait.

Question format: Multiple Choice Chapter 26: Ambulatory Aids Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 575

12. The right leg of a client who was involved in a motor vehicle accident needs to be amputated due to complications related to gangrene. When would a permanent prosthetic limb be constructed for this client?

A. when the stump swelling is controlled B. a month after the leg has been amputated C. when the stump size stabilizes D. a year after the amputation of the leg Answer: C Rationale: A permanent prosthetic leg is constructed once the stump size has stabilized.

Construction of a permanent prosthesis is delayed for several weeks or months until the wound heals and the stump size is relatively stable. In many cases, clients return from surgery with an immediate postoperative prosthesis (IPOP), which is a temporary artificial limb. An IPOP facilitates early ambulation and promotes an intact body image immediately after surgery. It also helps to control stump swelling. The client need not wait for a month or a year after amputation for a permanent prosthetic.

Question format: Multiple Choice Chapter 26: Ambulatory Aids Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 575 13. A nurse is caring for a client who underwent surgery for the amputation of the right foot.

The client has been fitted with a temporary prosthetic limb. What should the nurse ensure during this period?

A. The wound heals and no complications develop.

B. The measurement for the prosthetic limb is taken.

C. The client is provided with an ambulatory device.

D. The client is able to ambulate with assistance.

Answer: A Rationale: After amputation, the nurse needs to ensure that the client's wound heals and no complications such as joint contractures or infection develop. Complications delay rehabilitation. Contractures interfere with limb and prosthetic alignment, which ultimately affects the client's ability to walk. After amputation, the nurse need not ensure that the limb measurement is taken, because the client is fitted with an IPOP and a permanent prosthetic will be constructed only once the wound heals and the stump size is stabilized. The client would require muscle strengthening exercises before being provided with an ambulatory device or being assisted during ambulation.

Question format: Multiple Choice Chapter 26: Ambulatory Aids Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 574

14. A nurse is caring for a client whose legs have been amputated from above the knee due to a mountain climbing accident. The client has been fitted with an above-the-knee prosthetic limb. Which component can be found only in an above-the-knee prosthetic?

A. socket B. shank C. ankle/foot system D. knee system Answer: D Rationale: A knee system, which replaces the knee joint, is the component that can only be found in an above-the-knee prosthetic limb. Permanent prostheses for below-the-knee amputees include a socket, a shank, and an ankle/foot system.

Question format: Multiple Choice Chapter 26: Ambulatory Aids Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 575 15. A nurse is applying a leg prosthesis to a client at a health care facility. Why is it important for the nurse to observe the ease or difficulty of inserting the stump into the socket when applying the prosthesis?

A. to detect complications that may delay healing B. to determine if prosthetic maintenance is required C. to check the number of stump socks that are required D. to determine if lubrication of the joints is required Answer: C Rationale: When applying a leg prosthesis to a client at a health care facility, the nurse observes the ease or difficulty with which the client inserts the stump into the socket in order to determine the number or thickness of stump socks that would be required. The nurse inspects the stump for evidence of bleeding, edema, skin abrasions, and blisters in order to detect any complications that may delay healing and rehabilitation or interfere with ambulation. Joint connections in the prosthetic limbs need to be examined to determine if lubrication or prosthetic maintenance is required.

Question format: Multiple Choice Chapter 26: Ambulatory Aids Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 575 16. A nurse is caring for an older adult client at a health care facility. What should the nurse consider to be a normal, age-related change?

A. occasional falls B. decreased sensory perception C. decreased or unsteady mobility D. appearance of corns or calluses

Answer: C Rationale: Limited or unsteady mobility may be a problem for some older adults as a result of age-related postural changes. Limited or unsteady mobility may lead to the development of a swaying or shuffling gait. As a person ages, he may develop flexion of the spine, which can alter the center of gravity and may result in an increase in falls. If a client appears to have an unusual gait, assess the feet for corns, calluses, bunions, and ingrown or very long toenails. If any of these conditions are found, a podiatry referral may be indicated. Vascular changes may lead to numbness and a decreased sensory ability to perceive contact with the ground, which can also change a person's gait. Falls are more common in older adults, but these are not considered to be a normal event.

Question format: Multiple Choice Chapter 26: Ambulatory Aids Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 570 17. An elderly client with a diagnosis of osteoporosis and early stage Alzheimer disease requires the use of an assistive device that will maximize stability during ambulation. What device will best meet this client's needs?

A. walker B. axillary crutches C. forearm crutches D. cane Answer: A Rationale: A walker provides greater stability than crutches or a cane.

Question format: Multiple Choice Chapter 26: Ambulatory Aids Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 570 18. A 22-year-old woman has begun using axillary crutches following open reduction and internal fixation of an ankle fracture that she suffered during a basketball game. What assessment finding by the nurse should suggest that the client's crutches are fitted correctly?

A. The client's elbow joint is locked when she stands upright and grasps the handgrips.

B. The client's wrist is slightly hyperextended when she stands upright and grasps her crutches.

C. The level of the handgrips is at the client's waist when she stands upright with her crutches.

D. The axillary bar is 3 to 4 in below the client's axilla when she stands upright.

Answer: B

Rationale: With axillary crutches, there should be 30 degrees of elbow flexion and slight hyperextension of the wrist when the client is standing in place. The level of the handgrips will be near the client's thigh and the axillary bar should be adjusted within two fingers' space of the axilla.

Question format: Multiple Choice Chapter 26: Ambulatory Aids Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 580 19. An older adult has been admitted to a long-term care facility after unsuccessful attempts to continue living independently. The nurse's admission assessment reveals the presence of long, ingrown toenails that appear to contribute to the resident's unsteady gait and decreased mobility. How should the nurse follow up this assessment finding?

A. Have the client tested for type 2 diabetes.

B. Arrange for the client to be seen by a podiatrist.

C. Cut the client's toenails using a sharp blade rather than regular nail clippers.

D. Soak the client's feet in Epsom salts and trim them short.

Answer: B Rationale: Elderly clients' problematic toenails may warrant referral to podiatry. It may risk complications to cut them very short or with a sharp blade. Clients with diabetes are particularly at risk for foot complications, but the presence of long toenails does not suggest the presence of diabetes.

Question format: Multiple Choice Chapter 26: Ambulatory Aids Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 567 20. An elderly client is being seen at the clinic after experiencing a fall inside his home. He appears to have suffered no ill effects of the fall but his wife has asked the nurse if he might benefit from the use of a cane. The nurse should be aware of what criterion for the safe use of a cane?

A. The client's weakness must be bilaterally equal.

B. The client must be able to support his full body weight on his arms and upper body.

C. The client should first demonstrate that a walker does not provide sufficient support during ambulation.

D. The client's weakness must be primarily limited to one side of his body.

Answer: D Rationale: A client who has weakness on one side of the body uses a cane. The client does not need to be able to support his or her full body weight with the upper body in order to use a cane safely and effectively. A walker provides more support than a cane.

Question format: Multiple Choice Chapter 26: Ambulatory Aids

Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 570 21. The nurse is caring for a client who will be raised via a tilt table. Which intervention will the nurse perform first?

A. Tilt table 15 degrees.

B. Apply antiembolism stockings.

C. Position feet against the foot rest.

D. Transfer client from bed to table.

Answer: B Rationale: The nurse will first apply antiembolism stockings to prevent the pooling of blood in the extremities, which may trigger fainting. The client will then be transferred, feet will be placed against the foot rest, and the table will be tilted.

Question format: Multiple Choice Chapter 26: Ambulatory Aids Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 569 22. The nurse is delegating ambulation of a client with generalized weakness to the unlicensed assistive personnel (UAP). Which teaching will the nurse provide? Select all that apply.

A. Utilize a gait belt around the client's waist.

B. Walk slightly in front of the client to clear a path.

C. Support the client's leg on the dominant side.

D. Allow the client to ambulate independently if the client feels ready.

E. When available, use parallel bars for support.

Answer: A, E Rationale: The nurse will teach the UAP to utilize a gait belt for safety, walk slightly behind the client to provide support if the client becomes unsteady, support the client's arm, and use parallel bars for support if available. The client with generalized weakness should not be permitted to ambulate independently.

Question format: Multiple Select Chapter 26: Ambulatory Aids Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Communication and Documentation Reference: p. 570 23. The nurse is teaching a client who is recovering from surgery about using a walker.

Which teaching will the nurse include?

A. Stand just behind the walker.

B. Hold the walker at the padded handgrips.

C. Pick up the walker and advance it 10 to 12 inches.

D. Move the walker while taking a step forward.

Answer: B Rationale: The nurse will teach the client to hold the walker at the padded handgrips and stand within the walker. The walker should then be picked up and advanced 6 to 8 inches, and a step forward should be taken. The client is not instructed to stand behind the walker, to pick it up and advance it 10 to 12 inches, or to move the walker while taking a step forward, as these are inappropriate ways to utilize the walker and are unsafe for the client.

Question format: Multiple Choice Chapter 26: Ambulatory Aids Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 571 24. The nurse is educating a client and family about home safety. Which teaching will the nurse include? Select all that apply.

A. Place rugs over hard flooring to provide a buffer in case of falls.

B. Consider adding grab bars to shower or tub.

C. Have client use steps to facilitate mobility.

D. Replace rubber tips on cane as soon as they become worn or dirty.

E. Assess for adequate lighting so client can see clearly when walking.

Answer: B, D, E Rationale: Grab bars can be added to the bathrooms or outside entrances so the client can hold something to steady themselves. Adequate lighting should be ensured so that the client can see. Rubber tips of canes should be replaced when worn or dirty, as this can contribute to falls. The nurse will teach the client and family to remove scatter rugs, which can facilitate falls, and avoid using steps.

Question format: Multiple Select Chapter 26: Ambulatory Aids Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 569 25. The nurse is teaching a client who had a below-the-knee amputation about a temporary prosthetic limb. Which client statement demonstrates that teaching has been effective?

A. "This is a heavy artificial limb, so I will be careful."

B. "I will loosen the belt when I go to sleep."

C. "Swelling is expected when I wear my prosthetic limb."

D. "This can be worn even if I have an infection in the stump."

Answer: B Rationale: Client teaching has been effective when the client knows that the belt with garters can be loosened when going to bed. The temporary prosthetic limb is lightweight and helps to

control stump swelling. It should not be worn in the presence of joint contractures or infection.

Question format: Multiple Choice Chapter 26: Ambulatory Aids Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 574 26. Which teaching will the nurse include when educating a client about stump socks?

A. "Only wear one sock over the stump at a time."

B. "Tube socks work well to protect the length of the stump."

C. "If stump socks get holes in them, you can patch them."

D. "Stump socks can be made of cotton or wool."

Answer: D Rationale: The nurse will teach the client that cotton or wool stump socks are fine and come in a variety of thicknesses to accommodate slight changes in stump size. More than one sock can be worn at a time. Tube socks should not be used as stump socks. Patching or darning socks should not be done, as these areas can then contribute to skin breakdown.

Question format: Multiple Choice Chapter 26: Ambulatory Aids Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 576 27. What does the nurse identify as a goal for a client with the nursing diagnosis of Impaired Physical Mobility related to a new prosthetic limb?

A. ambulated 10 feet B. will take sixteen steps independently by Monday C. encourage walking three times daily D. has not ambulated since last week Answer: B Rationale: A goal involved setting a measurable, achievable action, such as taking sixteen steps by Monday. "Ambulated 10 feet" reflects an outcome; "encourage walking three times daily" is an intervention; "has not ambulated since last week" is assessment data.

Question format: Multiple Choice Chapter 26: Ambulatory Aids Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 574 28. The nurse is caring for a client who sustained a severe ankle sprain while playing soccer.

Which crutch-walking gait will the nurse teach?

A. swing-through

B. two-point C. four-point D. three-point non-weight-bearing Answer: D Rationale: Three-point non-weight-bearing crutch walking is appropriate for a client with one amputated, injured, or disabled extremity. Other choices are inappropriate.

Question format: Multiple Choice Chapter 26: Ambulatory Aids Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 571 29. The nurse is caring for a client with lower extremity paralysis who has been placed in bilateral leg braces. Which crutch-walking gait will the nurse teach?

A. swing-through B. two-point C. four-point D. three-point non-weight-bearing Answer: A Rationale: Swing-through crutch-walking is appropriate for a client who has an injury or disorder affecting one or both legs, such as a paralyzed client with leg braces or an amputee who is awaiting prosthetic fitting. Other techniques are not appropriate.

Question format: Multiple Choice Chapter 26: Ambulatory Aids Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Reference: p. 578 30. The nurse is fitting a client for axillary crutches. Which action will the nurse perform first?

A. Adjust handgrips for 30 degrees of elbow flexion and 15 degrees of wrist hyperextension.

B. Measure from anterior skinfold of axilla to approximately 4-8 inches diagonally from the foot.

C. Assist the client who can support his or her own body weight to a standing position at the bedside.

D. Lengthen or shorten crutches by removing wing nuts and replacing metal screws in the appropriate hole.

Answer: C Rationale: The nurse will measure the client for axillary crutches by performing steps in the following order: assisting the client to a standing position at the bedside; measuring from anterior skinfold of axilla to approximately 4-8 inches diagonally from the foot; adjusting handgrips for 30 degrees of elbow flexion and 15 degrees of wrist hyperextension; and

lengthening or shortening crutches by removing wing nuts and replacing metal screws in the appropriate hole.

Question format: Multiple Choice Chapter 26: Ambulatory Aids Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 579

Chapter 27 1. A client with abdominal incisions experiences excruciating pain when he tries to cough.

What should the nurse do to reduce the client's discomfort when coughing?

A. Administer prescribed pain medication just before coughing.

B. Ask the client to drink plenty of water before coughing.

C. Ask the client to lie in a lateral position when coughing.

D. Administer prescribed pain medication 30 minutes before deliberately attempting to cough.

Answer: D Rationale: Coughing is painful for clients with abdominal or chest incisions. Administering pain medication approximately 30 minutes before coughing, or splinting the incision when coughing, can reduce discomfort. Making the client lie in a lateral position or asking the client to drink plenty of water is not helpful because it will make breathing and coughing even more difficult for the client.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 596 2. A nurse is assessing the preoperative checklist of a client. Which observation listed in the preoperative checklist should the nurse verify?

A. if the client has urinated properly B. if the client has worn dentures C. if the client has worn a fresh set of clothes D. if the client is responding to reversal drugs Answer: A Rationale: In a preoperative checklist, the nurse verifies that the client has urinated, is wearing an identification bracelet, has removed their dentures, and is wearing only a hospital gown and hair cover. Nurses assess a client's response to reversal drugs not when checking the preoperative checklist but rather when the client is recovering from anesthesia. Reversal drugs are given to clients in case they become overly sedated.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Apply Client Needs Pn: Physiological Integrity: Reduction of Risk Potential Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 599

3. The health care provider has prescribed the nurse to administer conscious sedation to a client that will have a closed reduction of the left shoulder. What outcome after administering conscious sedation to a client does the nurse hope to achieve?

A. The client can respond verbally despite physical immobility.

B. The client can tolerate long therapeutic surgical procedures.

C. The client is relaxed, emotionally comfortable, and conscious.

D. The client's consciousness level can be monitored by equipment.

Answer: C Rationale: A client under conscious sedation is sedated in a state of relaxation and emotional comfort, but is not unconscious. The client is free of pain, fear, and anxiety and can tolerate unpleasant diagnostic and short therapeutic surgical procedures, such as an endoscopy or bone marrow aspiration. The client can respond verbally and physically. However, no equipment can replace a nurse's careful observations for monitoring clients.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 602 4. A nurse is taking care of a client during the immediate postoperative period. Which duty performed during the immediate postoperative period is most important?

A. Ensure the safe recovery of surgical clients.

B. Monitor the client for complications.

C. Prepare a room for the client's return.

D. Assess the client's health constantly.

Answer: B Rationale: The immediate postoperative period refers to the first 24 hours after surgery.

During this time, the nurse monitors for complications as the client recovers from anesthesia.

Once the client is stable, the nurse prepares a room for the client's return and assesses the client to prevent or minimize potential complications. The nurse ensures the safe recovery of the client after the client has stabilized.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 602-603 5. A nurse is reinforcing wound edges and applying a blinder to the separated incisions of a client after a surgery. Which postoperative complication has the client developed?

A. hypoxemia B. dehiscence C. evisceration D. shock

Answer: B Rationale: The nurse is taking care of a client with dehiscence. Hypoxemia develops when there is inadequate oxygenation of blood. Evisceration occurs when there is protrusion of abdominal organs through a separated wound. A client has shock when there is inadequate blood flow.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 604 6. A nurse is caring for an older adult client who has been prescribed fluid restriction before surgery. What should the nurse check most carefully to assess the risks of fluid restriction in older adult clients?

A. vital signs B. electrolyte levels C. liver function D. cognitive status Answer: A Rationale: The nurse should assess the client's vital signs, weight, and sternal skin turgor prior to fluid restriction to serve as a baseline for comparison. The period of fluid restriction before surgery may be shortened for older adults to reduce their risk of dehydration and hypotension. For most clients, vital signs are more significant than other assessments in determining the risks of fluid restriction.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 598 7. A nurse is preparing a client for endotracheal intubation. The anesthesiologist has ordered an anticholinergic medication for this client. What is an action of this medication?

A. It promotes induction of anesthesia.

B. It decreases gastric acidity and volume.

C. It promotes sleep or conscious sedation.

D. It decreases respiratory secretions.

Answer: D Rationale: An anticholinergic medication decreases respiratory secretions and prevents vagal nerve stimulation during endotracheal intubation. Antianxiety drugs slow motor activity and promote the induction of anesthesia. Histamine-2 receptor antagonists decrease gastric acidity and volume. Sedatives promote sleep or conscious sedation.

Question format: Multiple Choice Chapter 27: Perioperative Care

Cognitive Level: Remember Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 599 8. A nurse is assisting a cosmetic surgeon in removing the skin tattoos from a client's back.

What are the advantages offered by laser surgery as compared to conventional surgeries?

A. reduces scarring B. relieves pain C. eliminates all sensation D. eliminates wound infection Answer: A Rationale: Laser surgery offers advantages such as reduced scarring, minimal blood loss, cost effectiveness, smaller incisions, and less time recuperating. Laser surgery does not eliminate all sensation, but general anesthesia does. Laser surgery has decreased the incidence of, but not eliminated, wound infection. Laser surgery does not provide pain relief, but it can reduce pain to some extent.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Remember Client Needs Pn: Physiological Integrity: Reduction of Risk Potential Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 592 9. A nurse is caring for a client who is scheduled to undergo a breast biopsy. Which major task does the nurse perform immediately during the preoperative period?

A. Obtain a signature on the consent form.

B. Review the surgical checklist.

C. Conduct a nursing assessment.

D. Reduce the dosage of toxic drugs.

Answer: C Rationale: During the immediate preoperative period, the nurse conducts a nursing assessment. Nurses obtain the signature of the client, nearest blood relative, or someone with durable power of attorney before the administration of any preoperative sedatives. They also administer medications as ordered by the physician regardless of their toxicity. Nurses assist the client with psychosocial preparation and complete the surgical checklist, which is reviewed by the operating room personnel.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Apply Client Needs Pn: Physiological Integrity: Reduction of Risk Potential Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 594

10. A nurse is assisting a physician during a cesarean section for a client. The client is administered epidural anesthesia. What is an advantage of epidural anesthesia?

A. It counteracts the effects of conscious sedation.

B. It decreases the risk of gastrointestinal complications.

C. It prevents clients from remembering the initial recovery period.

D. It acts on the parasympathetic nervous system to produce loss of sensation.

Answer: B Rationale: Epidural anesthesia is a regional anesthesia administered to a client before surgery; it decreases the risk of gastrointestinal complications in clients. Reversal drugs are medications that counteract the effects of those used for conscious sedation. General anesthesia acts on the central nervous system to produce loss of sensation; it prevents clients from remembering their initial recovery period.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Remember Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 601 11. A client has come to a health care facility for autologous donation of blood. Which is a criterion for autologous donation?

A. Be free from blood-borne pathogens.

B. Have a physician's recommendation.

C. Be free from high-risk behaviors.

D. Be at least 17 years of age.

Answer: B Rationale: For autologous donation, the donor needs to have a physician's recommendation.

In the case of directed donation, the donor should be at least 17 years of age and be free from high-risk behaviors and blood-borne pathogens.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Remember Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 594 12. A nurse is caring for an elderly client with muscle atrophy. Which condition can lead to muscle atrophy in elderly clients?

A. age-related skin changes B. being bedridden for 1 or 2 days C. poor hydration D. indwelling catheter Answer: B

Rationale: Muscle atrophy can occur in older adults who have been on bed rest even for 1 or 2 days. Range of motion and muscle tone can be maintained through routine active or passive range of motion exercises. Elderly clients having age-related skin changes and poor hydration can have slow wound healing. An indwelling catheter in elderly clients can lead to urinary tract infection, not muscle atrophy.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Client Needs Pn: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 605 13. A nurse is completing the preoperative checklist of a client who will soon have a cholecystectomy (gallbladder removal). Which observation listed in the preoperative checklist should the nurse verify?

A. if the client's allergies have been identified and documented B. if the client has explored alternative treatment options C. if the client has received the prescription for postdischarge medications D. if the client's next of kin has been notified Answer: A Rationale: In a preoperative checklist, the nurse verifies the client's allergy status. Alternative treatments are not addressed in the preoperative checklist and the prescription is normally provided in the postsurgical setting. A preoperative checklist does not require that a client's next of kin be notified preoperatively.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 599 14. A nurse is caring for a client who has had antiembolism stockings applied to avoid thrombus formation. Which measure can prevent thrombi?

A. Drink plenty of fluids unless contraindicated.

B. Keep legs crossed at knees whenever possible.

C. Sit for 2 to 3 hours at a time.

D. Avoid ambulating unless absolutely necessary.

Answer: A Rationale: Drinking plenty of fluids can help to prevent thrombi because it promotes circulation by increasing the fluid component of blood. Avoiding long periods of sitting, avoiding keeping the legs crossed, especially at the knees, and ambulating are also methods to prevent thrombi.

Question format: Multiple Choice Chapter 27: Perioperative Care

Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 605 15. A nurse is taking care of a client during the immediate postoperative period. Which action performed during the immediate postoperative period is most important?

A. Initiate rehabilitation measures.

B. Monitor the client for complications.

C. Prepare a room for the client.

D. Assess the client's readiness to learn.

Answer: B Rationale: The immediate postoperative period refers to the first 24 hours after surgery.

During this time, the nurse monitors the client for complications as he or she recovers from anesthesia. Once the client is stable, the nurse prepares a room for the client's return and assesses the client to prevent or minimize potential complications. Rehabilitation and client education are important but are lesser priorities at this early stage of recovery.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 602-603 16. A nurse is caring for a client who is scheduled to undergo a mastectomy. Which major task does the nurse perform immediately during the preoperative period?

A. Explain the potential risks and benefits to the client.

B. Order preoperative medications to be given.

C. Conduct a comprehensive nursing assessment.

D. Inquire about autologous blood donation.

Answer: C Rationale: During the immediate preoperative period, the nurse conducts a nursing assessment. Explaining risks and benefits as well as ordering preoperative medications are the responsibilities of the physician. Blood donation should be explored well in advance, not in the immediate preoperative period.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 594 17. A client has come to a health care facility for autologous donation of blood. Which is a criterion for autologous donation?

A. The client must demonstrate why conventional blood transfusions are unacceptable.

B. The client must have a hematocrit that is within normal range.

C. The client must prove to be free from high-risk behaviors.

D. The client must donate between 30 and 120 days prior to surgery.

Answer: B Rationale: A client wishing to have an autologous blood donation must have a healthy hematocrit. Donation takes place 3 to 40 days before the anticipated date of use. An individual does not need to prove why conventional transfusion is unacceptable and does not necessarily need to be free of high-risk behaviors.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 594 18. A nurse has chosen to specialize in perioperative nursing. What is the primary goal in all three phases of contemporary perioperative nursing?

A. reduction of health care costs associated with surgery B. ensuring as short a perioperative period as possible C. treating a wider range of health problems with surgery rather than medication D. using surgery as a preventive measure rather than just a treatment option Answer: D Rationale: Although there are advances being made in prophylactic (preventive) surgery and in cost control measures, a major current trend is to facilitate as short a perioperative period as possible. In general, medication is preferable to surgery.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 590 19. A client has been admitted to the hospital in anticipation of surgery that is scheduled for later that afternoon. The nurse has taken the opportunity to perform preoperative teaching and is emphasizing the importance of leg exercises during the postoperative period. What instruction should the nurse provide to this client?

A. "Alternately flex and relax your thigh muscles, tightening the muscles for 20 seconds and then relaxing for 20 seconds."

B. "Lift your leg off of your bed, locked at the knee, and then rotate your leg as wide as possible, bending at the hip."

C. "Bend one of your knees and then raise and hold the leg over your mattress for a few seconds."

D. "Sit on the edge of your bed or in a chair and lift the provided leg weight a few times before resting."

Answer: C

Rationale: In order to correctly perform leg exercises, the client should be taught to bend one knee and then raise and hold the leg above the mattress for a few seconds. Leg weights, leg rotation, and quadriceps setting are not components of postoperative leg exercises.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 596-597 20. A male client is scheduled to have a suprapubic catheter inserted as part of his treatment for prostate cancer. The nurse is explaining the preoperative preparation that will be necessary, including hair removal. Hair removal will be accomplished with: A. a disposable razor.

B. electric clippers.

C. a hair-dissolving chemical agent.

D. chlorhexidine.

Answer: B Rationale: Shaving with a razor causes microabrasions, which are tiny cuts that provide an entrance for microorganisms. For this reason, institutions are switching from razors to electric or battery-operated clippers for hair removal. Depilatory agents, chemicals that remove hair, are another alternative, but their use is associated with skin irritation and allergic reactions.

Chlorhexidine is an antiseptic agent, not a hair removal product.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 597-598 21. A client is scheduled for thyroidectomy as part of treatment for thyroid cancer. Which aspect of care will be conducted in the receiving room of the operating department?

A. Preoperative medications are administered.

B. The client is intubated and anesthetized.

C. The client education process is begun.

D. The client is assessed for suitability as a surgical candidate.

Answer: A Rationale: In some hospitals, preoperative medication is administered when clients reach the receiving room rather than before leaving the nursing unit. The client is not anesthetized or intubated, however, until he or she is in the OR. Client education should begin prior to this stage in the surgical process, and the client will have been assessed for suitability as a surgical candidate much earlier.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential

Integrated Process: Nursing Process Reference: p. 600 22. A client had a total knee replacement performed 3 days ago and is now preparing for discharge home. What discharge teaching should the nurse provide to this client? Select all that apply.

A. guidelines for safely resuming normal activities B. potential side effects of prescribed medications C. information about the signs and symptoms of infection D. information about follow-up appointments that may be required E. the importance of leg exercises and deep breathing and coughing Answer: A, B, C, D Rationale: Discharge teaching should encompass many areas of relevance to the client's recovery, including signs of complications, drug information, follow-up, and activity guidelines. Deep breathing and coughing as well as leg exercises are more significant during the immediate postoperative period rather than after discharge.

Question format: Multiple Select Chapter 27: Perioperative Care Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 605 23. A client who came in through the emergency department with a severely fractured leg will be transported to surgery within the hour. When the client asks how long hospitalization will occur after surgery, what is the appropriate nursing response?

A. "Because you are having inpatient surgery, you will be hospitalized at least 1 day after surgery."

B. "Outpatient surgery patients usually get to go home the same day."

C. "With the type of injury you have sustained, you will be in the hospital about 4 days."

D. "The anesthesiologist will be able to give you a better idea of how long you will be hospitalized."

Answer: A Rationale: With a severe fracture, the client will be considered as having inpatient surgery and will be hospitalized at least a day. The nurse should not give a definitive period of time for hospitalization, and the surgeon (not the anesthesiologist) will give the best predictor of length of stay.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 591 24. The nurse is preparing a client for a laser procedure. Which nursing intervention is appropriate?

A. Cleanse the procedure area with alcohol.

B. Remove the client's nail polish with acetone before the procedure.

C. Apply goggles to the client.

D. Prepare the surgical tray with silver instruments.

Answer: C Rationale: The client, and all who are involved in the procedure, will wear goggles. Alcohol and acetone should not be used around lasers due to flammability. Therefore, the nurse should not remove the client's nail polish with acetone, nor clean the area with alcohol, before the procedure. Surgical instruments used should be coated in black to avoid heat retention.

Therefore, the surgical tray should not be prepared with silver instruments.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 592 25. The nurse is educating an older adult about products that cause bleeding that should be avoided before surgery. Which products should the nurse include? Select all that apply.

A. aspirin B. ibuprofen C. cetirizine D. warfarin E. ginkgo biloba F. milk of magnesia Answer: A, B, D, E Rationale: Aspirin, ibuprofen, warfarin, and ginkgo biloba may increase bleeding and should be avoided prior to surgery, unless otherwise specified by the health care provider. Cetirizine and milk of magnesia are not associated with bleeding.

Question format: Multiple Select Chapter 27: Perioperative Care Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 595 26. When reviewing a client's history prior to surgery to correct a wrist fracture, which factors does the nurse identify that place the client at a higher risk for perioperative complications? Select all that apply.

A. father suffered from alcohol use disorder B. BMI of 23 C. smokes cigarettes, ½ pack per day D. hemoglobin 14 g/dL (1.4 g/L) E. 23 years of age F. had surgery 2 years ago to repair torn anterior cruciate ligament G. skin turgor 4 seconds

Answer: C, G Rationale: Smoking is a factor that may increase the client's risk for perioperative complications. Skin turgor of 4 seconds may reflect mild dehydration, which also increases the risk. A family history of alcohol use disorder does not increase the client's risk unless the client also consumes alcohol. The BMI and hemoglobin presented are normal. The client's age is not a risk factor. A history of previous surgery without noted complications does not necessarily increase the risk for perioperative complications associated with the upcoming surgery.

Question format: Multiple Select Chapter 27: Perioperative Care Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 594-595 27. The nurse is teaching a client who will undergo abdominal surgery to repair a hernia about deep breathing. The client asks, "Why am I practicing breathing when I'm having hernia surgery." What is the appropriate nursing response?

A. "This technique will help with pain control."

B. "Deep breathing facilitates quicker healing of the incision."

C. "It decreases the postoperative risk for respiratory complications."

D. "Doing this reduces your risk of developing blood clots."

Answer: C Rationale: Deep breathing after surgery reduces the risk for development of postoperative respiratory complications. It does not help with pain control, facilitate quicker healing, or reduce the risk for blood clots.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 596 28. The nurse has delegated to the unlicensed assistive personnel (UAP) the application of antiembolism stockings to a client who had an endarterectomy earlier in the day. Which UAP action requires the nurse to immediately intervene?

A. cleanses hands with alcohol-based hand rub B. measures calf circumference C. massages legs prior to application D. elevates the legs 15 minutes after applying stockings Answer: C Rationale: Massaging the legs can dislodge clots. Other actions are appropriate and do not require intervention.

Question format: Multiple Choice

Chapter 27: Perioperative Care Cognitive Level: Analyze Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Communication and Documentation Reference: p. 596-597 29. The postanesthesia care unit (PACU) nurse has just received a client who underwent coronary artery bypass grafting (CABG). Which will the nurse assess while the client is in the PACU? Select all that apply.

A. condition of incision B. drains and drainage characteristics C. ease of breathing D. family perception of the surgery E. pain level F. urine output Answer: A, B, C, E, F Rationale: The nurse will assess all of these components with the exception of family perception of the surgery. Family will be allowed to visit after the client is stabilized and transitioned out of the PACU to a floor.

Question format: Multiple Select Chapter 27: Perioperative Care Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 602 30. A nurse is caring for a postoperative client and preparing to apply a pneumatic compression device. How does the nurse explain the device to the client prior to application?

A. The device fills with air and squeezes the legs, which increases blood flow through the veins of the legs and helps to prevent blood clots.

B. The device fills with air and squeezes the arms, which increases blood flow through the veins of the arms and helps to prevent blood clots.

C. The device fills with air supporting the legs during ambulation so blood flow will not pool in the legs and feet, thus preventing blood clots, and squeezes the legs, which increases blood flow through the veins of the legs.

D. The device fills with air and squeezes the legs which increase blood flow through the veins of the legs and should be worn in bed and while ambulating to help prevent blood clots.

Answer: A Rationale: A pneumatic compression device promotes the circulation of venous blood and relocation of excess fluid into the lymphatic vessels. The device is used on the legs and is worn while the client is in bed.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning

Reference: p. 603 31. A nurse wraps a client with antiembolism stockings to help avoid thrombus formation.

Which action can the client take directly to prevent formation of thrombi?

A. Drink plenty of fluids.

B. Keep legs crossed at knees.

C. Sit for longer durations.

D. Avoid ambulating.

Answer: A Rationale: Drinking plenty of fluids can help to prevent thrombi because it promotes circulation by increasing the fluid component of blood. Avoiding long periods of sitting, avoiding keeping the legs crossed (especially at the knees), and ambulating are also methods to prevent thrombi.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 605 32. A nurse is interacting with a client in the outpatient surgical unit intraoperatively. What is the nurse's priority responsibility?

A. Educating the client about postoperative protocols B. Establishing a nurse–client rapport C. Client safety D. Providing emotional support for the client and family Answer: C Rationale: Client safety is the most important nurse responsibility during the intraoperative phase. Safety concerns include equipment, electrical, chemical, radiation, surgical verification, client transport and positioning, and continuous asepsis. Postoperative protocol education is done preoperatively. Establishing a nurse–client rapport and providing emotional support are important, but they are not the most important nursing responsibility during the intraoperative phase.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 591 33. A 17-year-old client who lives with her parents wishes to have a breast reduction. The parents support the decision and have agreed to consent for the procedure. During preoperative education, which information is the most important physiological and psychological information the nurse will provide to the client?

A. Clarify what is in the consent form and the risks of surgery B. Teach the postoperative protocols

C. Describe scarring related to technique used by the surgeon D. Go over the anesthesia and length of surgical procedure Answer: C Rationale: Because teenagers are usually concerned with body image and possible disfigurement, information about scarring would be the most important information to share with the 17-year-old client. The surgeon is legally responsible for explaining the surgical procedure and obtaining the parents' signature on the consent form, which would include information about anesthesia and length of surgical procedure. Information about postoperative protocols is appropriate; however, it is not the most important information to share in this situation.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 596 34. The nurse is caring for a client who had a procedure under moderate sedation at the ambulatory surgical center. Which assessment finding indicates to the nurse that the client may be ready for discharge to home?

A. The client is alert and oriented with a blood pressure 122/74 mm Hg and respirations 18 breaths/min, able to ambulate, is not nauseated or vomiting, reports a pain level of 5 on a 0– 10 scale, and has no excessive bleeding or drainage.

B. The client is alert and oriented with a blood pressure 102/60 mm Hg and respirations 18 breaths/minute, is slightly dizzy, but not nauseated or vomiting, denies pain, and has no excessive bleeding or drainage.

C. The client is alert and oriented with a blood pressure 118/70 mm Hg and respirations 18 breaths/minute, is able to ambulate, is not nauseated or vomiting, pain is controlled with medication, and has no excessive bleeding and drainage is as expected.

D. The client is alert and oriented with a blood pressure of 136/90 mmHg and respirations 18 breaths/minute, states mild nausea but no vomiting, pain under control with pain medication, able to void and pass gas, and has mild expected drainage.

Answer: C Rationale: Stable vital signs, being alert and oriented, ability to ambulate, minimal nausea and vomiting, adequate pain control, and no excessive bleeding or drainage may indicate that the client is ready for discharge to home. The ability to void is a criterion after a spinal anesthesia or after pelvic surgery. Dizziness or inadequate pain control indicate that the client still needs to be monitored before discharge. Elevated blood pressure should be monitored and the client should not be discharged until stable.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 591

35. The nurse is caring for a confused older adult client who requires surgery for a broken hip. What steps does the nurse take to determine if the client has a durable power of attorney for health care and how to contact that person?

A. Review the medical chart for a copy of a durable power of attorney for health care or permission for disclosure contact.

B. Explain the client's need for hip surgery to visitors and ask them for information about a durable power of attorney for health care.

C. Look on the chart for a living will if a durable power of attorney for health care cannot be located.

D. Allow the surgeon to handle the issue as part of his or her legal responsibility for explaining the surgical procedure and obtaining the appropriate signature on the consent form.

Answer: A Rationale: The client cannot give consent due to confusion. In most cases, the durable power of attorney for health care document is discussed and obtained during the admission process.

The nurse should act as a client advocate by seeking someone with durable power of attorney to sign the informed consent form. It is the surgeon's responsibility to explain the surgical procedure and obtain the appropriate signature on the consent form; however, the nurse still acts as the client advocate to locate the designated person. A living will specifies the types of medical treatment the client wants should the client become unable to speak in a terminal or permanently unconscious medical condition, but it does not address matters related to client confusion. Telling visitors about the need for surgery may violate client confidentiality. If the nurse identifies who they have permission to disclose medical information to, they can ask that person about a durable power of attorney for health care.

Question format: Multiple Choice Chapter 27: Perioperative Care Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 592

Chapter 28 1. A client is brought to a health care facility for treatment of a bleeding cut. The client was injured by a sharp knife. How can the nurse describe the client's wound?

A. a clean separation of skin and tissue with smooth, even edges B. a shallow crater in which skin or mucous membrane is missing C. a wound in which the surface layers of the skin are scraped away D. a separation of skin and tissue in which the edges are torn and irregular Answer: A Rationale: The nurse can describe a wound caused by a sharp knife as an incision wound with clean separation of skin and tissue with smooth, even edges. Ulceration is a shallow crater in which skin or mucous membrane is missing. An abrasion is a wound in which the surface layers of the skin have been scraped away. A laceration is the separation of skin and tissue in which the edges are torn and irregular.

Question format: Multiple Choice Chapter 28: Wound Care Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 616 2. A nurse is caring for a client with a puncture wound in the proliferation phase of the wound repair process. Which description reflects this phase of the wound repair process?

A. physiologic defense immediately after tissue injury B. period during which new cells fill and seal a wound C. process by which damaged cells recover and reestablish normal function D. period during which the wound undergoes change and maturation Answer: B Rationale: The proliferation phase is the period during which new cells fill and seal a wound.

This phase occurs 2 days to 3 weeks after the inflammatory phase. The inflammatory phase is the physiologic defense immediately after tissue injury. Resolution is the process by which damaged cells recover and reestablish their normal function. Remodeling, which follows the proliferation phase, is the period during which the wound undergoes change and maturation.

Question format: Multiple Choice Chapter 28: Wound Care Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Physiological Adaptation Client Needs: Physiological Integrity: Physiological Adaptation Reference: p. 617 3. When assessing a client's wound, the nurse observes that the damaged tissue is being replaced with fibrous tissue. How should the nurse document this restoration of tissue integrity?

A. resolution

B. regeneration C. scar formation D. phagocytosis Answer: C Rationale: Scar formation is the replacement of damaged cells with fibrous tissue. The integrity of skin and damaged tissue is restored by resolution, which is the process by which damaged cells recover and re-establish their normal function, regeneration or cell duplication, and scar formation. Phagocytosis is the process by which types of white blood cells consume pathogens, coagulated blood, and cellular debris.

Question format: Multiple Choice Chapter 28: Wound Care Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Communication and Documentation Reference: p. 617 4. When the nurse is caring for a client with an open wound, which characteristic should be observed if the wound heals by primary intention?

A. The wound edges are directly next to each other.

B. Granulation tissue needs additional time to extend across the wound.

C. The wound edges have to be brought together with closure material.

D. Drainage devices have to be used to promote quick healing.

Answer: A Rationale: If the wound is to heal by primary intention, the wound edges are directly next to each other. Because the space between the wound edges is so narrow, only a small amount of scar tissue forms. If the wound edges are widely separated, leading to a more time-consuming and complex reparative process, then it is described as healing by secondary intention. With tertiary intention healing, the wound edges are widely separated and are later brought together with some type of closure material; the wounds may require a drainage device to promote quick healing.

Question format: Multiple Choice Chapter 28: Wound Care Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 618 5. A client at a health care facility who underwent an appendectomy says to the nurse that he feels like something has "given way." On inspecting the surgical wound, the nurse notes pinkish drainage on the dressing. What intervention should the nurse perform in this case?

A. positioning the client to put the least strain on the operated area B. placing sterile dressings moistened with normal saline over the area C. informing the head nurse immediately about the client's condition D. inspecting the wound to determine the extent of the secretion Answer: A

Rationale: If wound disruption is suspected, the nurse should position the client to put the least strain on the operated area. The nurse should inform the physician immediately rather than informing the head nurse first. If evisceration occurs, the nurse places sterile dressings moistened with normal saline over the protruding organs and tissues. The nurse must be alert for signs and symptoms of impaired blood flow, such as swelling, localized pallor or a mottled appearance, and coolness of the tissue in the area around the wound. Inspecting the wound to determine the extent of the secretion may not be an appropriate action in this case.

Question format: Multiple Choice Chapter 28: Wound Care Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 619 6. A nurse is caring for a client with draining wounds. The nurse needs to apply a dressing of a highly absorbent nature. Which type of dressing should the nurse use for this client?

A. gauze B. transparent C. hydrocolloid D. bandage Answer: A Rationale: Gauze dressing is ideal for covering fresh wounds because of its highly absorbent nature. Gauze is applied to fresh wounds that are likely to bleed or wounds that exude drainage. The nurse uses a hydrocolloid dressing when caring for a client with superficial burn wounds; hydrocolloid dressings are self-adhesive, opaque, air- and water-occlusive wound coverings that keep wounds moist. A transparent dressing allows the nurse to assess a wound without removing the dressing; transparent dressings are especially used for peripheral and IV insertion sites. A bandage is a strip or roll of cloth wrapped around a body part to help support the area around the wound.

Question format: Multiple Choice Chapter 28: Wound Care Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 620 7. A nurse uses an open drain to drain the blood and drainage from a client's wound. The nurse knows that an open drain functions in which way?

A. pulls fluid by creating a vacuum pressure B. drainage occurs passively by gravity and capillary action C. pulls fluid by creating a negative pressure D. pulls fluid by squeezing the drainage collection chamber Answer: B Rationale: Drainage in an open drain occurs passively by gravity and capillary action, which is the movement of a liquid at the point of contact with a solid (in this case, the gauze

dressing). Open drains are flat, flexible tubes that provide a pathway for drainage toward the dressing. Closed drains are more efficient than open drains because they pull fluid by creating a vacuum or negative pressure. This is done by opening the vent on the receptacle, squeezing the drainage collection chamber, and then capping the vent.

Question format: Multiple Choice Chapter 28: Wound Care Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 621 8. A physician uses sutures during the surgery on a client at a health care facility. What are sutures?

A. knotted ties that hold an incision together B. a bridge that holds two wound margins together C. a strip or roll of cloth wrapped around a body part D. tubes that provide a pathway for drainage Answer: A Rationale: Sutures are knotted ties that hold an incision together. Sutures generally are constructed from silk or synthetic materials such as nylon. Staples are wide metal clips that form a bridge to hold two wound margins together. A bandage is a strip or roll of cloth wrapped around a body part. Open drains are tubes that provide pathways for drainage toward the dressing.

Question format: Multiple Choice Chapter 28: Wound Care Cognitive Level: Remember Client Needs: Physiological Integrity: Reduction of Risk Potential Reference: p. 622 9. When treating a client for a sprained ankle, the nurse wraps the client's ankle in a bandage.

What is the purpose of wrapping the client's ankle in a bandage?

A. maintains a moist environment B. protects the wound from further injury C. holds the medication in place D. limits movement in the wound area Answer: D Rationale: The nurse wraps a bandage over the client's sprained ankle in order to limit movement in the wound area to promote healing. Bandages are also used to hold dressings in place, especially when tape cannot be used or the dressing is extremely large. Bandages also support the area around a wound or injury to reduce pain. A dressing is used to hold medication in place, maintain a moist environment, and protect the wound from further injury.

Question format: Multiple Choice Chapter 28: Wound Care Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort

Integrated Process: Nursing Process Reference: p. 622 10. A nurse is caring for a client with diabetes whose right leg has been amputated due to complications related to gangrene. Which technique should the nurse use in order to bandage the amputated leg?

A. figure-of-eight turn B. spica turn C. recurrent turn D. spiral turn Answer: C Rationale: The nurse should use the recurrent turn technique to wrap the amputated leg. A recurrent turn is made by passing the roll back and forth over the tip of a body part. Once several recurrent turns are made, the bandage is anchored by completing the application with another basic turn (such as the figure-of-eight). A recurrent turn is especially beneficial when the head or the stump of an amputated limb is being wrapped. A figure-of-eight turn is best when a joint such as the elbow or knee is being bandaged. A spica turn is a variation of the figure-of-eight pattern; the wrap includes a portion of the trunk or chest. Spiral turns are used in the wrapping of cylindrical parts of the body, such as the arms and legs.

Question format: Multiple Choice Chapter 28: Wound Care Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 623 11. A nurse is assisting a physician who is using the sharp debridement technique at the bedside of a client at a health care facility. What is the purpose of sharp debridement?

A. removes necrotic tissue from healthy area of a wound B. breaks down and liquefies wound debris C. allows the body's enzymes to soften and liquefy tissue D. physically removes exudate from a deep wound Answer: A Rationale: In the sharp debridement technique, necrotic tissue is removed from a healthy area of a wound with the use of sterile scissors, forceps, or other instruments. This method is preferred if the wound is infected, because it helps the wound heal quickly and well. The procedure is done at the bedside, or in the operating room if the wound is extensive.

Enzymatic debridement involves the use of topically applied chemical substances that break down and liquefy wound debris. Autolytic debridement, or self-dissolution, is a painless natural physiologic process that allows the body's enzymes to soften, liquefy, and release devitalized tissue. Mechanical debridement involves physical removal of debris from a deep wound.

Question format: Multiple Choice Chapter 28: Wound Care Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation

Integrated Process: Nursing Process Reference: p. 625 12. When irrigating a client's ear, the nurse avoids occluding the ear canal with the tip of the syringe. Why should the nurse take such a precaution?

A. Bodies such as peas may swell and become tightly fixed.

B. The pressure of the trapped solution could rupture the eardrum.

C. Drainage may saturate the client's gown and bed linen.

D. Dehydrated bodies may swell and become tightly fixed.

Answer: B Rationale: When performing ear irrigation, the nurse should avoid occluding the ear canal with the tip of the syringe, as the pressure of the trapped solution could rupture the eardrum.

Ear irrigation removes debris from the ear. Ear irrigation is contraindicated if the tympanic membrane is perforated. Performing a gross inspection of the ear is important if a foreign body is suspected, because a bean, pea, or other dehydrated substance can swell if the ear is irrigated, causing it to become even more tightly fixed. Solid objects may require removal with an instrument. If ear irrigation is not contraindicated, it is performed much like eye irrigation, except that the nurse directs the solution toward the roof of the auditory canal.

After the irrigation, the nurse places a cotton ball loosely within the ear to absorb drainage but not to obstruct its flow.

Question format: Multiple Choice Chapter 28: Wound Care Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 627 13. Following treatment in an inpatient setting, a client has recovered from cellulitis. The nurse recognizes that the client's recovery is partially attributable to the restoration of the client's biologic defense mechanisms. What is an example of a mechanical defense mechanism?

A. maintenance of intact skin surfaces B. adequate production of appropriate antibodies C. secretion of lysozyme in response to microorganisms D. synthesis of gastric acid by cells in the stomach Answer: A Rationale: Mechanical defense mechanisms are physical barriers that prevent microorganisms from entering the body or expel them before they multiply. Examples include intact skin and mucous membranes. Antibodies, enzymes, and secretions are all examples of chemical defense mechanisms.

Question format: Multiple Choice Chapter 28: Wound Care Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 615

14. A construction worker has recently suffered a deep wound to the hand as a result of an accident with a power saw. Which cells will participate in the process of phagocytosis during his body's inflammatory response to this injury? Select all that apply.

A. monocytes B. basophils C. neutrophils D. T cells E. B cells Answer: A, C Rationale: Monocytes and neutrophils perform phagocytosis. B cells, T cells, and basophils do not perform this function.

Question format: Multiple Select Chapter 28: Wound Care Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 616 15. An elderly client with limited mobility is being treated for a pressure ulcer that developed while the client was in a residential facility. A hydrocolloid dressing has been applied to the client's ulcer in order to ensure a moist wound environment. What is the primary rationale for keeping a wound moist?

A. Anaerobic bacteria cannot survive in a moist environment.

B. New body cells grow most quickly in a moist environment.

C. Fluid in a moist wound fills "dead space" in the wound, preventing infection.

D. Cellular debris dissolves more quickly in a moist environment.

Answer: B Rationale: Moist wounds heal more quickly because new cells grow more rapidly in a wet environment. Moisture does not necessarily inhibit bacterial growth, and it does not cause cellular debris to dissolve. It is not normally desirable to have "dead space" in a wound filled with fluid.

Question format: Multiple Choice Chapter 28: Wound Care Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 621 16. A client's plan of care after open abdominal surgery specifies the use of a binder. What desired outcome is most closely related to the use of this device?

A. The client's wound will be adequately supported at all times.

B. The client will not experience skin breakdown in the periwound region.

C. The client's wound will remain free of infection at all times.

D. The client will remain free of signs and symptoms of inflammation.

Answer: A Rationale: Binders are primarily used to provide support to surgical wounds in locations where the wound may be subject to stresses. Binders are not used to prevent skin breakdown, to prevent infection, or to prevent inflammation, though each of these goals is relevant to healthy wound healing.

Question format: Multiple Choice Chapter 28: Wound Care Cognitive Level: Analyze Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 625 17. A nurse is aware of the varied therapeutic applications for hot and cold application.

Which clients may benefit the most from the application of heat?

A. a client whose oral temperature is 38.6° C (101.5° F) B. a client whose injured knee is visibly swollen C. a client who is experiencing epistaxis (nosebleed) D. a client who is experiencing back spasms Answer: D Rationale: Muscle spasms often respond well to heat application. Fever, swelling, and bleeding are more responsive to cold.

Question format: Multiple Choice Chapter 28: Wound Care Cognitive Level: Analyze Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 628 18. An elderly woman's poor nutritional status, low body mass index, and impaired mobility have put her at high risk for pressure ulcers. This client's nurse should prioritize which action in order to prevent her development of pressure ulcers?

A. dragging the client slowly and carefully when repositioning B. massaging skin regions that show early signs of skin breakdown C. maintaining the client's hygiene and washing her frequently with soap D. ensuring that the client's position is changed frequently and regularly.

Answer: D Rationale: Frequent repositioning is imperative in preventing pressure ulcers. Clients should never be dragged while being repositioned, and the frequent use of soap should be avoided.

Healthy skin may be massaged, but areas showing early signs of skin breakdown should never be massaged.

Question format: Multiple Choice Chapter 28: Wound Care Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process

Reference: p. 629 19. A client's hand was severely wounded upon coming in contact with a running lawn mower blade. The nurse notes that large amounts of flesh are missing and the bones of two fingers are visible. How will the nurse document this assessment finding?

A. puncture B. laceration C. contusion D. avulsion Answer: D Rationale: An avulsion involves the stripping away of large areas of tissue, leaving cartilage and bone exposed. Therefore the nurse will document this assessment finding as an avulsion.

A puncture is an opening of the skin caused by a narrow, sharp, pointed object. A laceration is the separation of skin and tissue with torn, irregular edges. A contusion is an injury to soft tissue. Therefore the nurse would not document the finding as a puncture, laceration, or contusion.

Question format: Multiple Choice Chapter 28: Wound Care Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 616 20. The nurse is teaching a client about healing of a minor surgical wound by first intention.

What teaching will the nurse include?

A. "Very little scar tissue will form."

B. "This is a complex reparative process."

C. "The margins of your wound are not in direct contact."

D. "The surgeon will leave your wound open intentionally for a period of time."

Answer: A Rationale: Very little scar tissue is expected to form in a minor surgical wound. Secondintention healing involves a complex reparative process in which the margins of the wound are not in direct contact. Third-intention healing takes place when the wound edges are intentionally left widely separated and later brought together for closure.

Question format: Multiple Choice Chapter 28: Wound Care Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 618 21. A caregiver is preparing to take over wound care for a client being discharged from the hospital. Which teaching will the nurse provide about wound healing for an older adult client? Select all that apply.

A. "It may take longer for an older adult to heal."

B. "Increased appetite will provide better nutrition to help with healing."

C. "Consider having a home health aide to assist with bathing and personal care."

D. "Older adults with lots of sun exposure may experience delayed healing."

E. "Depression after surgery is normal; this will not affect healing processes."

Answer: A, C, D Rationale: The nurse will teach that wound healing is delayed in older adult clients, especially those with long-term sun exposure. Normal aging changes include decreased (not increased) appetite. A home health aide can assist with caregiving to reduce stress from the client. Depression after surgery can affect wound healing, but this is not a normal finding.

Question format: Multiple Select Chapter 28: Wound Care Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 618 22. A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention?

A. contacting the surgeon B. applying sterile dressings with normal saline over the protruding organs and tissue C. assessing for impaired blood flow to the area of evisceration.

D. monitoring for pallor and mottled appearance of the wound Answer: B Rationale: The nurse will immediately apply sterile dressing moistened with normal saline over the protruding organs and tissue and call out for someone to contact the surgeon. While waiting for the surgeon, the nurse will continue to assess the area of evisceration and monitor the client's status.

Question format: Multiple Choice Chapter 28: Wound Care Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 619 23. The nurse is teaching a client about wound care at home following a cesarean birth of her baby. Which client statement requires further nursing teaching?

A. "I may have staples in place for a number of days."

B. "I will not remove the staples myself."

C. "After delivery, I will have sutures in place."

D. "Reinforced adhesive skin closures will hold my wound together until it heals."

Answer: D Rationale: After a cesarean birth, a client will be sutured and have staples put in place for a number of days. The health care provider or nurse will remove staples. Reinforced adhesive skin closures are not strong enough to hold this type of wound together.

Question format: Multiple Choice

Chapter 28: Wound Care Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 622 24. The nurse is preparing to apply a roller bandage to the stump of a client who had a belowthe-knee amputation. What is the nurse's first action?

A. exerting equal, but not excessive, tension with each turn of the bandage B. wrapping distally to proximally C. elevating and supporting the stump D. keeping the bandage free of gaps between turn Answer: C Rationale: The nurse will first elevate and support the stump, then begin the process of bandaging. The bandage will be applied distally to proximally with equal tension at each turn; the nurse will monitor throughout the application to keep the bandage free from gaps between turns.

Question format: Multiple Choice Chapter 28: Wound Care Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 623 25. A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response?

A. "The drain has measurement marks on it so that nurses can measure the amount of drainage and report it the health care provider."

B. "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound."

C. "The drain works by suctioning out blood and drainage from the wound and will be removed when there is minimal or no drainage."

D. "This drain is called a Jackson-Pratt or bulb drain and is compressed and closed shut to create a gentle suction."

Answer: B Rationale: The bulb-like drain allows removal of blood and drainage from the surgical wound. All the statements are factual and true; however, the name of the drain, how it works, when it will be removed, and measurement of the exudate are drain management skills and knowledge. Only, "the drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound" answers the clients question about why the drain is present.

Question format: Multiple Choice Chapter 28: Wound Care Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning

Reference: p. 621 26. A 9-year-old child is brought to a health care facility after a fall on the playground. The nurse notes that surface layers of the skin have been scraped away in the fall. How would the nurse address this wound?

A. Prepare the client for sutures B. Approximate the wound using adhesive wound closure strips C. Cleanse the area with soap and water D. Provide the client with a tetanus vaccine Answer: C Rationale: The nurse would provide care for an abrasion, an open wound in which the surface layers of the skin are scraped off. This would require cleansing the area with soap and water to remove any debris and bacteria. An incision or laceration would require approximation and sutures or adhesive wound closure strips. A puncture is an opening in the skin which would require tetanus vaccine.

Question format: Multiple Choice Chapter 28: Wound Care Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 616 27. A nurse is caring for a client who has a pressure injury. Which documentation is an example of a complete assessment of the wound's physical appearance?

A. Stage IV pressure injury on the client's left heel, 1 × 2 × 1.5 cm pink wound base, small amount of serous drainage, tunnelling at 3 o'clock measuring 1.5 inches, no S/S of infection, skin cool to touch, no redness, client denies pain5% B. Full thickness pressure injury on the client's left heel, 3 × 4 × 3 cm, pink wound base, no drainage, tunnelling at 3 o'clock measuring 2 cm, no S/S of infection, skin cool to touch, no redness, client denies pain C. Full thickness pressure injury on the client's left heel, 1 × 2 × 1.5 cm, pink wound base, small amount of serous drainage, tunnelling at 3 o'clock measuring 1.5 inches, no S/S of infection, skin cool to touch, no redness, client denies pain D. Stage V pressure injury on the client's left heel, 3 × 4 × 3 cm, pink wound base, no drainage, skin cool to touch, no redness, client denies pain Answer: D Rationale: Assessment and documentation should include wound type, wound location, wound size, wound classification (if it is a pressure injury it should be staged), wound base, wound drainage, the presence or absence of tunnelling, tubes and drains if present, signs and symptoms of infection, condition of surrounding skin, and pain. Measurement should include length, width, and depth in centimeters. Tunnelling measured using the clock method.

Question format: Multiple Choice Chapter 28: Wound Care Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation

Reference: p. 630 28. The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to be intact, reddened, and nonblanchable. What is the best way to document the nurse's assessment finding?

A. As a stage I pressure injury B. As a stage II pressure injury C. As a stage III pressure injury D. As a stage IV pressure injury Answer: A Rationale: Stage I pressure injuries are characterized by intact but reddened skin that is nonblanchable. Therefore, the nurse categorizes and documents this pressure injury as stage I. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue. Stage IV exposes muscle and bone. Therefore, the nurse does not categorize this pressure injury as stage II, III, or IV. Question format: Multiple Choice Chapter 28: Wound Care Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 630

Chapter 29 1. A nurse is caring for a client who has taken an overdose of ibuprofen. Which tube is most suitable for removing the toxic substances?

A. orogastric B. nasointestinal C. sump D. nasogastric Answer: A Rationale: An orogastric tube inserted at the mouth into the stomach is used in an emergency to remove toxic substances that have been ingested. The diameter of the tube is large enough to remove pill fragments and stomach debris. A nasointestinal tube is used to provide nourishment to the client. Sump tubes are used almost exclusively to remove fluid and gas from the stomach. A nasogastric tube is placed through the nose and advanced to the stomach. It is smaller in diameter than an orogastric tube; hence, it is not suitable for removing pill fragments and stomach debris quickly.

Question format: Multiple Choice Chapter 29: Gastrointestinal Intubation Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 645 2. A nurse is caring for a client who is experiencing dumping syndrome following a nasointestinal intubation. Which symptom is seen in a client with dumping syndrome?

A. pallor B. wheezing C. headache D. dizziness Answer: D Rationale: The client will show symptoms of dizziness, sweating, and nausea, caused by fluid shifts from the circulating blood to the intestine, and low blood glucose level in case it is due to a surge of insulin. Pallor, headaches, and wheezing are not symptoms of dumping syndrome.

Question format: Multiple Choice Chapter 29: Gastrointestinal Intubation Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 652 3. A nurse needs to insert a gastrointestinal tube for a client with peptic ulcers. Which action is most suitable for the use of gastrointestinal intubation?

A. controlling gastric bleeding

B. examining the peptic ulcers C. measuring gastric residual volume D. reducing risk of reflux Answer: A Rationale: A gastric or intestinal tube is used for a variety of reasons, including controlling gastric bleeding, a process called compression or tamponade. An endoscope is used for examining peptic ulcers. Gastric residual and gastric reflux are caused by gastrointestinal intubation, so it would be incorrect to say that gastrointestinal intubation measures gastric residual or reduces the risk of reflux.

Question format: Multiple Choice Chapter 29: Gastrointestinal Intubation Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 644 4. A nurse notices a poorly draining nasogastric tube inserted in a client. Which is a possible cause of a poorly draining nasogastric tube?

A. A vent has been left unplugged by the nurse.

B. The drainage container is filled below capacity.

C. The tube is displaced above the cardiac sphincter.

D. The suction machine is turned on continuously.

Answer: C Rationale: Displacement above the cardiac sphincter is a possible cause of a poorly draining nasogastric tube. An unplugged vent will not cause poor drainage because, often, nurses remove the cap and restore the port to atmospheric pressure. A drainage container that is filled beyond, not below, capacity causes poor draining. A portable suction machine will not restore electrical power; it is not a generator.

Question format: Multiple Choice Chapter 29: Gastrointestinal Intubation Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 650 5. A nurse is caring for a client who is being tube-fed. Which action should the nurse perform when assessing a client's gastric residual volume?

A. Aspirate fluid from the tube using a 5-mL syringe.

B. Clamp the tube and wait for 15 minutes.

C. Stop the infusion of the tube-feeding formula.

D. Aspirate or flush the tube with water.

Answer: C Rationale: The nurse should stop the infusion of the tube-feeding formula to facilitate measurement. Next, the nurse should aspirate the fluid from the feeding tube using a 50-mL

syringe, not a 5-mL syringe. Clamping the tube and waiting for 15 minutes–or flushing the tube with water–is done to clear an obstructed feeding tube, not to assess the gastric residual volume of a client.

Question format: Multiple Choice Chapter 29: Gastrointestinal Intubation Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 654 6. A nurse is assessing the volume of liquid nutrition that has been tube-fed to a client. What will happen if the volume of feeding exceeds the client's physiologic capacity?

A. diarrhea B. pallor C. obesity D. gastric reflux Answer: D Rationale: Overfilling the client's stomach can cause gastric reflux, regurgitation, vomiting, aspiration, and pneumonia. Exceeding the volume of feeding beyond a client's physiologic capacity does not lead to diarrhea, pallor, or obesity. As a rule of thumb, the gastric residual should be no more than 100 mL or no more than 20% of the previous hour's tube-feeding volume.

Question format: Multiple Choice Chapter 29: Gastrointestinal Intubation Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 653 7. A nurse is administering prescribed medication through an intestinal decompression tube to a client with a complete bowel obstruction. Which is a feature of the tube used for intestinal decompression?

A. The tube propels itself beyond the stomach.

B. The tube is weighted with tungsten.

C. Two lumens are used for suctioning.

D. Mercury-weighted tubes are used.

Answer: B Rationale: Intestinal tubes used in intestinal decompression are now weighted with tungsten, not with mercury, because mercury is hazardous to both the client and the environment. One lumen is used to suction the intestinal contents, and the other acts as a vent to reduce suctioninduced trauma to the intestinal tissue. The weighted tip and peristalsis, if present, propel the tube beyond the stomach and into the intestine.

Question format: Multiple Choice Chapter 29: Gastrointestinal Intubation Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation

Integrated Process: Nursing Process Reference: p. 656 8. A nurse is providing liquid nourishment 4 to 6 times a day in feedings of less than 30minutes duration to a client who is being tube fed. To which of the following tube-feeding schedules is the nurse adhering?

A. cyclic B. variable C. continuous D. bolus Answer: D Rationale: A bolus or intermittent feeding is the instillation of liquid nourishment 4 to 6 times a day in less than 30 minutes, usually 250 to 400 mL of formula per administration. Cyclic feeding (over a period of 8 to 12 hours) is followed by a 16- to 12-hour pause. Continuous feeding is administered at a steady rate of approximately 1.5 mL/minute. Feeding schedules are not characterized as being variable.

Question format: Multiple Choice Chapter 29: Gastrointestinal Intubation Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 653 9. A nurse is assisting a physician in placing a tube inside a client with the help of an endoscope to provide access to various parts of the GI tract. Which tube is being inserted inside the client?

A. nasointestinal B. myringotomy C. transabdominal D. colon Answer: C Rationale: A transabdominal tube provides access to various parts of the GI tract. A transabdominal gastrostomy tube is inserted with the use of an endoscope. Myringotomy tubes are small tubes that are surgically placed into a child's eardrum to help drain the fluid out of the middle ear in order to reduce the risk of ear infections. A nasointestinal tube is inserted through the nose for distal placement below the stomach. Colon tubes are inserted into the rectum for an enema.

Question format: Multiple Choice Chapter 29: Gastrointestinal Intubation Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 645 10. A nurse is unable to clean an obstruction in a tube. Which is most suitable if the nurse is unable to remove the obstruction?

A. Use a meat tenderizer.

B. Remove the tube.

C. Use a pancreatic enzyme.

D. Delay nutrition a bit.

Answer: B Rationale: When an obstruction cannot be cleared, the tube should be removed and another inserted, rather than compromising nutrition by the delay. It is possible to clear the tube with a solution of meat tenderizer or pancreatic enzyme, but both methods require written medical orders.

Question format: Multiple Choice Chapter 29: Gastrointestinal Intubation Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 654 11. A nurse is assessing the nasal passages of a client before inserting a nasointestinal tube.

Which observation excludes nostril use for tube insertion?

A. wide nasal passage B. small growths of tissue C. nasal hair growth D. undeviated nasal septum Answer: B Rationale: A nostril is excluded from intubation if there is the presence of small growths of tissue, a deviated septum, or a narrow nasal passage. Nasal hair growth is not part of the assessment that a nurse makes before inserting a nasointestinal tube, as the hair can always be clipped.

Question format: Multiple Choice Chapter 29: Gastrointestinal Intubation Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 647 12. A nurse is determining the length of a nasogastric sump tube before inserting it inside a client. The nurse is placing the distal tip of the tube at the client's nose. To which places should the nurse measure the tube distance for proper placement?

A. the jaw and then midway to the sternum B. the mouth and then between the nipples C. the midsternum and then to the umbilicus D. the nose to earlobe to the xiphoid process Answer: D Rationale: The nurse obtains the length from the nose to the earlobe to the xiphoid process and marks the tube appropriately. The first mark on the tube is made at the measured distance

from the nose to the earlobe. It indicates the distance to the nasal pharynx, a location that places the tip at the back of the throat but above where the gag reflex is stimulated.

Question format: Multiple Choice Chapter 29: Gastrointestinal Intubation Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 647 13. A nurse notices that, even with intermittent suctioning, a nasogastric tube is becoming obstructed. Which intervention will promote tube patency?

A. Give liberal amounts of water to the client.

B. Inspect the tube carefully.

C. Give ice chips to the client.

D. Remove and wash the tube.

Answer: C Rationale: Giving ice chips or occasional sips of water to a client promotes tube patency. The fluid helps to dilute the gastric secretions. However, both must be given sparingly because water is hypotonic and draws electrolytes into the gastric fluid. Because the diluted fluid is ultimately removed, giving the client liberal amounts of water can deplete serum electrolytes.

Removing and washing the tube is not recommended, as it will lead to pain and trauma to the client.

Question format: Multiple Choice Chapter 29: Gastrointestinal Intubation Cognitive Level: Remember Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 649 14. An older adult client's small-bowel obstruction has resolved, and the intestinal decompression tube has been prescribed to be removed. When performing this nursing action, what should the nurse prioritize?

A. Instill a small amount of water to provide lubrication while withdrawing the tube.

B. Remove the tube slowly to avoid injuring the client.

C. Change from continuous to intermittent suction during removal.

D. Aspirate the tube while removing it in order to normalize pressure.

Answer: B Rationale: An intestinal decompression tube is removed slowly because removal is in a reverse direction through the curves of the intestine and the valves of the lower and upper ends of the stomach. The tube is withdrawn 6 to 10 in (15 to 25 cm) at 10-minute intervals. It is incorrect to aspirate or instill water during removal, and the suction should be turned off, not merely changed to intermittent suction.

Question format: Multiple Choice Chapter 29: Gastrointestinal Intubation Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care

Integrated Process: Nursing Process Reference: p. 656 15. A client has been receiving tube feedings for the past several days. The client's plan of care identifies the nursing diagnosis risk for fluid imbalance. How should this risk be best mitigated?

A. Ensure that the client adheres to the correct fluid restriction while receiving feedings.

B. Use the smallest amount of water necessary to flush the tube after feedings or administering medications.

C. Administer supplementary water after considering the quantity of feedings and flushes.

D. Aspirate the stomach contents if the client develops peripheral edema.

Answer: C Rationale: Clients on tube feedings are generally susceptible to dehydration, not fluid volume overload. As such, fluid restrictions and minimal flushes are unnecessary. Stomach contents are not aspirated to maintain fluid balance.

Question format: Multiple Choice Chapter 29: Gastrointestinal Intubation Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Reference: p. 655 16. A nurse is providing care for a client who has dysphagia secondary to a stroke. The client has recently begun continuous tube feedings in order to meet nutritional needs. The nurse has assessed the client's gastric residual as ordered and identified a gastric residual volume of 210 mL. How should the nurse follow up this finding?

A. Administer an additional 90 to 140 mL of feeding formula.

B. Instill 60 to 120 mL of sterile water to dilute the stomach contents.

C. Dilute the feedings by 50% with tap water for the next 6 hours.

D. Stop the feeding until the client's gastric residual is less than 100 mL. Answer: D Rationale: As a rule of thumb, the gastric residual should be no more than 100 mL or no more than 20% of the previous hour's tube-feeding volume. If the gastric residual is high, the feeding is stopped, and the gastric residual is rechecked again every 30 minutes until it is within a safe volume for resuming the feeding. Adding more formula or water would exacerbate the problem.

Question format: Multiple Choice Chapter 29: Gastrointestinal Intubation Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 653 17. A client has recently been changed from intermittent tube feedings to a cyclic feeding schedule, in which the client receives feedings for 8 to 12 hours, followed by several hours without feedings. What is the most likely rationale for this change in the client's feeding schedule?

A. The client's nutritional needs are lower than they previously were.

B. The client is transitioning from tube feedings to oral food intake.

C. The client has experienced a fluid imbalance or electrolyte imbalance.

D. The client's activity level and mobility have increased.

Answer: B Rationale: Cyclic feedings are often used to wean clients from tube feedings while continuing to maintain adequate nutrition. This change would not likely be prompted by increased nutritional needs, fluid and electrolyte imbalances, or increased activity.

Question format: Multiple Choice Chapter 29: Gastrointestinal Intubation Cognitive Level: Analyze Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 653 18. A nurse has replaced the bag and tubing that are being used to administer intermittent tube feedings to an elderly client with modest nutritional needs. How often should the nurse change the tubing and bag that are used to administer this client's tube feedings?

A. after each intermittent feed B. after 24 hours C. every 5 to 7 days D. immediately after each time that the tube is flushed Answer: B Rationale: Tube-feeding administration sets are replaced every 24 hours, regardless of the feeding schedule.

Question format: Multiple Choice Chapter 29: Gastrointestinal Intubation Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 653 19. The nurse is preparing to insert a nasogastric tube. Which nursing intervention is appropriate? Select all that apply.

A. Measure from the nose to the earlobe to the xiphoid process.

B. Assess the client's level of consciousness.

C. Arrange a cue with the client if a pause during insertion is needed.

D. Arrange for an abdominal x-ray following tube insertion.

E. Obtain sterile gloves.

Answer: A, B, C, D Rationale: The nurse will prepare for a nasogastric tube insertion by obtaining the NEX measurement (the length from the nose to the earlobe to the xiphoid process), assessing the client, arranging for a cue if the client needs a pause during insertion, and arranging for an

abdominal x-ray following insertion to confirm placement. The nurse will also obtain clean gloves; this is not a sterile procedure.

Question format: Multiple Select Chapter 29: Gastrointestinal Intubation Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 646-647 20. The health care provider has placed an order for a client's nasogastric tube to be clamped.

Which assessment finding indicates to the nurse that the client's condition has improved?

A. absence of bowel sounds B. no nausea or vomiting C. increasing abdominal distension D. epigastric pain of 4 on a scale of 1 to 10 Answer: B Rationale: No nausea or vomiting indicates that symptoms associated with the need for a nasogastric tube are improving. All other symptoms demonstrate that symptoms are still present and require other intervention.

Question format: Multiple Choice Chapter 29: Gastrointestinal Intubation Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 650 21. The nurse is caring for a client with dementia who has not been eating. The health care provider suggests insertion of a feeding tube, yet the client's power of attorney refuses this procedure. What is the appropriate nursing response?

A. "Your loved one will die without a feeding tube."

B. "Why do you not want your loved one to have a feeding tube?"

C. "The health care provider will make the final decision about a feeding tube."

D. "I understand this is a difficult choice for you, and I support your decision."

Answer: D Rationale: The use of feeding tubes in older adults with dementia involves many ethical considerations. Legally, the power of attorney makes the decision about treatment options, and the nurse is to act as the advocate.

Question format: Multiple Choice Chapter 29: Gastrointestinal Intubation Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 651

22. The nurse is caring for a client with second- and third-degree (partial- and full-thickness) burns who requires tube feeding. Which type of formula does the nurse anticipate will be ordered?

A. standard isotonic B. high-calorie C. fiber-containing D. partially hydrolyzed Answer: B Rationale: The nurse anticipates that the client with second- and third-degree (partial- and full-thickness) burns will require high-calorie feeding since the body is utilizing a high amount of energy to heal. Standard isotonic formulas are used for clients with normal digestion and absorption. Fiber-containing formulas provide fiber for clients who have impaired bowel function. Partially hydrolyzed formulas provide nutrients in simple form that require little or no digestion for clients with impaired digestive processes.

Question format: Multiple Choice Chapter 29: Gastrointestinal Intubation Cognitive Level: Analyze Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 652 23. The health care provider has ordered a bolus feeding for a client. Which client response does the nurse anticipate may occur after the bolus? Select all that apply.

A. diarrhea B. abdominal discomfort C. vomiting D. constipation E. reflux F. aspiration Answer: B, C, E, F Rationale: Clients who receive bolus feedings may experience discomfort from the rapid delivery of fluid; they may also be at higher risk for vomiting, reflux, and aspiration. Bolus feedings are not associated with diarrhea and constipation.

Question format: Multiple Select Chapter 29: Gastrointestinal Intubation Cognitive Level: Analyze Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 653 24. The nurse is preparing to check gastric residual for a client who had a tube feeding. After washing hands and donning gloves, what is the nurse's first action?

A. Measure the aspirated fluid.

B. Stop the tube-feeding infusion.

C. Report excessive residual amounts to the health care provider.

D. Reinstill the fluid that was aspirated.

Answer: B Rationale: The nurse will first stop the tube-feeding infusion and then continue to aspirate fluid, measure, and resinstill the aspirated fluid before reporting excessive amounts to the health care provider.

Question format: Multiple Choice Chapter 29: Gastrointestinal Intubation Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 654 25. A client who weighs 198 pounds (90 kg) is receiving nutrition via a feeding tube. How much additional daily water does the nurse calculate that the client needs?

A. 1000 mL/day B. 1600 mL/day C. 2200 mL/day D. 2700 mL/day Answer: D Rationale: Clients need 30 mL of water per kilogram of body weight, or 1 mL/kcal, on a daily basis. A 90-kg client would require 2700 mL of water daily. The other values are too low.

Question format: Multiple Choice Chapter 29: Gastrointestinal Intubation Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 654 26. The nurse is caring for an older adult client with confusion who continues to pull at a nasogastric feeding tube despite nursing interventions. What is the appropriate nursing action? Select all that apply.

A. Remind the client to leave the tube alone.

B. Contact the health care provider for an order for restraints.

C. Stay with the client during the remainder of the shift.

D. Assess for fluid or electrolyte imbalance.

E. Arrange for a hospital sitter to remain with the client.

Answer: B, D, E Rationale: After other interventions have been exhausted, it is appropriate for the nurse to contact the health care provider to consider an order for restraints to keep the client from pulling the tube. The nurse should assess for possible fluid and electrolyte imbalance, as behaviors can often be associated with physiological causes. It is not reasonable to tell the client with confusion to leave the tube alone, nor can the nurse remain with the client throughout the entire shift; however, a hospital sitter may be available to stay with the client to gently redirect the behavior.

Question format: Multiple Select

Chapter 29: Gastrointestinal Intubation Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 656 27. A client with multiple pressure ulcers requires a feeding tube. Which type of formula does the nurse anticipate will be ordered?

A. standard isotonic B. fiber-containing C. high-protein D. partially hydrolyzed Answer: C Rationale: The nurse anticipates that the client with multiple pressure ulcers will need a formula that is high in protein and other nutrients to support tissue integrity and healing.

Standard isotonic formulas are used for clients with normal digestion and absorption, but they do not supply the extra protein needed for healing purposes. Fiber-containing formulas are appropriate for clients who need to normalize bowel function. Partially hydrolyzed formulas provide nutrients in simple form that require little or no digestion for clients with impaired digestive processes.

Question format: Multiple Choice Chapter 29: Gastrointestinal Intubation Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 652 28. A nurse is writing instructions on the discharge sheet of a client with a nasointestinal tube inserted. What should the nurse add to the discharge sheet?

A. method for clearing an obstruction B. guidelines for delaying a feed C. technique for removing the tube D. method of assessing gastric residual Answer: B Rationale: The nurse provides a written instruction sheet that includes guidelines for delaying a feed, a schedule of and amount to feed, as well as what problems to report and names and contact numbers in case questions arise. The nurse does not write about the technique for removing the tube, clearing an obstruction, nor assessing gastric residual, as these functions are nursing interventions performed by the nurse.

Question format: Multiple Choice Chapter 29: Gastrointestinal Intubation Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Reference: p. 656

29. A pediatric client with failure to thrive will have a gastrostomy tube placed. The caregiver asks the nurse, "Why does my infant need this?" Which is the best response by the nurse?

A. "This will be placed in the infant's stomach to help with nutrition."

B. "Your infant will need this for about 1 week to receive medication."

C. "Your infant will need this so the nurses can suction the lungs."

D. "Your infant will need this to assist with breathing."

Answer: A Rationale: A gastrostomy tube is placed surgically into the stomach to provide nutrition to the infant for an extended period of time. It will remain in place for as long as it is needed and typically is a more long-term solution. Explaining this to the caregiver is the appropriate nursing response. A gastrostomy tube does not affect the respiratory system.

Question format: Multiple Choice Chapter 29: Gastrointestinal Intubation Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 646

Chapter 30 1. The nurse is caring for an 18-year-old client with a urinary tract infection. What is a factor that affects the pattern of urine elimination in this client?

A. integrity of the spinal cord B. diminished bladder capacity C. degenerative changes in the cerebral cortex D. relaxation of pelvic floor muscle tone Answer: A Rationale: Patterns of urinary elimination depend on the integrity of the spinal cord as well as physiologic, emotional, and social factors. Diminished bladder capacity, relaxation of pelvic floor muscle tone, and degenerative changes in the cerebral cortex are age-related changes that increase the risk of incontinence and lead to urinary urgency, respectively, in older adults.

Question format: Multiple Choice Chapter 30: Urinary Elimination Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 675 2. When collecting a urine sample from a client for examination, the nurse notes that the sample appears reddish-brown in color. What could cause this variation in color of the urine?

A. dehydration B. infection C. stasis D. blood Answer: D Rationale: A reddish-brown urine sample is indicative of the presence of blood. The urine appears dark amber in color due to dehydration. Infection and stasis would cause the urine to appear cloudy.

Question format: Multiple Choice Chapter 30: Urinary Elimination Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Physiological Adaptation Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 675 3. A nurse collects a clean-catch specimen from a client at a health care facility. Which statement describes a clean-catch urine sample?

A. a sample of fresh urine collected in a clean container B. a sample of urine collected in a sterile environment C. a sample of urine collected over a period of 24 hours

D. a sample of urine that is considered sterile Answer: D Rationale: A clean-catch specimen is a sample of urine that is considered sterile. A cleancatch specimen is preferred to a randomly voided specimen. This method of collection is preferred when a urine specimen is needed during a client's menstrual cycle. A void specimen is a sample of fresh urine collected in a clean container. A catheter specimen is a sample of urine collected in a sterile environment using a catheter. A 24-hour specimen is a sample of urine collected over a 24-hour period.

Question format: Multiple Choice Chapter 30: Urinary Elimination Cognitive Level: Remember Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 675 4. A nurse is caring for an older adult client at his home. The client has had a condom catheter applied. Which describes a condom catheter?

A. a flexible sheath that is rolled around the penis B. a bag attached by adhesive backing to the skin around the genitals C. a urine drainage tube inserted but not left in place D. a urine drainage tube that is left in place over a period of time Answer: A Rationale: A condom catheter is a flexible sheath that is rolled around the penis. A urinary bag (U-bag) is a bag attached by adhesive backing to the skin surrounding the genitals. A straight catheter is a urine drainage tube inserted but not left in place. A retention (or indwelling) catheter is a urine drainage tube that is left in place over a period of time.

Question format: Multiple Choice Chapter 30: Urinary Elimination Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs Pn: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 681 5. A nurse uses a catheter to collect a sterile urine specimen from a client at a health care facility. If a catheter is required temporarily, which type of catheter should the nurse use?

A. condom catheter B. urinary bag C. straight catheter D. retention catheter Answer: C Rationale: The nurse should use a straight catheter to collect a sterile urine specimen from the client. A straight catheter is a urine drainage tube inserted but not left in place. It drains urine temporarily or provides a sterile urine specimen. Condom catheters are helpful for clients

with urinary incontinence receiving care at home, because they are easy to apply. A urinary bag is more often used to collect urine specimens from infants. A retention catheter, also called an indwelling catheter, is left in place for a period of time.

Question format: Multiple Choice Chapter 30: Urinary Elimination Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 682 6. A client reports that he is often unable to retain urine until he locates a toilet because his mobility is decreased. The nurse should recognize the characteristics of what type of incontinence?

A. stress B. urge C. functional D. total Answer: C Rationale: The nurse should document the client's condition as functional incontinence when the client is unable to retain urine for some time after getting an urge to void. Stress incontinence can result in the loss of small amounts of urine when intra-abdominal pressure rises. Urge incontinence is the need to void, perceived frequently with a short-lived ability to sustain control of flow. Total incontinence is the loss of urine without any identifiable pattern.

Question format: Multiple Choice Chapter 30: Urinary Elimination Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 679 7. A nurse at a health care facility provides continence training to a client. During the training, the nurse plans a trial schedule for voiding that correlates with the time when the client is usually incontinent. What is a possible reason for the nurse's action?

A. reveals the client's type of incontinence B. prevents self-defeating consequences C. ensures adequate urine volume D. reduces potential for unintentional voiding Answer: D Rationale: During the training, the nurse plans a trial schedule for voiding that correlates with the time when the client is usually incontinent so as to reduce the potential for accidental voiding or sustained urinary retention. Compiling a log of the client's urinary elimination pattern helps reveal the client's type of incontinence. Setting realistic, specific, short-term goals for the client prevents self-defeating consequences. Discouraging strict limitation of fluid intake ensures adequate urine volume.

Question format: Multiple Choice

Chapter 30: Urinary Elimination Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 680 8. A nurse performs catheter irrigation for a client at a health care facility only after verifying that a medical order has been written. Why should the nurse take this precaution?

A. complies with medical directives B. demonstrates legal limits of nursing C. provides baseline for assessing outcome of procedure D. provides an opportunity for health teaching Answer: B Rationale: Before performing the catheter irrigation, the nurse checks the client's record to verify that a medical order has been written as this demonstrates the legal limit of nursing.

The nurse needs to verify the irrigation solution prescribed in order to comply with the medical directives. In order to provide a baseline for assessing the outcome, the nurse should assess the characteristics of the urine. The nurse determines how much the client understands about catheter teaching as it provides an opportunity for health teaching.

Question format: Multiple Choice Chapter 30: Urinary Elimination Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs Pn: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 695 9. A client at a health care facility is being treated for cancer of the bladder. The physician uses a urinary diversion to help the client with urinary elimination. What describes a urinary diversion?

A. inability to control either urinary or bowel elimination B. hygiene measures used to keep meatus and adjacent area of the catheter clean C. use of a catheter to collect urine in a sterile environment D. one or both of the ureters are surgically implanted elsewhere Answer: D Rationale: The nurse should understand that in a urinary diversion, one or both of the ureters are surgically implanted elsewhere. This procedure is done for various life-threatening conditions. Incontinence is the inability to control either urinary or bowel elimination.

Catheter care means the hygiene measures used to keep meatus and adjacent area of the catheter clean. In order to collect a catheter specimen, the nurse uses a catheter to collect a sample of urine in a sterile environment.

Question format: Multiple Choice Chapter 30: Urinary Elimination Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process

Reference: p. 686 10. The nurse is caring for a client who uses a urostomy to eliminate urine from the body.

Which should the nurse use when changing the urinary appliance?

A. tampons B. skin barrier products C. antibiotic ointments D. steroid ointments Answer: A Rationale: The nurse should use a tampon when changing the urinary appliance. When changing the appliance, it may help to place a tampon within the stoma to absorb urine temporarily while the skin is cleansed and prepared for another appliance. In order to maintain the integrity of the peristomal skin, skin barrier products are used, and sometimes antibiotic or steroid ointment is applied.

Question format: Multiple Choice Chapter 30: Urinary Elimination Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 686 11. A nurse is caring for an older adult client who experiences urinary urgency. What is a possible cause of the client's condition?

A. impaired mobility B. kidney dysfunction C. diminished bladder capacity D. diuretic medication therapy Answer: C Rationale: Older adults are likely to experience urinary urgency and frequency because of normal physiologic changes such as diminished bladder capacity and degenerative changes in the cerebral cortex. Impaired mobility could lead to functional incontinence. Kidney dysfunction would lead to a reduction in the volume of urine. Diuretic therapy, commonly prescribed for older adults, can increase the risk for urinary incontinence.

Question format: Multiple Choice Chapter 30: Urinary Elimination Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 677 12. A nurse is caring for a 65-year-old male client who is postoperative day 1 following a total hip replacement. Which should the nurse use in order to assist the client to eliminate urine?

A. commode B. raised toilet C. bedpan

D. fracture pan Answer: D Rationale: The nurse should use a fracture pan to assist a client with a musculoskeletal disorder to eliminate urine. A fracture pan, a modified version of a conventional bedpan, is flat on the sitting end rather than rounded. Clients with musculoskeletal disorders who cannot elevate their hips and sit on a bedpan in the usual manner use a fracture pan. Clients who are weak or cannot walk to the bathroom may need a commode. Clients confined to bed use a urinal or bedpan.

Question format: Multiple Choice Chapter 30: Urinary Elimination Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 678 13. A nurse is caring for a male client whose prostatic hypertrophy has resulted in impaired urinary elimination. The nurse is aware of the vital importance of maintaining healthy urinary production and elimination because the functions of the urinary system include: A. mobilizing glucose for distribution to body cells.

B. eliminating the waste products of cellular metabolism.

C. maintaining osmotic pressure within the bladder.

D. eliminating indigestible components of the diet.

Answer: B Rationale: Urinary elimination is the process of releasing excess fluid and metabolic wastes.

Indigestible products are primarily excreted by the GI system, not the GU system. The urinary system does not distribute glucose and the maintenance of osmotic pressure in the bladder is not a primary role of this body system.

Question format: Multiple Choice Chapter 30: Urinary Elimination Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 674 14. An elderly client has been experiencing urinary hesitancy, and this has resulted in the client's bladder becoming overdistended with urine. What intervention should the nurse attempt before resorting to the insertion of a urinary catheter?

A. Increase the client's intake of low-pH fluids in order to stimulate bladder function.

B. Encourage the client to perform some vigorous exercise.

C. Run water from the tap in the client's room to stimulate the urge to void.

D. Position the client in a side-lying position.

Answer: C

Rationale: General measures to promote urination include using stimuli such as running water from a tap to initiate voiding. A side-lying position does not stimulate voiding. Similarly, acidic fluids and exercise do not stimulate normal urinary function.

Question format: Multiple Choice Chapter 30: Urinary Elimination Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 675 15. A client in a health care facility has had a urinary catheter in situ for the past several days.

The client's nurse has amended the client's plan of care to reflect the use of the device. What nursing diagnosis is a priority in this aspect of the client's care?

A. risk for deficient fluid volume B. risk for infection C. risk for impaired mobility D. risk for acute pain Answer: B Rationale: Indwelling urinary catheters pose a high risk of infection; this risk must be addressed by providing meticulous nursing care. Catheters do not result in fluid volume deficit. The risk of infection is more likely a threat to the client than risks for pain and impaired mobility.

Question format: Multiple Choice Chapter 30: Urinary Elimination Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 686 16. A postsurgical client has been admitted to the unit with an indwelling urinary catheter that was inserted in the operating room and which is scheduled for removal the following morning. How can the nurse best avoid backflow of urine into the client's bladder and subsequent infection?

A. Ensure that the collection bag is always lower than the client's bladder.

B. Irrigate the catheter if clots or pus are visible in the tubing or collection bag.

C. Ensure that the contents of the collection bag do not exceed 50% of capacity.

D. Position the client in a high Fowler position unless contraindicated.

Answer: A Rationale: The nurse always positions the drainage system lower than the bladder to avoid backflow of urine. High Fowler positioning, catheter irrigation, and frequent emptying do not necessarily prevent the backflow of urine into the client's bladder.

Question format: Multiple Choice Chapter 30: Urinary Elimination Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process

Reference: p. 682 17. A 69-year-old man had a transurethral resection of the prostate early this morning and now has continuous bladder irrigation running. What is the primary goal of this form of irrigation?

A. The client's catheter will remain patent and free of blood clots.

B. The client's urinary output will be medium-amber to dark-amber in color.

C. The client's bladder will contain between 100 and 300 mL of urine at all times.

D. The client will maintain a normal cycle of bladder filling and urine elimination.

Answer: A Rationale: Continuous irrigation is intended to keep a catheter patent after prostate or other urologic surgery in which blood clots and tissue debris collect within the bladder and catheter. Because of the client's recent surgery and the volume of solution being instilled, the output will not be amber-colored. As well, bladder contents will be scant because of the continuous drainage. This intervention temporarily precludes normal bladder filling.

Question format: Multiple Choice Chapter 30: Urinary Elimination Cognitive Level: Analyze Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 685 18. The nurse is caring for a client who has been experiencing nausea, vomiting, and diarrhea for 3 days. Which urine characteristics does the nurse anticipate?

A. cloudy, foul odor B. light yellow, clear C. clear, colorless D. strongly aromatic, dark amber Answer: D Rationale: The nurse anticipates that the client may be dehydrated, which is characterized by strongly aromatic, dark amber urine. The other characteristics are not associated with dehydration.

Question format: Multiple Choice Chapter 30: Urinary Elimination Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 675 19. The nurse is caring for a client with weakness who is ambulatory but tires easily. Which method for urinary elimination does the nurse recommend?

A. fracture pan B. bedside commode C. bedpan D. regular bathroom

Answer: B Rationale: The client with weakness who tires easily may benefit from a bedside commode.

Because the client is ambulatory, a bedpan or fracture pan is not needed. Ambulating to the regular bathroom may increase the risk for falls.

Question format: Multiple Choice Chapter 30: Urinary Elimination Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 678 20. The nurse is caring for a client who reports urinary incontinence over the past 2 months.

In reviewing the electronic health record, which new prescriptions will the nurse look for that may be related to the concern? Select all that apply.

A. diuretics B. antihypertensives C. antidepressants D. stool softeners E. sleeping pills Answer: A, B, C, E Rationale: The nurse anticipates that medications for hypertension, diuretics, antidepressants, and sleeping pills may contribute to urinary incontinence. Stool softeners are not associated with urinary incontinence.

Question format: Multiple Select Chapter 30: Urinary Elimination Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 678 21. A client reports frequently experiencing urine loss when moving from the wheelchair to bed. Which type of incontinence does the nurse anticipate?

A. urge B. total C. reflex D. functional Answer: D Rationale: Functional incontinence takes place when attempting to overcome obstacles, such as transferring from the wheelchair to the bed. Urge incontinence takes place when there is a delay in accessing a toilet. Reflex incontinence takes place when a client automatically releases urine and cannot control it. Total incontinence takes place without a pattern or warning, and without client control.

Question format: Multiple Choice Chapter 30: Urinary Elimination Cognitive Level: Understand

Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 679 22. A client reports an episode of losing control of urination when a bathroom wasn't close by. The client states, "I'm worried this means that I'm starting to lose control of my bladder."

What is the appropriate nursing response?

A. "I agree; please make an appointment with your health care provider."

B. "This only happened one time, so it is nothing to worry about."

C. "Let's review your medication history and whether you consume bladder irritants."

D. "I suggest that you invest in incontinence undergarments."

Answer: C Rationale: Urge incontinence can be aggravated by bladder irritants such as caffeine or alcohol, and can take place if diuretics are taken in the morning. The nurse will start by reviewing these factors. The nurse should not discount this as an isolated event without further assessment. It is too soon to refer the client to the health care provider, or to recommend incontinence undergarments.

Question format: Multiple Choice Chapter 30: Urinary Elimination Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 679 23. An older adult client informs the nurse that they are experiencing urinary incontinence.

The client has no other health problems, and states, "I don't want anybody to know about this problem." How will the nurse promote the client's self-esteem?

A. Discuss the use of protective undergarments to avoid embarrassment from incontinence.

B. Encourage the client to confide in family members and tell them about the accidents.

C. Inform the client that this is not normal and make a referral to a urologist.

D. Tell the client that this happens to all people when they get older.

Answer: A Rationale: The nurse will promote the client's self-esteem by openly discussing adult undergarments. The client has no other health problems, and can benefit by learning how to self-manage this concern. Encouraging the client to tell family members does not support the client's desire to refrain from telling others about this issue. The client does not need referral to a urologist at this time. Reassuring the client that others have this concern is nontherapeutic and does not directly meet the client's concern.

Question format: Multiple Choice Chapter 30: Urinary Elimination Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 680

24. Three days post-surgery for breast reconstruction, the nurse assesses that the client is ambulating several times daily. The health care provider has not yet written an order to discontinue the client's urinary catheter. What is the appropriate nursing action? Select all that apply.

A. Contact the health care provider to ask for an order for catheter discontinuation.

B. Delegate catheter discontinuation to the Unlicensed Assistive Personnel (UAP).

C. Perform, or allow client to perform, perineal hygiene at least once daily.

D. Ensure that the drainage bag is above the level of the bladder at all times.

E. Discontinue to catheter and report this to the healthcare provider.

Answer: A, C Rationale: The nurse should advocate for catheter discontinuation to prevent catheterassociated urinary tract infections (CAUTI), and still perform or encourage the client to perform daily perineal care. Discontinuation of the catheter should not take place until the nurse has received and order, and delegation should take place only if appropriate based on the UAP's qualification and the nurse's ongoing appropriate supervision. The drainage bag should never remain above the level of the bladder.

Question format: Multiple Select Chapter 30: Urinary Elimination Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 689 25. The health care provider notifies a client of a diagnosis of glycosuria. Which additional assessment information will the nurse obtain from the client next?

A. Frequency of urine B. Intake and output C. Blood pressure D. Blood sugar Answer: D Rationale: Glycosuria is a condition that describes the finding of glucose in the urine. The natural next step would be to obtain a fingerstick for blood glucose level. Vital signs are a baseline indicator of any illness or injury. Intake and output may be important going forward, but the diagnosis directs the next action.

Question format: Multiple Choice Chapter 30: Urinary Elimination Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 676 26. A client who visits a health care facility for a routine assessment reports to the nurse being unable to control urinary elimination. This has resulted in the client soiling clothes and has led to a lot of embarrassment. Which nursing intervention will be appropriate to use with this client?

A. Encouraging the client to stay close to home

B. Fluid restriction C. Indwelling catheterization D. Regular toileting routine Answer: D Rationale: The nurse should document the client's condition as urinary incontinence. A toileting routine and verbal reminders, external catheters for men, absorbent products, and excellent skin care and hygiene are appropriate interventions. Indwelling catheterization and fluid restriction can lead to urinary tract infection. Encouraging the client to stay home may be isolating.

Question format: Multiple Choice Chapter 30: Urinary Elimination Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 688 27. The nurse is teaching an older adult female client who must provide a urine specimen.

Which is the proper method to instruct the client to use to obtain a clean-catch urine specimen?

A. Catch the urine while holding the labia apart, after allowing the first urine to flow into the toilet.

B. Catch the urine while holding the labia apart, then cleanse each side of the labia with prepared aseptic swabs.

C. Catch the urine while holding the labia apart, after cleansing. Fill the specimen cup.

D. Catch the urine in the cup after cleansing the perineum.

Answer: A Rationale: The client should first perform hand hygiene, then separate the labia minora and cleanse the perineum with commercially prepared aseptic swabs, starting in front of the urethral meatus and moving the swab toward the rectum. The client should repeat this cleansing process three times with different cotton balls or swabs, then begin to urinate while continuing to hold the labia apart. Next, the client should allow the first urine to flow into the toilet, followed by holding the specimen container under the urine stream. Then, the client should remove the specimen container, release the hand from the labia, seal the container tightly, and finish voiding. The client then performs hand hygiene again.

Question format: Multiple Choice Chapter 30: Urinary Elimination Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 676 28. A nurse notes that the volume of the client's urinary elimination is less than 300 ml/day.

Which nursing intervention will be appropriate to use with this client?

A. Requesting diuretic medication B. Screening for hyperglycemia C. Evaluating fluid intake

D. Advising client to drink extra coffee Answer: C Rationale: Kidney dysfunction could be a possible cause for the low volume of urination by the client. The nurse should evaluate fluid intake to determine approximate urinary output.

Diuretic medication can increase the volume of urination, but the health care provider cannot make that decision before the nurse provides other assessment data. Hyperglycemia would increase urinary output. Drinking additional coffee each day may cause an increase in urinary output, but the nurse has not evaluated the possible causes of the low output.

Question format: Multiple Choice Chapter 30: Urinary Elimination Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 675 29. A client has burning upon urination. The urinalysis indicates pyuria. Which is the next action the nurse will take?

A. Monitor vital signs B. Contact the health care provider C. Encourage fluids D. Instruct on proper wiping technique Answer: B Rationale: The term pyuria refers to the presence of pus in the urine. The nurse should first contact the health care provider, as antibiotic therapy may be necessary. Encouraging fluids, instruction on wiping technique and monitoring vital signs will follow.

Question format: Multiple Choice Chapter 30: Urinary Elimination Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 677 30. A client at a health care facility has been diagnosed with polyuria. Which question should the nurse ask the client to determine the cause?

A. "Have you ever had an elevated blood sugar?"

B. "Have you ever had urinary retention before?"

C. "Have you ever had kidney disease?"

D. "Is it uncomfortable to urinate?"

Answer: A Rationale: Polyuria means greater than normal urinary elimination. Untreated diabetes insipidus and hyperglycemia can greatly increase urine output. Ingestion of diuretics, caffeine, and alcohol also results in polyuria. Kidney disease is associated with a lack of urine output.

Question format: Multiple Choice

Chapter 30: Urinary Elimination Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 677

Chapter 31 1. A nurse is caring for a client with an abdominal injury at a health care facility. The client informs the nurse about passing blood-stained stool. Which nursing action is appropriate at this time?

A. Save a sample of the stool in a container.

B. Perform a screening test on stool samples.

C. Send the stool sample to the laboratory.

D. Inform the client to report the occurrence if it happens again.

Answer: B Rationale: The nurse should independently perform a screening test on the stool samples to determine the presence of blood. Once the nurse confirms the presence of blood, the nurse can keep the stool sample in a covered container and then report to the physician. The nurse does not send the stool sample to the laboratory because it is the physician who may order more specific laboratory or diagnostic tests. Immediate action is required and should not be postponed until it can happen again.

Question format: Multiple Choice Chapter 31: Bowel Elimination Cognitive Level: Apply Client Needs Pn: Physiological Integrity: Reduction of Risk Potential Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 708 2. A nurse is caring for a client with pseudoconstipation. What can cause pseudoconstipation in a client?

A. insufficient fluid intake B. adequate intake of fibrous foods C. overuse of suppositories D. inadequate intake of laxatives Answer: C Rationale: Overuse of suppositories and enemas can lead to pseudoconstipation. Eating highfiber foods does not lead to pseudoconstipation but rather eases elimination. Insufficient fluid intake leads to primary constipation, not pseudoconstipation. Inadequate intake of laxatives does not lead to pseudoconstipation, but abuse of laxatives does.

Question format: Multiple Choice Chapter 31: Bowel Elimination Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 711 3. A nurse is administering a prescribed hypertonic saline enema to a client with constipation.

Which is a function of hypertonic saline enema?

A. promotes bowel movement without irritation effect B. lubricates and softens the stool C. draws fluid from body tissues into the bowel D. causes chemical irritation of the mucous membranes Answer: C Rationale: A hypertonic saline enema draws fluid from body tissues into the bowel. A retention enema lubricates and softens the stool. A tap water and normal saline solution has a non-irritating effect on the rectum but moistens the stool. Soap solution enemas cause chemical irritation of the mucous membranes.

Question format: Multiple Choice Chapter 31: Bowel Elimination Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 714 4. A nurse is assisting a client when he is draining a continent ileostomy. The catheter suddenly becomes plugged with stool. Which action should the nurse take to rectify the problem?

A. Avoid milking the catheter.

B. Wait for 8 hours to obtain drainage.

C. Avoid removing the catheter.

D. Rotate the catheter tip inside the stoma.

Answer: D Rationale: When the catheter becomes plugged with stool or mucus, the nurse should try to rotate the catheter tip inside the stoma to clear the obstruction. The nurse could also try to milk the catheter in order to clear it. However, the nurse or client should not wait longer than 6 hours without obtaining drainage as it could lead to further complications. If all the above actions fail, the nurse should simply remove the catheter, rinse it, and try again.

Question format: Multiple Choice Chapter 31: Bowel Elimination Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 718 5. A nurse is caring for a client with primary constipation. Which factor is responsible for primary constipation?

A. high intake of fiber B. constant urges to defecate C. inadequate intake of liquid D. constant physical activity Answer: C

Rationale: Primary constipation results from lifestyle factors such as insufficient fluid intake, inadequate intake of fiber, inactivity, or ignoring the urge to defecate.

Question format: Multiple Choice Chapter 31: Bowel Elimination Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 711 6. A nurse needs to administer an oil-retention enema to a client. Which intervention should the nurse perform if disposable equipment is unavailable?

A. Insert a 14F to 22F tube into the rectum.

B. Insert 100 to 200 mL of warm oil into the rectum.

C. Insert a suppository into the rectum.

D. Insert a small funnel and instill solution in the rectum.

Answer: A Rationale: If disposable equipment is not available during an oil retention enema, the nurse should lubricate and insert a 14F to 22F tube into the rectum. A small funnel is not inserted into the rectum but is attached to the tube. The nurse instills approximately 100 to 200 mL of warmed oil slowly only after the tube is inserted in the rectum, not before that. Inserting a suppository in the rectum is not done in an oil retention enema.

Question format: Multiple Choice Chapter 31: Bowel Elimination Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Reference: p. 716 7. A nurse is caring for a constipated client who has abdominal distention. Which is another sign accompanying constipation?

A. severe dehydration B. severe headache C. infrequent stool elimination D. oozing liquid stool Answer: D Rationale: A client with constipation can have other accompanying signs or symptoms including changes in stool characteristics such as oozing, liquid stool or hard, small stool.

Infrequent elimination of stool does not necessarily indicate that a person is constipated.

Severe headache is not a symptom associated with constipation. Dehydration is not associated with constipation but is a symptom of diarrhea.

Question format: Multiple Choice Chapter 31: Bowel Elimination Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Physiological Adaptation Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 710

8. A nurse is caring for a client who is to undergo a rectal examination. What should the nurse administer to cleanse the bowel in preparation?

A. tap water and normal saline solution B. tap water and soap solution C. hypertonic saline solution D. cottonseed or olive oil solution Answer: A Rationale: Tap water and normal saline solution is preferred for cleansing the bowel in preparation for a rectal examination because of its non-irritating effects. A combination of tap water and soap solution is not suitable because soap causes chemical irritation of the mucous membranes. A concentrated hypertonic saline solution also acts as a local irritant on the mucous membranes. Cottonseed or olive oil solution is also not suitable because the oil solution is held within the large intestine, and if the client has premature defecation, it could defeat the purpose of retention.

Question format: Multiple Choice Chapter 31: Bowel Elimination Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 714 9. A nurse is educating a client on how to irrigate his colostomy. The nurse informs the client that the colostomy should be irrigated in order to: A. promote the drainage of liquid stool.

B. regulate the timing of bowel movements.

C. control the osmolarity of stool.

D. prevent skin breakdown near the ostomy.

Answer: B Rationale: The purpose of irrigation is to remove formed stool and, in some cases, to regulate the timing of bowel movements. Irrigation does not affect the osmolarity of stool. The drainage of liquid stool and urine is part of continent ostomy. Irrigating a colostomy does not prevent the breakdown of skin, but providing peristomal care to the client does.

Question format: Multiple Choice Chapter 31: Bowel Elimination Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 718 10. When assessing an elderly client for constipation, the nurse learns that the client uses mineral oil daily to relieve constipation. Which is an effect of prolonged use of mineral oil to relieve constipation?

A. reduces elasticity in intestinal walls and slows motility B. affects absorption of fat-soluble vitamins C. causes periodic bleeding and tissue trauma

D. develops healthier bowel elimination patterns Answer: B Rationale: Elderly clients who use mineral oil to prevent or relieve constipation need to be informed that prolonged use affects the absorption of fat-soluble vitamins such as A, D, E, and K. Bleeding and tissue trauma does not occur due to use of mineral oil for constipation but during the digital removal of faction. Use of mineral oil for constipation does not develop healthier bowel elimination patterns, but the use of bulk-forming products containing psyllium or polycarbophil does. Loss of elasticity in intestinal walls and slower motility is due to old age, not the use of mineral oil.

Question format: Multiple Choice Chapter 31: Bowel Elimination Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 711 11. A nurse is assessing a client with constipation and severe rectal pain. Which action should the nurse perform to determine the presence of fecal impaction?

A. Insert a lubricated, gloved finger into the rectum.

B. Obtain a sharp intestinal x-ray.

C. Insert a lubricated rectal tube into the rectum.

D. Administer an oil retention enema into the rectum.

Answer: A Rationale: The nurse should insert a lubricated, gloved finger into the rectum to determine the presence of fecal impaction. Fecal impaction occurs when a large, hardened mass of stool interferes with defecation. Obtaining a sharp intestinal x-ray is not a good idea because the barium retained in the intestine causes fecal impaction. Insertion of a rectal tube and administration of an oil retention enema are measures used to remove hardened stool, not assess it.

Question format: Multiple Choice Chapter 31: Bowel Elimination Cognitive Level: Apply Client Needs Pn: Physiological Integrity: Reduction of Risk Potential Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 712 12. A nurse is assessing the stoma of a client with an ostomy. Which intervention should the nurse perform when providing peristomal care to the client to preserve skin integrity?

A. Wash it with a mild cleanser and water.

B. Avoid using commercial skin preparations.

C. Clean it with a dry, cotton bandage.

D. Avoid applying a barrier substance.

Answer: A

Rationale: Washing the stoma and surrounding skin with a mild cleanser and water and patting it dry can preserve skin integrity. When using a cleanser, it is important to rinse the area thoroughly. Any residue left on the skin can cause problems with the wafer adhering.

Another way to protect the skin is to apply barrier substances such as karaya, a plant substance that becomes gelatinous when moistened, and commercial skin preparations around the stoma. Cleaning the stoma with just a dry, cotton bandage is not the correct way of preserving skin integrity.

Question format: Multiple Choice Chapter 31: Bowel Elimination Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 716 13. A hospital client with impaired mobility has rung the call bell for assistance with transferring from the bed to a commode in order to have a bowel movement. The urge to defecate is triggered by: A. pressure on the peritoneal membrane.

B. friction of stool against the sigmoid colon.

C. distention of the rectum by stool.

D. osmotic changes in the lower bowel.

Answer: C Rationale: The increased peristalsis of the gastrocolic reflex usually precedes defecation. Its accelerated wavelike movements, sometimes perceived as slight abdominal cramping, propel stool forward, packing it within the rectum. As the rectum distends, the person feels the urge to defecate. The urge to defecate does not result from friction on the colon, pressure against the peritoneum, or osmotic changes.

Question format: Multiple Choice Chapter 31: Bowel Elimination Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 707 14. A nurse is preparing to administer an acetaminophen suppository. For which client would a suppository be preferable to oral medication administration?

A. a client who has dysphagia following a stroke but who also has a fever B. a client who requires rapid onset of acetaminophen to treat pain C. a febrile client who has decreased mobility following orthopedic surgery D. a client who has had an ostomy created following bowel surgery for cancer Answer: A Rationale: Drugs administered in suppository form are chosen when clients have difficulty retaining or absorbing oral medications because of chronic vomiting or an impaired ability to swallow (dysphagia). The presence of an ostomy does not necessitate the rectal administration of drugs. Individuals who require a rapid onset of a drug or who have

decreased mobility do not necessarily have to receive medications by suppository when an oral version is available.

Question format: Multiple Choice Chapter 31: Bowel Elimination Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 714 15. A hospital client went five days without having a bowel movement despite maintaining adequate food and fluid intake. The nurse obtained an order for hypotonic cleansing enemas as needed and has administered two in succession, each with good effect. The nurse should be wary of administering more enemas because of the risk of causing: A. intestinal rupture.

B. electrolyte imbalances.

C. backflow of feces into the small intestine.

D. dependence on enemas for normal bowel function.

Answer: B Rationale: If several enemas are administered in succession, fluid and electrolyte imbalances may occur due to fluid shifts in the intestines. Rupture is a risk with large volume enemas rather than successive enemas and backflow of feces is not a common occurrence.

Dependence on enemas results from prolonged use over time, not frequent use over a short time.

Question format: Multiple Choice Chapter 31: Bowel Elimination Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 714 16. For which client would a cleansing enema most likely be indicated?

A. a client who has developed gastrointestinal bleeding from overuse of NSAIDs B. a client who has recently been diagnosed with Crohn disease C. a client who has severe nausea and who has been vomiting frequently for the past 48 hours D. a client who is scheduled to be screened for colorectal cancer the following morning Answer: D Rationale: Cleansing enemas are often used to remove stool from the bowel in preparation for diagnostic imaging procedures. GI bleeding and Crohn disease are usually contraindications for the use of enemas. It is unnecessary to administer enema in cases of severe nausea and vomiting.

Question format: Multiple Choice Chapter 31: Bowel Elimination Cognitive Level: Analyze Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 714

17. A nurse is changing the ostomy appliance of a client who had her ostomy created several days ago following a hemicolectomy. The nurse has measured the size of the client's stoma and is trimming the new faceplate to ensure comfort and adequate adhesion. The opening in the faceplate should be: A. 1/8 to 1/4 in (0.32 to 0.64 cm) larger than the diameter of the stoma.

B. the same size as the client's stoma.

C. slightly smaller than the diameter of the client's stoma.

D. 1/2 to 1 in (1.2 to 2.5 cm) smaller than the measured diameter.

Answer: A Rationale: To avoid pinching of or pressure on the stoma and causing circulatory impairment, the nurse should trim the opening in the faceplate to the measured diameter plus approximately 1/8 to 1/4 in (0.32 to 0.64 cm) larger.

Question format: Multiple Choice Chapter 31: Bowel Elimination Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 730 18. A client has been given fecal immunochemical test (FIT) testing supplies. What teaching will the nurse provide about the purpose for this test?

A. "This will determine what foods you are allergic to that affect digestion and elimination."

B. "This test, if positive, will indicate bleeding in the lower gastrointestinal tract."

C. "This test detects heme, an iron compound in blood within the stool."

D. "This test will help determine whether you have an infectious process in the intestines."

Answer: B Rationale: The fecal immunochemical test (FIT) uses antibodies directed against human hemoglobin to detect blood in the stool. A positive FIT is more specific for bleeding in the lower gastrointestinal tract . No drug restrictions are required for the FIT. Question format: Multiple Choice Chapter 31: Bowel Elimination Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 710 19. In preparing a client to utilize fecal occult blood testing (FOBT) supplies, what teaching will the nurse provide?

A. Avoid acetaminophen 7 days prior to testing.

B. Drink orange juice to stay hydrated through the testing process.

C. Refrain from eating red meat 3 days before testing.

D. Eat plenty of raw vegetables before testing.

Answer: C

Rationale: The nurse will teach that the client should avoid eating red meat 3 days before testing, refrain from consuming citrus fruits or juices for 3 days before beginning the test, and to avoid certain raw vegetables 2-3 days prior to testing. Acetaminophen use is acceptable; nonsteroidal anti-inflammatory drugs (NSAIDs) must be avoided 7 days before selfcollecting stool.

Question format: Multiple Choice Chapter 31: Bowel Elimination Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 709 20. A client has been given Cologuard testing supplies. What teaching will the nurse provide about the purpose for this test?

A. "This will determine what foods you are allergic to that affect digestion and elimination."

B. "This test detects mutant DNA from tumor cells present in stool."

C. "This test detects heme, an iron compound in blood within the stool."

D. "This test will help determine whether you have an infectious process in the intestines."

Answer: B Rationale: The nurse will teach that the Cologuard test detects mutant DNA from tumor cells present in stool. It does not test for allergic foods, nor does it test for infection. FOBT detects heme.

Question format: Multiple Choice Chapter 31: Bowel Elimination Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 710 21. The nurse is providing health teaching for four clients. Which client should consider a colonoscopy screening?

A. 33-year-old client who reports painful elimination B. 42-year-old client with diarrhea twice weekly C. 50-year-old client with a family history of polyps D. 67-year-old client with constipation Answer: C Rationale: The nurse will teach that the 50-year-old client with a family history of polyps should consider a colonoscopy screening. Screenings should start at 50 years old and continue every 10 years thereafter. Other answers are incorrect.

Question format: Multiple Choice Chapter 31: Bowel Elimination Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 710

22. A client with no significant medical history reports experiencing diarrhea over the past week. Which assessment question will the nurse ask? Select all that apply.

A. "Have you started a new medication?"

B. "What are your normal bowel habits?"

C. "Are you experiencing rectal fullness?"

D. "Do you use laxatives?"

E. "Is the stool difficult to pass?"

Answer: A, B, D Rationale: The nurse will ask about new medications because these can often cause diarrhea; what the client's normal bowel habits are like, to establish a baseline; and whether the client is using laxatives, which can contribute to diarrhea. Rectal fullness and stool that is difficult to pass are associated with constipation.

Question format: Multiple Select Chapter 31: Bowel Elimination Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Reference: p. 719 23. A client reports experiencing uncomfortable, frequent episodes of flatulence to the nurse.

Which foods will the nurse recommend that the client avoid? Select all that apply.

A. cucumbers B. lentils C. shrimp D. pork products E. onions F. cabbage Answer: A, B, E, F Rationale: Cucumbers, lentils, onions, and cabbage are known to produce gas; therefore, this client should avoid these foods. Shrimp and pork products are not associated with formation of gas.

Question format: Multiple Select Chapter 31: Bowel Elimination Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 713 24. The nurse is caring for a client with a stoma placed before the terminal ileum. Which vitamin does the nurse anticipate will be prescribed?

A. vitamin A B. vitamin B12 C. vitamin C D. vitamin D Answer: B

Rationale: The nurse anticipates that vitamin B12 will be prescribed for a client with this type of ostomy, an ileostomy. This helps prevent vitamin B12-deficiency anemia, which can occur because ileostomies are placed before the terminal ileum where vitamin B12 is absorbed.

Question format: Multiple Choice Chapter 31: Bowel Elimination Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 716 25. The nurse is administering a cleansing enema when the client reports cramping. What is the appropriate nursing action?

A. Discontinue the administration of the enema B. Remove the tubing.

C. Continue infusing at a faster rate to finish the enema quicker.

D. Clamp the tube for a brief period and resume at a slower rate.

Answer: D Rationale: Cramping can occur with the administration of a cleansing enema. The nurse will clamp the tube for a brief period while the client takes deep breaths, and then resume the infusion, possibly at a slower rate. Other choices are incorrect, as these do not facilitate administration of the enema while providing comfort measures.

Question format: Multiple Choice Chapter 31: Bowel Elimination Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 728 26. The nurse has completed client teaching about draining a continent ileostomy. Which client statement indicates that teaching has been effective? Select all that apply.

A. "To help with drainage, I will bear down as if having a bowel movement."

B. "I will stop advancing the tube if I encounter resistance."

C. "It will take 5-10 minutes for complete emptying."

D. "The catheter should be cleaned with alcohol and water."

E. "I will lower the external end of the catheter at least 12 in (30 cm) below my stoma."

Answer: A, C, E Rationale: Teaching has been effective when the client understands that bearing down can assist with drainage, it will take 5-10 minutes for complete emptying, and the external end of the catheter should be positioned at least 12 in (30 cm) below the stoma. Further teaching is needed to clarify that resistance is expected at approximately 2 in (5 cm) into insertion, and that the catheter should be cleaned with warm, soapy water.

Question format: Multiple Select Chapter 31: Bowel Elimination Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning

Reference: p. 718 27. A cleansing enema has been ordered for the client to draw water into the bowel. Which type of solution does the nurse gather?

A. mineral oil B. tap water C. soap and water D. hypertonic saline Answer: D Rationale: The nurse will gather a hypertonic solution, which is used to irritate local tissue and draw water into the bowel. Mineral oil is used for lubrication and softening of stool. Tap water is used to distend the rectum and moisten stool; soap and water are used to do the same plus irritate local tissue.

Question format: Multiple Choice Chapter 31: Bowel Elimination Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 714 28. A nurse is preparing a discharge note for an older adult client with constipation. Which suggestion should the nurse write in the client's discharge note for a healthier bowel elimination habit?

A. Prepare meals that are high in fiber.

B. Hold stool for 5 to 10 minutes when you have an urge to defecate.

C. Use laxatives and enemas regularly.

D. Avoid foods high in water content.

Answer: A Rationale: The nurse should suggest the client add more fiber to the diet to prevent constipation. Holding stool when an urge to defecate arises can lead to further constipation and the possibility of incontinence. If medication is needed to promote bowel regularity, the client should have a bulk-forming agent, as it is a better choice than laxatives or enemas.

Foods high in water content can increase fluid intake and prevent constipation.

Question format: Multiple Choice Chapter 31: Bowel Elimination Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Reference: p. 708 29. A nurse is assessing and documenting the eating habits of a client with repeated reports of gas who wants to include more fiber in the diet. Which suggestion should the nurse include in the teaching plan?

A. Eat more cabbage and brussels sprouts to decrease gas and add fiber.

B. Drink a soft drink daily to prevent gas and allow fiber to break down.

C. Increase fiber slowly over a period of time to prevent gas.

D. Include more protein in the diet to increase fiber and decrease gas.

Answer: C Rationale: Vegetables such as cabbage, cucumbers, and onions are commonly known for producing gas. By introducing fiber over a period of time, the client can get used to fiber intake and note which foods cause more gas. Flatulence, or flatus, results from swallowing air while eating or sluggish peristalsis. Drinking soft drinks can increase gas and have no effect on fiber breakdown in the body. Another cause is the gas that forms as a byproduct of bacterial fermentation in the bowel. Protein does not produce gas that leads to flatus.

Question format: Multiple Choice Chapter 31: Bowel Elimination Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 713

Chapter 32 1. A nurse is caring for a client with pneumonia at a health care facility. The nurse checks the medication order in the client's chart for the drugs prescribed to the client. Which component is a required component of the medication order?

A. client's name B. client's age C. client's diagnosis D. client's signature Answer: A Rationale: The client's name is an important component of the medication order; without it, the nurse should withhold the administration of the drug. The client's age, diagnosis, and signature are not components of the medication order. Other components of the medication order include the date and time the order is written, the drug name, the dose to be administered, the route of administration, the frequency of administration, and the signature of the person ordering the drug.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Remember Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Communication and Documentation Reference: p. 737 2. A nurse is caring for a client who has undergone surgery. When the client regains consciousness, the nurse telephones the physician to update the client's health status. What care should the nurse take when taking telephone orders?

A. Record the drug order on the client's medical record.

B. Use the abbreviation "V.O." at the end of the order.

C. Write out numbers in words rather than numerals to avoid misinterpretation.

D. Leave space after the order for the prescriber's signature.

Answer: A Rationale: The nurse should directly record the drug order on the client's medical record because a written documentation avoids errors in memory. The nurse should use the abbreviation "T.O.," not "V.O.," at the end of the order to indicate that it is a telephone order.

The nurse should spell or repeat numbers that could be misinterpreted, such as the number 15 as "one, five." The nurse should write the prescriber's name and cosign the order.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 739

3. A nurse who is caring for a client with a diagnosis of asthma needs to keep the client's medication ready in case the client has an attack. Which method of supplying medication would be relevant in this situation?

A. individual supply B. unit dose supply C. stock supply D. automated system Answer: C Rationale: The nurse should use the stock supply method to supply medication to the client in case of an emergency. A stock supply remains on the nursing unit for use in an emergency or so that a nurse can give the prescribed drug without delay. An individual supply is a container with enough of the prescribed drug for several days or weeks and is common in long-term care facilities such as nursing homes. A unit dose supply is a self-contained packet that holds one tablet or capsule. It is most common in acute care hospitals that stock drugs for individual clients several times in one day. Some facilities use automated medicationdispensing systems. These systems usually contain frequently used medications for that unit, any as-needed (p.r.n.) medications, controlled drugs, and emergency medications.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Communication and Documentation Reference: p. 741 4. A nurse needs to administer a prescribed dose of a narcotic medication to a client with acute neck pain. These medications should be stored in a: A. double-locked drawer.

B. single container.

C. self-contained packet.

D. disguised container.

Answer: A Rationale: The nurse should place narcotic drugs in a double-locked drawer. Narcotics are controlled substances, meaning that federal laws regulate their possession and administration.

Health care facilities keep narcotics in a double-locked drawer, box, or room on the nursing unit. A narcotic drug may not be placed in a single container, self-contained packet, or in disguised containers.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 741

5. A nurse is administering medications through an enteral tube to a client with swallowing difficulties due to a cerebrovascular accident (CVA). Which action should the nurse perform to prevent gastric reflux?

A. Help the client into a Fowler position.

B. Check for drug allergies in the client's history.

C. Add diluted medication to the syringe.

D. Administer the medication over several minutes.

Answer: A Rationale: Assuming a Fowler position can help prevent gastric reflux when medications are administered through an enteral tube. The nurse checks the client's medical history for drug allergies to avoid potential complications. Adding diluted medication to the syringe as it becomes nearly empty prevents instilling air into the syringe. Administering the medication over several minutes has no effect on reflux.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Remember Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 752 6. A nurse brings a client the prescribed dose of medication and finds that the client is not in the unit. What should the nurse do in this case?

A. Inform the physician about the client's absence.

B. Leave the medication on the client's bedside table.

C. Return the medication to the medication cart or medication room.

D. Inform the head nurse about the client's absence.

Answer: C Rationale: If the client is not present at the time when the medication needs to be administered, the nurse should return the medication to the medication cart or medication room. Leaving medications on the client's bedside table may result in their loss or accidental ingestion by someone else. The nurse need not inform the physician or the head nurse about the client's absence.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 741 7. A nurse needs to administer a prescribed dosage of oral medication to a client with influenza. Which action should the nurse perform when administering oral medication to the client?

A. Prepare the exact dosage of medication in front of the client.

B. Avoid administering medication prepared by another nurse.

C. Bring the prescribed medication in a ceramic cup or glass container.

D. Check the label of the medication container three times at the bedside.

Answer: B Rationale: A nurse should never administer medications prepared by another nurse. The nurse administers only those medications that she has prepared. The nurse should prepare and bring oral medications to the client's bedside in a paper or plastic cup, not in a glass container or ceramic cup, in order to avoid accidents and spills. The nurse checks the label of the medication container three times when preparing it, not when administering it to the client.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 742 8. A nurse at a health care facility administers a prescribed drug to a client and does not record doing so in the medical administration record. The nurse who comes during the next shift, assuming that the medication has not been administered, administers the same drug to the client again. The nurse on the previous shift calls to inform the health care facility that the administration of the drug to this client in the earlier shift was not recorded. What should the nurse on duty do immediately upon detection of the medication error?

A. Report the incident to the physician.

B. Report the incident to the supervising nurse.

C. Check the client's condition.

D. Fill in the accident report sheet.

Answer: C Rationale: On detection of the medication error, the nurse should immediately check the client's condition. When medication errors occur, nurses have an ethical and legal responsibility to report them to maintain the client's safety. As soon as the nurse recognizes an error, he or she should check the client's condition, then report the mistake to the prescriber and supervising nurse. Health care agencies have a form for reporting medication errors called an incident sheet or accident sheet.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Communication and Documentation Reference: p. 745 9. When educating an older adult client about the administration of medication during discharge, the nurse notes that the client is having difficulty comprehending the instructions.

What intervention should the nurse follow in this case to ensure the client's safety?

A. Ask a second nurse to repeat the instructions.

B. Ask the client's physician to provide instructions.

C. Involve a second responsible person in the instructions.

D. Write discharge instructions on the medication containers.

Answer: C

Rationale: If an older adult client is having difficulty comprehending the discharge instructions, the nurse should involve a second responsible person in the instructions in order to ensure client safety. A referral for skilled nurse visits is appropriate for homebound older adults who need additional instructions about medication routines after discharge. However, the nurse would not ask a second nurse to simply repeat the instructions or delegate the teaching to somebody else. The nurse will also not write all the discharge instructions on the various medication containers, but instead will write all the instructions in detail on the discharge sheet for the client's convenience.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 743 10. The nurse is preparing the dosage for a client as per the medication administration record.

Which precautions should the nurse always take when preparing medications?

A. Ask another nurse to assist in preparing the medication.

B. Avoid relabeling containers with missing labels.

C. Check the label of the drug container once before administration.

D. Transfer medications from large containers to small containers.

Answer: B Rationale: The nurse should avoid using medication from containers with missing labels because this eliminates speculating on the drug name or dosage. The nurse should work alone without interruptions and distractions to promote concentration rather than asking another nurse to assist with preparing the medication. The nurse should check the label of the drug container three times before administration at various stages of preparing the dosage in order to ensure accuracy. Medication should not be transferred between containers in order to prevent mismatching contents.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 743 11. A nurse is caring for a client who has been prescribed oral medication. What care should the nurse take when administering oral medication to the client?

A. Identify the client visually to confirm identity.

B. Ask the client to take all the tablets together.

C. Ask the client to slightly flex the head to swallow.

D. Raise the head of the bed to 30° during administration.

Answer: C Rationale: During the administration of medication, the nurse should encourage the client to keep the head in a neutral position or with a slight flexion, rather than hyperextending the

neck, so as to protect the airway during administration. The nurse should check the client's wristband to confirm the identity. The nurse should ask the client to take medication one at a time or in amounts easily swallowed, rather than taking all the tablets together, to prevent choking. The nurse should assist the client to a sitting position rather than raising the head of the bed to 30°.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 750 12. A nurse is reviewing the previous medical history of a new client and is cross-referencing the client's preadmission medication regimen with the current medication orders. The nurse reads that the client was taking ginseng on a regular basis, but another nurse is adamant that this is not considered to be a "medication." The nurse should be aware that a medication is defined as: A. a substance that affects health status.

B. any physical substance that the client ingests in any form.

C. a nonnutritional substance that is taken for health purposes.

D. a chemical substance that changes body function.

Answer: D Rationale: Medications are defined as chemical substances that change body function.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Remember Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Communication and Documentation Reference: p. 736 13. A nursing supervisor is reviewing a clinical incident in which a client received a double dose of a prescribed anticoagulant. The incident occurred because a nurse was unaware that the trade name and the generic name refer to the same drug. Which statement is true of generic drug names?

A. The names of generic drugs are usually capitalized.

B. Generic names often refer to the chemical makeup of the drug.

C. Generic names vary widely between jurisdictions and markets.

D. A generic drug name is more reliable than the trade name.

Answer: B Rationale: Generic drug names often refer to "hydrochloride," "sodium," "phosphate," "sulfate," or other chemical terms; these are not included in trade names. Generic names are standardized across jurisdictions and markets, but this does not necessarily mean that these names are more "reliable." Trade names are capitalized, but generic names are not.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Understand

Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 737 14. A nurse has admitted a client during a night shift and has completed and documented a nursing assessment. The nurse is now creating the client's medication administration record (MAR). What is the primary purpose of the MAR? A. to ensure the medical health record is available to other disciplines when needed B. to provide a secure place for the pharmacy to document changes and observations C. to facilitate the safe and timely administration of drugs to clients D. to allow nurses to make the administration of medications more efficient Answer: C Rationale: Use of the MAR ensures timely and safe medication administration. Timeliness is not necessarily synonymous with efficiency, however. The MAR does not primarily exist to free up the medical health record or to provide a venue for pharmacists' documentation.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 740 15. A client has been prescribed metoprolol 12.5 mg po b.i.d. At the small, rural hospital where the client is being treated, this drug is only available in 50 mg tablets. How many tablets will the client receive in any given 24-hour period?

A. 2 tablets B. 4 tablets C. 1/2 tablet D. 1 tablet Answer: C Rationale: Each of the client's two daily doses will be 1/4 tablet, resulting in a daily total of 1/2 tablet.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Analyze Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Communication and Documentation Reference: p. 742 16. The nurse is creating a professional development presentation about medication orders.

Which teaching will the nurse include? Select all that apply.

A. Use abbreviations as much as possible.

B. The health care providers must sign all orders.

C. Be extra cautious with look-alike and sound-alike drugs.

D. U and IU are acceptable abbreviations to use.

E. The prescribing provider is the only person accountable for drug orders.

Answer: B, C Rationale: The nurse's teaching will include that health care providers must sign all orders, and care must be taken with look-alike and sound-alike drugs. Abbreviations should not be used. The nurse is held accountable for making sure that all components of a medication order are present and for clarifying any portion that is not understood.

Question format: Multiple Select Chapter 32: Oral Medications Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 737 17. The nurse is teaching a client about venlafaxine XR. When the client asks, "What does the XR mean?" what is the appropriate nursing response?

A. "It means sustained release."

B. "It means continuous release."

C. "It means extended release."

D. "It means sustained action."

Answer: C Rationale: The nurse will clarify that XR means extended release. SR means sustained release; CR means continuous release; and SA means sustained action.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Communication and Documentation Reference: p. 738 18. When calling the health care provider for a telephone order, what is the nurse's initial action?

A. identifying self and agency B. verifying order given C. providing situation, background, assessment, and recommendation (SBAR) information D. authenticating the prescriber's identity Answer: A Rationale: When calling to obtain a telephone order, the nurse will first identify self and agency. Then the nurse will authenticate the prescriber's identity, following SBAR processes, and verify the order given.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 739

19. The nurse is preparing to give the second dose of ordered antibiotics to a client and notes that no one has documented that the first dose was given. What is the appropriate nursing action?

A. Hold the second dose of antibiotics.

B. Call the pharmacy before notifying anyone else.

C. Notify the health care provider.

D. Ask the nurse manager if the first dose was given.

Answer: C Rationale: The nurse will notify the health care provider and follow internal policies regarding incident reporting. The nurse will receive information from the health care provider about new orders to make sure the client gets both doses of medication. The pharmacy may be notified later, but it is not appropriate to initially notify them without clarifying with the health care provider. The nurse manager may be notified about the discrepancy but will not be able to confirm if the first dose was given.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Communication and Documentation Reference: p. 745 20. Nurse A is having difficulty logging into the automated medication-dispensing system, and asks Nurse B to log in momentarily so that Nurse A is not delayed in administering client medications. What is Nurse B's appropriate response?

A. "I will log in so that you can proceed with medication delivery."

B. "I am giving you my password so you can log in."

C. "I will get the hospital's information system's phone number for you."

D. "I can log in and give the medications for you."

Answer: C Rationale: Passwords and logins should never be shared with anyone else, nor should a nurse use his or her own password or login information to allow another individual to access the automated medication-dispensing system. Nurse B will not log in and give the medications, but rather will provide a solution by offering contact information for information systems to Nurse A so that he or she can work through their login issue.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Communication and Documentation Reference: p. 741 21. The nurse is preparing medications and is notified that a health care provider is on the phone. What is the nurse's appropriate response?

A. Leave medication preparation and take the call.

B. Speak to the provider while finishing medication preparation.

C. Ask the unit clerk to take a message from the provider.

D. Ask another nurse to finish gathering medications and take the call.

Answer: C Rationale: Preparing medications requires uninterrupted concentration. The nurse will ask that a message be taken and contact the provider after medication preparation is complete.

The nurse should not be on the phone and attempt to complete medication preparation, nor should the nurse ask another nurse to prepare medications for his or her clients.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 743 22. The nurse is preparing medications for enteral tube administration. Which nursing action is appropriate? Select all that apply.

A. Use the liquid form of the drug if available.

B. Mix powdered drugs with hot water.

C. Pulverize enteric-coated medications.

D. Open the shell of capsules to release the powdered drug.

E. Add bulk-forming laxatives to the mix.

Answer: A, D Rationale: Liquid forms of drugs should be used, as this promotes tube patency. Powdered drugs should be mixed with warm, not hot, water. Medications, with the exception of entericcoated drugs, should be pulverized. The shell of capsules should be opened to release the powdered drug. Bulk-forming laxatives should not be administered through an enteral tube if possible, since this can cause tube obstruction.

Question format: Multiple Select Chapter 32: Oral Medications Cognitive Level: Analyze Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Reference: p. 744 23. The nurse is caring for a client who has been prescribed an enteric-coated drug. Which should the nurse include when teaching the client proper administration of this drug?

A. It can be cut into smaller pieces.

B. It should not be chewed or crushed.

C. It should not be opened.

D. It is available in liquid form if needed.

Answer: B Rationale: The nurse should inform the client that enteric-coated drugs should not be chewed, crushed, or cut because if the integrity of the coating is impaired, it dissolves prematurely in the gastric secretions and can irritate the lining of the stomach (or be absorbed too quickly).

Solid oral drugs that are not enteric-coated may have a groove so that they can be cut into

pieces. Capsules, not enteric tablets, can but should not be opened. Enteric drugs are not available in liquid form.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 737 24. The health care provider has prescribed an enteric-coated naproxen for arthritic pain to a client who typically prefers a liquid or chewable medication. Which instruction should the nurse provide the client to ensure the medication is taken appropriately?

A. Do not chew the medication as disrupting the enteric coating can cause irritation in the lining of the stomach.

B. Particles of the crushed medication can be inhaled causing respiratory irritation.

C. The potency of the medication will be increased due to early exposure to gastrointestinal acids if crushed or chewed.

D. Crushing or chewing can cause the medication to be ineffective for pain relief.

Answer: A Rationale: It is important to explain to clients that enteric-coated medications are intended to deliver medication in a specific manner and chewing or crushing alters the delivery of the primary ingredients including the timing. Gastrointestinal discomfort can be an issue due to the potency of the ingredients causing irritation in the lining of the gastrointestinal tract.

Likewise, the early introduction of acid to the medication can decrease the potency once it is introduced to the stomach. Particles can be inhaled on some medications that are crushed, but this is rare and not a priority reason to not crush medication. Simply stating ineffectiveness is not advisable as this is not a consistently true statement.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 737 25. The nurse is caring for several postoperative clients prescribed "hydrocodoneacetaminophen 5/300 mg 1-2 tabs q6h" which has already been administered at different times during the shift. When one client requests pain medication, which important medication administration "right" would the nurse check first before administering the medication?

A. Is it time for the client to have more medication?

B. Is this the right client?

C. How much medication should be given?

D. Did the pharmacy provide the correct medication?

Answer: A Rationale: Based on information in the scenario, some clients have had medication during the shift. Thus, the nurse should consider the timing of the medication to ensure it is not too soon after the requesting client's previous dose. Once it is determined this client can have another

dose of medication, then the nurse would verify the medication and the dose are correct and then verify the client prior to administering the medication.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 742-743 26. The nurse is caring for a client with a secondary urinary tract infection for which amoxicillin 250 mg PO has been prescribed. The nurse recognizes this as a drug that is routinely administered every 8 hours; however, the prescription does not state the frequency of administration. The health care provider is no longer present. What is the appropriate nursing action?

A. Ask the nursing supervisor to validate the frequency as every 8 hours and update the electronic medical record (EMR).

B. Input the prescription into the electronic medical record (EMR) to reflect that the drug is given every 8 hours, after verifying with the pharmacy.

C. Contact the health care provider to clarify the prescription by reading back to the provider, update the electronic medical record (EMR) while on the phone, then document it was a phone prescription.

D. Ask another nurse to validate the frequency as every 8 hours, update the electronic medical record (EMR), flagging the prescription for the health care provider to review and cosign the prescription within 24 hours.

Answer: C Rationale: The nurse should always have the health care provider clarify the prescription. The nurse cannot assume that a medication is to be given at certain times, nor should another nurse verify the frequency or clarify the prescription. The nurse should remain on the phone with the provider and read back the entire prescription for verification. Documentation should reflect that it is a phone prescription. Usually the phone prescription has to be reviewed and cosigned by the provider within 24 hours.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 739 27. Nurse A receives an urgent phone call and hands several medications to Nurse B stating "Please give these to my client. I will be right back." What is the rationale behind Nurse B's response not to administer the medication to the client?

A. The client's allergies are unknown to Nurse B. B. It violates the rights of medication administration.

C. It violates the rights of the client's privacy.

D. It is not Nurse B's responsibility to administer medications for Nurse A's clients.

Answer: B

Rationale: Nurses must never administer medications prepared by another nurse. It violates the second "right" of the seven rights of medication administration "select the right medication" and could cause a medication error. Nurse B will professionally reply, "I cannot give medications for you". Identify the right client, the "first right" could be accomplished, but Nurse B has no way absolutely identifying all the medications. Even identifying pills is risky given the variety of generic and name-brand medications. Knowing or not knowing the client's allergies is irrelevant if the nurse is unable to identify the medication. The division of responsibilities is not a rationale in this scenario.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 742 28. The nurse is preparing to administer an enteric-coated aspirin to a client. The client states, "I cannot swallow that so you will have to crush it and put it in applesauce for me as the other nurse does." Which is an appropriate reply from the nurse?

A. "The nurse should not have crushed this medication. It could have caused an allergic reaction."

B. "I can crush the medication but will not be able to mix it in the applesauce, because it will limit the effectiveness."

C. "Crushing the medication may cause the medication to irritate the stomach, so it must be swallowed whole."

D. "I will ask the health care provider to cancel the prescription for aspirin since you are unable to take it."

Answer: C Rationale: An enteric-coated medication should never be crushed since it disrupts the integrity of the pill and may cause irritation. The drug will dissolve prematurely in the gastric secretions and irritate the lining of the stomach. Crushing the medication does not cause an allergic reaction unless the client is already allergic to the medication. It is not appropriate for the nurse to make disparaging comments about other nurses to the client. The prescription should not be canceled. If needed, the nurse may contact the prescriber for a different form of the medication.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Communication and Documentation Reference: p. 737 29. The nurse is instructing a client with xerostomia (dry mouth) about taking several pills and capsules that have been prescribed. What statement made by the client indicates to the nurse that the client understood the instructions?

A. "I will take a sip or two of water prior to taking my pills."

B. "I will have to get a speech therapy appointment before taking the pills."

C. "The best time to take my medications is first thing in the morning before eating."

D. "If I cannot swallow the pills, I will hold the dose and take both doses later in the day."

Answer: A Rationale: The nurse knows the client has understood the instructions when the client mentions drinking water prior to taking medications. Xerostomia, or dry mouth, may be present in some older adult clients who have diminished salivary gland secretions, which makes taking medication difficult without moisture. The client should not double up on any medication without the advice of the health care provider. Taking the medication in the morning may be difficult due to the dryness. Speech therapy consultation is beneficial when the client has dysphagia, especially after experiencing a stroke, but there is no evidence in this scenario to indicate this client has dysphagia.

Question format: Multiple Choice Chapter 32: Oral Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 742

Chapter 33 1. A client with dry skin has been prescribed inunction. What should the nurse do to promote absorption of the ointment?

A. shake the contents of the ointment B. apply inunction with a cotton ball C. rub the ointment into the skin D. warm the inunction before application Answer: C Rationale: In order to promote absorption, the nurse should rub the ointment into the client's skin. Shaking the contents would mix the contents uniformly, whereas applying the ointment with a cotton ball would distribute the substance over a wide area. Warming the ointment before application would provide comfort.

Question format: Multiple Choice Chapter 33: Topical and Inhalant Medications Cognitive Level: Apply Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 755 2. A client at a health care facility has been prescribed scopolamine, to be administered transdermally. Which statement describes transdermal application?

A. drugs within a thick base applied, not rubbed, into the skin B. drugs bonded to an adhesive and applied to the skin C. drugs placed against the mucous membrane of the inner cheek D. drugs placed under the tongue and allowed to dissolve slowly Answer: B Rationale: Transdermal applications are drugs that are bonded to an adhesive and applied to the skin. After application, the drug migrates through the skin and eventually is absorbed into the bloodstream. Pastes are drugs within a thick base that are applied, but not rubbed, into the skin. Sublingual applications are drugs that are placed under the tongue and left to dissolve slowly. Buccal applications are drugs that are placed against the mucous membrane of the inner cheek.

Question format: Multiple Choice Chapter 33: Topical and Inhalant Medications Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 755

3. A nurse is caring for a client at a health care facility who is undergoing nicotine withdrawal therapy and has been prescribed a nicotine patch. Which is true with regard to the application of a transdermal patch?

A. The patch is mostly applied to lower parts of the body.

B. A new patch is placed in exactly the same location as the previous one.

C. The patch is applied to a skin area with adequate circulation.

D. The drug becomes inactive immediately after the patch is removed.

Answer: C Rationale: When applying a transdermal patch, the nurse should be aware that a patch is applied to a skin area with adequate circulation. Most patches are applied to parts of the upper body such as the chest, shoulders, and upper arms. Small patches can be applied behind the ear. Each time a new patch is applied, it is placed in a slightly different location. The drug may still be active for up to 30 minutes after removal of the patch.

Question format: Multiple Choice Chapter 33: Topical and Inhalant Medications Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 755 4. A nurse needs to instill eye medication in a client with conjunctivitis. Which action should the nurse take to distribute the medication over the surface of the eye?

A. gently rub the client's eyelids B. make a pouch in the lower eyelid C. ask the client to blink the eye D. instill medication drops in the upper eyelid Answer: C Rationale: To distribute the eye medication over the surface of the eye, the nurse should ask the client to blink the eyes rather than rubbing them. In order to provide a natural reservoir for liquid medication, the nurse makes a pouch in the lower lid by pulling the skin downward over the bony orbit. To prevent injury and blink reflexes, the nurse should not instill medication in the upper eyelid but should steady the medication container and move it from below the client's line of vision or from the side of the eye instead.

Question format: Multiple Choice Chapter 33: Topical and Inhalant Medications Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 757 5. A nurse at a health care facility has to instill ear drops in a client. The nurse knows that which technique varies for an adult and child client?

A. manipulation of the client's ear to straighten the auditory canal B. dilution of the medication drops before instilling in the client's ear

C. position in which the client remains until medication reaches the eardrum D. amount of time before instilling medication in the client's opposite ear Answer: A Rationale: The nurse should be aware that the method of manipulation of the client's ear to straighten the auditory canal varies between an adult and child. In a young client, the nurse pulls the ear down; in an adult client, the nurse pulls the ear up and back. The medication is not diluted; the number of medication drops instilled is as per the physician's prescription, and does not depend on the client's age. The position in which the client remains until the medication reaches the eardrum, and the amount of time before instilling medication in the client's opposite ear, does not differ with the age of the client.

Question format: Multiple Choice Chapter 33: Topical and Inhalant Medications Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 757 6. When teaching a client to administer nasal drops, the nurse cautions the client against instilling more than the recommended amount of nasal medication. Which is a possible outcome of overdose?

A. onset of pain in the nares and sinuses B. development of a sinus infection C. swelling of the nasal mucosa D. dryness of the nasal mucosa Answer: C Rationale: Administration of more than the recommended dosage of nasal medication could lead to swelling of the nasal mucosa within the short time of drug administration. However, administering more than the recommended dosage may not cause onset of pain in the nares and sinuses, development of a sinus infection, or dryness of the nasal mucosa.

Question format: Multiple Choice Chapter 33: Topical and Inhalant Medications Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 758 7. When instructing a client regarding sublingual application, the nurse should inform the client that which action is contraindicated when administering the drug?

A. swallowing the medication B. taking the medication on an empty stomach C. talking when taking the medication D. performing physical activities Answer: A

Rationale: When administering medication by sublingual application, the client should avoid swallowing or chewing the medication. Eating or smoking during administration is also contraindicated. Taking the medication on an empty stomach, talking, or performing physical activities may not be contraindicated when administering drugs sublingually.

Question format: Multiple Choice Chapter 33: Topical and Inhalant Medications Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 758 8. A nurse is caring for an elderly client with a vaginal yeast infection. Which actions should the nurse perform when instilling the medication in the client's vagina?

A. Apply the medication before the client goes to sleep.

B. Apply local anesthesia before applying the cream.

C. Avoid lubricating the applicator tip.

D. Apply the topical cream gently with a finger.

Answer: A Rationale: The nurse should plan to instill the medication before the elderly client goes to sleep so that it can be retained for a prolonged period. The nurse should not apply any local anesthesia or other cream near the vaginal area as it could lead to further complications and skin rashes. The nurse does not apply the medication cream with a finger, but with an applicator that is well lubricated with a water-soluble lubricant.

Question format: Multiple Choice Chapter 33: Topical and Inhalant Medications Cognitive Level: Apply Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 759 9. A nurse is explaining to a client the correct method of using a metered-dose inhaler when self-administering a prescribed dose of medication. What is a feature of a metered-dose inhaler?

A. It is a battery-operated device that spins.

B. It suspends finely powdered medication.

C. It is a canister that contains pressurized medication.

D. It has propellers that get activated during inhalation.

Answer: C Rationale: A meter-dose inhaler has a canister that contains medication under pressure. It is much more commonly used than the turbo-inhaler, which is a propeller-driven device that spins and suspends a finely powdered medication. A turbo-inhaler, not a meter-dose inhaler, has propellers that get activated during inhalation.

Question format: Multiple Choice Chapter 33: Topical and Inhalant Medications

Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 760 10. A nurse is caring for an asthmatic client who reports an unpleasant aftertaste after using the inhaler. What should the nurse tell the client to gargle with to avoid this aftertaste?

A. mineral water B. potassium permanganate C. boiled water D. salt water Answer: D Rationale: The nurse should suggest that the client gargle with salt water to diminish the unpleasant aftertaste after using an inhaler. Gargling with mineral water, potassium permanganate, or boiled water would not help diminish the unpleasant aftertaste.

Question format: Multiple Choice Chapter 33: Topical and Inhalant Medications Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 761 11. A physician at a health care facility suggests the use of a metered-dose inhaler for an asthmatic client. Which describes the mechanism of a metered-dose inhaler?

A. a canister containing medication that is released when the container is compressed B. a propeller-driven device that spins and suspends a finely powdered medication C. a device that forces liquid drug through a narrow channel using pressurized air D. a device that forces medication through a narrow channel with the help of inert gas Answer: A Rationale: A metered-dose inhaler is a canister that contains medication under pressure; the aerosolized drug is released when the container is compressed. A turbo-inhaler is a propellerdriven device that spins and suspends a finely powdered medication. An aerosol results after a liquid drug is forced through a narrow channel using pressurized air or an inert gas.

Question format: Multiple Choice Chapter 33: Topical and Inhalant Medications Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 760 12. The nurse is caring for a client who has problems coordinating his breathing with the inhaler use. Therefore, the client is unable to receive the full dose. Which would help maximize drug absorption in this client?

A. turbo-inhaler

B. metered-dose inhaler C. spacer D. nasal drops Answer: C Rationale: A spacer would help maximize the absorption of the drug in a client who is having problems coordinating his breathing with the inhaler use. A spacer provides a reservoir for the aerosol medication. As the client takes additional breaths, he continues to inhale the medication held in the reservoir. This tends to maximize the drug's absorption, because it prevents drug loss. A metered-dose inhaler is a canister that contains medication under pressure; the aerosolized drug is released when the container is compressed. A turbo-inhaler is a propeller-driven device that spins and suspends a finely powdered medication. Nasal drops are liquid medication sprayed or dropped into the client's nose. These, however, would not help in maximizing the absorption of the medication.

Question format: Multiple Choice Chapter 33: Topical and Inhalant Medications Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 761 13. When treating a client at a health care facility with nitroglycerin paste, how can the nurse prevent self-contamination during application?

A. avoid touching the application with bare fingers B. place an application paper on a clean area of skin C. rotate the site of medication placement D. remove one application before applying another Answer: A Rationale: When applying the nitroglycerin paste, the nurse should remove one application before applying another and remove any residue remaining on the skin in order to prevent excessive drug levels in the client during application. The nurse should place the application paper on a clean, non-hairy area of skin, as it facilitates drug absorption. The nurse rotates the site of medication to prevent potential skin irritation.

Question format: Multiple Choice Chapter 33: Topical and Inhalant Medications Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 756 14. A nurse is caring for a client with difficulty breathing due to nasal congestion. What care should the nurse take to prevent the client from inhaling large droplets of the medication when the nasal spray is being administered?

A. instruct the client to breathe through the mouth B. place a rolled towel or pillow behind the client's neck C. place the tip of the container just inside the nostril D. help the client to a sitting position with the head tilted backward

Answer: A Rationale: In order to prevent the client from inhaling large droplets of medication, the nurse should instruct the client to breathe through the mouth. To provide support and aid positioning, the nurse could place a rolled towel or a pillow behind the neck if the client cannot sit. Placing the tip of the container just inside the nostril confines the spray within the nasal passage. In order to facilitate depositing the drug where its effect is desired, the nurse should help the client to a sitting or lying position with her head tilted backward or to the side if the drug needs to reach one or the other sinus.

Question format: Multiple Choice Chapter 33: Topical and Inhalant Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 767 15. A client with a diagnosis of eczema has been prescribed an inunction and the nurse is performed relevant client education. What instruction should the nurse provide in order to ensure that the client correctly self-administers this medication?

A. "Remove the hair from any area where you need to apply your medication."

B. "If you find the medication difficult to apply, you can dilute it slightly with tap water."

C. "Make sure that the skin where you'll apply your medication is clean and dry."

D. "Put ice on your skin for a few seconds before you rub in the medication to help absorption."

Answer: C Rationale: Skin surfaces where an inunction is to be applied should be clean and dry. Hair removal and ice application are unnecessary and dilution with water is not normally appropriate.

Question format: Multiple Choice Chapter 33: Topical and Inhalant Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 755 16. A nurse is teaching a client to correctly administer an inunction in order to maximize therapeutic effect. Which product is an inunction?

A. hydrocortisone cream applied to a client's rash B. barrier cream applied to a client's peristomal skin C. moisturizing cream applied to a client's dry skin D. potassium chloride elixir used to treat a client's hypokalemia Answer: A Rationale: An inunction is a medication incorporated into an agent (such as an ointment, oil, lotion, or cream) that is administered by rubbing it into the skin. Unmedicated products such

as barrier cream and moisturizing cream are not considered inunctions. An elixir is a form of compounded liquid oral medication.

Question format: Multiple Choice Chapter 33: Topical and Inhalant Medications Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 755 17. A nurse is reviewing a client's medication administration record and notes that the specified route for a particular medication is "pr," denoting rectal administration. Rectally administered medications are most commonly administered in what form?

A. enema B. suppository C. ointment D. inunction Answer: B Rationale: Suppositories are the most common form of rectal administration. Enemas and ointments are possible but less commonly used than suppositories. An ointment, if it contains medication, is a form of inunction.

Question format: Multiple Choice Chapter 33: Topical and Inhalant Medications Cognitive Level: Remember Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 763 18. An elderly client with a diagnosis of chronic bronchitis is being treated with scheduled and PRN administration of albuterol, an inhaled bronchodilator. After administering this drug, which of the client's vital signs should the nurse monitor closely because of potential adverse effects of this drug? Select all that apply.

A. temperature B. blood pressure C. respiratory rate D. heart rate E. oxygen saturation Answer: B, D Rationale: Monitoring heart rate and blood pressure in older adults who use inhaled bronchodilators is important because these medications commonly cause tachycardia and hypertension. Either or both of these effects increase the risks for complications, especially in older adults with underlying cardiovascular disease.

Question format: Multiple Select Chapter 33: Topical and Inhalant Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process

Reference: p. 761 19. A hospital client has been experiencing agitation and has consequently been prescribed a one-time dose of lorazepam that is to be administered sublingually. The nurse knows that this route of administration will result in a rapid onset and peak because: A. saliva potentiates (increases) the therapeutic effect of the drug.

B. the drug is absorbed at a location that is close to the central nervous system.

C. the drug bypasses the effects of digestive enzymes.

D. the drug is rapidly absorbed by the rich blood supply under the tongue.

Answer: D Rationale: A tablet given by sublingual application (drug placed under the tongue) is left to dissolve slowly and become absorbed by the rich blood supply in the area. Sublingual administration is made effective by virtue of proximity to the CNS, the potentiating effect of saliva, or avoidance of digestive enzymes.

Question format: Multiple Choice Chapter 33: Topical and Inhalant Medications Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 758 20. The nurse is teaching a client about the proper use of transdermal patches. Which location will the nurse teach the client to apply the patch? Select all that apply.

A. chest B. abdomen C. upper arms D. behind knee E. foot F. buttock Answer: A, B, C, F Rationale: Transdermal patches are generally applied to the upper body (chest, abdomen, upper arms) and the buttocks. They are not applied behind the knee or to the feet.

Question format: Multiple Select Chapter 33: Topical and Inhalant Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 755 21. The nurse is preparing to apply nitroglycerin paste. After checking the order, washing hands, checking the client's identity, and applying gloves, which is the next nursing action?

A. removing prior application and any remaining residue from skin B. covering application paper with plastic with transparent semipermeable dressing C. squeezing prescribed amount of paste from tube onto application paper D. using wooden applicator to spread paste over the paper

Answer: A Rationale: The nurse will remove one application and residue before applying another, as this prevents excessive drug levels when a new application is placed. The nurse will then proceed to squeeze the paste onto the paper, spread the paste over the paper, apply the paper, and cover it with a transparent semipermeable dressing.

Question format: Multiple Choice Chapter 33: Topical and Inhalant Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 756 22. The nurse is caring for a client who is taking nitroglycerin. Which client statement requires immediate nursing intervention?

A. "I will wear gloves when applying this."

B. "I will apply this as frequently as prescribed."

C. "I am taking tadalafil in addition to nitroglycerin."

D. "I understand that this drug may lower my blood pressure."

Answer: C Rationale: Clients taking nitroglycerin in any form should not take drugs or herbs for erectile dysfunction. This may cause severe hypotension due to the combined vasodilation effect.

Other client statements are appropriate and do not require further nursing teaching.

Question format: Multiple Choice Chapter 33: Topical and Inhalant Medications Cognitive Level: Analyze Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 757 23. The nurse is caring for an older adult client who has been prescribed an inhaled bronchodilator. Which priority assessments will the nurse perform before and after administering the medication? (Select all that apply.)

A. temperature B. blood pressure C. neurological status D. heart rate E. pain level Answer: B, D Rationale: Blood pressure and heart rate should be assessed before and after administering inhaled bronchodilators to older adults, as these can commonly cause hypertension and tachycardia. Temperature, neurological status, and pain level can always be assessed, but these are not the priority assessments that should be performed at these specific times.

Question format: Multiple Select Chapter 33: Topical and Inhalant Medications Cognitive Level: Analyze

Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 761 24. The nurse is teaching a client about using two inhalers. Which client statement reflects that nursing teaching has been effective?

A. "I should be careful to refrain from shaking the canisters of medication."

B. "I will breathe in for about 10 seconds and exhale quickly."

C. "I must wait at least 1 full minute between inhalers."

D. "I will wash the holder in warm water mixed with some bleach."

Answer: C Rationale: Teaching has been effective when the client states that a full minute must elapse between taking doses of medication from different inhalers. The canisters must be shaken after being placed in the holder. After breathing the medication in over 10 seconds, the client should exhale slowly through pursed lips. Holders should be rinsed in warm water daily and cleaned weekly with mild soap and water.

Question format: Multiple Choice Chapter 33: Topical and Inhalant Medications Cognitive Level: Analyze Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 760 25. The nurse is caring for a client with visual impairment who has been prescribed two different types of eye drops. Which nursing intervention will best assist the client in differentiating between the bottles of drops?

A. Write the names of the medications on the bottle.

B. Place a rubber band snugly around one of the bottles.

C. Color code the bottles with different colors of pens.

D. Teach the client to place bottles on different ends of the table.

Answer: B Rationale: The client with visual impairment will best benefit from a tactile difference between bottles; therefore, placing a rubber band snugly around one bottle is the best approach. Names written on the bottles may be difficult for the client with visual impairment to read, and color-coding may not work if the client is colorblind. Placing bottles on different ends of the table can be confusing if the client forgets which medication is which.

Question format: Multiple Choice Chapter 33: Topical and Inhalant Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 757 26. A nurse is caring for a client with scabies for which a topical medication has been prescribed. When educating the client on how to use the medication, which should the nurse tell the client regarding the application?

A. Remove medication every 12 hours and reapply.

B. Do not bathe or rinse off for 24 hours.

C. Use gloves to apply.

D. Apply medication in a thick layer and cover with gauze or sterile wrapping.

Answer: C Rationale: The nurse should tell the client that the drug is to be administered by application on the skin wearing gloves because as a topical route of administration gloves can reduce inadvertent absorption through the hands. The medication will be absorbed through the skin so there is no need to remove the previous dose and reapply, avoid taking baths or showers, or cover with gauze.

Question format: Multiple Choice Chapter 33: Topical and Inhalant Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 755 27. A nurse is preparing a prescribed dosage of a steroid inhalant medication for a client with asthma. Which action should the nurse take after administering the medication?

A. Instruct the client to rinse the mouth following inhalation.

B. Instruct the client to hold the breath for 1 minute.

C. Instruct the client to exhale slowly.

D. Instruct the client to exhale deeply following inhalation.

Answer: A Rationale: The inhalant method distributes medication to distal areas of the airways, but some clients find that the inhaled drugs leave an unpleasant aftertaste or can develop oral candidiasis. For this reason the client should rinse the mouth following inhalation. There is no need to hold the breath, exhale slowly or exhale deeply after inhalation.

Question format: Multiple Choice Chapter 33: Topical and Inhalant Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 761 28. The nurse has provided a client with a sublingual medication. Which is the most appropriate nursing intervention to ensure proper administration of this medication?

A. crushing the drug for better absorption B. ensuring client does not swallow the medication C. providing a cup of water if the client's mouth is dry D. looking under the client's tongue to verify administration Answer: D Rationale: The nurse should look under a client's tongue after administration of a sublingual medication to make sure it has been appropriately taken and has dissolved. The client should

refrain from chewing or swallowing the drug and the nurse should not crush the medication.

If the client's mucus membranes are dry, the nurse should use 1 ml of normal saline solution or water to wet the membranes underneath the tongue so that absorption can occur.

Question format: Multiple Choice Chapter 33: Topical and Inhalant Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 758

Chapter 34 1. A nurse needs to combine two different prescribed drugs in a syringe and then administer them to a client with influenza. Which precaution should the nurse take when combining drugs?

A. Withdraw exact amounts of each drug from each container.

B. Mix the two drugs together thoroughly before administering.

C. Shake the two drug containers before withdrawing.

D. Expel both the drugs separately in a vial before use.

Answer: A Rationale: When combining more than one drug in a single syringe, the nurse should take exact amounts from each drug container because, once the drugs are in the barrel of the syringe, there is no way to expel one without expelling the other. Mixing the two drugs before administering, or shaking the drug containers before withdrawing, is not suitable because it can cause chemical reactions and precipitates. Expelling both the drugs separately in a vial before use could also lead to a chemical reaction, which often causes a precipitate to form.

Question format: Multiple Choice Chapter 34: Parenteral Medications Cognitive Level: Apply Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 774 2. A nurse should read the instructions stated on a vial container before reconstituting it and administering it to a client. Which instructions are stated on the label of a vial container?

A. type of needle to be used for withdrawal B. directions for administering the drug C. best site for administering the drug D. amount of diluent to be added Answer: D Rationale: When reconstitution is necessary, the drug label lists instructions such as the amount of diluent to be added and the type of diluent to be used, but not the type of needle.

The label states the dosage per volume after reconstitution, not the best site for administering the drug after the reconstitution. It also states the directions for storing the drug, not the directions for administering the drug to a client.

Question format: Multiple Choice Chapter 34: Parenteral Medications Cognitive Level: Remember Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 772

3. A nurse is administering an injection to a client at a 15-degree angle. The client has a venous access port. Which injection can be administered at this angle?

A. intradermal B. subcutaneous C. intramuscular D. intravenous Answer: A Rationale: When giving an intradermal injection, the nurse instills the medication shallowly at a 10- to 15-degree angle of entry. When the nurse administers a subcutaneous injection, the angle of entry is either 45 degrees or 90 degrees, whereas for intramuscular injections, the angle is 90 degrees. Intravenous injections are instilled into the veins of the client at an angle of around 15 degrees, but only if no venous access port is in place.

Question format: Multiple Choice Chapter 34: Parenteral Medications Cognitive Level: Remember Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 775 4. A nurse needs to administer a prescribed heparin injection to a client subcutaneously.

Which syringe ensures accuracy when administering heparin subcutaneously?

A. tuberculin syringe B. conventional syringe C. insulin syringe D. syringe calibrated in 0.2 mL Answer: A Rationale: Heparin dosages are very small volumes; hence, they may require a tuberculin syringe to ensure accuracy. Conventional syringes and needles are being redesigned to avoid needlestick injuries and ensure accuracy. Insulin syringes are specially designed to prepare insulin dosages. A syringe calibrated in 0.2 mL is used in 3- or 5-mL dosages for an intramuscular injection.

Question format: Multiple Choice Chapter 34: Parenteral Medications Cognitive Level: Remember Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 775 5. A nurse is bunching the tissue of a client when administering a subcutaneous injection to that client. What is the reason for bunching when injecting subcutaneously?

A. to prevent needlestick injuries B. to ensure the accuracy of landmarking C. to facilitate blood circulation at the injection site D. to avoid instilling medication within the muscle

Answer: D Rationale: Nurses bunch tissue between the thumb and fingers before administering the injection to avoid instilling medication within the muscle. Bunching does not prevent needlestick injuries, it does not facilitate blood circulation at the injection site, nor does it ensure the accuracy of landmarking.

Question format: Multiple Choice Chapter 34: Parenteral Medications Cognitive Level: Remember Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 777 6. A nurse needs to administer an intramuscular injection to a client. The site that the nurse has chosen contains the sciatic nerve. Which action should the nurse perform first to locate the appropriate landmarks and avoid damaging the sciatic nerve?

A. Palpate the sciatic nerve before proceeding with the injection.

B. Divide the buttock into four imaginary quadrants.

C. Place one hand above the knee and the other at the top of the thigh.

D. Palpate the lower edge of the acromion process.

Answer: B Rationale: The dorsogluteal site contains the sciatic nerve. To locate the appropriate landmarks of the dorsogluteal site, the nurse should divide the buttock into four imaginary quadrants. Palpating the sciatic nerve before proceeding with the injection is not done by the nurse. The nurse locates the vastus lateralis site by placing one hand above the knee and the other below the greater trochanter at the top of the thigh. Palpating the lower edge of the acromion process is done for safety reasons when administering an injection at the deltoid site.

Question format: Multiple Choice Chapter 34: Parenteral Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 780 7. A nurse has administered an injection to a client. Which intervention should the nurse perform to reduce discomfort and provide quick relief?

A. Massage the site following injection.

B. Numb the skin with an ice pack after the injection.

C. Apply pressure to the site during needle withdrawal.

D. Apply a eutectic mixture of local anesthetic to the site.

Answer: C Rationale: To reduce the discomfort associated with an injection, the nurse should apply pressure to the site during needle withdrawal. Applying a eutectic mixture of local anesthetic

to the site will not help because provides relief after 1 or 2 hours. The nurse should numb the skin with an ice pack not after the injection it only, but before it. The nurse should not massage the site following an injection because, in some clients, it could lead to further complications and discomfort.

Question format: Multiple Choice Chapter 34: Parenteral Medications Cognitive Level: Apply Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 783 8. A nurse needs to administer an injection to a client in the deltoid site. Which action should the nurse perform to avoid the risk of damaging the radial nerve and artery?

A. Avoid asking the client to lie down or sit.

B. Aspirate for blood return from the tissue.

C. Draw an imaginary line at the axilla between the acromion and brachial vessels.

D. Pull the tissue laterally until it is taut.

Answer: C Rationale: To avoid the risk of damaging the radial nerve and artery in the deltoid site, the nurse should draw an imaginary line at the axilla first and then inject between the acromion and brachial vessels. The nurse should ask the client to lie down, sit, or stand with the shoulder well exposed. Pulling the tissue until it is taut and aspirating blood return from the tissue is part of the Z-track method, not part of the technique used to avoid the risk of damaging the radial nerve and artery.

Question format: Multiple Choice Chapter 34: Parenteral Medications Cognitive Level: Apply Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 781 9. A nurse needs to administer an intradermal injection to a client. What is the most common site for administering an intradermal injection?

A. forearm B. chest C. back D. stomach Answer: A Rationale: The most common site for an intradermal injection is the inner aspect of the forearm. Intradermal injections are commonly used for diagnostic purposes. Examples include tuberculin tests and allergy testing. Small volumes, usually 0.01 to 0.05 mL, are injected because of the small tissue space. Other areas that may be used are the back and upper chest, not the stomach.

Question format: Multiple Choice

Chapter 34: Parenteral Medications Cognitive Level: Remember Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 774 10. A nurse has to administer a subcutaneous injection to a client. For which client can the nurse administer a subcutaneous injection at a 90-degree angle?

A. infant B. thin client C. child D. obese client Answer: D Rationale: The nurse inserts the needle at a 90-degree angle to reach the subcutaneous tissue in normal-size or obese clients who have a 2-inch (5-cm) tissue fold when it is bunched. For thin clients who have a 1-inch (2.5-cm) fold of tissue, the nurse inserts the needle at a 45degree angle. Bunching is preferred for infants, most children, and thin adults.

Question format: Multiple Choice Chapter 34: Parenteral Medications Cognitive Level: Apply Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 777 11. A nurse is using the Z-track technique to administer an injection to a client. Which injection route utilizes the Z-track technique?

A. intravenous B. intramuscular C. intradermal D. subcutaneous Answer: B Rationale: When administering intramuscular injections, nurses may administer drugs that may be irritating to the upper levels of tissue by the Z-track technique. Clients report slightly less pain during (and the day after) a Z-track injection compared with the usual intramuscular injection technique. The Z-track technique is not suitable for intravenous injections, as they are administered into the veins, nor is it used for intradermal or subcutaneous injections.

Question format: Multiple Choice Chapter 34: Parenteral Medications Cognitive Level: Remember Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 782

12. A nurse needs to administer a subcutaneous injection to a client. How far from the previous injection site to the area should the nurse administer the injection?

A. at least 1 inch (2.5 cm) B. at least 2 inches (5 cm) C. at least 3 inches (8 cm) D. at least 4 inches (10 cm) Answer: A Rationale: Injection sites are rotated a finger's width apart, or about 1 inch (2.5 cm), from a previous site to avoid repeatedly injecting into the same area in a short amount of time.

Rotating sites avoids tissue injury.

Question format: Multiple Choice Chapter 34: Parenteral Medications Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 776 13. A nurse is using an 18-gauge needle to administer medication to a client. The nurse knows that, when compared with a 27-gauge needle, an 18-gauge needle has which feature?

A. shorter length B. greater length C. larger diameter D. smaller diameter Answer: C Rationale: For most injections, 18- to 27-gauge needles are used; the smaller the number, the larger the diameter. For example, an 18-gauge needle is wider than a 27-gauge needle. The needle gauge, or the diameter, refers to its width.

Question format: Multiple Choice Chapter 34: Parenteral Medications Cognitive Level: Remember Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 770 14. After administering medication to a client subcutaneously, the nurse removes the needle at the same angle at which it was inserted. Which explains the nurse's action?

A. verifies correct injection of the drug B. minimizes tissue trauma to the client C. prevents needlestick injuries D. helps to control placement of the needle Answer: B

Rationale: Removing the needle at the same angle at which it was inserted to administer medication minimizes tissue trauma and discomfort to the client. To verify correct injection of the drug, the nurse pushes the plunger and watches for a small wheal. To prevent needlestick injuries, the nurse covers the needle with a protective cap. Holding the client's arm and stretching the skin taut helps to control placement of the needle.

Question format: Multiple Choice Chapter 34: Parenteral Medications Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 787 15. A nurse is administering a subcutaneous injection to a client. What is the maximum volume that the nurse may administer by this route?

A. 3 ml B. 2.5 ml C. 1 ml D. 0.05 ml Answer: C Rationale: The volume of a subcutaneous injection is usually up to 1 ml. An intramuscular injection is the administration of up to 3 ml of medication into one muscle or muscle group.

Intradermal injections are commonly used for diagnostic purposes in small volumes, usually 0.01 to 0.05 ml.

Question format: Multiple Choice Chapter 34: Parenteral Medications Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 775 16. A nurse is administering an intramuscular injection to a client using the Z-track technique. Which of the following actions should the nurse perform during this administration?

A. Withdraw the needle and release taut skin immediately after injection.

B. Depress the plunger with the index finger of the nondominant hand.

C. Apply pressure and massage the site immediately after withdrawing the needle.

D. Use the side of the hand to pull the tissue laterally about 1 inch (2.5 cm) before injection.

Answer: D Rationale: When using the Z-track technique, the nurse should use the side of the hand to pull the tissue laterally about 1 inch (2.5 cm) until the tissue is taut. The needle is depressed with the thumb, not the finger, and the needle should be left in place for several seconds following injection. Massage is contraindicated.

Question format: Multiple Choice Chapter 34: Parenteral Medications Cognitive Level: Apply

Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 782 17. A nurse needs to administer an intramuscular injection to a thin and frail elderly client.

Which of the following actions should the nurse perform to avoid striking the bone when injecting?

A. Massage the injection site.

B. Pinch the muscular tissue.

C. Obtain an x-ray of the injection site.

D. Inject using a subcutaneous rather than an intramuscular technique.

Answer: B Rationale: The muscular tissue should be pinched together to avoid striking the bone when administering an intramuscular injection if the older person has decreased subcutaneous fat.

Massaging the injection site will not help avoid the possibility of striking the bone.

Performing the injection using a subcutaneous rather than intramuscular technique is not done because injection techniques are not interchangeable. It is not common practice to obtain an x-ray for administering an injection.

Question format: Multiple Choice Chapter 34: Parenteral Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 782 18. A group of nursing students have begun learning about the rationale and technique for administering injections. The students should identify which of the following parts of a syringe? Select all that apply.

A. orifice B. piston C. barrel D. tip E. plunger Answer: C, D, E Rationale: All syringes contain a barrel (the part of the syringe that holds the medication), a plunger (the part of the syringe within the barrel that moves back and forth to withdraw and instill the medication), and a tip or hub (the part of the syringe to which the needle is attached).

Question format: Multiple Select Chapter 34: Parenteral Medications Cognitive Level: Remember Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 770

19. A hospital is in the process or replacing the current stock of conventional syringes and needles with new, redesigned models. What is the priority outcome that is sought by this change?

A. increased accuracy of parenteral drug doses B. reduction in nurses' risks of needlestick injuries C. interchangeability of needles for subcutaneous and intramuscular injections D. reduction in clients' risks of nosocomial infections Answer: B Rationale: Conventional syringes and needles are being redesigned to avoid needlestick injuries and thus to reduce the risk for acquiring a blood-borne viral disease such as hepatitis or AIDS. Redesigned syringes in needles do not increase the accuracy of drug administration or reduce the risk of nosocomial infections. Subcutaneous and intramuscular injections require different-sized needles.

Question format: Multiple Choice Chapter 34: Parenteral Medications Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 771 20. A hospital client with type 1 diabetes requires the administration of 4 units of regular (short-acting) insulin and 12 units of NPH (long-acting) insulin. The nurse knows to combine these two types of insulin immediately before administration. What is the rationale for the nurse's action?

A. Leaving the insulins combined for too long reduces the individual characteristics of each.

B. Having the insulins remain combined in the syringe increases the likelihood that precipitates will form.

C. Combining the insulins for an extended period is associated with the growth of microorganisms in the syringe.

D. Having the insulins combined for more than 15 minutes can cause cytotoxic effects (cell death) after administration.

Answer: A Rationale: When mixed together, insulins tend to bind and become equilibrated. This means that the unique characteristics of each are offset by those of the other. For this reason, most types of insulin are combined just before administration. Combining insulins too early does not create a risk of precipitate formation, infection, or cytotoxicity.

Question format: Multiple Choice Chapter 34: Parenteral Medications Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 778 21. As part of a postsurgical client's regimen for deep vein thrombosis prevention, she is to receive 5000 units of heparin subcutaneously b.i.d. How can the nurse reduce this client's risk of bruising at the injection sites?

A. by aspirating slightly once the needle is inserted B. by gently massaging the injection site for a few seconds after injection C. by changing the needle after withdrawing the drug from the vial D. by using the Z-track injection technique consistently Answer: C Rationale: Certain modifications are necessary to prevent bruising in the area of heparin injection. The nurse changes the needle after filling the syringe with the dose of heparin; that is, before injecting the client. The nurse does not aspirate the plunger once the needle is in place. Massaging the site is contraindicated because this can increase the tendency for local bleeding. The Z-track technique is used exclusively for IM injections.

Question format: Multiple Choice Chapter 34: Parenteral Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 780 22. A nurse has just administered a subcutaneous dose of morphine to a client who is experiencing significant pain. What is the first action that the nurse should do after withdrawing the needle from the client's arm?

A. Apply a 2" × 2" piece of gauze to the injection site.

B. Provide firm pressure on the injection site for 10 to 15 seconds.

C. Deposit the syringe and needle in a designated sharps container.

D. Initial the client's medication administration record.

Answer: C Rationale: To reduce the risk of needlestick injuries, the nurse should immediately dispose of the needle and syringe after administration. This should be done before the nurse completes the necessary documentation. Sustained pressure or the application of gauze is not necessary.

Question format: Multiple Choice Chapter 34: Parenteral Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 771 23. The nurse is teaching a client with diabetes about insulin dosing. Which teaching will the nurse include? Select all that apply.

A. "Insulin needles are very short in length."

B. "Insulin in prefilled syringes expires after 60 days."

C. "Insulin injections are usually less painful than other injections."

D. "Insulin syringes that are prefilled do not need to have needles changed."

E. "Insulin can only be administered by insulin pen."

Answer: A, C

Rationale: The nurse will teach that insulin needles are short in length, and thus, this type of injection is usually less painful than other types of injections. Insulin in prefilled syringes is stable for up to 30 days. The disposable needle on a prefilled insulin syringe must be changed each time a client uses it. Insulin can be given with an insulin syringe used to draw up the drug from a vial.

Question format: Multiple Select Chapter 34: Parenteral Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 770 24. A nurse works for a facility that does not utilize modified safety injection equipment.

How will the nurse prevent needlesticks? Select all that apply.

A. Recap the needle after use to avoid sticking others.

B. Leave the needle uncapped and dispose of it in the nearest biohazard container.

C. Scoop the cap back onto a used needle with one hand without touching the cap.

D. Ask the client to place the cap back onto a used needle.

E. Refuse to administer medications until modified safety injection devices are ordered.

Answer: B, C Rationale: The nurse using a traditional syringe can avoid needlesticks by leaving the needle uncapped and depositing it into the nearest biohazard container or using the scoop method.

Recapping needles increases the risk for needlesticks. The client should never be asked to recap a needle. It is not reasonable, nor is it professional, to refuse medication administration responsibilities.

Question format: Multiple Select Chapter 34: Parenteral Medications Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 771 25. While administering a medication via a syringe, a client sharply moves and the nurse accidentally encounters a needlestick. What is the priority nursing action?

A. Request counseling on the potential for infection.

B. Document the injury.

C. Report the needlestick to the nurse manager.

D. Obtain the client's blood to be tested for HIV and HBV. Answer: C Rationale: Upon encountering a needlestick, the nurse's priority action is to report the injury.

Other actions can take place after the injury has been reported.

Question format: Multiple Choice Chapter 34: Parenteral Medications Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process

Reference: p. 772 26. The nurse is preparing to withdraw medication from an unbroken glass ampule. Which nursing actions are appropriate? Select all that apply.

A. Tap the top of the ampule.

B. Don sterile gloves before opening the ampule.

C. Snap the neck of the ampule while holding it close to the nurse's body.

D. Avoid allowing the needle to touch the outside of the ampule.

E. Invert the ampule to withdraw medication.

Answer: A, D, E Rationale: The nurse will tap the top of the ampule to distribute medication to the lower part of the container, protect fingers with a gauze square, snap the neck of the ampule away from the nurse's body, refrain from allowing the needle to touch the outside of the ampule to maintain needle sterility, and invert the ampule to facilitate medication withdrawal. The nurse does not don sterile gloves before opening the ampule and does not snap the neck of the ampule while holding it close to the nurse's body for safety reasons.

Question format: Multiple Select Chapter 34: Parenteral Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 773 27. The nurse is preparing to administer insulin to an obese client. At what angle will the nurse plan to insert the needle into the client?

A. 10 to15 degrees B. 20 to 30 degrees C. 45 degrees D. 90 degrees Answer: D Rationale: Insulin injections are given subcutaneously to clients with obesity at a 90-degree angle. Other answers are incorrect.

Question format: Multiple Choice Chapter 34: Parenteral Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 777 28. The nurse is preparing to administer insulin to an older client who is frail and has failure to thrive. At what angle will the nurse plan to insert the needle into the client?

A. 10 to 15 degrees B. 20 to 30 degrees C. 45 degrees D. 90 degrees

Answer: C Rationale: Insulin injections are given subcutaneously to clients who are very thin at a 45degree angle. Other answers are incorrect.

Question format: Multiple Choice Chapter 34: Parenteral Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 777 29. The nurse is preparing to administer heparin to prevent deep venous thrombosis in a client who has had surgery. What is the appropriate nursing action? Select all that apply.

A. Change the needle after filling the syringe.

B. Use the area 2 inches around the umbilicus for injection.

C. Aspirate with the plunger.

D. Leave needle in place for 15 seconds.

E. Press on the injection site with gauze following administration.

Answer: A, E Rationale: To prevent bruising associated with heparin administration, the nurse changes the needle after filling the syringe, does not aspirate the plunger, leaves the needle in place for 5 seconds, and presses on the injection site with gauze after administration. Avoid the area 2 inches around the umbilicus and the belt line for injection.

Question format: Multiple Select Chapter 34: Parenteral Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 780 30. The nurse is teaching a client about insulin. What teaching will the nurse include? Select all that apply.

A. Insulins should never be mixed together in a syringe.

B. Mix glargine, a long-acting insulin, with intermediate-acting insulin.

C. Rapid-acting insulin and short-acting insulin are often combined with intermediate-acting insulin.

D. Most types of insulin are combined at least an hour before administration.

E. Humulin 50/50 contains equal amounts of intermediate-acting and short-acting insulin.

Answer: C, E Rationale: The nurse will teach that certain types of insulins may be mixed together in a syringe just before administration. Glargine is never mixed with any other type of insulin.

Rapid-acting insulin and short-acting insulin are often combined with intermediate-acting insulin. For example, Humulin 50/50 contains equal amounts of intermediate-acting and short-acting insulin.

Question format: Multiple Select Chapter 34: Parenteral Medications

Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 779 31. A nurse is showing an older adult client the correct method of self-administering an insulin injection at home. Which statement best describes lipoatrophy and lipohypertrophy to the client?

A. "Lipoatrophy and lipohypertrophy are conditions of the muscle that can occur from not rotating injection sites."

B. "Lipoatrophy and lipohypertrophy are conditions of the fatty tissue that can occur from not rotating injection sites."

C. "Lipoatrophy and lipohypertrophy are conditions of the skin that can only occur when injecting insulin."

D. "Lipoatrophy and lipohypertrophy will not occur if you always inject the insulin in the same location."

Answer: B Rationale: Lipoatrophy is the term describing the localized loss of fat tissue. This may occur as a result of subcutaneous injections of insulin in the treatment of diabetes. Lipohypertrophy is a lump under the skin caused by accumulation of extra fat at the site of many subcutaneous injections of insulin. It may be unsightly, mildly painful, and may change the timing or completeness of insulin action. Both of these conditions can be avoided by rotating injection sites. Lipoatrophy and lipohypertrophy may occur as a result of many types of injections where the site has not been rotated.

Question format: Multiple Choice Chapter 34: Parenteral Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 777-778

Chapter 35 1. A nurse is caring for a client undergoing IV therapy. The nurse knows that intravenous administration of medication is appropriate in which situation?

A. when the client has disorders that affect the absorption of medications B. when the drug needs to act on the client very slowly C. when the client wants to avoid the discomfort of an intradermal injection D. when the drug needs to be administered only once Answer: A Rationale: Intravenous administration may be chosen when clients have disorders, such as severe burns, that affect the absorption and metabolism of medications. IV therapy is also used in an emergency when a quick response is needed. Intravenous administration is not chosen when a client wants to avoid the discomfort of an intradermal injection but rather when the client wants to avoid the discomfort of repeated intramuscular injections. A single administration of a drug does not indicate the need for intravenous administration.

Question format: Multiple Choice Chapter 35: Intravenous Medications Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 794 2. A nurse needs to administer a continuous medication drip to a client. The nurse knows that, for a continuous infusion, she will likely need to add medication to which volume of IV solution?

A. 15 to 50 mL B. 150 to 250 mL C. 500 to 1,000 mL D. 50 to 100 mL Answer: C Rationale: A continuous infusion is the instillation of a parenteral drug over several hours. It is also called a continuous drip, which involves adding medication to a large volume of IV solution—approximately 500 to 1,000 mL, not less.

Question format: Multiple Choice Chapter 35: Intravenous Medications Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 794 3. A nurse is administering an intermittent secondary infusion to a client. How long before administration should the nurse remove a refrigerated secondary solution?

A. 5 minutes B. 10 minutes C. 15 minutes D. 30 minutes Answer: D Rationale: The nurse should remove a refrigerated secondary solution 30 minutes before administration because it warms the solution slightly, preventing lowering of blood temperature, and also promotes comfort during instillation. Removing the refrigerated solution anywhere between 5 and 15 minutes before administration will not help, as the solution will still remain cold.

Question format: Multiple Choice Chapter 35: Intravenous Medications Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 806 4. A nurse is using an IV port when administering medication to a client. Which IV administration has the greatest potential to cause life-threatening changes?

A. bolus administration B. electronic infusion device C. continuous administration D. secondary administration Answer: A Rationale: Because the entire dose is administered quickly, bolus administration has the greatest potential to cause life-threatening changes should a drug reaction occur. An electronic infusion device, continuous administration, and secondary administration do have the potential to cause life-threatening changes, but not to the same degree as a bolus administration, since the rate at which medication is administered is not as fast as during a bolus.

Question format: Multiple Choice Chapter 35: Intravenous Medications Cognitive Level: Remember Client Needs Pn: Safe, Effective Care Environment: Safety and Infection Control Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 794 5. A nurse needs to administer a prescribed dosage of antineoplastic drugs to a client with cancer. Which piece of medical equipment is used to administer antineoplastic drugs?

A. tuberculin injection B. conventional syringe C. central venous catheter D. syringe with a large-bore needle Answer: C

Rationale: Central venous catheters (CVCs) are often used to administer antineoplastic drugs to clients with cancer. CVCs provide a means of administering parenteral medication in a large volume of blood. A tuberculin injection is used when administering intradermal injections of small volumes to a client, whereas a wider-gauge syringe is used to administer medication into the tissue of the client. They do not provide a means of administering parenteral medication in a large volume of blood. Conventional syringes may not be suitable for administering antineoplastic drugs to clients with cancer.

Question format: Multiple Choice Chapter 35: Intravenous Medications Cognitive Level: Remember Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 797 6. A nurse is accessing a client's Hickman catheter in order to administer a prescribed IV medication. The nurse knows that these tunneled catheters help the client in which of the following ways?

A. administer short-term medication therapy B. stabilize the catheter C. provide maximum protection against infection D. hold the catheter in place for several years Answer: B Rationale: Tunneling helps to stabilize the catheter and reduces the potential for infection. A percutaneous catheter is used when clients require short-term medication therapy. An implanted catheter, not a tunneled catheter, provides maximum protection against infection and can be held in place for several years.

Question format: Multiple Choice Chapter 35: Intravenous Medications Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 797 7. A nurse accidentally spills some powdered antineoplastic drugs on the floor when removing them from the storage cabinet. Which of the following actions should the nurse take to clear the drug spill?

A. Display a warning sign in the spill area.

B. Place a wet towel over the spill area.

C. Use a vacuum cleaner to clear the spill.

D. Wash the spill area with normal saline.

Answer: B Rationale: When there is a spill of powdered antineoplastic drugs, the nurse should immediately place a wet towel or cloth over the spilled material for quick absorption. The nurse can also display a warning sign as a secondary safety measure. Using a vacuum cleaner to clear the drug spill may not correct the problem, as fine particles of the powder could still

be scattered on the floor. The best way to clear a powdered drug spill is to absorb all the powder, wash the spill area with water and detergent at least three times, and then rinse it with clean water again.

Question format: Multiple Choice Chapter 35: Intravenous Medications Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 799 8. A nurse needs to administer a prescribed medication to a client using IV push. In which way is the medication being administered to the client?

A. continuous drip B. bolus administration C. gravity infusion D. electronic infusion device Answer: B Rationale: A bolus is a relatively large amount of medication given all at once; bolus administration sometimes is described as a drug given by IV push, or rapid intravenous administration. A continuous infusion, also called continuous drip, is instillation of a parenteral drug over several hours. It involves adding medication to a large volume of IV solution. After the medication is added, the solution is administered by gravity infusion or, more commonly, with an electronic infusion device such as a controller or pump.

Question format: Multiple Choice Chapter 35: Intravenous Medications Cognitive Level: Remember Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 794 9. A nurse is administering medication to a client with a triple-lumen central venous catheter.

Which action should the nurse perform to maintain patency of an unused lumen?

A. Flush it with normal saline.

B. Avoid releasing the clamp on the catheter tubing.

C. Swab the port with an alcohol sponge.

D. Pinch the tubing above the access port.

Answer: A Rationale: The unused lumen is kept patent by scheduled flushes with normal saline and/or heparin. Releasing the clamp, if there is one on the exposed section of the catheter, facilitates flushing the catheter and helps in maintaining the patency. When administering medication through an intravenous port, the nurse pinches the tube above the access port and swabs the port with alcohol.

Question format: Multiple Choice Chapter 35: Intravenous Medications Cognitive Level: Remember

Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 797 10. A nurse is administering a piggyback infusion to a client with partial-thickness or seconddegree burns. Which describes the most important feature of a piggyback infusion?

A. The primary IV solution is infused by gravity.

B. Medication is given all at one time as quickly as possible.

C. Medication locks are changed every 72 hours.

D. A parenteral drug is given in tandem with an IV solution.

Answer: D Rationale: In a piggyback infusion, a parenteral drug is administered in tandem with a primary IV solution. Medication locks are not changed during piggyback infusion specifically, but in general to maintain patency. IV medication or fluid is given all at one time as quickly as possible in a bolus administration, not in piggyback infusion. It is not the primary IV solution but the secondary infusions that are administered by gravity in tandem with the currently infused primary solution.

Question format: Multiple Choice Chapter 35: Intravenous Medications Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 796 11. A nurse is assessing the reading on a volume-control set when administering an IV drug to a client. Which of the following functions is performed by a volume-control set?

A. eliminates the need for an additional bag of fluid B. administers a large volume of solution C. allows instant access to the venous system D. holds solution from a smaller container Answer: A Rationale: A volume-control set eliminates the need for additional fluid by substituting for the separate secondary container of solution. It is used to administer IV medication in a small volume of solution at intermittent intervals and to avoid accidentally overloading the circulatory system. A medication lock, not a volume-control set, allows instant access to the venous system. A volume-control set is a chamber in IV tubing that holds a portion of the solution from a larger container, not a smaller container.

Question format: Multiple Choice Chapter 35: Intravenous Medications Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 796

12. When performing a piggyback infusion, the nurse lowers the container of primary solution approximately 10 in (25 cm) below the height of the secondary solution. Which reason explains the nurse's action?

A. instills secondary infusion within specified time B. uses gravity to infuse the secondary medication C. prevents backfilling with the primary solution D. prevents separation from the port Answer: B Rationale: Lowering the primary solution container approximately 10 in (25 cm) below the height of the secondary solution uses gravity to infuse the secondary medication solution rather than the primary solution. Instilling the secondary infusion within the specified time is done by checking the drop factor on the package of secondary tubing and calculating the rate for infusion. To prevent backfilling with the primary solution, the nurse clamps the tubing when the solution has instilled. Locking the connection prevents separation from the port.

Question format: Multiple Choice Chapter 35: Intravenous Medications Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 796 13. A nurse is caring for a client with an implanted catheter. The nurse knows that a dressing is applied over the implanted catheter on which of the following occasions?

A. when the client requires extended therapy B. when the effect of the local anesthetic is reduced C. when the client has an active infection D. when the port is pierced and a catheter is in use Answer: D Rationale: A dressing is applied only when the port is pierced and the implanted catheter is being used. Implanted catheters remain patent with periodic flushing with heparin. A local anesthetic is applied to reduce the skin discomfort of a client. A percutaneous catheter is used when the client has an active infection. When the client requires extended therapy, tunneled catheters are inserted into a central vein with part of the catheter secured in the subcutaneous tissue.

Question format: Multiple Choice Chapter 35: Intravenous Medications Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 798 14. A nurse spills a bottle of antineoplastic drug on the unit floor. What should the nurse do to avoid self-contamination with the antineoplastic drug?

A. Cover the drug spill with a disposable paper pad.

B. Pour a disinfectant on the drug spill.

C. Pour a 70 percent alcohol solution over the drug spill.

D. Avoid cleaning the spill area with water.

Answer: C Rationale: The nurse should pour a 70 percent alcohol solution over the antineoplastic drug spill to inactivate the drug. Nurses cover the drug preparation area, not the spill area, with a disposable paper pad and wear surgical latex to reduce the potential of skin contact and inhalation of drug powder. Pouring disinfectant on the drug spill is inappropriate. The spill area should be cleaned with detergent and water at least three times, then rinsed with clean water.

Question format: Multiple Choice Chapter 35: Intravenous Medications Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 799 15. A nurse is caring for a client with an intravenous catheter. When administering medication by IV push through the port, the nurse pinches the tubing upstream from the port when instilling the medication. Which of the following reasons explains the nurse's action?

A. provides access to the inside of the tubing B. creates negative pressure in the syringe C. validates that the IV catheter is in the vein D. ensures that the medication reaches the client Answer: D Rationale: Pinching the tubing when instilling it with the drug ensures that the tube does not get backfilled and that the drug gets administered to the client. Piercing the port with the needle provides access to the inside of the tubing. Negative pressure is created by pulling back the plunger of the syringe. Pinching the tubing when instilling it with the drug does not validate that the IV catheter is in the vein, but the presence of blood in the tubing does.

Question format: Multiple Choice Chapter 35: Intravenous Medications Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 795 16. A nurse is using a volume-control set to administer a dose of prescribed medication to a client. The nurse opens the lower clamp until the tubing is filled with fluid and then reclamps it. Which of the following statements explains the nurse's action?

A. provides diluent for the medication B. removes colonizing microorganisms C. purges air from the tubing D. mixes the drug throughout the fluid Answer: C

Rationale: The nurse opens the lower clamp until the tubing is filled with fluid and then reclamps it because doing so purges air from the tubing. In order to provide diluent for the medication, the nurse opens the clamp above the calibrated container, fills the chamber with the desired volume of fluid, and reclamps. To remove colonizing microorganisms, the nurse swabs the injection port on the calibrated container. To mix the medication thoroughly with the fluid, the nurse rotates the fluid chamber back and forth.

Question format: Multiple Choice Chapter 35: Intravenous Medications Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 796-797 17. A group of nursing students is learning about the rationale for intravenous (IV) drug and fluid administration as well as the various methods of delivering these parenterally. The intravenous (IV) route of administration delivers drugs or fluids directly into which structures? Select all that apply.

A. central veins B. capillaries C. arterioles D. central arteries E. peripheral veins Answer: A, E Rationale: The IV route involves drug administration through peripheral and central veins.

Question format: Multiple Select Chapter 35: Intravenous Medications Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 793 18. A nurse is providing care for an elderly client whose analgesia has been ordered by the IV route. While reviewing the client's medication administration record, the nurse observes that the dosage range differs from that of most young adult clients. What is the most likely rationale for this difference?

A. Older adults are often more susceptible to toxic drug effects than younger adults.

B. Older adults typically require higher doses than younger adults to achieve a therapeutic effect.

C. Older adults tend to absorb drugs into their adipose tissue, requiring lower doses.

D. Older adults benefit from more frequent administration of lower doses of drugs.

Answer: A Rationale: Older adults tend to metabolize and excrete drugs at a slower rate. This factor may predispose them to toxic effects from accumulation of medications. As well, older adults tend to have more free drug in proportion to bound drug because of diminished protein components in their blood and may, therefore, experience an increased effect from the drug.

Both of these phenomena necessitate lower doses. Increased frequency of administration does not offset these factors.

Question format: Multiple Choice Chapter 35: Intravenous Medications Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 793 19. A client has a saline lock (medication lock) in place in her left forearm. The client had been receiving normal saline at 75 ml per hour but this has now been discontinued, as the client is drinking well. There is an order for IV administration of an antibiotic and the nurse must now access the client's saline lock. What guideline should the nurse follow when planning when to flush the client's saline lock?

A. Flush before administering the drug but not after administering the drug.

B. Flush before administering the drug and after administering the drug.

C. Flush after administering the drug but not before administering the drug.

D. The nurse should not flush the saline lock because administration of the drug will keep it patent.

Answer: B Rationale: Nurses use the mnemonic "SAS" or "SASH" as a guide to the steps involved in administering IV medication into a lock. SAS stands for flush with Saline—Administer drug— flush again with Saline.

Question format: Multiple Choice Chapter 35: Intravenous Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 795 20. A recent nursing graduate who now works on an acute medicine unit administers many intravenous medications to clients on the unit. The nurse is vigilant when checking the five rights of safe medication administration because intravenous (IV) medications carry a heightened possibility of what nursing diagnosis?

A. Risk for Impaired Skin Integrity B. Risk for Fluid Volume Deficit C. Risk for Fluid Volume Excess D. Risk for Injury Answer: D Rationale: The IV route provides an immediate effect and drugs given in this manner cannot be retrieved once they have been delivered. Consequently, this route of drug administration is the most dangerous because of the significant risk for injury to the client. This risk supersedes the possibility of fluid imbalances, which can usually be resolved. Impaired skin integrity is not specifically associated with the IV route.

Question format: Multiple Choice Chapter 35: Intravenous Medications

Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 800 21. A client has rung his call bell and states that he is experiencing nausea. The client has an antiemetic ordered on a PRN (as-needed) basis and the drug is kept on hand on the unit in ampules. However, the nurse must combine the drug with an appropriate amount of normal saline in order to administer it by secondary infusion over 30 minutes. How much normal saline is the nurse likely to require?

A. 10 to 25 mL B. 25 to 50 mL C. 50 to 100 mL D. 100 to 250 mL Answer: C Rationale: A secondary infusion is the administration of a parenteral drug that has been diluted in a small volume of IV solution, usually 50 to 100 mL, over 30 to 60 minutes.

Question format: Multiple Choice Chapter 35: Intravenous Medications Cognitive Level: Analyze Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 796 22. A client is receiving three different intravenous medications. Two of the medications are not compatible with each other. Which type of access is most appropriate for this client?

A. 22-gauge IV catheter with two lumens B. 20-gauge IV catheter with three lumens C. 7-French triple lumen central catheter D. 18-gauge IV catheter port Answer: C Rationale: With a multiple lumen central line, incompatible medications can be administered simultaneously, as each lumen is a channel that exits the catheter at a separate location near the heart. While peripheral IV catheters could be used, more than one line would be necessary for this client. While peripheral catheters can have multiple lumens to administer medication through, the actual venous access is one channel, which allows medications to mix. This would not be an appropriate option for this client.

Question format: Multiple Choice Chapter 35: Intravenous Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 797 23. A nursing student is teaching the client regarding insertion of a central line catheter.

Which statement by the student would cause the nurse to intervene?

A. "Central lines can prevent multiple sticks to gain intravenous access."

B. "The risks are the same for a central line as they are for peripheral lines."

C. "Multiple medications can be infused through a central line catheter."

D. "A central line can stay in longer than a peripheral catheter."

Answer: B Rationale: Clot formation, pneumothorax, and bacteremia risks are higher with a central line.

As a result, the risks associated with central line placement are higher than those associated with a peripheral IV. Other options are correct regarding central lines.

Question format: Multiple Choice Chapter 35: Intravenous Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 797 24. Which action(s) by a licensed practical nurse (LPN) will illicit immediate intervention by the registered nurse (RN)? Select all that apply.

A. preparing to apply a topical antibiotic to a client with an abrasion B. assisting a client with congestion with prescribed nasal spray C. administering packed red blood cells to a client with anemia D. flushing an implanted central venous access device E. giving a diuretic by mouth to a client with excess fluid volume Answer: C, D Rationale: LPNs are generally not permitted within their scope of practice to administer IV chemotherapy, blood, or blood products; to push IV medications; or to administer medications and flushes through tunneled or implanted central venous access devices. Other actions are generally within the scope of practice of an LPN and do not require immediate RN intervention.

Question format: Multiple Select Chapter 35: Intravenous Medications Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 797 25. The experienced nurse is teaching a new nurse about chemotherapy administration. What teaching will the experienced nurse include? Select all that apply.

A. Double-glove when administering these drugs.

B. Chemotherapy agents are only toxic to the nurse if contact is made through skin.

C. Pharmacists must be specifically trained to prepare chemotherapy agents.

D. It is safe for pregnant nurses to administer chemotherapy.

E. Central venous catheters (CVCs) are often used to administer antineoplastic drugs.

Answer: A, C, E

Rationale: The experienced nurse will teach that a nurse should double-glove when administering chemotherapy agents to protect form exposure; that toxic effects can occur after skin contact, inhalation of tiny fluid droplets, or oral absorption of drug residue during hand-to-mouth contact; that pharmacists must be specifically trained to prepare chemo; that exposure can affect sperm, ova, or fetal tissue; and that CVCs are often used to administer chemo.

Question format: Multiple Select Chapter 35: Intravenous Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 798-799 26. A client is receiving a secondary infusion of a new antibiotic through a peripherally inserted central line (PICC). After 5 minutes of administration, the client reports itching and appears flushed. What is the most appropriate nursing intervention?

A. Remove the PICC line.

B. Flush the PICC line.

C. Clamp the PICC line.

D. Slow the rate through the PICC line.

Answer: C Rationale: The client may be experiencing a reaction to the antibiotic. Because intravenous administration occurs quickly, life-threatening reactions can also occur quickly. The first nursing action is to stop the infusion. Clamping the PICC line will stop the infusion. Slowing the rate is inappropriate, as this will not solve the problem if the client is having a reaction.

Removing the PICC is unnecessary, and flushing the line may introduce more of the medication to the client.

Question format: Multiple Choice Chapter 35: Intravenous Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 797 27. The nurse is providing discharge teaching for an older adult with arthritis who also has an implanted catheter. Which care does the nurse anticipate the client will need to provide catheter care?

A. home care B. long-term care facility C. inpatient admission D. assisted living Answer: A Rationale: The nurse anticipates the client will need home care to maintain and care for the implanted catheter, something that may be difficult to do with arthritis. The scenario presented does not indicate that the client needs long-term care or assisted living. An inpatient admission is not anticipated to be needed for the sole purpose of catheter care.

Question format: Multiple Choice Chapter 35: Intravenous Medications Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 798 28. A client has been diagnosed with stage II breast cancer and will require 8 weeks of chemotherapy. Which intravenous access would the nurse anticipate?

A. Groshong catheter tunneled under the subclavian vein B. PICC catheter inserted in the axillary vein C. 18 gauge peripheral IV port in the left forearm D. percutaneous catheter in the jugular vein Answer: A Rationale: A Groshong catheter is a tunneled catheter that is frequently used for extended therapy. The tunneling helps to secure the catheter, as well as reduce the potential for infection. The other catheter choices are not the most appropriate.

Question format: Multiple Choice Chapter 35: Intravenous Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 797 29. The nurse has inserted a peripheral intravenous catheter into a client. What is the appropriate action when a blood return is not obtained?

A. Insert the IV catheter further.

B. Begin infusing the IV fluid.

C. Change the site of catheter insertion.

D. Pinch the IV tubing to prohibit initial infusion.

Answer: C Rationale: If a blood return is not obtained, the IV catheter is not appropriately placed. The nurse will remove the IV catheter and change the site. It is not appropriate to insert the catheter further, begin infusion, or pinch the IV tubing.

Question format: Multiple Choice Chapter 35: Intravenous Medications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 796

Chapter 36 1. A client at a health care facility has been diagnosed with an upper respiratory disorder. The nurse understands that which of the following structures forms a part of the upper airway?

A. pharynx B. bronchi C. alveoli D. trachea Answer: A Rationale: The pharynx forms a part of the upper airway. The upper airway consists of the nose and pharynx, which is subdivided into the nasopharynx, oropharynx, and laryngopharynx. The lower airway consists of the trachea, bronchi, bronchioles, and alveoli.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 811 2. A nurse is caring for a client with a sinus infection at a health care facility. The physician has prescribed aerosol therapy to keep the mucous membranes moist and the mucus thin.

What is a benefit of using aerosol therapy?

A. promotes gravity drainage of secretions B. helps to produce mucus continuously C. encourages spontaneous coughing D. prevents infection of the lungs Answer: C Rationale: Aerosol therapy encourages spontaneous coughing. It also improves breathing and helps to raise sputum for diagnostic purposes by loosening secretions. Postural drainage is a positioning technique that promotes gravity drainage of secretions from various lobes or segments of the lungs. Aerosol therapy does not prevent lung infections. Aerosol therapy also does not produce mucus; the body continuously produces mucus.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 811 3. The nurse plans to collect a sputum specimen from a client for laboratory diagnosis after the client awakens. Which of the following reasons explains the nurse's choice of an early morning collection?

A. prevents contamination of specimen B. ensures more mucus is available

C. removes food residue and microorganisms D. mobilizes secretions from the lower airway Answer: B Rationale: The nurse should plan to collect a sputum specimen just after a client awakens or after an aerosol treatment, as this timing ensures that more mucus is available or is in a thin state. Encouraging the client to rinse his mouth with tap water removes some microorganisms and food residue. Collecting sputum in a sterile sputum specimen cup prevents contamination of the specimen. Instructing the client to take deep breaths, attempt a forceful cough, and to expectorate into the specimen container helps to mobilize secretions from the lower airway.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 814 4. A nurse is teaching a client in a long-term care facility the proper technique for performing postural drainage. Which of the following suggestions should the nurse give to the client?

A. Perform postural drainage once a day before lunchtime.

B. Avoid remaining in prescribed positions for more than 5 minutes.

C. Administer prescribed inhalant medications before performing postural drainage.

D. Remain in a prescribed position when tired or feeling lightheaded.

Answer: C Rationale: When teaching the client and family to perform postural drainage, the nurse should tell the client to administer prescribed inhalant medications before performing postural drainage. The nurse should also tell the client to plan and perform postural drainage two to four times daily, before meals and at bedtime. The nurse should remind the client to stay in each prescribed position for 15 to 30 minutes and to change to a comfortable position if the client is tired or feels lightheaded.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 813 5. A nurse needs to use a wall suction machine on an adult client with breathing difficulties due to chest congestion, as per the order from the client's physician. What amount of negative pressure should the nurse apply for this client?

A. 100 to 140 mm Hg B. 145 to 150 mm Hg C. 95 to 100 mm Hg D. 50 to 95 mm Hg Answer: A

Rationale: The nurse needs to apply a negative pressure between 100 and 140 mm Hg, depending on institutional policy, for adult clients when a wall suction machine is used.

When using a wall suction machine, 95 to 100 mm Hg of negative pressure is applied for children and 50 to 95 mm Hg of negative pressure is applied for infants.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 815 6. A nurse uses suction to remove liquid secretions from a client's chest. How far should the nurse advance the catheter in the client's nose so that the distal tip is placed in the client's pharynx?

A. 3 to 4 inches B. 5 to 6 inches C. 7 to 8 inches D. 8 to 9 inches Answer: B Rationale: The nurse should advance the catheter to 5 to 6 inches (12.5 to 15 cm) in the nose or 3 to 4 inches (7.5 to 10 cm) in the client's mouth in order to place the distal tip in the client's pharynx.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Remember Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 822 7. A nurse performs tracheal suctioning in order to remove the liquid secretions of a client at a health care facility. What should the nurse do to ease the insertion of the tube below the larynx?

A. Advance the catheter 5 to 6 inches in the throat.

B. Occlude the air vent and rotate the catheter.

C. Advance the catheter 3 to 4 inches in the mouth.

D. Wait until the client takes a breath before advancing the tubing.

Answer: D Rationale: In order to ease the insertion below the larynx, the nurse should wait until the client takes a breath and then advance the tubing 8 to 10 inches (20 to 25 cm). Advancing the catheter 5 to 6 inches (12.5 to 15 cm) in the nose or 3 to 4 inches (7.5 to 10 cm) in the mouth places the distal tip in the pharynx. The nurse occludes the air vent and rotates the catheter as it is withdrawn in order to maximize the effectiveness of suctioning.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential

Integrated Process: Nursing Process Reference: p. 822 8. A nurse has to perform nasotracheal suctioning for a client with difficulty breathing due to congestion. Which statement describes the purpose of nasotracheal suctioning?

A. removes secretions from the upper portion of the lower airway through a nasally inserted catheter B. removes secretions from the bottom portion of the lower airway through a nasally inserted catheter C. removes secretions from the mouth using a Yankauer-tip or tonsil-tip catheter D. removes secretions from the throat through a nasally inserted catheter Answer: A Rationale: Nasotracheal suctioning is the removal of secretions from the upper portion of the lower airway through a nasally inserted catheter. Oral suctioning is the removal of secretions from the mouth using a Yankauer-tip or tonsil-tip catheter. Nasopharyngeal suctioning means removing secretions from the throat through a nasally inserted catheter.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 815 9. A nurse at a health care facility uses a tonsil-tip catheter to remove the secretions from the mouth of a client with chest congestion. Which suctioning technique is the nurse using in this case?

A. nasopharyngeal suctioning B. nasotracheal suctioning C. oropharyngeal suctioning D. oral suctioning Answer: D Rationale: The nurse uses oral suctioning to remove liquid secretions from the mouth of a client with chest congestion. Nurses perform oral suctioning, removal of secretions from the mouth, with a suctioning device called a Yankauer-tip or tonsil-tip catheter. Nasopharyngeal suctioning is the removal of secretions from the throat through a nasally inserted catheter.

Nasotracheal suctioning is the removal of secretions from the upper portion of the lower airway through a nasally inserted catheter. Oropharyngeal suctioning is the removal of secretions from the throat through an orally inserted catheter.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 816

10. A nurse at a health care facility is caring for a client who requires an artificial airway. The nurse could use an oral airway for which client?

A. client who is recovering from general anesthesia B. client who has an upper airway obstruction C. client who requires prolonged mechanical ventilation D. client with saddle nose deformity and difficulty breathing Answer: A Rationale: The nurse could use the oral airway for a client who is recovering from general anesthesia. An oral airway is a curved device that keeps a relaxed tongue positioned forward within the mouth, preventing the tongue from obstructing the upper airway. It is most commonly used in clients who are unconscious and cannot protect their own airways, such as those recovering from general anesthesia or a seizure. Clients who are less stable, have an upper airway obstruction, or require prolonged mechanical ventilation and oxygenation are more likely to be candidates for a tracheostomy, a surgically created opening into the trachea.

A client with saddle nose deformity and difficulty breathing may have an upper airway obstruction and would require a tracheostomy tube instead of an oral airway.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 816 11. A nurse is caring for a client who is prone to epileptic seizures. The nurse uses an oral airway in order to maintain the client's airway. What should the nurse do in order to open the airway and facilitate the insertion of the oral airway in the client?

A. Perform oral suctioning if necessary.

B. Open the client's mouth using a gloved finger and thumb.

C. Position the client supine with neck hyperextended.

D. Hold the airway so that the curved tip points upward.

Answer: C Rationale: In order to open the airway and facilitate the insertion of the artificial airway in the client, the nurse should place the client in the supine position with the neck hyperextended, unless this is contraindicated for the client. Performing oral suctioning clears the saliva from the mouth and prevents aspiration. The nurse should open the client's mouth using a gloved finger and thumb or a tongue blade to prevent injury to the teeth during insertion. Holding the airway so that the curved tip faces upward toward the roof of the mouth is done in order to prevent pushing the tongue into the pharynx during insertion.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 817

12. A client at a health care facility who requires prolonged mechanical ventilation has a tracheostomy tube inserted through a surgically created opening into the trachea. The tracheostomy tube also has a balloon cuff. How does the inflated balloon cuff aid the client?

A. prevents the aspiration of oral fluids B. keeps the tongue in a relaxed position C. eliminates the need for frequent suctioning D. facilitates insertion of the tracheostomy tube Answer: A Rationale: A tracheostomy tube may have a balloon cuff; when inflated, the cuff seals the upper airway to prevent aspiration of oral fluids and provide more efficient ventilation. An oral airway is a curved device that keeps a relaxed tongue positioned forward within the mouth, preventing the tongue from obstructing the upper airway. During insertion of a tracheostomy tube, an obturator, a curved guide, is used. Most clients with tracheostomy tubes require frequent suctioning.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 818 13. A nurse at a health care facility is caring for a client who requires prolonged oxygenation and therefore has a tracheostomy tube to aid ventilation. When should the nurse perform tracheostomy care for this client?

A. at least every 4 hours B. after performing suctioning C. at least every 8 hours D. after feeding the client Answer: C Rationale: The nurse should perform tracheostomy care at least every 8 hours, or as often as clients need to keep the secretions from becoming dried and then narrowing or occluding the airway. Tracheal suctioning may happen after or at the same time as tracheostomy care. The nurse need not wait until after suctioning or feeding the client to perform tracheostomy care.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 818 14. A nurse needs to provide tracheostomy care to a client at a health care facility. What should the nurse do before performing the tracheostomy care in order to provide continuity of care?

A. Check the nursing care plan to determine the schedule for providing care.

B. Avoid reviewing the client's records for documentation concerning previous care.

C. Assess the condition of the dressing and skin around the tracheostomy tube.

D. Determine the client's understanding of tracheostomy care.

Answer: A Rationale: In order to provide continuity of care, the nurse should check the nursing plan to determine the schedule for tracheostomy care. The nurse should review the client's records for documentation concerning previous tracheostomy care, as it provides a database for comparison. In order to determine if the client needs skin care and a change of dressing, the nurse should assess the condition of the dressing and the skin around the tracheostomy tube.

Determining the client's understanding of tracheostomy care provides an opportunity for health education.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 823 15. The nurse is caring for an elderly client who is having difficulty raising secretions in order to clear her airway. The nurse understands that which of the following conditions affects the client's ability to clear her airway?

A. reduced air exchange B. exposure to airborne toxins C. reduced efficiency in ventilation D. atrophy of the larynx Answer: D Rationale: The nurse should understand that the muscular structures of the larynx tend to atrophy with age, which can affect the ability to clear the airway in the elderly client.

Reduced air exchange and efficiency in ventilation are the primary age-related changes affecting the older adult's respiratory system. Exposure to airborne toxins leads to pathologic pulmonary changes.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 811 16. The nurse is caring for an elderly client with a persistent, dry cough. Which of the following would be the result if this persistent, dry cough is not treated quickly?

A. consumes the client's energy B. eliminates respiratory secretions C. contributes to retention of secretions D. influences the production of respiratory secretions Answer: A

Rationale: The nurse should be aware that if not relieved quickly, a persistent, dry cough may consume the elderly client's energy and result in fatigue. Usually, the bases of the older adult's lungs receive less ventilation, contributing to retention of secretions, decreased air exchange, and compromised ventilation. Deep-breathing exercises improve the elderly client's ability to eliminate respiratory secretions. Weather conditions such as high humidity or damp conditions influence the production of respiratory secretions.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 811 17. A nurse is performing an admission assessment of a client who has multiple health problems, including a history of respiratory disease. The nurse is aware of the priority of airway management in this client. How is airway management best defined?

A. the prevention and treatment of infections in the upper and lower airway B. the systematic application of nursing interventions that address the neck and thorax C. the maintenance of natural or artificial airways for compromised clients D. the assessment of gas exchange and the mobilization of secretions Answer: C Rationale: Airway management is the application of essential nursing skills that maintain natural or artificial airways for compromised clients. This may involve the treatment of infections or assistance with the mobilization of secretions, but these are not definitive of airway management. Interventions involving a client's neck or thorax are not always aimed at issues involving the airway.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 810 18. The nurse is providing care for a client who has a persistent cough that is producing copious quantities of thick, sticky secretions. What intervention should the nurse perform to decrease the viscosity (thickness) of the client's respiratory secretions?

A. Promote increased fluid intake.

B. Teach the client deep breathing exercises.

C. Administer bronchodilators as ordered.

D. Implement a scheduled program of postural drainage.

Answer: A Rationale: Increased fluid intake can reduce the viscosity of secretions, making them easier to mobilize. Other interventions such as postural drainage, bronchodilators, and deep breathing may aid respiratory function, but none of these has the potential to reduce the thickness of the client's secretions.

Question format: Multiple Choice

Chapter 36: Airway Management Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 811 19. A client suffered a spinal cord injury during a motor vehicle accident, which necessitated the creation of a tracheostomy. What nursing diagnosis should the nurse recognize as a likely consequence of this intervention?

A. Risk for deficient fluid volume B. Impaired verbal communication C. Unilateral neglect D. Decisional conflict Answer: B Rationale: Because a tracheostomy tube is below the level of the larynx, clients usually cannot speak. A tracheostomy does not necessarily create a risk for fluid volume deficit.

Functional deficits are unlikely to be unilateral and the client's possible decisional conflict is not likely to be a direct consequence of the tracheostomy.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 818 20. An 81-year-old client is being rehabilitated in an inpatient setting following her recovery from the acute stages of a stroke. The stroke resulted in dysphagia, which creates a risk of what respiratory problem?

A. increased viscosity (thickness) of secretions B. aspiration of food or fluid C. increased quantity of secretions D. laryngeal atrophy Answer: B Rationale: Older adults with difficulty swallowing (dysphagia), often associated with strokes or middle and late stages of dementia, are more vulnerable to aspiration pneumonia.

Evaluation of dysphagia is important for implementing appropriate interventions to prevent aspiration. Dysphagia does not directly increase the viscosity or quantity of secretions.

Atrophy of the larynx is not a direct result of dysphagia.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 811

21. A client has been admitted to the emergency department with a head injury that has required the insertion of an artificial oral airway. What is the primary purpose of this intervention?

A. to prevent aspiration of saliva or secretions B. to prevent the client's tongue from obstructing the airway C. to bypass the nasal portion of the client's airway D. to prevent injury to the client's oral mucosa Answer: B Rationale: An oral airway is used to ensure airway patency by preventing the tongue from obstructing the upper airway. It does not bypass the airway, prevent aspiration, or protect the oral mucosa.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 816 22. The health care provider has prescribed a short-acting beta-2 agonist (SABA) for a client with a history of bronchospasm. What teaching about this drug will the nurse include?

A. "Use this drug daily to prevent bronchospasm."

B. "This drug is to be used as a rescue inhalant."

C. "You only need this drug if you are exercising."

D. "Always keep this drug at home where you can reach it quickly."

Answer: B Rationale: SABAs are used for quick relief and in rescue situations. They are not drugs to be used daily, or just when exercising. The client should be taught to keep the drug handy at all times, not just at home.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 811 23. The health care provider has prescribed a long-acting bronchodilator for a client with a history of bronchospasm. What teaching about this drug will the nurse include?

A. "You only need this drug if you are exercising."

B. "Take this drug when you need quick relief."

C. "This drug is to be used as a rescue inhalant."

D. "Use this drug daily to prevent bronchospasm."

Answer: D

Rationale: Long-acting bronchodilators are used daily for preventing asthma attacks or exercise-induced bronchospasm. SABAs are used for quick relief and in rescue situations.

They are not to be used only when exercising.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 811 24. The nurse is teaching the family of a client with a tracheostomy about home care. Which family statement requires nursing intervention?

A. "Our loved one will not be able to speak."

B. "We will check on our loved one often."

C. "We will remove the outer cannula for cleaning."

D. "Our loved one may require frequent suctioning."

Answer: C Rationale: The inner cannula is removed periodically for cleaning. The outer cannula stays in place until the entire tube is replaced. All other family statements are appropriate and demonstrate understanding.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 816 25. The nurse is creating a plan of care for a client with ineffective airway clearance related to a weak, persistent cough. What expected outcome will the nurse identify for the client?

A. clear airway as evidenced by clear lung sounds by Friday B. client smokes two packs of cigarettes daily C. performs oral/pharyngeal suctioning as needed D. maintains 2,000-3,000 mL/fluid intake over 24-hour period Answer: A Rationale: A reasonable expected outcome is that the client will achieve a clear airway as evidenced by clear lung sounds by a certain time frame. Smoking two packs of cigarettes daily is an assessment finding. Performing suctioning as needed and maintaining fluid intake are interventions.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 819

26. The nurse is providing tracheostomy care to a client. After removing the soiled stomal dressing and discarding it, what is the nurse's next action?

A. Open a sterile tracheostomy kit.

B. Wash hands or perform an alcohol-based hand rub.

C. Don sterile gloves.

D. Unlock the inner cannula of the tracheostomy.

Answer: B Rationale: The nurse will first wash hands or perform an alcohol-based hand rub to minimize risk for infection. Then the nurse will open the kit, don sterile gloves and set up the basins, and proceed to provide care by unlocking and removing the inner cannula for cleansing.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 821 27. The nurse is caring for four clients on a pulmonary hospital floor. Which client does the nurse identify that would most benefit from vibration therapy?

A. 22-year-old client with cystic fibrosis B. 40-year-old client with influenza C. 67-year-old client with chronic obstructive pulmonary disease D. 90-year-old client with weakness and cough Answer: D Rationale: Vibration is usually used as an alternative to percussion and is beneficial for frail clients. Thus, the 90-year-old client with weakness and cough would benefit the most. The other clients would not benefit as much from vibration therapy.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 815 28. A client with chronic obstructive pulmonary disease (COPD) continues to smoke cigarettes. What is the appropriate nursing action? Select all that apply.

A. Remind the client to not smoke near oxygen.

B. Teach the client that inhaled smoke increases mucus production.

C. Advocate for the client's autonomy in making this decision.

D. Forbid the client from smoking in any environment.

E. Acknowledge that the client will likely die from this behavior.

Answer: A, B, C Rationale: The nurse will remind the client of the dangers of smoking around oxygen, and teach the client that inhaled smoke increases mucus production, which can contribute to

breathing difficulties. The nurse can act as the client's advocate since the client does have autonomy. It is not therapeutic to forbid the client from smoking in any environment (although the nurse can enforce a no-smoking rule in the hospital or clinic setting), nor is it therapeutic to point out that the client will likely die from this behavior.

Question format: Multiple Select Chapter 36: Airway Management Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 819 29. A client has come to the urgent care with a congested cough. The client states, "I am having trouble coughing anything up, but I feel it rattling around in my chest." Which type of medication does the nurse anticipate will be prescribed?

A. decongestant B. antihistamine C. expectorant D. antipyretic Answer: C Rationale: An expectorant, which loosens the adhesive quality of mucus, will help the client to cough up secretions. A decongestant alleviates nasal congestion, an antihistamine is used for allergic symptoms, and an antipyretic is used to treat fever.

Question format: Multiple Choice Chapter 36: Airway Management Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 819 30. The nurse is teaching a client about performing postural drainage. Which teaching will the nurse include? Select all that apply.

A. Take inhalant medications after performing postural drainage.

B. Keep tissues and a waterproof container nearby for sputum.

C. Remain in the prescribed position for at least 45 minutes.

D. Resume a comfortable position if lightheadedness occurs.

E. Perform this procedure two to four times daily.

Answer: B, D, E Rationale: The nurse will teach the client to take inhalant medications before performing postural drainage, to keep tissues and a waterproof container nearby to collect sputum, to remain in the prescribed position for 15-30 minutes (no longer than 45 minutes), to resume a comfortable position if lightheadedness occurs, and to perform this procedure 2-4 times daily.

Question format: Multiple Select Chapter 36: Airway Management Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning

Reference: p. 813

Chapter 37 1. A nurse needs to perform the Heimlich maneuver on an 8-month-old infant with a partial airway obstruction. Which action should the nurse perform?

A. Support the client with a safety belt on a table.

B. Use the heel of one hand to administer back blows.

C. Use finger sweeps to locate the obstruction.

D. Give a series of subdiaphragmatic thrusts.

Answer: B Rationale: For infants, the nurse or rescuer uses the heel of one hand to administer five back blows between the shoulder blades. The rescuer supports the baby over his forearm, not with a safety belt on a table or stretcher. The nurse does not use finger sweeps unless the nurse can see the obstructing object. The nurse does not give a series of subdiaphragmatic thrusts to infants but, rather, to children between 1 and 8 years of age.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 828 2. A nurse is using an automated external defibrillator (AED) to try to resuscitate a middleaged client outside the hospital. The nurse knows that, ideally, an AED should be used within how much time of beginning resuscitation efforts outside the hospital?

A. 5 minutes B. 10 minutes C. 15 minutes D. 20 minutes Answer: A Rationale: Ideally, an automated external defibrillator (AED) is used within 5 minutes of beginning resuscitation efforts outside the hospital and within 3 minutes of beginning resuscitation efforts within a health care facility. Using an AED within 10, 15, or 20 minutes of resuscitation efforts outside the hospital may not be of much help because the chances of resuscitating the client are diminished.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 834 3. A nurse is delivering five chest thrusts to a conscious infant with an airway obstruction.

Which steps should the nurse take if the client becomes unconscious?

A. Turn the infant in prone position and give five back slaps.

B. Give chest thrusts at the rate of one per second.

C. Sweep a finger in the throat to see if there is an object.

D. Turn the infant supine and perform cardiopulmonary resuscitation (CPR).

Answer: D Rationale: If the infant becomes unconscious, the rescuer performs cardiopulmonary resuscitation (CPR). A nurse does not sweep a finger inside the infant's throat unless the object is visible. Nurses should not waste time giving chest thrusts or giving back slaps to an infant when the infant is unconscious.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 828 4. A nurse needs to relieve a client with airway obstruction. Which of the following interventions carries a risk of spinal injury?

A. head-tilt technique B. chin-lift technique C. jaw-thrust technique D. rescue-breathing technique Answer: C Rationale: The jaw-thrust technique is not recommended for lay rescuers because it is difficult to perform safely and may cause injury to the spine. In the absence of head or neck trauma, nurses use the head-tilt or chin-lift technique for opening the airway. The rescuebreathing technique is performed through the client's mouth, nose, or stoma. Rescue breathing is not injurious to the spine, but rescuers should use protective face shield devices.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 831 5. A nurse is assisting a client who has a partial airway obstruction and is coughing. What resuscitation efforts should the nurse perform to provide relief to a client with a partial airway obstruction of the throat?

A. Perform the Heimlich maneuver.

B. Encourage and provide physical support to the client.

C. Sweep the finger in the throat and remove the obstruction.

D. Activate the emergency medical system immediately.

Answer: B Rationale: Other than encouraging and supporting the client, a partial obstruction requires no additional resuscitation efforts. The Heimlich maneuver is performed on clients with

complete, not partial, obstructions. It involves the use of subdiaphragmatic thrusts or chest thrusts. Nurses avoid sweeping the finger inside a client's throat to remove an obstruction unless the obstruction is clearly visible. Activating the emergency medical system is appropriate if the client's independent efforts to relieve a partial obstruction are unsuccessful.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 828 6. A nurse is performing the Heimlich maneuver on a young client to relieve a mechanical airway obstruction. Which action should the nurse perform to increase intrathoracic pressure?

A. Give five quick abdominal thrusts above the navel.

B. Assist the client onto the floor and into a prone position.

C. Activate the emergency response system.

D. Avoid opening the client's airway with the head-tilt maneuver.

Answer: A Rationale: For all people older than 1 year of age, the rescuer gives a series of five quick abdominal upward thrusts slightly above the navel to increase intrathoracic pressure. The rescuer opens the client's airway with the head-tilt or chin-lift maneuver and continues administering upward thrusts if initial efforts are not successful. Only if the client becomes unconscious should nurses assist clients to the floor, activate the emergency response system, and begin performing cardiopulmonary resuscitation (CPR).

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 828 7. A nurse is giving chest thrusts with two fingers to an infant with a partial obstruction.

Which place is most suitable for giving chest thrusts to an infant?

A. above the nipple line B. over the heart C. the middle of the sternum D. below the rib cage Answer: C Rationale: Nurses turn the infant supine and use two fingers to give five chest thrusts at approximately one per second to the middle of the breastbone just below the nipple line, not above the nipple line. They do not give thrusts below the rib cage or close to the heart. They should repeatedly alternate five back blows and chest thrusts until the object is dislodged or the infant fails to respond.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Remember

Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 828 8. Two nurses have initiated cardiopulmonary resuscitation (CPR) on a middle-aged client with cardiac arrest. An automated external defibrillator (AED) is not available, and the arrival of emergency resuscitation personnel is delayed. When should the nurse first assess the victim to determine whether CPR is effective?

A. after five cycles of compressions and ventilations B. after the arrival of emergency resuscitation personnel C. at the rate of 15 compressions to 2 ventilations D. after the client shows signs of spontaneous breathing Answer: A Rationale: The nurses or rescuers should perform an assessment after five cycles of compressions and ventilations and every few minutes thereafter. Assessment for signs of spontaneous breathing can take place only by interrupting chest compressions; such interruptions should not last more than 5 seconds. The nurse performs CPR at a rate of 15 compressions to 2 ventilations. The nurse does not wait for assessment until the emergency resuscitation personnel arrive but, rather, assesses the client periodically to check if the CPR is effective or not.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Remember Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 835 9. A nurse is performing mouth-to-mouth breathing for a client with a myocardial infarction.

The nurse is giving a breath that lasts a full second. The nurse's action should bring about which of the following desired effects?

A. Promote systemic blood flow.

B. Increase pressure in the ventricles.

C. Increase pressure in thoracic blood vessels.

D. Prevent regurgitation and aspiration.

Answer: D Rationale: Giving a breath that lasts a full second reduces the potential for distending the esophagus and stomach, which may promote regurgitation and aspiration. Chest compression increases pressure in the ventricles, increases pressure in thoracic blood vessels, and also promotes systemic blood flow.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 833

10. A nurse is performing cardiopulmonary resuscitation (CPR) on a client with myocardial infarction. Which of the following can be a reason for interrupting CPR? A. The client exhibits cyanosis.

B. The rescuer becomes exhausted.

C. The client opens his or her eyes.

D. The client makes hoarse sounds.

Answer: B Rationale: Basic CPR is not interrupted for more than 7 seconds, except when the rescuer becomes exhausted or there is a pulse and the client resumes breathing. The rescuer or nurse does not stop CPR if the client exhibits cyanosis, makes hoarse sounds, or opens his or her eyes because these could be signs of partial or complete airway obstruction.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Remember Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 831 11. A nurse is assisting a very obese client with a partial airway obstruction caused by a large piece of food. Which action should the nurse take to relieve the client's obstruction?

A. Give back blows.

B. Give subdiaphragmatic thrusts.

C. Give a chest thrust with two fingers.

D. Give chest thrusts.

Answer: D Rationale: For obese and pregnant clients, nurses give chest thrusts. To avoid any further complications, nurses avoid giving subdiaphragmatic thrusts to pregnant and obese clients.

Nurses give chest thrusts with two fingers to infants along with alternating back blows.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 828 12. After opening the airway of a client with a complete airway obstruction, the nurse helps the client lie in the recovery position. Which reason explains the nurse's action?

A. to assess the spontaneous breathing of the client B. to maintain an open airway and prevent aspiration of fluid C. to allow the client to regain strength D. to maximize ventilation to the lower airway Answer: B

Rationale: After opening the airway, nurses place a breathing client in the recovery position to maintain an open airway and prevent aspiration of fluid. If breathing is not restored within 10 seconds, the client remains supine, and two rescue breaths are administered.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 832 13. A nurse is performing a chest compression on an adult client. The nurse knows that, for the chest compression to be effective, the correct ratio of chest compressions to rescue breaths should be: A. 60:4.

B. 15:2.

C. 30:30.

D. 30:2.

Answer: D Rationale: The correct sequence is 30 chest compressions followed by 2 rescue breaths, or a ratio of 30:2. If there are 2 rescuers and the client is less than 1 year old, the ratio is 15 compressions to 2 breaths (15:2); if the rescuer is alone; a 30:2 ratio is maintained.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 830 14. A nurse has attached electrode pads to a client's chest. However, the monitor displays an error message. What could be responsible for the message?

A. The client's skin is diaphoretic.

B. The client is extremely obese.

C. The client has dysrhythmia.

D. The client is very young.

Answer: A Rationale: If the monitor displays an error message, it may be because the client's skin is diaphoretic or extremely hairy, which interferes with effective contact. The rescuer can wipe the skin with a towel, shave or clip chest hair, and apply a second set of electrode pads. The monitor does not display an error message because the client is young, has dysrhythmia, or is very obese.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 834

15. A nurse is attending to a client who has had a cardiac arrest. Which step does the nurse take first in the chain of survival?

A. early cardiopulmonary resuscitation B. early cardiac defibrillation C. early access of emergency services D. early advanced life support Answer: C Rationale: The first step involved in the chain of survival is early recognition and access of emergency services. This is followed by early cardiopulmonary resuscitation (CPR), early defibrillation, and early advanced life support.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 829 16. A nurse is administering a shock from an automated external defibrillator to a client with cardiac arrest. What is the most important action that the nurse should perform?

A. Give five rescue breaths.

B. Say, "Everybody clear."

C. Place both hands correctly on the client's chest.

D. Ensure that emergency medications are accessible.

Answer: B Rationale: The nurse says, "Everybody clear," in order to prevent accidental shock to members of the team and then administers shock to the client when the automated external defibrillator (AED) indicates "shock." Nurses check the correct placement of hands when performing chest compressions but would risk electrical shock by doing so during defibrillation. They administer emergency medications to the client when providing early advanced life support. Nurses do not perform rescue breathing on a client when defibrillating.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 834 17. A nurse is assisting an obese client with a total airway obstruction caused by a large piece of food. Which of the following actions should the nurse take to relieve the client's obstruction?

A. Give five back blows.

B. Give five subdiaphragmatic thrusts.

C. Give a chest thrust with two fingers.

D. Give five chest thrusts.

Answer: B Rationale: For all people older than 1 year, the rescuer gives a series of five quick subdiaphragmatic (abdominal) upward thrusts slightly above the navel. These guidelines do not differ based on whether the client is obese. Nurses give chest thrusts with two fingers to infants along with alternating back blows.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 828 18. A nurse in a long-term care facility regularly oversees the lunchtime meal in the facility's dining room. What event should signal the nurse to the fact that a resident is experiencing an airway obstruction?

A. A resident stops eating and quickly turns pale.

B. A resident grasps at her throat and wheezes.

C. A resident falls off his chair and clutches his chest.

D. A resident stops eating and vomits unexpectedly.

Answer: B Rationale: Grasping at the throat and wheezing often accompany a partial airway obstruction.

Pallor can have many causes, but the nurse would be prudent to rule out an airway obstruction if a client displays sudden pallor. Clutching at the chest suggests cardiac ischemia. Obstructions do not normally precede vomiting.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 828 19. A nurse has pressed the code blue button at a client's bedside after finding her unresponsive and has initiated resuscitation efforts. What is the priority in the procedure of this client's resuscitation?

A. airway B. breathing C. circulation D. consciousness Answer: C Rationale: Resuscitation must proceed with CAB (circulation, airway, breathing if the rescuer is a trained health provider or hands-only chest compressions if untrained in defibrillation) of cardiopulmonary resuscitation.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Apply

Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 830 20. A client in apparent cardiac arrest has been brought to the emergency department by emergency medical services. The nurse immediately recognizes the need to implement the principles of the chain of survival. During which component of the chain of survival will medications be administered to the client?

A. early cardiopulmonary resuscitation B. rapid defibrillation C. effective advanced life support D. rapid cardiac assessment Answer: C Rationale: Advanced cardiac life support (ACLS) involves the systematic administration of drugs that affect the cardiovascular system. Cardiopulmonary resuscitation (CPR) does not involve the administration of medication, and defibrillation relies on electrical stimulation, rather than pharmacological interventions. Rapid cardiac assessment is not a discrete component of the chain of survival.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 835 21. A nurse has been called to the scene where an individual is unconscious after experiencing an airway obstruction. The nurse has consequently initiated chest compressions.

This intervention will help the client in what way?

A. increasing intrathoracic pressure in order to clear the obstruction B. increasing cardiac output in order to help the client spontaneously clear the obstruction C. creating temporary pressure on client's vascular system to facilitate airway clearance D. stimulating the client's vagus nerve to relax the upper airway Answer: A Rationale: Chest compression in CPR creates enough pressure in unconscious victims to eject a foreign body from the airway. The efficacy of chest compressions in obstructed clients is not related to their effect on cardiac output, the vascular system, or the nervous system.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 828 22. A nurse has initiated rescue breathing with the aid of a one-way valve mask. What is the primary benefit of using this mask?

A. maintains positive pressure in the client's lungs while the nurse stops exhaling to take a breath B. reduces the nurse's risk of acquiring an infectious disease from the client C. directs the nurse's breath into the lower airway by preventing air from escaping through the client's nose D. ensures an airtight seal between the client's mouth and the nurse's mouth Answer: B Rationale: The nurse should use a one-way valve mask or other protective face shield if available. These devices theoretically reduce the potential for acquiring infectious diseases.

They do not maintain positive lung pressure or redirect the flow of air. A valve mask may facilitate a higher-quality seal around the client's mouth, but their primary purpose is for protection against infection.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 832 23. A client is eating steak and suddenly exhibits coughing and holding of the throat. What is the priority nursing response?

A. Monitor the client.

B. Begin the Heimlich maneuver.

C. Activate the emergency medical system (EMS).

D. Administer five successive back blows.

Answer: A Rationale: Because the client is able to cough, this indicates a partial obstruction. Other than encouraging and supporting the victim, a partial airway obstruction requires no additional resuscitation efforts. If the victim's independent efforts to relieve a partial obstruction are unsuccessful or if the situation worsens, EMS should be activated and the Heimlich should be performed. Back blows are not appropriate for an adult.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 828 24. A nurse finds a victim unconscious on the floor of a restaurant. What is the first nursing action?

A. Recognize and call for emergency services.

B. Begin chest compressions.

C. Search for an automated external defibrillator (AED).

D. Perform a finger sweep of the victim's mouth.

Answer: A

Rationale: Anytime the nurse finds an unconscious client who may be experiencing a cardiac arrest, it is imperative to initiate the chain of survival, which starts with recognizing and calling for help. Chest compression and an AED may follow. Sweeping the victim's mouth assumes that the victim choked and is not appropriate.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 829 25. The nurse has instructed a bystander to call for help after finding an unconscious victim on the floor in a restaurant. Which information will the nurse instruct the bystander to give when calling 911? Select all that apply.

A. The victim does not have anyone with them.

B. The victim is not breathing, and CPR has been started.

C. There is no AED on site.

D. The address is 1289 Collins Way. E. The victim was found on the floor near a table where they were dining.

F. The victim may have been drinking a glass of wine.

G. The victim does have a mobile phone.

Answer: B, C, D, E Rationale: The person making the call gives the following facts: the address where assistance is needed, a description of the situation, the victim's current condition, and what actions have been taken. Informing of AED availability is important. However, the fact that the victim does have a mobile phone, may have been drinking wine, and does not have someone with them does not affect the overall care situation.

Question format: Multiple Select Chapter 37: Resuscitation Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 830 26. A client is choking on food. Which assessment data would the nurse expect with a partial or complete airway obstruction? Select all that apply.

A. coughing or gagging B. verbally asking for help C. holding the throat D. asking for water to drink E. attempting to clear the throat F. audible wheezing Answer: A, C, E, F

Rationale: Coughing or gagging, holding the throat, clearing the throat, and audible wheezing are all signs of partial and/or complete airway obstruction. The victim will not be able to talk and will likely refuse food or water, rather than ask for water.

Question format: Multiple Select Chapter 37: Resuscitation Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 828 27. While placing shingles on a house, a roofer fell two stories from the roof to the concrete.

Which emergency response is most appropriate?

A. Use the jaw-thrust maneuver to open the airway.

B. Roll the victim into the recovery position.

C. Use the chin-lift technique to provide rescue breaths.

D. Perform a finger sweep to clear the airway.

Answer: C Rationale: The jaw-thrust maneuver should not be used to open the airway if spinal injury is suspected. The victim should not be rolled until the spine has been stabilized. The chin-lift technique is the most appropriate method to open the airway. Performing a finger sweep is not indicated, as the victim was not choking.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 831 28. A nurse applied an automated external defibrillator (AED) to a victim found unconscious on the floor at the mall. The AED advises a shock to the victim. What is the nursing priority?

A. Inform the victim that they will feel a shock.

B. Ask the family if the victim has an advance directive.

C. Make sure that no one is touching the victim or the area around the client.

D. Continue chest compressions at a rate of 110 per minute.

Answer: C Rationale: The priority is the safety of the rescuer and those around the victim. When the AED indicates "shock," the rescuer looks to make sure that no one is touching the victim.

Saying "Clear!" or "Everybody clear!" in a loud voice is recommended before pressing the shock button. The victim is unconscious, so they will not be aware of the impending shock.

After the shock, if there is no pulse, the rescuer will resume compressions. Advance directive information may not be available and is not the priority in this situation.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process

Reference: p. 834 29. An 8-month-old had a small toy in her mouth and is now drooling and appears distressed, but the infant is not crying. Which intervention should be first?

A. Administer five chest thrusts.

B. Administer five back slaps.

C. Hold the infant prone with the head downward.

D. Place the infant supine.

Answer: C Rationale: For infants, the rescuer supports the baby over his or her forearm. Holding the infant prone with the head downward, the rescuer uses the heel of one hand to administer five back slaps between the shoulder blades. The rescuer turns the infant supine and uses two fingers to give five chest thrusts at approximately one per second to the middle of the breastbone, just below the nipple line.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 828 30. A 6-year-old is found unconscious with no pulse. Which nursing intervention is most appropriate?

A. Begin chest compressions in the center of the chest between the nipples.

B. Begin chest compressions one finger width below the nipples.

C. Begin chest compressions below the xiphoid process.

D. Begin chest compressions by encircling the chest with the hands.

Answer: A Rationale: Chest compressions on a child (1 to 8 years old) should be in the center of the chest between the nipples. Other options are not appropriate for this age.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 831 31. A 7-year-old is found unconscious with no pulse. Which nursing intervention is most appropriate?

A. Compress the chest one-third the depth of the chest.

B. Compress the chest at a rate of 80 to 90 per minute.

C. Compress the chest 2 inches.

D. Compress the chest below the nipples.

Answer: A

Rationale: For a child, the chest should be compressed at least one-third the depth of the chest, about 2 inches. The appropriate rate is 100 to 120, and the location for compression is between the nipples. Therefore, the other answers are incorrect.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 831 32. A client is discussing advance directives with the nurse. Which statement made by the client indicates a need for further teaching?

A. "I don't want to be on a ventilator, but I am willing to receive medication."

B. "If I sign a DNR, then I may not receive continued care."

C. "My daughter is my power of attorney, and she knows my wishes."

D. "Without a signed DNR, I will receive all resuscitation efforts."

Answer: B Rationale: Some older adults fear if they specify that they do not wish to be resuscitated, they will receive less-than-appropriate care and treatment of their illness. The client's record must contain his or her resuscitation status. If no information is documented, CPR is administered in any life-threatening situation, regardless of the client's age.

Question format: Multiple Choice Chapter 37: Resuscitation Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 835

Chapter 38 1. A client severely injured in a motor vehicle accident is rushed to the health care facility with severe head injuries and profuse loss of blood. Which sign indicates approaching death?

A. The frequency of urination decreases.

B. The arms and legs are warm to touch.

C. The client is calm and peaceful.

D. The client's breathing becomes noisy.

Answer: D Rationale: Noisy breathing, or death rattle, is common during the final stages of dying because of the accumulation of secretions in the lungs. Reduced urination is not seen during the final stages of dying. Instead, the client develops loss of control over bladder and bowels due to loss of neurological control. The peripheral parts of the client's body such as the arms and the legs are cold to touch (not warm) because the circulation is directed away from the periphery and toward the core of the body. Clients in the last stages of dying are usually not calm and peaceful; they occasionally exhibit sudden restlessness due to hunger for oxygen.

Question format: Multiple Choice Chapter 38: End-of-Life Care Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 846 2. A nurse is caring for a young client who is dying of renal failure. What should the nurse do when caring for the dying client's family members?

A. Inform the family that the client may soon be out of danger.

B. Request the family members not to talk about death to the client.

C. Inform the family members that it is time to bid farewell to the client.

D. Encourage the family to leave the client to rest quietly without people around.

Answer: C Rationale: The nurse should ask the family members to meet the client so that they can have a chance to say a final goodbye. The nurse should not provide any false hope to the client's family by telling them that the client may soon be out of danger. The nurse should not ask the client's family members to avoid talking about death, because the client would want to know that he or she is loved and will be missed by the family. The client should feel the presence of loved ones and the family should not be asked to leave during the last stages.

Question format: Multiple Choice Chapter 38: End-of-Life Care Cognitive Level: Apply Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Caring Reference: p. 846

3. A nurse is caring for a client with a terminal illness. Which statement is true of a terminal illness?

A. Recovery is very slow.

B. Recovery is beyond reasonable expectation.

C. Recovery is dependent on the client's treatment options.

D. Recovery takes a minimum of 3 months.

Answer: B Rationale: A terminal illness is a condition from which recovery is beyond reasonable expectation. Clients with terminal illness do not recover from the illness; they may be treated symptomatically and provided care and comfort.

Question format: Multiple Choice Chapter 38: End-of-Life Care Cognitive Level: Remember Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 840 4. A nurse is caring for a client with HIV-related pneumonia. The client is unable to come to terms with the fact that she is dying and feels that life has been unfair to her. How can the nurse promote acceptance in this client?

A. Tell the client that the illness can be overcome.

B. Ask the client if she wants to meet and thank her loved ones.

C. Inform the client that the reports show improvement.

D. Ask relatives not to discuss death in front of the client.

Answer: B Rationale: The nurse should ask the client if she wants to meet and thank her loved ones or say anything in particular to anyone. The nurse should help the client to maintain her dignity at all times, provide emotional support, and support the client's choices concerning terminal care. Telling the client that the illness can be overcome, or informing the client that the reports show improvement, is being dishonest with the client, which contradicts the Dying Person's Bill of Rights. The nurse must not ask the relatives to avoid discussing death in front of the client, as the client needs to know that her family will miss her after death.

Additionally, her family may find it helpful to talk with her.

Question format: Multiple Choice Chapter 38: End-of-Life Care Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 842 5. A client with a terminal illness is being cared for at home. When caring for a client who is in home care, the nurse discusses the importance of respite care. Which of the following interventions leads to respite care?

A. encouraging the caregiver to identify surrogate caregivers B. sharing responsibilities within the immediate family C. arranging for home nursing visits

D. securing home equipment Answer: A Rationale: The nurse should encourage the caregiver to identify volunteers who will care for the client and allow the primary caregiver to enjoy brief periods away from home, as caring for the client can be very stressful. Arranging for home nursing visits and securing home equipment are all activities performed by the nurse caring for the client in home care but are not related to respite care. Sharing responsibilities within the immediate family of the client may improve the client's care, but will not necessarily lead to respite for the caregivers unless time away from responsibility is allowed for.

Question format: Multiple Choice Chapter 38: End-of-Life Care Cognitive Level: Apply Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Caring Reference: p. 842 6. A nurse is caring for a terminally ill client with inadequate fluid volume. Which of the following actions represents one of the last reflexes to disappear as death approaches?

A. taking sips of water B. sucking on wrapped ice cubes C. drinking fresh juices D. eating hot soups Answer: B Rationale: Sucking is one of the last reflexes to disappear as death approaches. Therefore, the nurse can provide a moist cloth or wrapped ice cubes for the client to suck. Eventually, the client may need intravenous fluids. The client who finds eating very exhausting may not agree to take water, fresh juices, or soups.

Question format: Multiple Choice Chapter 38: End-of-Life Care Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 844 7. A nurse is providing end-of-life care to a terminally ill client. Which action should the nurse take to remove mucus and saliva from the client's mouth?

A. Apply mineral oil to the lips.

B. Position the client in the supine position.

C. Perform suction in the client's mouth.

D. Administer oxygen to the client.

Answer: C Rationale: Suctioning helps to remove mucus and saliva that the client cannot swallow or expectorate. A lateral, not supine, position keeps the mouth and throat free of accumulating

secretions. The lips may need periodic lubrication because they may become dried from mouth breathing or administration of oxygen.

Question format: Multiple Choice Chapter 38: End-of-Life Care Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 845 8. A nurse is caring for a terminally ill client. The client is exhibiting signs of multiple organ failure. Which of the following signs indicates failure of the liver?

A. dyspnea B. anorexia C. oliguria D. anuria Answer: B Rationale: Anorexia, impaired digestion, distention, nausea, and vomiting are some of the signs of liver failure in a client with multiple organ failure. Dyspnea is a sign of lung failure.

Oliguria and anuria indicate failure of the kidneys.

Question format: Multiple Choice Chapter 38: End-of-Life Care Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Physiological Adaptation Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 846 9. A young client who was severely injured in a motor vehicle accident has died. The client had signed a donor card a few years ago, expressing the wish to donate the corneas. Which statement is true of organ donation?

A. Corneas should be harvested within a few hours.

B. Organs can be harvested on verbal agreement.

C. Corneas can only be donated by clients less than 55 years of age.

D. Organ donation need not be discussed with the next of kin.

Answer: A Rationale: Corneas or any other organs should be harvested within a few hours of death to ensure successful transplant. Organs cannot be harvested on verbal agreement; to protect the health care facility from any legal consequences, permission is always obtained in writing.

Corneas can be donated by clients of any age. If the dying or dead client meets the donation criteria, the possibility of harvesting organs after death is discussed with the next of kin.

Question format: Multiple Choice Chapter 38: End-of-Life Care Cognitive Level: Understand Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process

Reference: p. 847 10. A client at a health care facility has died after a prolonged illness. A nurse is assigned to perform postmortem care for the client. Which intervention should the nurse perform when providing postmortem care?

A. Avoid replacing dentures in the mouth.

B. Place a rolled towel under the head.

C. Cleanse drainage from the skin.

D. Apply hairpins and clips.

Answer: C Rationale: The nurse should cleanse secretions and drainage from the skin to ensure delivery of a hygienic body. The dentures should be replaced in the mouth, as they maintain the natural contour of the face. A small rolled towel is placed beneath the chin of the client to close the mouth; it is not placed under the head. The nurse should remove all hairpins or clips to prevent accidental trauma to the client's face.

Question format: Multiple Choice Chapter 38: End-of-Life Care Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs Pn: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 853 11. An older adult client at a health care facility dies after a prolonged illness. Which is a psychological reaction associated with the different stages of grief?

A. refusal to accept death B. behaving in a morbid manner C. tightness in the throat D. difficulty breathing Answer: A Rationale: The most common psychological reaction is shock and disbelief or the refusal to accept that a loved one is about to die or has died. Some grieving people report physical symptoms such as difficulty breathing or tightness in the throat, whereas some people show signs of pathologic grief through morbid behaviors.

Question format: Multiple Choice Chapter 38: End-of-Life Care Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 849 12. A client has been recently informed that death is imminent because her lung cancer has metastasized to her liver and bones. The client has rung the call bell because her incontinence brief needs to be changed. When the nurse enters the room, the client sarcastically accuses the nurse of "taking your sweet time to get here." The nurse should recognize that the client may be experiencing what stage of dying?

A. denial B. anger C. bargaining D. depression Answer: B Rationale: Lashing out or complaining about care may be a result of a client experiencing the anger stage of dying. Denial, bargaining, and depression would be less likely to motivate the client's hostile statement.

Question format: Multiple Choice Chapter 38: End-of-Life Care Cognitive Level: Analyze Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 841 13. An elderly client is dying in the hospital and has had few visitors because he is estranged from his children. While the nurse is providing his morning hygiene, the client states, "If I had it to do all over again, I'd do a lot of things differently." How should the nurse react to this client's admission?

A. Ask the client if he thinks he would benefit from counseling.

B. Ask the client if he would like to receive a visit from the hospital chaplain.

C. Encourage the client to elaborate and listen carefully.

D. Reassure the client that everyone makes mistakes in their lives.

Answer: C Rationale: Sometimes a dying client simply wants an opportunity to express feelings and verbally work through emotions. Nurses can act as a nonjudgmental sounding board in such instances. This is a more appropriate immediate response than offering counseling or spiritual care, though these may be of benefit to the client at some point. Reassurance may not be appropriate because this may not be what the client needs at this point.

Question format: Multiple Choice Chapter 38: End-of-Life Care Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 841 14. A nurse provides care on the palliative unit of a busy hospital. The unit's mission statement makes explicit reference to the principle of dying with dignity. What action best demonstrates the principle of dying with dignity?

A. encouraging clients to maintain hope until the end B. explicitly describing the stages of dying to clients and their families C. prioritizing clients' psychosocial and spiritual needs over their physical needs D. caring for clients with respect, regardless of the current state Answer: D

Rationale: Dying with dignity means the process by which the nurse cares for dying clients with respect, no matter what their emotional, physical, or cognitive state. This does not always entail an emphasis on hope. Some clients and families may benefit from education on the stages of dying, but this is not universally the case. It is simplistic to prioritize nonphysical needs at all times and for all clients.

Question format: Multiple Choice Chapter 38: End-of-Life Care Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 842 15. A client is dying of brain tumor but has maintained her level of consciousness and cognition, even as death is now imminent. The client's physical condition has deteriorated significantly over the past 48 hours and she adamantly states that she no longer wishes to eat.

How should the care team respond to the client's statement?

A. Initiate total parenteral nutrition.

B. Insert a nasogastric tube for tube feeding.

C. Have the dietitian liaise with the family to convince the client to eat.

D. Stop trying to feed the client.

Answer: D Rationale: Clients who maintain their mental capacity have the right to refuse care. The client's wishes should be explored in more detail, but it would be inappropriate to coerce or force the client to continue taking nutrition. Clients who are dying should not be made to feel guilty for not wanting to eat or drink.

Question format: Multiple Choice Chapter 38: End-of-Life Care Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 844 16. A client is dying of Alzheimer's disease and is being cared for in an inpatient setting for his last days. In anticipation of the client's imminent death, assessments and interventions have been limited to those necessary to maintain comfort. However, the nurse has taken a set of vital signs in response to signs of multiple organ failure. What vital signs are consistent with multiple organ failure? Select all that apply.

A. hypotension B. hypothermia C. bradypnea D. a weak, thready pulse E. increased oxygen saturation Answer: A, D Rationale: Multiple organ failure is often accompanied by hypotension and a weak, irregular pulse. Hypothermia and low respiratory rate are less common than fever and dyspnea or

increased irregular respirations. It would be unusual for oxygen saturation to increase near death.

Question format: Multiple Select Chapter 38: End-of-Life Care Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 846 17. A client diagnosed with liver failure in hospice care died 10 hours ago. The client's spouse is having difficulty leaving the room and is crying uncontrollably. What situation does the nurse identify is happening with this client's spouse?

A. anticipatory grief B. pathologic grief C. grief reaction D. bargaining grief Answer: C Rationale: The client's spouse is demonstrating behaviors related to a grief reaction. The anticipatory grief occurs prior to the death. The client's spouse has not had enough of a length of time to determine if the grief is pathologic. The spouse is experiencing the denial stage of grief and not the bargaining stage.

Question format: Multiple Choice Chapter 38: End-of-Life Care Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 849 18. It has been determined that a client who sustained a head injury following a motorcycle accident is brain dead. The client did not have an organ donation directive. However, the client did have records to indicate a wish not to have prolonged life support. What is the most appropriate action for the nurse?

A. Contact the organ procurement team to discuss organ donation with the family.

B. Explain to the family that organ donation is not an option, as the client has refused life support.

C. Wait until the family arrives from out of town to discuss organ donation.

D. Prepare to remove the client from life support to align with life support records.

Answer: A Rationale: The organ procurement team should be contacted as soon as possible to discuss transplantation with the family. This discussion cannot wait, as the fragility of organs increases as time passes. While it is important to honor a client's wishes, life support cannot be withdrawn until the potential for organ donation is determined, even if doing so contradicts a person's advance directive because life support that has the potential to save lives overrides the desire to withdraw life support.

Question format: Multiple Choice Chapter 38: End-of-Life Care

Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 847 19. The daughter of an older client is concerned that her mother is depressed because she is reading the obituaries every day. What is the most appropriate nursing response?

A. "This is common in older adults and doesn't necessarily indicate depression."

B. "This indicates that your mother is entering into the bargaining stage of grief."

C. "This is a clear indicator that your mother is depressed."

D. "This is a sign of impending death and we need to notify the provider."

Answer: A Rationale: Older adults may read obituaries and death notices in the newspaper daily in an effort to keep up with acquaintances. Although this activity may be viewed as potentially depressing, it may be an effective coping mechanism in helping to develop a peaceful and accepting attitude toward death. The other responses are not appropriate.

Question format: Multiple Choice Chapter 38: End-of-Life Care Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Caring Reference: p. 840 20. A client has been diagnosed with a terminal illness and has periods of depression and periods of anger. The client's spouse is concerned, feeling as though their loved one is not moving forward in the stages of grief. What teaching is most appropriate for the nurse to include? Select all that apply.

A. Anger follows depression in the stages of grief.

B. Movement between stages can be progressive.

C. Movement back and forth between stages is expected.

D. Depression is not a stage in the grief process.

E. Bargaining should occur between depression and anger.

Answer: B, C Rationale: The Five Stages of Grief (the Kübler-Ross Model) are denial, anger, bargaining, depression, and acceptance. These stages, which represent a pattern of adjustment, may occur in a progressive fashion, or a person can move back and forth through the stages. There is no specific time period for the rate of progression, duration, or completion of the stages.

Question format: Multiple Select Chapter 38: End-of-Life Care Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 841 21. Following surgery, the surgeon informed the client's spouse that invasive cancer was found during the procedure and the client may only have days to live. The client's spouse has

told the physician and the nurse that they do not want the client to know the severity of the diagnosis. How will the nurse respond?

A. not disclosing any information to the client B. understanding that learning about impending death will create unnecessary worry C. understanding that this directive would violate the client's rights D. understanding that the client's spouse has the right to direct care for the dying client Answer: C Rationale: The Dying Person's Bill of Rights includes the right to not be deceived and to receive truthful answers regarding prognosis and care. The nurse will be honest with the client. Impending worry will likely occur, but the client has a right to know their prognosis and the client's spouse does not have the right to direct care.

Question format: Multiple Choice Chapter 38: End-of-Life Care Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Caring Reference: p. 842 22. The caregiver of a client who is terminally ill is becoming short tempered with the client and states, "I just can't take this anymore." Which nursing response is most appropriate?

A. "Have you considered respite care so that you can rest for a few days?"

B. "It won't help for you to be intolerant of the client."

C. "Have you considered residential care so you don't have to care for your loved one?"

D. "It is hard to care for someone who is ill."

Answer: A Rationale: Respite care (relief for the caregiver by a surrogate) is important because it gives the caregiver an opportunity to enjoy brief periods away from home. Short-term respite care can be arranged in an inpatient facility and would allow the caregiver time to rest. A residential home (long-term care facility) may not be warranted. Being critical of the caregiver is not helpful and while it is important to be empathetic, it is imperative to provide options that may be helpful, such as respite care. The focus of support may shift back and forth between the client and the caregiver.

Question format: Multiple Choice Chapter 38: End-of-Life Care Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 842 23. A home hospice client who has Medicare is experiencing extreme pain at home and is refusing to receive inpatient care due to concerns over the cost of inpatient care. What teaching will the nurse include in the plan of care?

A. Inpatient pain management for hospice patients is covered by Medicare.

B. Medicare does not cover costs that are not directly related to the diagnosis.

C. Medicare does not cover pain control in the home; it must be in the inpatient care.

D. Worry about payment should not be a concern for the client.

Answer: A Rationale: Inpatient pain management is covered by Medicare as are any other Medicarecovered services needed to manage pain and other symptoms as recommended by the hospice team. Medicare will cover pain control in the home as well, but for extreme pain, hospitalization may be required. Telling a client not to worry about payment does not educate about what services are available.

Question format: Multiple Choice Chapter 38: End-of-Life Care Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 842 24. The nurse is caring for several clients in the home care setting. Which client, when found deceased, will the nurse report as a case for the medical examiner?

A. a client treated for end-stage kidney failure who is on home hemodialysis B. a client with lung cancer who refused hospice and is living with a spouse C. a client found with an empty bottle for a newly-prescribed opioid by the bedside D. a client who was recently discharged from the hospital after a myocardial infarction Answer: C Rationale: A death that is reportable to the medical examiner would include one that is suspicious for suicide (in this instance, as demonstrated by an empty prescription bottle for an opioid). The deaths of the other clients described are not suspicious. The client with end-stage kidney disease is under the regular care of a health care provider since receiving dialysis at home. A client with cancer is not suspicious. Even with the refusal of hospice care, the client has been diagnosed with an end-stage disease, thus not qualifying for a medical examiner case. A client who was recently discharged after a myocardial infarction who had also been receiving care from a primary care provider is not considered suspicious. Other indications for reporting to a medical examiner include a death that occurs when a client is otherwise in good health and not under the care of a provider, a client who was involved in a violent crime such as a homicide, a client who dies while in police custody or in prison, a client who has had a criminal abortion, or if the deceased poses a potential threat to public health (such as a client who had an infectious disease).

Question format: Multiple Choice Chapter 38: End-of-Life Care Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 849 25. A client that is dying yells at the nurse, "I put my light on a long time ago and you do not even care enough to see what I need!" How should the nurse respond?

A. "I apologize for not responding more quickly and would be glad to help with whatever you need now."

B. "I do not appreciate that you are speaking to me in that tone and would like you to lower your voice."

C. "I was with another client that had pain which was a priority for me at that time."

D. "You have not had the light on for long and I got here as quickly as I could."

Answer: A Rationale: The client who is dying may be experiencing a myriad of emotions such as anger at the situation, pain, fear of dying, and fear of being alone. The nurse should be accepting of the client's behavior, whatever it is, and adapt to it. By giving an apology and acknowledging the client's feelings, the nurse is demonstrating empathy and acceptance. Admonishing the client to speak more quietly makes the issue personal and about the nurse's feelings and emotions. The client is not interested in the nurse's activity with another client, and the activity of administering medication should not be discussed with the client. Insinuating that the client is being untruthful about the time spent waiting is argumentative and accusatory, which is non-therapeutic.

Question format: Multiple Choice Chapter 38: End-of-Life Care Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 841