TEST BANK for Canadian Clinical Nursing Skills and Techniques 1st Edition Perry Griffin, Potter Patr

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Canadian Clinical Nursing Skills and Techniques 1st Edition Perry Test Bank Chapter 01: Evidence-Informed Nursing Practice Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. Evidence-informed practice is a problem-solving approach to making decisions about patient

care that is grounded in a. the latest information found in textbooks. b. systematically conducted research studies. c. tradition in clinical practice. d. quality improvement and risk-management data.

ANS: B

The best evidence comes from well-designed, systematically conducted research studies described in scientific journals. Portions of a textbook often become outdated by the time it is published. Many health care settings do not have a process to help staff adopt new evidence in practice, and nurses in practice settings lack easy access to risk-management data, relying instead on tradition or convenience. Some sources of evidence do not originate from research.

These include quality improvement and risk-management data, infection control data, retrospective or concurrent chart reviews, and clinicians’ expertise. Although non–research-based evidence is often very valuable, it is important that you learn to rely more on research-based evidence.

DIF: Cognitive Level: Comprehension REF: Purpose OBJ: Differentiate between evidence-based and evidence-informed practice.

TOP: Evidence-Based Practice NURSINK rsM ing Process Step: Assessment GETYB: .NCuO MSC: NCLEX: Safe and Effective Care Environment (management of care) 2. When evidence-informed practice is used, patient care will be a. standardized for all. b. unhampered by patient culture. c. variable according to the situation. d. safe from the hazards of critical thinking.

ANS: C

Using your clinical expertise and considering patients’ cultures, values, and preferences ensures that you will apply available evidence in practice ethically and appropriately. Even when you use the best evidence available, application and outcomes will differ; as a nurse, you will develop critical thinking skills to determine whether evidence is relevant and appropriate.

DIF: Cognitive Level: Application REF: Purpose OBJ: Differentiate between evidence-based and evidence-informed practice.

TOP: Evidence-Based Practice KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment (management of care) 3. When a PICO(TS) question is developed, the letter that corresponds with the usual standard of

care is NURSING TEST BANK

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. P. b. I. c. C. d. O. ANS: C

C = Comparison of interest. What standard of care or current intervention do you usually use now in practice?

P = Patient population of interest. Identify your patient by age, gender, ethnicity, disease, or health problem.

I = Intervention of interest. What intervention (e.g., treatment, diagnostic test, and prognostic factor) do you think is worthwhile to use in practice?

O = Outcome. What result (e.g., change in patient’s behaviour, physical finding, and change in patient’s perception) do you wish to achieve or observe as the result of an intervention?

DIF: Cognitive Level: Understanding REF: Ask a Clinical Question OBJ: Explain the components of a PICO(TS) question.

TOP: PICO KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 4. A well-developed PICO(TS) question helps the nurse a. search for evidence. b. include all five elements of the sequence. c. find as many articles as possible in a literature search. d. accept standard clinical routines.

ANS: A

The more focused a question that you ask is, the easier it is to search for evidence in the scientific literature. A well-designed PICOT question does not have to include all five elements, nor does it have to foNllU ow ICTOBT.sCeO quMence. Do not be satisfied with clinical RSthIeNPG routines. Always question and use critical thinking to consider better ways to provide patient care.

DIF: Cognitive Level: Analysis REF: Ask a Clinical Question OBJ: Explain the components of a PICO(TS) question.

TOP: Evidence-Based Practice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 5. The nurse is not sure that the procedure the patient requires is the best possible for the

situation. Using which of the following resources would be the quickest way to review research on the topic? a. CINAHL b. PubMed c. MEDLINE d. The Cochrane Database ANS: D

The Cochrane Community Database of Systematic Reviews is a valuable source of synthesized evidence (i.e., preappraised evidence). The Cochrane Database includes the full text of regularly updated systematic reviews and protocols for reviews currently happening.

MEDLINE, CINAHL, and PubMed are among the most comprehensive databases and represent the scientific knowledge base of health care.

DIF: Cognitive Level: Synthesis

REF: Search for the Best Evidence

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY OBJ: Discuss the process for critiquing evidence in the literature.

TOP: Evidence-Based Practice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 6. The nurse is getting ready to develop a plan of care for a patient who has a specific need. The

best source for developing this plan of care would probably be a. The Cochrane Database. b. MEDLINE. c. NGC. d. CINAHL. ANS: C

The National Guidelines Clearinghouse (NGC) is a database supported by the Agency for Healthcare Research and Quality (AHRQ). It contains clinical guidelines—systematically developed statements about a plan of care for a specific set of clinical circumstances involving a specific patient population. The NGC is a valuable source when you want to develop a plan of care for a patient. The Cochrane Community Database of Systematic Reviews, MEDLINE, and CINAHL are all valuable sources of synthesized evidence (i.e., preappraised evidence).

DIF: Cognitive Level: Synthesis REF: Search for the Best Evidence OBJ: Discuss the process for critiquing evidence in the literature.

TOP: Evidence-Informed Practice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 7. The nurse has done a literature search and found 25 possible articles on the topic that he or

she is studying. To determine which of those 25 best fit his or her inquiry, the nurse first should look at a. the abstracts. b. the literature reviews. c. the “Methods” sections. d. the narrative sections.

ANS: A

An abstract is a brief summary of an article that quickly tells you whether the article is research based or clinically based. An abstract summarizes the purpose of the study or clinical query, the major themes or findings, and the implications for nursing practice. The literature review usually gives you a good idea of how past research led to the researcher’s question.

The “Methods” or “Design” section explains how a research study is organized and conducted to answer the research question or to test the hypothesis. The narrative of a manuscript differs according to the type of evidence-informed article—clinical or research.

DIF: Cognitive Level: Application REF: Critique the Evidence OBJ: Discuss the process for critiquing evidence in the literature.

TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 8. The nurse wants to determine the effects of cardiac rehabilitation program attendance on the

level of depression in individuals who have had a myocardial infarction. The type of study that would best capture this information would be a a. randomized controlled trial. b. qualitative study.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY c. case–control study. d. descriptive study.

ANS: B

Qualitative studies examine individuals’ experiences with health problems and the contexts in which these experiences occur. A qualitative study is best in this case of an individual nurse who wants to examine the effectiveness of a local program. Randomized controlled trials involve close monitoring of control groups and treatment groups to test an intervention against the usual standard of care. Case–control studies typically compare one group of participants with a certain condition against another group without the condition to look for associations between the condition and predictor variables. Descriptive studies focus mainly on describing the concepts under study.

DIF: Cognitive Level: Synthesis REF: Search for the Best Evidence OBJ: Discuss ways to apply evidence in nursing practice.

TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 9. Six months after an early mobility protocol was implemented, the incidence of deep vein

thrombosis in patients has been decreased. This is an example of what stage in the evidence-informed practice process? a. Asking a clinical question b. Applying the evidence c. Evaluating the practice decision d. Communicating your results ANS: C

After implementing a practice cNhUanRgSeI , yNoG urTnBe. xtCsO teM p is to evaluate the effect. You do this by analyzing the outcomes data that you collected during the pilot project. Outcomes evaluation tells you whether your practice change improved conditions, created no change, or worsened conditions.

DIF: Cognitive Level: Application REF: Knowledge-To-Action Framework OBJ: Discuss ways to apply evidence in nursing practice.

TOP: Evidence-Based Practice KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe and Effective Care Environment (safety and infection control) 10. A systematic review explains whether the evidence that you are searching for exists and

whether there is good cause to change practice. In information on systematic reviews. a. CINAHL b. MEDLINE c. The Cochrane Database d. The National Guidelines Clearinghouse

, all entries include

ANS: C

A systematic review explains whether the evidence that you are searching for exists and whether there is good cause to change practice. In the Cochrane Database, all entries include information on systematic reviews.

DIF: Cognitive Level: Synthesis REF: Search for the Best Evidence OBJ: Discuss ways to apply evidence in nursing practice.

TOP: Systematic Reviews

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 11. Which of the following are the gold standard for research? a. Randomized controlled trials (RCTS) b. Systematic reviews c. Case–control studies d. Cohort studies ANS: A

Individual randomized controlled trials (RCTs) are the gold standard for research. An RCT establishes cause and effect and is excellent for testing therapies.

DIF: Cognitive Level: Understanding REF: Search for the Best Evidence OBJ: Discuss the process for critiquing evidence in the literature.

TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 12. The researcher explains how to apply findings in a practice setting for the types of participants

studied in the a. Abstract b. Introduction c. Methods d. Results

section of a research article.

ANS: D

A research article includes a section called “Results” or “Findings” that explains whether the findings from the study have clN inUicRaS l iI mN plGicTaB tio.nC s.OTMhe researcher explains how to apply findings in a practice setting for the types of participants studied.

DIF: Cognitive Level: Application REF: Critique the Evidence OBJ: Discuss the process for critiquing evidence in the literature.

TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 13. Which of the following is the extent to which a study’s findings are valid, reliable, and

relevant to your patient population of interest? a. Scientific rigour b. Ethics c. Peer review d. Knowledge translation ANS: A

Scientific rigour is the extent to which a study’s findings are valid, reliable, and relevant to your patient population of interest.

DIF: Cognitive Level: Application REF: Search for the Best Evidence OBJ: Discuss the process for critiquing evidence in the literature.

TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care)

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 14. Which is the intervention in the following PICO(TS) question: “In children with asthma, does

humidified oxygen decrease the frequency of prn salbutamol when compared with regular oxygen?” a. Asthma b. Humidified oxygen c. Regular oxygen d. Salbutamol ANS: B

The intervention being studied is humidified oxygen. Children with asthma is the population; regular oxygen is the comparison; prn salbutamol is the outcome.

DIF: Cognitive Level: Application REF: Ask a Clinical Question OBJ: Explain the components of a PICO(TS) question.

TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 15. Which is the outcome in the following PICO(TS) question: “Does family-centred care

decrease the rate of hospital readmissions in patients who have suffered from a myocardial infarction, compared with standard discharge practices?” a. Family-centred care b. Patients who have suffered from a myocardial infarction c. Rate of hospital readmissions d. Standard discharge practices ANS: C

The outcome that will be observed is the rate of hospital readmissions. Family-centred care is the intervention; patients who hNaU veRsSuI ffN erG edTfBro.mCO aM myocardial infarction is the population; standard discharge practices is the comparison.

DIF: Cognitive Level: Application REF: Ask a Clinical Question OBJ: Explain the components of a PICO(TS) question.

TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) MULTIPLE RESPONSE 1. To use evidence-informed practice (EIP) appropriately, you need to collect the most relevant

and best evidence and to critically appraise the evidence you gather. This process also includes (Select all that apply.) a. asking a clinical question. b. applying the evidence. c. evaluating the practice decision. d. communicating your results.

ANS: A, B, C, D

EIP comprises six steps (Melnyk and Fineout-Overholt, 2010): 1. Ask a clinical question.

2. Search for the most relevant and best evidence that applies to the question.

3. Critically appraise the evidence you gather.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

4. Apply or integrate evidence along with one’s clinical expertise and patient preferences and values in making a practice decision or change.

5. Evaluate the practice decision or change.

6. Communicate your results.

DIF: Cognitive Level: Analysis REF: Knowledge-To-Action Framework OBJ: Discuss how scientific evidence improves the relevance and efficacy of nursing skills.

TOP: Evidence-Based Practice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 2. In a clinical environment, evidence-informed practice (EIP) has the ability to improve (Select

all that apply.) a. the quality of care provided. b. patient outcomes. c. clinician satisfaction. d. patients’ perceptions.

ANS: A, B, C, D

EIP has the potential to improve the quality of care that nurses provide, patient outcomes, and clinicians’ satisfaction with their practice. Your patients expect nursing professionals to be informed and to use the safest and most appropriate interventions. Use of evidence enhances nursing, thereby improving patients’ perceptions of excellent nursing care.

DIF: Cognitive Level: Application REF: Purpose OBJ: Discuss how scientific evidence improves the relevance and efficacy of nursing skills.

TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 3. Which of the following could be considered as an intervention in a PICO(TS) question?

(Select all that apply.) a. Family-centred care b. Acetaminophen c. Women with breast cancer d. Decreased pain scores ANS: A, B

Family-centred care and medication (such as acetaminophen) are considered interventions.

Women with breast cancer would be considered a patient or population. Decreased pain scores would be considered an outcome.

DIF: Cognitive Level: Application REF: Ask a Clinical Question OBJ: Explain the components of a PICO(TS) question.

TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care)

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 02: Transitions in Care Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The patient is scheduled to go home after having coronary angioplasty. What would be the

most effective way to provide discharge teaching to this patient? a. Provide him with information on health care websites. b. Provide him with written information on what he has to do. c. Sit and carefully explain what is required before his follow-up. d. Use a combination of verbal and written information.

ANS: D

For discharge teaching, use a combination of verbal and written information. This most effectively provides patients with standardized care information, which has been shown to improve patient knowledge and satisfaction.

DIF: Cognitive Level: Application REF: Skill 2.3 (Teaching) OBJ: Identify the ongoing needs of patients in the discharge planning process.

TOP: Admission to Discharge Process KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 2. While preparing for the patient’s discharge, the nurse uses a discharge planning checklist and

notes that the patient is concerned about going home because she has to depend on her family for care. The nurse realizes that successful recovery at home is often based on a. the patient’s willingness to go home. b. the family’s perceived abiliN tyUtR oS caIreNfGoT r tBh. eC paOtiM ent. c. the patient’s ability to live alone. d. allowing the patient to make her own arrangements.

ANS: B

Discharge from a facility is stressful for a patient and family. Before a patient is discharged, the patient and family need to know how to manage care in the home and what to expect with regard to any continuing physical problems. Family caregiving is a highly stressful experience. Family members who are not properly prepared for caregiving are often overwhelmed by patient needs, which can lead to unnecessary hospital readmissions.

DIF: Cognitive Level: Analysis REF: Skill 2.3: Discharging Patients OBJ: Identify the ongoing needs of patients in the discharge planning process.

TOP: Medication Reconciliation KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 3. The patient arrives in the emergency department and is complaining of severe abdominal pain

and vomiting, and is severely dehydrated. The physician prescribes intravenous (IV) fluids for the dehydration and an IV antiemetic for the patient. However, the patient states that she is fearful of needles and adamantly refuses to have an IV started. The nurse explains the importance of and rationale for the prescribed treatment, but the patient continues to refuse.

What should the nurse do? a. Summon the nurse technician to hold the arm down while the IV is inserted. b. Use a numbing medication before inserting the IV.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY c. Document the patient’s refusal and notify the physician. d. Tell the patient that she will be discharged without care unless she complies.

ANS: C

Patients have the right to accept or reject medical treatment. The patient has the right to refuse treatment. Refusal should be documented and the health care provider consulted about alternate treatment.

DIF: Cognitive Level: Application REF: Box 2.3: Patients’ Rights OBJ: Describe the role communication plays in maintaining continuity of care through a patient’s admission, transition, and discharge from an acute care agency.

TOP: Patient Self-Determination Act KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 4. An unconscious patient is admitted through the emergency department. How and when is

identification of the patient made? a. Determined only when the patient is able b. Postponed until family members arrive c. Given an anonymous name under the “blackout” procedure d. Determined before treatment is started ANS: B

If a patient is unconscious, identification often is not made until family members arrive.

Delaying treatment can cause deterioration of the patient’s condition. Blackout procedures are intended mainly to protect crime victims.

DIF: Cognitive Level: Application REF: Skill 2.1 (Admission Process) OBJ: Describe the role communication plays in maintaining continuity of care through a patient’s NURSINGTB.COM admission, transition, and discharge from an acute care agency. TOP: The Unconscious Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. During admission of a patient, the nurse notes that the patient speaks another language and

may have difficulty understanding English. What should the nurse do to facilitate communication? a. Use hand gestures to explain. b. Request and wait for an interpreter. c. Work with the family to gather information. d. Complete as much of the admission assessment as possible using simple phrases.

ANS: B

If patient does not speak, read, or understand English, arrange for a professional translator to help with the nursing assessment. Use telephone interpreter services as a supplemental system when an interpreter is needed instantly or when services are needed in an unusual or infrequently encountered language. Translation services are preferable to using caregiver or family members to promote effective communication.

DIF: Cognitive Level: Application REF: Skill 2.1 (Admission Process) OBJ: Describe the role communication plays in maintaining continuity of care through a patient’s admission, transition, and discharge from an acute care agency.

TOP: The Patient Who Does Not Speak English KEY: Nursing Process Step: Implementation

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY MSC: NCLEX: Safe and Effective Care Environment 6. The patient has been admitted to the emergency department after being physically abused. She

is frightened that her attacker may find her in the hospital and try to kill her. What should the nurse tell her? a. She is safe in the hospital, and she needs to provide her name. b. She can be admitted to the hospital without anyone knowing it. c. Her records will be used as evidence in the trial. d. Because she has come to the hospital, she has to be examined by the doctor.

ANS: B

A patient who has been a victim of crime can be admitted anonymously under an agency’s “blackout” or “do not publish” procedure.

DIF: Cognitive Level: Analysis REF: Skill 2.1 (Admission Process) OBJ: Explain the role of a patient’s caregiver in the admission, transition, or discharge process.

TOP: Victim of Crime KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 7. The patient is admitted to the critical care unit (CCU) after having been in a motor vehicle

accident. He was intubated in the emergency department and needs to receive two units of packed red blood cells. He is conscious but is indicating that he is in pain by guarding his abdomen. To admit this patient, the nurse first will focus on a. examining the patient and treating the pain. b. orienting the family to the CCU visitation policy. c. making sure that the consent forms are signed. d. informing the patient of his rights.

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ANS: A

When a critically ill patient reaches a hospital’s nursing division, the patient immediately undergoes extensive examination and treatment procedures. Little time is available for the nurse to orient the patient and family to the division or to learn of their fears or concerns.

DIF: Cognitive Level: Analysis REF: Skill 2.1 (Admission Process) OBJ: Explain the role of a patient’s caregiver in the admission, transition, or discharge process.

TOP: Role of the Nurse KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The nurse is admitting the patient to the medical unit. The patient indicates that he has had

several surgeries in the past and has had diabetes for the past 15 years. He also stated that he is allergic to morphine. What does this information prompt the nurse to do next? a. Provide the patient with an allergy armband and document his allergies. b. Postpone routine admission procedures immediately. c. Ask the patient if he wants a smoking room. d. Have all family or friends leave the room.

ANS: A

Provide the patient with an allergy armband listing allergies to foods, drugs, latex, or other substances; document allergies according to hospital policy. Postpone routine admission procedures only if the patient is having acute physical problems. Smoking is prohibited throughout the hospital, and family or friends can remain if the patient wishes to have them assist with changing into a hospital gown or pajamas.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

DIF: Cognitive Level: Analysis REF: Skill 2.1 (Admission Process) OBJ: Explain the role of a patient’s caregiver in the admission, transition, or discharge process.

TOP: Allergies KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. At what age is separation anxiety a common problem? a. School-aged children b. Preschoolers c. Middle infancy d. Newborns ANS: C

Separation anxiety is most common from middle infancy throughout the toddler years, especially from ages 16 to 30 months. Preschoolers are better able to tolerate brief periods of separation, but their protest behaviours are more subtle than those of younger children (e.g., refusal to eat, difficulty sleeping, withdrawing from others). School-aged children are able to cope with separation but have an increased need for parental security and guidance.

DIF: Cognitive Level: Synthesis REF: Skill 2.1 (Pediatric) OBJ: Explain the role of a patient’s caregiver in the admission, transition, or discharge process.

TOP: Pediatric Considerations KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 10. The patient is being transferred from the emergency department to another institution for

treatment. Which of the following cannot be delegated to an unregulated care provider (UCP)? a. Helping the patient get dressed b. Gathering intravenous line N eqUuR ipSmIeN ntGtoTB go.w CiOthMthe patient c. Escorting the patient to the transport area d. Assessing the patient’s respiratory status before transport ANS: D

The assessment and decision making conducted during transfers cannot be delegated to UCPs. UCPs can assist the patient with dressing, can gather and secure the patient’s personal belongings and any necessary equipment, and can escort the patient to the nursing unit or transport area.

DIF: Cognitive Level: Application REF: Skill 2.2 (Delegation and Collaboration) OBJ: Explain the role of a patient’s caregiver in the admission, transition, or discharge process.

TOP: Delegation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 11. When does the plan for patient discharge from a health care facility begin? a. At admission b. After a medical diagnosis has been determined c. When the patient’s physical needs are identified d. After a home environment assessment is completed ANS: A

Planning for discharge begins at admission and continues throughout the patient’s stay in the agency. Separating the processes of admission and discharge is a critical error; the two are simultaneous and continuous.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

DIF: Cognitive Level: Comprehension REF: Principles for Practice OBJ: Explain the role of a patient’s caregiver in the admission, transition, or discharge process.

TOP: Discharge Planning KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 12. The phase of the discharge process where medical attention dominates discharge planning

efforts is known as the a. transitional b. continuing c. acute d. multidisciplinary

phase.

ANS: C

The discharge process occurs in three phases: acute, transitional, and continuing care. In the acute phase, medical attention dominates discharge planning efforts. During the transitional phase, the need for acute care is still present, but its urgency declines and patients begin to address and plan for their future health care needs. In the continuing care phase, patients participate in planning and implementing continuing care activities needed after discharge.

There is no multidisciplinary stage; the discharge planning process is comprehensive and multidisciplinary.

DIF: Cognitive Level: Comprehension REF: Skill 2.3: Discharging Patients OBJ: Explain the purpose and importance of discharge planning.

TOP: Discharge Planning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

beUeR nS coImNpGleTteBd. ,w ch activity may be delegated to 13. Once a patient’s discharge has N ChOiM unregulated care providers (UCPs)? a. Provision of prescriptions to the patient b. Completion of the discharge summary c. Gathering of the patient’s personal care items d. Provision of instructions on community health resources ANS: C

The assessment, care planning, and instruction included in discharging patients cannot be delegated to UCPs. The nurse may direct the UCP to gather and secure the patient’s personal items and any supplies that accompany the patient.

DIF: Cognitive Level: Application REF: Skill 2.3 (Delegation and Collaboration) OBJ: Explain the role of a patient’s caregiver in the admission, transition, or discharge process.

TOP: Discharge Planning KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 14. The nurse is providing discharge instruction to an 80-year-old patient and her daughter. The

patient lives in a two-story home. When asked if the patient has difficulty climbing stairs, the patient says “No,” but the nurse notices a look of surprise on the daughter’s face. What should the nurse do in this circumstance? a. Speak with the daughter separately. b. Cancel the discharge immediately. c. Order a visiting nurse consult. d. Notify the physician.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

ANS: A

Patients and family members often disagree on the health care needs of a patient after discharge. Identifying these discrepancies early leads to more accurate development of the discharge plan. It is often necessary to talk with the patient and family separately to learn about their true concerns or doubts.

DIF: Cognitive Level: Application REF: Teaching OBJ: Describe the role communication plays in maintaining continuity of care through a patient’s admission, transition, and discharge from an acute care agency. TOP: Discharge Planning KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 15. The patient has decided that he would like to create an advance directive. The nurse is asked if

she would be a witness. What is the best response for the nurse to make to this request? a. Agree to be a witness. b. Refuse to be a witness. c. Contact social work. d. Contact the physician.

ANS: C

A social worker often fulfills this requirement. Witnesses for an advance directive document should not be medical personnel, and direct refusal does not meet the nurse’s obligation to meet the patient’s needs. Referral to a department that can ensure this service is required.

DIF: Cognitive Level: Application REF: Box 2.4: Advance Directives OBJ: Explain the role of a patient’s caregiver in the admission, transition, or discharge process.

TOP: Advance Directives rsing Process Step: Implementation NURSINKGETYB: .NCuO M MSC: NCLEX: Safe and Effective Care Environment 16. Completing and documenting an accurate medication history from the patient is the important

first step in the a. admission b. medication reconciliation c. discharge d. person-centred care

process.

ANS: B

Medication reconciliation compares the patient’s home medication list with the medications prescribed at admission, transfer, or discharge to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. Medication reconciliation is an important part of the admission process.

DIF: Cognitive Level: Understanding REF: Evidence-Informed Practice OBJ: Explain the role of a patient’s caregiver in the admission, transition, or discharge process.

TOP: Medication Reconciliation KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 17. What is the name of a document that provides a patient’s instructions in terms of future

medical care or that designates another person(s) to make medical decisions if the individual loses decision-making capacity is known? a. Admission document

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY b. Medication reconciliation form c. Discharge record d. Advance directive ANS: D

An advance directive is a document that provides a patient’s instructions about future medical care or that designates another person(s) to make medical decisions if the individual loses decision-making capacity. An advance directive conveys the patient’s choice in continuing medical care when the patient is unable to speak or make decisions.

DIF: Cognitive Level: Understanding REF: Box 2.4: Advance Directives OBJ: Explain the role of a patient’s caregiver in the admission, transition, or discharge process.

TOP: Advance Directives KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE 1. The patient is being admitted to the intensive care department with multiple fractures and

internal bleeding. Which of the following are considered roles of the nurse in this situation?

(Select all that apply.) a. Anticipate physical and social deficits to resuming normal activities. b. Involve the family and significant others in the plan of care. c. Assist in making health care resources available to the patient. d. Identify the psychological needs of the patient.

ANS: A, B, C, D

The nurse identifies patients’ ongoing health care needs; anticipates physical, psychological, and social deficits that have imN plU icRatSioInN sG foT rB re. suCmOinMg normal activities; involves family and significant others in a plan of care; provides health education; and assists in making health care resources available to the patient. Separating the processes of admission and discharge is a critical error; the two are simultaneous and continuous.

DIF: Cognitive Level: Application REF: Skill 2.1 (Admission Process) OBJ: Explain the role of a patient’s caregiver in the admission, transition, or discharge process.

TOP: Admission to Discharge Process KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 2. The patient is admitted to the unit for a cardiac catheterization. Which of the following can be

delegated to an unregulated care provider (UCP)? (Select all that apply.) a. Obtaining admission vital signs b. Preparing the patient’s room c. Gathering and securing personal care items d. Orienting patient and family to the nursing unit ANS: B, C, D

The nursing assessment conducted during admission to a health care facility cannot be delegated to a UCP. You cannot delegate admission vital signs because they provide a baseline for all further comparisons. The nurse directs the UCP to (1) prepare the patient’s room with necessary equipment before admission; (2) gather and secure the patient’s personal care items; and (3) escort and orient the patient and family to the nursing unit.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY DIF: Cognitive Level: Analysis REF: Skill 2.1 (Delegation and Collaboration) OBJ: Explain the role of a patient’s caregiver in the admission, transition, or discharge process.

TOP: Delegation Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 3. Which of the following are considered advance directives? (Select all that apply.) a. Living will b. Power of attorney for health care c. Notarized handwritten document d. Nursing progress note ANS: A, B, C

Advance directives may include a living will, power of attorney for health care, or a notarized handwritten document.

DIF: Cognitive Level: Analysis REF: Box 2.4: Advance Directives OBJ: Explain the purpose and importance of advance directives.

TOP: Advance Directives KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 4. The patient is being transferred from the intensive care unit to the acute care unit. The nurse

must ensure that the following activities are completed: (Select all that apply.) a. Providing the receiving nurse with a report before the transfer b. Determining any equipment needs for the patient during the transfer c. Providing an updated report after transferring the patient to the receiving unit d. Making sure a registered nurse accompanies the patient ANS: A, B, C

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When providing a “hand-off” of a patient to another unit, it is essential that information about the patient’s care, treatment, services, and current condition and any recent or anticipated changes are communicated accurately to meet patient safety goals. The nurse first provides a telephone report to the receiving nurse. This allows the receiving nurse to prepare for the patient (e.g., preparing the room, securing necessary equipment). As clinically appropriate, a nurse or technician accompanies the patient during transport, providing the receiving nurse with the patient’s medical record; introducing the patient to the receiving nurse; and providing an updated report, including any changes in clinical status or plan of care.

DIF: Cognitive Level: Application REF: Skill 2.2: Transitioning Patients OBJ: Explain the role of a patient’s caregiver in the admission, transition, or discharge process.

TOP: Continuum of Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 03: Communication and Collaboration Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The patient is a 54-year-old man who has made a living as a construction worker. He dropped

out of high school at age 16 and has been a laborer ever since. He never saw any need for “book learning” and has lived his life “my way” since he was a teenacger. He has smoked a pack of cigarettes a day for 40 years and follows no special diet, eating a lot of “fast food” while on the job. He now is admitted to the coronary care unit for complaints of chest pain and is scheduled for a cardiac catheterization in the morning. Which of the following would be the best way for the nurse to explain why he needs the procedure? a. “The doctor believes that you have atherosclerotic plaques occluding the major arteries in your heart, causing ischemia and possible necrosis of heart tissue.” b. “There may be a blockage of one of the arteries in your heart, causing the chest discomfort. He needs to know where it is to see how he can treat it.” c. “We have pamphlets here that can explain everything. Let me get you one.” d. “It’s just like a clogged pipe. All the doctor has to do is ‘Roto-Rooter’ it to get it cleaned out.”

ANS: B

To send an accurate message, the sender of verbal communication must be aware of different developmental perspectives and cultural differences between sender and receiver, such as the use of dialect or slang.

DIF: Cognitive Level: ApplicatiN onURSINRGETFB : .EC viO dM ence-Informed Practice OBJ: Explain the communication process.

TOP: Verbal Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 2. The nurse is assessing a patient who says that she is feeling fine. The patient, however, is

wringing her hands and is teary eyed. The nurse should respond to the patient in which of the following ways? a. “You seem anxious today. Is there anything on your mind?” b. “I’m glad you’re feeling better. I’ll be back later to help you with your bath.” c. “I can see you’re upset. Let me get you some tissue.” d. “It looks to me like you’re in pain. I’ll get you some medication.”

ANS: A

When assessing a patient’s needs, assess both the verbal and the nonverbal messages and validate them. In this case, if you see a patient wringing her hands and sighing, it is appropriate to ask, “You seem anxious today. Is there anything on your mind?” It is not enough to accept only the verbal message if nonverbal signals conflict, and it is inappropriate to jump to conclusions about what the nonverbal signals mean.

DIF: Cognitive Level: Application REF: Skill 3.2: Communicating With Patients Who Have Difficulty Coping OBJ: Explain the communication process.

TOP: Nonverbal Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

3. Nonverbal communication incorporates messages conveyed by a. touch. b. cadence. c. tone quality. d. use of jargon.

ANS: A

Nonverbal communication describes all behaviours that convey messages without the use of words. This type of communication includes body movement, physical appearance, personal space, and touch. Cadence, tone quality, and the use of jargon are all part of verbal communication.

DIF: Cognitive Level: Understanding REF: Principles for Practice OBJ: Explain the communication process.

TOP: Nonverbal Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 4. The patient is an older person who had hip surgery 3 days ago. He states that his hip hurts, but

he does not like how the medicine makes him feel. He believes that he can tolerate the pain better than he can tolerate the medication. What would be the best response from the nurse? a. Explain the need for the pain medication using a slower rate of speech. b. Explain the need for the pain medication using a simpler vocabulary. c. Explain the need for the pain medication, but ask the patient if he would like the doctor called and the medication changed. d. Explain in a loud manner the need for the pain medication.

ANS: C

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Suggesting, which is presenting alternative ideas for patient consideration relative to problem solving, can be effective in helping the patient maintain control by increasing the patient’s perceived options or choices. Nurses often use elder-speak, which includes a slower rate of speech, greater repetition, and simpler grammar than normal adult speech, when caring for older persons. However, many older patients perceive this type of communication as patronizing.

DIF: Cognitive Level: Application REF: Box 3.2: Therapeutic Communication Techniques OBJ: Identify the purpose of therapeutic communication, communication in various phases of the nurse–patient relationship.

TOP: Communication with the Elderly KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 5. When comparing therapeutic communication with social communication, the professional

nurse realizes that therapeutic communication a. allows equal opportunity for personal disclosure. b. allows both participants to have personal needs met. c. is goal directed and patient centered. d. provides an opportunity to compare intimate details.

ANS: C

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Therapeutic communication empowers patients to make decisions but differs from social communication in that it is patient centered and goal directed, with limited disclosure from the professional. Social communication involves equal opportunity for personal disclosure, and both participants seek to have personal needs met. Nurses do not share with patients intimate details of their personal lives.

DIF: Cognitive Level: Application REF: Box 3.2: Therapeutic Communication Techniques OBJ: Develop skills for therapeutic communication in various phases of the nurse–patient relationship.

TOP: Establishing the Nurse–Patient Relationship KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 6. The nurse is explaining a procedure to a 2-year-old child. Which is the best approach to use? a. Showing the needles and bandages in advance b. Telling the patient exactly what discomfort to expect c. Using dolls and stories to demonstrate what will be done d. Asking the child to draw pictures of what he or she thinks will happen ANS: C

Some age-appropriate communication techniques for a 2-year-old child include storytelling and drawing. Showing the child needles or telling the child about discomfort would increase anxiety. Having a child draw what he expects does not explain what is going to happen.

DIF: Cognitive Level: Application REF: Skill 3.1 (Pediatric Considerations) OBJ: Develop skills for therapeutic communication in various phases of the nurse–patient relationship.

TOP: Establishing the Nurse–Patient Relationship—Pediatric Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial InteNgU ritR ySINGTB.COM 7. The nurse is about to go over the patient’s preoperative teaching per hospital protocol. She

finds the patient sitting in bed wringing her hands, which are sweaty, and acting slightly agitated. The patient states, “I’m scared that something will go wrong tomorrow.” How should the nurse respond? a. Redirect her focus to dealing with the patient’s anxiety. b. Tell the patient that everything will be alright and continue teaching. c. Tell the patient that she will return later to do the teaching. d. Give the patient antianxiety medication.

ANS: A

Anxiety interferes with comprehension, attention, and problem-solving abilities and thus interferes with the patient’s care and treatment. To ensure the effectiveness of treatment, the nurse should try to help the patient understand the source of the anxiety. Ignoring the anxiety, medicating for it, and postponing the discussion are all inappropriate.

DIF: Cognitive Level: Application REF: Box 3.2: Therapeutic Communication Techniques OBJ: Develop therapeutic communication skills for communicating with patients who have difficulty coping because of feelings such as anxiety, anger, and depression.

TOP: Establishing the Nurse–Patient Relationship KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 8. The nurse is attempting to teach the patient and his family about his care after discharge. The

patient and the family demonstrate signs of anxiety during the teaching session. The nurse should consider doing what? a. Using more gestures or pictures b. Focusing on the physical complaints c. Getting another staff member to speak to the patient d. Repeating information to the patient and the family at a later time ANS: D

Remember that patients and their family members who are under stress often require repeated explanations. Increasing gestures and pictures is additional stimulation that may increase anxiety. Physical complaints should be acknowledged, but dwelling on them can also increase the patient’s anxiety. Involving another staff member would cause a break in the continuity of care.

DIF: Cognitive Level: Application REF: Skill 3.2 (Teaching Considerations) OBJ: Develop therapeutic communication skills for communicating with patients who have difficulty coping because of feelings such as anxiety, anger, and depression.

TOP: Establishing the Nurse–Patient Relationship KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 9. The patient is an older person who was brought to the hospital from an assisted-living

community with complaints of anorexia and general malaise. The nurse at the assisted-living community reported that the patient was very ritualistic in his behaviour and fastidious in his dress and always took a shower in the evening before bed. The patient became very angry and upset when the patient care technician asked him to take his bath in the morning. What does this behaviour tell the nurse? NURSINGTB.COM a. The patient is exhibiting anxiety because of a change in his rituals. b. The patient is suffering from sensory overstimulation. c. The patient is an angry person. d. The patient has to follow hospital protocol.

ANS: A

Patients often become ritualistic and intent on performing activities a certain way. Anxiety develops as a result of a specific event or a general pattern of change.

DIF: Cognitive Level: Analysis REF: Box 3.2: Therapeutic Communication Techniques OBJ: Develop therapeutic communication skills for communicating with patients who have difficulty coping because of feelings such as anxiety, anger, and depression.

TOP: Gerontological Considerations—Anxiety KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity 10. The nurse is preparing to give an intramuscular injection to the patient in room 320. The

unregulated care provider (UCP) comes to the medication room and tells the nurse that the patient in room 316 is very angry with his roommate and is threatening to hit him. How should the nurse respond? a. Tell the UCP to calm the patient down until she can get there. b. Have the angry patient’s roommate moved to another location. c. Tell the angry patient to calm down until she can get there. d. Tell the angry patient that he has to act civilized in the hospital, and that’s that.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY ANS: B

A potentially violent patient needs to be in an environment with decreased stimuli and to have protection from injury to self and against others. Encourage other people, particularly those who provoke anger, to leave the room or area. De-escalation is a skill that cannot be delegated to an unregulated care provider (UCP).

DIF: Cognitive Level: Application REF: Skill 3.2 (Delegation and Collaboration) OBJ: Develop therapeutic communication skills for communicating with patients who have difficulty coping because of feelings such as anxiety, anger, and depression.

TOP: Communicating with the Angry Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 11. Which behaviour should the nurse who is communicating with a potentially violent patient

employ? a. Sit closer to the patient. b. Speak loudly and firmly. c. Use slow, deliberate gestures. d. Always block the door to prevent escape.

ANS: C

Make sure that gestures are slow and deliberate rather than sudden and abrupt. There is less chance for misinterpretation of the message, and slow, deliberate gestures are less threatening.

Keep an adequate distance between yourself and the patient to reduce your risk of injury and to avoid making the patient feel pressured. Try to talk in a comfortable, reassuring voice.

Position yourself closest to the door to facilitate escape from a potentially violent situation.

Do not block the exit; if the patient feels unable to escape, this may cause a violent outburst.

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DIF: Cognitive Level: Application REF: Skill 3.2: Communicating With Patients Who Have Difficulty Coping OBJ: Develop therapeutic communication skills for communicating with patients who have difficulty coping because of feelings such as anxiety, anger, and depression.

TOP: Communicating with the Angry Patient KEY: Nursing Process Step: Intervention MSC: NCLEX: Psychosocial Integrity 12. The patient is sitting at the bedside. He has not been eating and is just staring out of the

window. The nurse approaches the patient and asks, “What are you thinking about?” What type of communication technique is this? a. Restating b. Clarification c. Broad openings d. Reflection ANS: C

Broad openings encourage patients to select topics for discussion. They affirm the value of the patient’s initiative. Restating is repeating a main thought that the patient has expressed.

Clarification is attempting to put into words vague ideas or asking the patient to explain what he or she means. Reflection is directing back to the patient ideas, feelings, questions, or content.

DIF: Cognitive Level: Understanding REF: Box 3.2: Therapeutic Communication Techniques OBJ: Explain the communication process.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity 13. A patient tells the nurse, “I want to die.” Which response is the most appropriate for the nurse

to make? a. “Why would you say that?” b. “Tell me more about how you are feeling.” c. “The doctor should be told how you feel.” d. “You have too much to live for to think that way.”

ANS: B

Broad openings encourage the patient to select topics for discussion and indicate acceptance by the nurse and the value of the patient’s initiative. “Why” questions can cause defensiveness and can hinder communication. Saying you will inform the doctor leads the conversation away from the patient’s feelings. Saying the patient has too much to live for is false reassurance and negates the patient’s feelings.

DIF: Cognitive Level: Application REF: Box 3.2: Therapeutic Communication Techniques OBJ: Explain the communication process.

TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Intervention MSC: NCLEX: Psychosocial Integrity 14. The patient states, “I don’t know what my family will think about this.” The nurse wishes to

use the communication technique of clarification. Which of the following statements would fit that need best? a. “You don’t know what your family will think?” b. “I’m not sure that I understand what you mean.”

ReStIalNk GmToB c. “I think it would be helpfulNifUw re.aC boOuMt your family.” d. “I sense that you may be anxious about something.”

ANS: B

The definition of clarification is attempting to put into words vague ideas or unclear thoughts of the patient to enhance the nurse’s understanding, or asking the patient to explain what he or she means. Repeating main thoughts expressed by patients is known as “restating.” Using questions or statements that help patients expand on a topic of importance is known as “focusing.” Asking a patient to verify the nurse’s understanding of what the patient is thinking or feeling is known as “sharing perceptions.”

DIF: Cognitive Level: Application REF: Box 3.2: Therapeutic Communication Techniques OBJ: Explain the communication process.

TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Intervention MSC: NCLEX: Psychosocial Integrity 15. A patient tells the nurse, “I think that I must be really sick. All of these tests are being done.”

Which response by the nurse uses the specific communication technique of reflection? a. “I sense that you are worried.” b. “I think that we should talk about this more.” c. “You think that you must be very sick because of all the tests.” d. “I’ve noticed that this is an underlying issue whenever we talk.”

ANS: C

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Reflecting is directing back to the patient ideas, feelings, questions, or content, validating the nurse’s understanding of what the patient is saying, and signifying empathy, interest, and respect for the patient. Asking the patient to confirm your sense of his or her anxiety is sharing perceptions. Stating that “we should talk about this more”—that is, putting forth questions or statements to expand on a topic—is focusing. Pointing out underlying issues or problems that occur repeatedly is known as theme identification.

DIF: Cognitive Level: Application REF: Box 3.2: Therapeutic Communication Techniques OBJ: Explain the communication process.

TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Intervention MSC: NCLEX: Psychosocial Integrity 16. The patient is admitted to the hospital with complaints of headache, nausea, and dizziness.

She states that she has a final exam in the morning and needs to do well on it to pass the course, but she can’t seem to get into it. She appears nervous and distracted and is unable to recall details. She most likely is showing manifestations of anxiety. a. mild b. moderate c. severe d. a panic state of ANS: C

Severe anxiety manifests as a focus on fragmented details, headache, nausea, dizziness, inability to see connections between details, and poor recall. Mild anxiety manifests as increased auditory and visual perception, increased awareness of relationships, and increased alertness and ability to problem solve. Moderate anxiety manifests as selective inattention, decreased perceptual field, focus only on relevant information, muscle tension, and diaphoresis. A panic state of anNxU ieR tySmIaNnG ifeTsB ts.aC s aOnMinability to notice surroundings, feelings of terror, and inability to cope with any problem.

DIF: Cognitive Level: Analysis REF: Box 3.3: Behavioural Manifestations of Anxiety OBJ: Develop therapeutic communication skills for communicating with patients who have difficulty coping because of feelings such as anxiety, anger, and depression.

TOP: Manifestations of Anxiety KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 17. The patient is admitted to the emergency department for trauma received in a fist fight. He

states that he could not control himself. He says that his wife left him for another man. He thinks it was because he was always too tired after working to do things. He says he has to work, and there is nothing he could do to change things. He says that he feels trapped in his job, but he knows nothing else. What could the altercation with the other man be a manifestation of? a. Mild anxiety b. Depression c. Severe anxiety d. Moderate anxiety ANS: B

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Symptoms of depression include apathy, sadness, sleep disturbances, hopelessness, helplessness, worthlessness, guilt, anger, fatigue, thoughts of death, decreased libido, ruminations of inadequacy, psychomotor agitation, verbal berating of self, spontaneous crying, dependency, and passiveness. Mild anxiety manifests as increased auditory and visual perception, increased awareness of relationships, increased alertness, and an increased ability to problem solve. Moderate anxiety manifests as selective inattention, decreased perceptual field, focus only on relevant information, muscle tension, and diaphoresis. Severe anxiety manifests as a focus on fragmented details, headache, nausea, dizziness, an inability to see connections between details, and poor recall.

DIF: Cognitive Level: Analysis REF: Box 3.4: Symptoms of Depression OBJ: Develop therapeutic communication skills for communicating with patients who have difficulty coping because of feelings such as anxiety, anger, and depression.

TOP: Manifestations of Depression KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity 18. An active process of receiving information that nonverbally communicates to the patient the

nurse’s interest and acceptance is classified as which of the following? a. Listening b. Broad openings c. Reflection d. Informing ANS: A

Listening is an active process of receiving information and examining one’s reaction to messages received. Its therapeutic value is that it nonverbally communicates to the patient the nurse’s interest and acceptance.

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DIF: Cognitive Level: Understanding REF: Box 3.2: Therapeutic Communication Techniques OBJ: Explain the communication process.

TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity 19. The patient is talking about his fear of having surgery but is being vague and is using a lot of

jargon. The nurse states, “I’m not sure what you mean. Could you tell me again?” This is an example of . a. listening b. broad openings c. reflection d. clarification ANS: D

Clarification is attempting to put into words vague ideas or unclear thoughts of the patient to enhance the nurse’s understanding, or asking the patient to explain what he or she means. This may help clarify the patient’s feelings, ideas, and perceptions and may provide an explicit correlation between them and the patient’s actions.

DIF: Cognitive Level: Application REF: Box 3.2: Therapeutic Communication Techniques OBJ: Explain the communication process.

TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 20. Directing the conversation back to patient ideas, feelings, questions, or content is known as

. a. b. c. d.

listening broad openings reflection clarification

ANS: C

Reflection or directing back to the patient ideas, feelings, questions, or content validates the nurse’s understanding of what the patient is saying and signifies empathy, interest, and respect for the patient.

DIF: Cognitive Level: Understanding REF: Box 3.2: Therapeutic Communication Techniques OBJ: Explain the communication process.

TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity 21. The patient tells the nurse that his mother left him when he was 5 years old. The nurse

responds by saying, “You say that your mother left you when you were 5 years old?” This is an example of . a. listening b. restating c. reflection d. clarification ANS: B

Restating is a technique whereby the nurse repeats the main thought that the patient has expressed. It indicates that the N nuUrsReSisIlN isG teT niBn. g,CaO ndMvalidates, reinforces, or calls attention to something important that has been said.

DIF: Cognitive Level: Application REF: Box 3.2: Therapeutic Communication Techniques OBJ: Explain the communication process.

TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 22. Lack of verbal communication for a therapeutic reason is known as a. listening b. silence c. reflection d. focusing

.

ANS: B

Lack of verbal communication for a therapeutic reason is known as therapeutic silence. It allows the patient time to think and gain insights, slows the pace of the interaction, and encourages the patient to initiate conversation, while conveying the nurse’s support, understanding, and acceptance.

DIF: Cognitive Level: Comprehension REF: Box 3.2: Therapeutic Communication Techniques OBJ: Explain the communication process.

TOP: Therapeutic Silence KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 23. Anxiety that is the source of inattention, decreased perceptual field, and diaphoresis is

classified as a. mild b. moderate c. severe d. panic

.

ANS: B

Moderate anxiety is characterized by selective inattention, decreased perceptual field, the ability to focus only on relevant information, muscle tension, and/or diaphoresis.

DIF: Cognitive Level: Comprehension REF: Box 3.3: Behavioural Manifestations of Anxiety OBJ: Develop therapeutic communication skills for communicating with patients who have difficulty coping because of feelings such as anxiety, anger, and depression.

TOP: Anxiety KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 1. Verbal communication includes which of the following? (Select all that apply.) a. Speech b. Personal space c. Body movement d. Writing ANS: A, D

Verbal communication includes both spoken word and written word. Nonverbal communication describes all beNhU avRioSuIrsNtG haTt B co.nCvO eyMmessages without the use of words. This type of communication includes body movement, physical appearance, personal space, and touch.

DIF: Cognitive Level: Analysis REF: Principles for Practice OBJ: Explain the communication process.

TOP: Verbal Communication KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 2. In caring for patients of different cultures, it is important for the nurse to (Select all that

apply.) a. use appropriate linguistic services. b. display empathy and respect. c. use accurate health history-taking techniques. d. use patient-centered communication.

ANS: A, B, C, D

The following factors are essential in providing effective care for culturally and linguistically diverse patients: (1) use of appropriate linguistic services (e.g., interpreter or bilingual health care workers) and/or other communication strategies, (2) display of empathy and respect for culturally and linguistically diverse patients, (3) use of accurate health history–taking techniques for diagnostic and treatment purposes and health teaching, and (4) use of patient-centered communication behaviours, including participatory decision making. It also is helpful to speak plainly and to avoid mimicking a patient’s accent or dialect.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY DIF: Cognitive Level: Comprehension REF: Person-Centred Care OBJ: Identify the purpose of therapeutic communication, communication in various phases of the nurse–patient relationship.

TOP: Cultural Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 3. In establishing the nurse–patient relationship, personal self-disclosure by the nurse is useful

for which of the following goals? (Select all that apply.) a. To educate the patient b. To build the therapeutic alliance c. To encourage the patient’s independence d. To offer opinions that may influence the patient’s decisions ANS: A, B, C

Personal self-disclosure is used with caution and only in selected situations. Personal self-disclosure by the nurse is useful for the following goals: (1) to educate the patient, (2) to build a therapeutic alliance with the patient, and (3) to encourage the patient’s independence.

Barriers to therapeutic communication include giving an opinion, offering false reassurance, being defensive, showing approval or disapproval, stereotyping, and asking “Why?” The use of “why” questions causes increased defensiveness in the patient and hinders communication.

DIF: Cognitive Level: Application REF: Principles for Practice OBJ: Develop skills for therapeutic communication in various phases of the nurse–patient relationship.

TOP: Establishing the Nurse–Patient Relationship KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 4. In dealing with angry patients, N thUeRnS urI seNrG eaTliB ze.sCthOaM t anger (Select all that apply.) a. may be important to recovery. b. may be a means to cope with grief. c. often hides a specific problem. d. should not be allowed to compromise care.

ANS: A, B, C, D

It is important for you to understand that in many cases the patient’s ability to express anger is important for recovery. For example, when a patient has experienced a significant loss, anger becomes a means to help cope with grief. Some patients express anger toward the nurse, but the anger often hides a specific problem or concern. Allow patients to express anger openly, and do not feel threatened by their words. However, do not allow a patient’s anger to threaten or compromise care.

DIF: Cognitive Level: Application REF: Skill 3.2: Communicating With Patients Who Have Difficulty Coping OBJ: Develop therapeutic communication skills for communicating with patients who have difficulty coping because of feelings such as anxiety, anger, and depression.

TOP: Establishing the Nurse–Patient Relationship KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 5. The nurse observes that the patient is pacing in his room with clenched fists. When asked

“What’s wrong?” the patient states, “There’s nothing wrong. I just want out of here.” He then bangs his fist on the table and yells, “I’ve had it!” How should the nurse respond? (Select all that apply.) a. Tell the patient that he needs to calm down. b. Pause to collect her own thoughts. c. Block the doorway. d. Notify the proper authorities.

ANS: B, D

Awareness and control of your own reaction and responses will facilitate more constructive interaction. Maintain an open exit. Position yourself closest to the door to facilitate escape from a potentially violent situation. Do not block the exit so the patient feels escape is unattainable; this may cause a violent outburst. An angry patient loses the ability to process information rationally and therefore may impulsively express anger through intimidation. If a strong likelihood of imminent harm to another is present on discharge, notify the proper authorities (e.g., nurse manager).

DIF: Cognitive Level: Synthesis REF: Skill 3.2: Communicating With Patients Who Have Difficulty Coping OBJ: Develop therapeutic communication skills for communicating with patients who have difficulty coping because of feelings such as anxiety, anger, and depression.

TOP: Communicating with the Angry Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity

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Chapter 04: Documentation and Informatics Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The patient is a 24-year-old man who is diagnosed with possible human immunodeficiency

virus (HIV) infection while being treated for active pneumonia. He has stated that the nurse may share test result information with his significant other but nothing else at this time. With whom may the nurse communicate regarding this information? a. The patient’s parents b. The patient’s significant other only c. No one in the hospital until the patient says so d. The patient’s physician, significant other, and laboratory personnel ANS: D

All members of the health care team are legally and ethically obligated to keep patient information confidential. Do not discuss the patient’s examinations, observations, conversations, or treatments with other patients or staff not involved in the patient’s care, unless permission is granted by the patient.

DIF: Cognitive Level: Application REF: Principles for Practice OBJ: Describe measures to maintain confidentiality of patient information.

TOP: Confidentiality KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 2. Which of the following is the best example of objective charting? a. “The patient states that he hNaU sR beSeI nN haGvT inB g.seCvO erMe chest discomfort.” b. “The patient is lying in bed and seems to be in considerable pain.” c. “The patient appears to be pale and diaphoretic and complains of nausea.” d. “The patient’s skin is ashen and respiratory rate is 32 and laboured.”

ANS: D

A record or report contains descriptive, objective information about what you see, hear, feel, and smell. An objective description is the result of direct observation and measurement, such as “respiratory rate 20 and unlaboured.” Objective documentation should include your observations of patient behaviour. For example, objective signs of pain include increased pulse rate, increased respiration, diaphoresis, and guarding of a body part. The only subjective data included in a record are what the patient actually verbalizes. Write subjective information with quotation marks, using the patient’s exact words whenever possible. For example, you record, “Patient states, ‘My stomach hurts.’” Avoid terms such as appears, seems, and apparently, which are often subject to interpretation. For example, the description “the patient seems to be in pain” does not accurately communicate the facts to another caregiver. The phrase seems is not supported by any objective facts.

DIF: Cognitive Level: Analysis REF: Table 4.1: Examples of Criteria for Communicating and Documenting OBJ: List guidelines for effective communication and reporting.

TOP: Objective Documentation KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 3. Which of the following is the best example of accurate documentation? a. “Abdominal wound is 5 cm in length without redness, edema, or drainage.” b. “OD to be irrigated qd with NS.” c. “No complaint of abdominal pain this shift.” d. “Patient watching TV entire shift.”

ANS: A

The use of exact measurements in documentation establishes accuracy. For example, charting that an abdominal wound is “5 cm in length without redness, edema, or drainage” is more descriptive than “large wound healing well.” It is essential to know the institution’s abbreviation list and to use only accepted abbreviations, symbols, and measures (e.g., metric), so that all documentation is accurate and is in compliance with standards. For example, the abbreviation for every day (qd) is no longer used. If a treatment or medication is needed daily, the nurse should write out the word “daily” or “every day” on the written prescription or care plan. The abbreviation qd (every day) can be misinterpreted to mean O.D. (right eye). The phrase “no complaint” may indicate stoicism on the part of the patient. He may have been in excruciating pain but never complained of it. It also creates a question related to the assessment skills of the nurse. It is essential to avoid unnecessary words and irrelevant details.

For example, the fact that the patient is watching TV is only necessary to report when this activity is significant to the patient’s status and plan of care.

DIF: Cognitive Level: Evaluation REF: Safety Guidelines OBJ: List guidelines for effective communication and reporting.

TOP: Accurate Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. Patients on the unit have their vital signs taken routinely at 0800, 1200, 1600, and 2000 hours.

At 1000, a patient complains ofNfUeeRliSnI gN “lG igT htB-h.eC adOeM d.” The nurse takes the patient’s vital signs and finds blood pressure to be lower than usual. Within 15 minutes, the patient says that he feels better. The nurse rechecks the blood pressure and finds that it is now back to normal.

How should the nurse handle documentation for this episode? a. Document the 1000 vital signs in the graphic record only. b. Not report the incident because it was a transient episode. c. Document the vital signs in the graphic and progress record. d. Document the vital signs as 12 o’clock signs.

ANS: C

When documenting a significant change on a flow sheet, you describe the change, including the patient response to nursing interventions, in the progress notes. For example, if a patient’s blood pressure becomes dangerously low, record the blood pressure in the progress notes, as well as relevant assessment such as pallor and dizziness and any interventions performed to raise the blood pressure. Common issues in malpractice caused by inadequate or incorrect documentation include failing to give a report or giving an incomplete report to an oncoming shift and failing to document the correct time of events.

DIF: Cognitive Level: Application REF: Flow Sheets and Graphic Records OBJ: Identify the purpose of the patient record.

TOP: Flow Sheets and Graphic Records KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 5. The nurse manager is attempting to determine the staffing needs of the unit. One tool that she

may use to determine the level of care needed would be a. the standardized care plan. b. the acuity record. c. the patient care summary. d. flow sheets.

ANS: B

Health care organizations use a patient acuity system as a method of determining the intensity of nursing care required for a group of patients. Acuity measurements for patients on a unit serve as a guide for determining staffing needs. An acuity recording system determines the hours of nursing care and the number of staff required for a nursing unit. Some health care organizations use standardized care plans for more efficient documentation. These plans, based on the institution’s standards of nursing practice, are preprinted, established guidelines used to care for patients with similar health problems. Many health care organizations now have computerized systems that provide concise, summative information in the form of a patient care summary. Flow sheets and graphic records permit concise documentation of nursing information and patient data over time. Records include documentation of routine observations or repeated specific measurements about the patient such as vital signs, intake and output, hygiene, and medication administration.

DIF: Cognitive Level: Analysis REF: Acuity Records OBJ: Identify the purpose of the patient record.

TOP: Acuity Records KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 6. A preprinted guideline used to care for patients with similar health problems is known as the a. b. c. d.

acuity record. standardized care plan. patient care summary. flow sheet.

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ANS: B

Some health care organizations use standardized care plans for more efficient documentation.

These plans, based on the institution’s standards of nursing practice, are preprinted, established guidelines that are used in caring for patients with similar health problems. Health care organizations use a patient acuity system as a method of determining the intensity of nursing care required for a group of patients. Acuity measurements for patients on a unit serve as a guide for determining staffing needs. Many health care organizations now have computerized systems that provide concise, summative information in the form of a patient care summary. Flow sheets and graphic records permit concise documentation of nursing information and patient data over time. Records include documentation of routine observations or repeated specific measurements about the patient such as vital signs, intake and output, hygiene, and medication administration.

DIF: Cognitive Level: Analysis REF: Standardized Care Plans OBJ: Identify the purpose of the patient record.

TOP: Standardized Care Plans KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 7. The patient is ready to go home from the hospital. What does the nurse provide to the patient

and his family before he leaves the facility? a. Discharge summary b. Standardized care plan c. Patient care summary d. Flow sheet ANS: A

When a patient is discharged from a health care institution, the members of the health care team prepare a discharge summary. A discharge summary provides important information related to the patient’s ongoing health problems and need for health care after discharge. You enhance discharge planning when you are responsive to changes in patient condition and involve the patient and family in the planning process. Some health care organizations use standardized care plans for more efficient documentation. These plans, based on the institution’s standards of nursing practice, are preprinted, established guidelines used to care for patients with similar health problems. Many health care organizations now have computerized systems that provide concise, summative information in the form of a patient care summary. Flow sheets and graphic records permit concise documentation of nursing information and patient data over time. Records include documentation of routine observations or repeated specific measurements about the patient such as vital signs, intake and output, hygiene, and medication administration.

DIF: Cognitive Level: Application REF: Discharge Summary Information OBJ: Identify the purpose of the patient record.

TOP: Discharge Summary Forms KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment

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8. The patient has been in the hospital for a hip replacement. According to his critical pathway,

he should have his Foley catheter discontinued on the fourth day after surgery. Instead, the patient has it removed on the third day and is voiding normally with no problems. This would be a sign of a. a negative variance. b. positive case management. c. a positive variance. d. use of SBAR. ANS: C

Variances are unexpected occurrences, unmet goals, and interventions not specified within the critical pathway time frame that reflect a positive or negative change. A positive variance occurs when a patient progresses more rapidly than is anticipated in the case-management plan (e.g., use of a Foley catheter is discontinued a day early). A negative variance occurs when activities on the critical pathway do not happen as predicted, or outcomes are unmet (e.g., oxygen therapy is necessary for a new-onset breathing problem). Case management is a delivery model that coordinates and links health care services to patients and families while streamlining costs and maintaining quality. SBAR (Situation, Background, Assessment, Recommendation) is a technique that provides a framework for communication between members of the health care team about a patient’s condition. SBAR is a concrete mechanism used for framing conversations, especially critical ones, requiring a nurse’s immediate attention and action.

DIF: Cognitive Level: Analysis

REF: Critical Pathways

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY OBJ: Describe the role of critical pathways in multidisciplinary documentation.

TOP: Variances KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 9.

Which is a primary difference between care in the community and hospital care? a. Documentation systems need to provide information for the home nurse only. b. Computerized patient records are not an option in the community setting. c. Services are assumed and need less documentation. d. The patient and the family witness most of the care provided.

ANS: D

One primary difference is that the patient and the family rather than the nurse witness most of the care provided. Documentation systems need to provide the entire health care team with the necessary information to work together effectively. Computerized patient records are evolving in the community setting. The electronic health record facilitates clarity, continuity of care, and comprehensiveness because of increased standardization of language.

DIF: Cognitive Level: Analysis REF: Documentation of Care in the Community OBJ: Explain guidelines used in documentation of home care and long-term care.

TOP: Home Care Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 10. The unregulated care provider (UCP) tells the registered nurse (RN) that when the patient’s

vital signs were taken, the patient complained that she was in a lot of pain. The UCP then tells the nurse that she charted the patient’s complaint when she charted the vital signs. What instruction does the nurse need to provide to the nursing assistant? a. The UCP needs to make sure she uses the SBAR format when entering notes. b. UCPs are not allowed to chN arUt R viS taI lN sigGnTs.B.COM c. Only the nurse can write in the progress notes. d. The UCP needs to write using blue ink to distinguish from the RN note.

ANS: C

The task of writing a progress note may not be delegated to a UCP. The nurse instructs the UCP about what repetitive care activities should be documented on flow sheets, including vital signs, intake and output (I&O), and routine care related to activities of daily living.

DIF: Cognitive Level: Analysis REF: PG 4.2 (Delegation and Collaboration) OBJ: Identify the purpose of the patient record.

TOP: Delegation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 11. The patient was in bed with all side rails up. During the night, the patient tried to get up to go

to the bathroom and fell while trying to climb over the side rails. After meeting the patient’s needs and assessing that the patient was not harmed, what step should the nurse take (if any)? a. Complete an incident report and put it in the medical record. b. Chart what happened and state that an incident report has been filled out. c. Do nothing because the patient was not harmed. d. Document what happened in the patient record without mentioning the incident report.

ANS: D

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Document in the patient’s record an objective description of what you observed and follow-up actions taken without reference to the incident report. Incident reports are not a part of the permanent medical record but are an important source of risk-management data for identifying and addressing the causes of errors made in health care organizations. You complete the report even if an injury does not occur or is not apparent.

DIF: Cognitive Level: Analysis REF: PG 4.3: Adverse Event/Incident Reporting OBJ: Complete an incident report accurately.

TOP: Incident Reports KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 12. Which of the following provides a quick, easy reference for health care team members in

assessing the patient’s status, and includes specific measurements such as vital signs, intake and output, and pain assessment? a. Flow sheets b. Admission history forms c. Narrative notes d. Problem list ANS: A

Flow sheets provide a quick, easy reference for health care team members in assessing the patient’s status.

DIF: Cognitive Level: Application REF: Flow Sheets and Graphic Records OBJ: Identify the purpose of the patient record.

TOP: Flow Sheets and Graphic Records KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment

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13. Standardized care plans (SCPs) are effective ways to plan care for the patient. To be most

effective, however, the SCP must be a. objective, not subjective b. individualized to meet the patient’s needs c. tested using a pilot project d. inclusive of discharge planning

.

ANS: B

Standardized care plans must be individualized for each patient. Most standardized care plans allow for the addition of specific patient outcomes and target dates for achievement of these outcomes. Objective and subjective measures are descriptive of assessment documentation.

Not all SCPs are tested using pilot projects, but they should be evidence informed.

DIF: Cognitive Level: Application REF: Standardized Care Plans OBJ: Identify the purpose of the patient record.

TOP: Standardized Care Plans KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 14. Multidisciplinary care plans that include key interventions and expected outcomes within an

established time frame are known as a. charting by exception (CBE) b. source records c. focus charting d. critical pathways

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

ANS: D

Critical pathways are multidisciplinary care plans that include key interventions and expected outcomes within an established time frame. Charting by exception involves a narrative nursing note only when there is an exception to the established standard or abnormal data are present. Source records divide the patient’s chart by each profession. Focus charting focuses on patient concerns such as a sign or symptom, condition, nursing diagnosis, and uses DAR (Data, Action, Response).

DIF: Cognitive Level: Comprehension REF: Critical Pathways OBJ: Describe the role of critical pathways in multidisciplinary documentation.

TOP: Critical Pathways KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Safe and Effective Care Environment 15. Which of the following must be complied with when using the electronic health record

(EHR)? a. Only open EHRs for patients on your unit. b. Share your password with your manager only. c. Use the copy/paste function to save time. d. Log out when you leave the computer.

ANS: D

Do not leave information about a patient displayed on a monitor where others can see it; log out as soon as you are leaving the computer. You should only open EHRs for patients for whom you are caring. You should never share passwords with anyone. The copy-and-paste features should be used sparingly because of the potential for error.

DIF: Cognitive Level: AnalysisNURSINRGETFB : .BCoO xM 4.1: Use of the Electronic Health Record OBJ: Describe measures to maintain confidentiality of patient information.

TOP: Patient Record KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE 1. Nursing documentation (Select all that apply.) a. ensures continuity of care. b. provides legal evidence. c. evaluates patient outcomes. d. increases the risk of litigation.

ANS: A, B, C

Nursing documentation ensures continuity of care, provides legal evidence, and evaluates patient outcomes. Effective documentation ensures continuity of care, maintains standards, and reduces errors.

DIF: Cognitive Level: Understanding REF: Principles for Practice OBJ: List guidelines for effective communication and reporting.

TOP: Communication KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 2. Nursing documentation must have which of the following characteristics? (Select all that

apply.)

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. b. c. d.

Factual Organized Public Complete

ANS: A, B, D

Quality documentation and reporting have six characteristics: they are factual, accurate, complete, current, organized, and confidential.

DIF: Cognitive Level: Comprehension REF: Safety Guidelines OBJ: List guidelines for effective communication and reporting.

TOP: Guidelines for Reporting and Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 3. Which of the following should be documented at the time of occurrence? (Select all that

apply.) a. Vital signs b. Administration of medications c. Preparation for diagnostic tests d. Patient response to intervention ANS: A, B, C, D

Document the following activities or findings at the time of occurrence: vital signs, pain assessment and evaluation, administration of medications and treatments, preparation for diagnostic tests or surgery, change in patient’s status and who was notified, treatment for a sudden change in patient’s status, patient response to intervention, admission, transfer, discharge, and death of a patienNt.URSINGTB.COM DIF: Cognitive Level: Comprehension REF: Safety Guidelines OBJ: List guidelines for effective communication and reporting.

TOP: Guidelines for Reporting and Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment

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Chapter 05: Medical Asepsis Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The nurse understands that the priority nursing action needed when medical asepsis is used

includes a. handwashing. b. surgical procedures. c. autoclaving of instruments. d. sterilization of equipment.

ANS: A

Medical asepsis, or clean technique, includes procedures used to reduce the number, and prevent the spread, of microorganisms. Hand hygiene, barrier techniques, and routine environmental cleaning are examples of medical asepsis. Surgical asepsis, or sterile technique, includes procedures used to eliminate all microorganisms from an area. Sterilization destroys all microorganisms and their spores. The techniques used in maintaining surgical asepsis are more rigid than those performed under medical asepsis.

DIF: Cognitive Level: Application REF: Safety Guidelines OBJ: Explain the difference between medical and surgical asepsis.

TOP: Medical Asepsis KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 2. Handwashing with soap and water is a. the most effective way to reNdU ucReSthIeNnGuT mB be.rCoO f bMacteria on the nurse’s hands. b. more effective than alcohol-based products for washing hands. c. necessary for hand hygiene if hands are visibly soiled. d. not necessary if the nurse wears artificial nails.

ANS: C

Handwashing with soap and water is still necessary for hand hygiene if hands are visibly soiled. Recent research has shown that handwashing with plain soap sometimes results in paradoxical increases in bacterial counts on the skin. Alcohol-based products have been more effective for standard handwashing or hand antisepsis than soap or antiseptic soaps. Studies have shown the efficacy of alcohol-based hand sanitizers in reducing infection in a variety of settings from intensive care to long-term care. Studies have shown that health care workers with chipped nail polish or long or artificial nails have high numbers of bacteria on their fingertips. For this reason, the US Centers for Disease Control and Prevention recommends that health care workers not wear artificial nails and extenders and that they keep natural nails less than 0.25 inch (6 mm) long when caring for high-risk patients.

DIF: Cognitive Level: Analysis REF: Evidence-Informed Practice OBJ: Describe factors that can influence nursing staff compliance with hand hygiene.

TOP: Hand Hygiene KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. When caring for patients, the nurse understands that the single most important technique to

prevent and control the transmission of infection is

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. b. c. d.

hand hygiene. the use of disposable gloves. the use of isolation precautions. sterilization of equipment.

ANS: A

The most important and most basic technique in preventing and controlling transmission of infection is hand hygiene. Use of disposable gloves may help reduce the transmission of infection, but it is not the single most important technique to prevent and control the transmission of infection. Neither the use of isolation precautions nor the sterilization of equipment is the single most important technique to prevent and control the transmission of infection.

DIF: Cognitive Level: Application REF: Safety Guidelines OBJ: Describe factors that can influence nursing staff compliance with hand hygiene.

TOP: Hand Hygiene KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. Which of the following measures is appropriate when a nurse is washing his or her hands? a. Use very hot water. b. Leave rings and watches in place. c. Lather for at least 15 to 20 seconds. d. Keep the fingers and hands up and the elbows down.

ANS: C

Perform hand hygiene using plenty of lather and friction for at least 15 to 20 seconds.

Interlace fingers and rub palms and back of hands with circular motion at least five times each. Keep fingertips down to fNaU ciR litSatIeNreGmToB va.lCoO fm Microorganisms. Hot water can be damaging to the skin. Regulate the flow of water so that the temperature is warm. Warm water removes less of the protective oils on the hands than hot water. Jewelry and watches can be a place for pathogens to hide. Push wristwatch and long uniform sleeves above wrists. Avoid wearing rings. If worn, remove during washing. This provides complete access to fingers, hands, and wrists. Wearing rings increases the numbers of microorganisms on the hands. The position of hands and arms will aid in washing pathogens away. Wet hands and wrists thoroughly under running water. Keep hands and forearms lower than elbows during washing.

Hands are the most contaminated parts to be washed. Water flows from the least to the most contaminated area, rinsing microorganisms into the sink.

DIF: Cognitive Level: Application REF: Skill 5.1: Hand Hygiene OBJ: Perform proper procedures for hand hygiene.

TOP: Hand Hygiene KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse shows an understanding of the psychological implications for a patient on isolation

when planning care to control the risk for a. denial. b. aggression. c. regression. d. isolation.

ANS: D

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A sense of loneliness may develop because normal social relationships become disrupted. The nurse should plan care to control the risk that the patient may feel isolated. Denial and regression are not risks related to isolation. Aggression is not a risk for the patient on isolation precautions.

DIF: Cognitive Level: Application REF: Person-Centred Care OBJ: Perform correct routine practices and additional precautions.

TOP: Isolation KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 6. An appropriate technique for the nurse to implement for the patient on isolation precautions is

to a. b. c. d.

double-bag all disposable items and linens. put another gown over the one worn if it has become wet. place specimen containers in plastic bags for transport. hand items to be reused directly to a nurse standing outside the room.

ANS: C

Transfer the specimen to a container without soiling the outside of the container. Place the container in a plastic bag and label the outside of the bag or as per agency policy. Specimens of blood and body fluids are placed in well-constructed containers with secure lids to prevent leaks during transport. Use single bags that are impervious to moisture and sturdy to contain soiled articles. Use the double-bagging technique if necessary for heavily soiled linen or heavy wet trash. Linen or refuse should be totally contained to prevent exposure of personnel to infective material. Avoid allowing the isolation gown to become wet; carry the wash basin outward, away from the gown; avoid leaning against wet tabletops. Moisture allows organisms to travel through the gown to the uniform. Remove all reusable pieces of equipment. Clean any contaminNaU teR dSsuIrN faG ceTsBw.itC hO hoMspital-approved disinfectant. All items must be properly cleaned, disinfected, or sterilized for reuse.

DIF: Cognitive Level: Application REF: Skill 5.2: Caring for Patients Under Transmission-Based Precautions OBJ: Perform correct routine practices and additional precautions.

TOP: Isolation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. Before entering the room of a patient on isolation where all protective barriers are required,

the nurse first puts on the a. gown. b. gloves. c. eyewear. d. mask/respirator.

ANS: A

Apply the gown first, making sure that it covers all outer garments. Pull sleeves down to the wrist. Tie securely at the neck and waist. Next, apply either a surgical mask or a fitted respirator around the mouth and nose. Goggles or a face shield is put on after the gown and mask are applied. Gloves are put on last.

DIF: Cognitive Level: Application REF: Skill 5.2: Caring for Patients Under Transmission-Based Precautions

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY OBJ: Perform correct routine practices and additional precautions.

TOP: Isolation KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 8. The patient is presenting to the hospital with a high fever and a productive cough. He says that

he hasn’t felt right since he returned from visiting Somalia about a month before admission.

He also states that he has lost about 9 kg (20 pounds) in the past month and often wakes up in the middle of the night sweaty and “clammy.” What should the nurse prepare to do? a. Place the patient on contact isolation. b. Place the patient in a negative-pressure room. c. Place the patient on droplet precautions. d. Use routine practices only.

ANS: B

Suspect tuberculosis (TB) in any patient with respiratory symptoms lasting longer than 3 weeks accompanied by other suspicious symptoms, such as unexplained weight loss, night sweats, fever, and a productive cough often streaked with blood. Isolation for patients with suspected or confirmed TB includes placing the patient on airborne precautions in a single-patient negative-pressure room. In addition to routine practices, use contact precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient’s environment. Examples of such illnesses include gastrointestinal, respiratory, skin, or wound infection and colonization with multidrug-resistant bacteria judged by the infection control program as follows: (1) enteric with a low infectious dose or prolonged environmental survival, including Clostridium difficile, Escherichia coli, Shigella, hepatitis A, or rotavirus; (2) skin infections that are highly contagious or that may occur on dry skin, including diphtheria (cutaneous), herpes simplex virus (neonatal or mucocutaneoNuU s)R , iSmIpN etG igToB ,m .aCjoOrM(noncontained) abscesses, cellulitis, decubiti, pediculosis, scabies, staphylococcal furunculosis in infants and young children, or zoster; or (3) viral/hemorrhagic conjunctivitis or viral hemorrhagic infection (Ebola, Lassa, or Marburg). In addition to routine practices, use droplet precautions for patients known or suspected to have serious illnesses transmitted by large particle droplets. Examples of such illnesses include invasive Haemophilus influenzae type b disease, including meningitis, pneumonia, epiglottitis, and sepsis; and invasive Neisseria meningitidis disease, including meningitis, pneumonia, and sepsis. Other serious bacterial respiratory infections spread by droplet transmission include diphtheria (pharyngeal), Mycoplasma pneumoniae, pertussis, pneumonic plague, streptococcal pharyngitis, pneumonia, and scarlet fever in infants and young children. Serious viral infections spread by droplet transmission include adenovirus, influenza, mumps, parvovirus B19, and rubella.

DIF: Cognitive Level: Synthesis REF: Box 5.1: Special Tuberculosis Precautions OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection.

TOP: Airborne Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. For patients with which of the following conditions should the nurse implement airborne

precautions? a. Rubella b. Mumps c. Tuberculosis d. Adenovirus

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY ANS: C

In addition to routine practices, use airborne precautions for patients known or suspected to have serious illnesses transmitted by airborne droplet nuclei. Examples of such illnesses include measles, varicella (including disseminated zoster), and tuberculosis. Airborne precautions are not appropriate for viral infections spread by droplet transmission, including adenovirus, mumps, parvovirus B19, and rubella.

DIF: Cognitive Level: Comprehension REF: Box 5.1: Special Tuberculosis Precautions OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection.

TOP: Airborne Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. The patient is admitted to the pediatric unit with severe pertussis. The nurse explains to the

parents and the child that the patient will be treated with the use of a. airborne precautions. b. routine practices only. c. droplet precautions. d. contact isolation.

ANS: C

In addition to routine practices, use droplet precautions for patients known or suspected to have serious illnesses transmitted by large particle droplets. Examples of such illnesses include invasive Haemophilus influenzae type b disease, invasive Neisseria meningitidis disease, and other serious bacterial respiratory infections spread by droplet transmission, such as diphtheria (pharyngeal), Mycoplasma pneumoniae, and pertussis. Pertussis is spread by large particle droplets. For infection spread via airborne routes, use airborne precautions, in addition to routine practices. Examples of such illnesses include measles, varicella, and tuberculosis. Routine practicesNapUpRlyStI oNbG loT odB,.alCl O boMdy fluids, secretions, excretions, nonintact skin, and mucous membranes. People who have infections that are spread by large particle droplets, such as pertussis, need more than just routine practices. Pertussis is not spread through direct patient contact. For patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient’s environment, use contact precautions in addition to routine practices. Examples of such illnesses include gastrointestinal, respiratory, skin, or wound infection, Clostridium difficile, Escherichia coli, Shigella, hepatitis A, rotavirus, and skin infections that are highly contagious or that may occur on dry skin.

DIF: Cognitive Level: Analysis REF: Table 5.2: PIDAC: Routine Practices and Additional Precautions in All Health Care Settings for Use With Specific Types of Patients OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection.

TOP: Droplet Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. Droplet precautions will be instituted for the patient admitted to the infectious disease unit

with a. respiratory syncytial virus (RSV). b. herpes simplex. c. pulmonary tuberculosis (TB). d. measles.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY ANS: A

Droplet precautions are instituted when droplets are larger than 5 µm, as in the case of RSV. Contact precautions are instituted for herpes simplex. Airborne precautions are instituted for pulmonary TB and measles.

DIF: Cognitive Level: Analysis REF: Table 5.2: PIDAC: Routine Practices and Additional Precautions in All Health Care Settings for Use With Specific Types of Patients OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection.

TOP: Droplet Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The patient has been hospitalized for several days and has received multiple intravenous

antibiotic medications. This morning, the patient had three episodes of severe, foul-smelling diarrhea. The nurse should institute a. contact precautions. b. routine practices only. c. airborne precautions. d. droplet precautions.

ANS: A

In addition to routine practices, use contact precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient’s environment. Examples of such illnesses include gastrointestinal, respiratory, skin, or wound infection and colonization with multidrug-resistant bacteria judged by the infection control program as follows: (1) enteric with a low infectious dose or prolonged environmental survival, including Clostridium difficile, Escherichia coli, Shigella, hepatitis A, or rotavirus; or (2) skin infectioNnU sR thS atIaN reGhTigBh. lyCcOoM ntagious or that may occur on dry skin.

Routine practices apply to blood, all body fluids, secretions, excretions, nonintact skin, and mucous membranes. Patients who may be infected by pathogens that can be spread through direct patient contact may need more. The patient is not exhibiting signs of infection or colonization by pathogens that can be spread via the airborne route. In addition to routine precautions, use airborne precautions for patients known or suspected to have serious illnesses transmitted by airborne droplet nuclei. Examples of such illnesses include measles, varicella, and tuberculosis. The patient is not exhibiting signs of infection or colonization by pathogens that can be spread via large particle droplets. In addition to routine precautions, use droplet precautions for patients known or suspected to have serious illnesses transmitted by large particle droplets. Examples of such illnesses include invasive Haemophilus influenzae type B disease, pertussis, pneumonic plague, streptococcal pharyngitis, pneumonia, scarlet fever in infants and young children, mumps, parvovirus B19, and rubella.

DIF: Cognitive Level: Analysis REF: Table 5.2: PIDAC: Routine Practices and Additional Precautions in All Health Care Settings for Use With Specific Types of Patients OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection.

TOP: Contact Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. What should the nurse do to break the chain of infection at the reservoir level? a. Change a soiled dressing. b. Keep drainage systems intact.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY c. Cover the nose and mouth when sneezing. d. Avoid contact of the uniform with soiled items.

ANS: A

The reservoir is the site or source of microorganism growth. Control: sources of body fluids and drainage. Perform hand hygiene. Bathe the patient with soap and water. Change soiled dressings. Dispose of soiled tissues, dressings, or linen in moisture-resistant bags. Place syringes, uncapped hypodermic needles, and intravenous needles in designated puncture-proof containers. Keep table surfaces clean and dry. Do not leave bottled solutions open for prolonged periods. Keep solutions tightly capped. Keep surgical wound drainage tubes and collection bags patent. Empty and dispose of drainage suction bottles according to agency policy. The portal of entry is the site through which a microorganism enters a host. Urinary: Keep all drainage systems closed and intact, maintaining downward flow. The portal of exit is the means by which microorganisms leave a site. Respiratory: Avoid talking, sneezing, or coughing directly over a wound or sterile dressing field. Cover nose and mouth when sneezing or coughing. Wear mask if suffering from respiratory tract infection. Transmission is the means of spread. Reduce microorganism spread. Perform hand hygiene. Use personal set of care items for each patient. Avoid shaking bed linen or clothes; dust with damp cloth. Avoid contact of soiled item with uniform.

DIF: Cognitive Level: Analysis REF: Principles for Practice OBJ: Identify nursing care measures intended to break the chain of infection.

TOP: Breaking the Chain of Infection KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. The patient is admitted with mumps. The nurse knows that she will have to a. put the patient in a private room. b. place the patient on routineNpU raRctSicIesN. GTB.COM c. wear a mask when closer than 3 feet to the patient. d. place the patient on contact precautions.

ANS: C

For diseases transmitted by large droplets (larger than 5 µm), such as streptococcal pharyngitis, pneumonia, scarlet fever in infants or small children, pertussis, mumps, meningococcal pneumonia or sepsis, or pneumonic plague, place the patient in a private room, or cohort the patient and wear a mask when closer than 3 feet from the patient. For diseases transmitted by small droplet nuclei (smaller than 5 µm), such as measles, chickenpox, disseminated varicella zoster, and pulmonary or laryngeal tuberculosis, place the patient on airborne precautions in a private room with negative airflow of at least six air exchanges per hour, and wear a respirator or mask. Routine practices apply to blood, all body fluids, secretions, excretions, nonintact skin, and mucous membranes. For diseases transmitted by direct patient or environmental contact, such as colonization or infection with multidrug-resistant organisms, respiratory syncytial virus, major wound infection, herpes simplex, and scabies, place the patient on contact precautions in a private room, or cohort the patient. Wear gloves and gowns.

DIF: Cognitive Level: Analysis REF: Table 5.2: PIDAC: Routine Practices and Additional Precautions in All Health Care Settings for Use With Specific Types of Patients OBJ: Identify nursing care measures intended to break the chain of infection.

TOP: Breaking the Chain of Infection KEY: Nursing Process Step: Implementation

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY MSC: NCLEX: Physiological Integrity 15. The nurse has a “scratchy throat” and has been sniffling for 2 days. While at work, she wears

a protective mask when coming into contact with her patients. She does this in an attempt to protect them from a. a health care–acquired infection. b. Clostridium difficile. c. methicillin-resistant Staphylococcus aureus (MRSA). d. vancomycin-resistant Enterococcus (VRE).

ANS: A

Health care–acquired infections (HAIs) are those that develop as a result of contact with a health care facility or provider; the infection was not present or incubating at the time of admission. The other three infections are specific types of HAIs but are likely not what would be transmitted by the nurse based on the nurse’s symptoms.

DIF: Cognitive Level: Analysis REF: Safety Guidelines OBJ: Identify nursing care measures intended to break the chain of infection.

TOP: Health Care–Acquired Infection KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

is the absence of pathogenic (disease-producing) microorganisms.

16. a. b. c. d.

Reservoir Transmission Asepsis Infection

ANS: C

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Asepsis is the absence of pathogenic (disease-producing) microorganisms.

DIF: Cognitive Level: Comprehension REF: Principles for Practice OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection.

TOP: Asepsis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 17. The nurse is preparing to provide care for the patient. Before making patient contact, she

washes her hands. This practice is known as a. person-centred care b. medical asepsis c. surgical asepsis d. the chain of infection

.

ANS: B

Medical asepsis, or clean technique, includes procedures used to reduce the number, and prevent the spread, of microorganisms. Hand hygiene, barrier techniques, and routine environmental cleaning are examples of medical asepsis.

DIF: Cognitive Level: Comprehension REF: Principles for Practice OBJ: Explain the difference between medical and surgical asepsis.

TOP: Medical Asepsis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 18.

, also known as sterile technique, includes procedures used to eliminate all microorganisms from an area. a. Person-centred care b. Medical asepsis c. Surgical asepsis d. The chain of infection ANS: C

Surgical asepsis, or sterile technique, includes procedures used to eliminate all microorganisms from an area. Sterilization destroys all microorganisms and their spores.

DIF: Cognitive Level: Understanding REF: Principles for Practice OBJ: Explain the difference between medical and surgical asepsis.

TOP: Surgical Asepsis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19. The primary strategies for prevention of infection transmission with regard to contact with

blood, body fluids, nonintact skin, and mucous membranes are known as a. routine practices b. additional precautions c. hand hygiene practices d. standard prevention

.

ANS: A

Routine practices, the primary strategies for prevention of infection transmission, apply to contact with (1) blood, (2) body fluids, (3) nonintact skin, and (4) mucous membranes, as well as with equipment or surfaces contaminated with these potentially infectious materials.

NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Table 5.2: PIDAC: Routine Practices and Additional Precautions in All Health Care Settings for Use With Specific Types of Patients OBJ: Perform correct routine practices and additional precautions.

TOP: Standard Precautions KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 20. Health care workers who care for patients with suspected or confirmed tuberculosis (TB) must

wear special a. gloves b. face shields c. respirators d. gowns

.

ANS: C

Health care workers who care for patients with suspected or confirmed TB must wear special respirators. These respirators are high-efficiency particulate masks that have the ability to filter particles at 95% or better efficiency. Health care workers who use these respirators must be fit-tested in a reliable way to obtain a face-seal leakage of 10% or less.

DIF: Cognitive Level: Application REF: Box 5.1: Special Tuberculosis Precautions OBJ: Perform correct routine practices and additional precautions.

TOP: OSHA Guidelines—Respirators KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

MULTIPLE RESPONSE 1. For an infection to take place, which of the following must be present? (Select all that apply.) a. Pathogen and reservoir b. Portals of exit and entry c. Mode of transmission d. Susceptible host ANS: A, B, C, D

The mere presence of a pathogen does not mean that an infection will begin. Development of an infection occurs in a cyclic process, often referred to as the chain of infection, which depends on the following six elements: an infectious agent or pathogen, a reservoir or source for pathogen growth, a portal of exit from the reservoir, a mode of transmission, a portal of entry to the host, and a susceptible host.

DIF: Cognitive Level: Analysis REF: Principles for Practice OBJ: Describe how each element of the infection chain contributes to infection.

TOP: Chain of Infection KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. If hands are not visibly soiled, the nurse may use an alcohol-based hand rub in which of the

following situations? (Select all that apply.) a. Before having direct contact with patients b. After contact with a patient’s intact skin c. After contact with body fluids or excretions d. After removing gloves NURSINGTB.COM ANS: A, B, C, D

If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands before having direct contact with patients, before putting on sterile gloves, and before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices; after contact with a patient’s intact skin (e.g., when taking a pulse or blood pressure, lifting a patient); after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled; when moving from a contaminated body site to a clean body site during care; after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; and after removing gloves.

DIF: Cognitive Level: Application REF: Table 5.2: PIDAC: Routine Practices and Additional Precautions in All Health Care Settings for Use With Specific Types of Patients OBJ: Perform proper procedures for hand hygiene.

TOP: Hand Hygiene KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The nurse is planning to care for a patient diagnosed with possible tuberculosis (TB).

Assessment of possible TB may be based on which of the following? (Select all that apply.) a. A positive AFB smear or culture b. Signs or symptoms of TB c. Cavitation on chest x-ray study d. History of recent exposure e. TB skin test

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

ANS: A, B, C, D

Signs of infectious pulmonary or laryngeal TB include documentation of positive acid-fast bacillus (AFB) smear or culture, signs or symptoms of TB, cavitation on chest x-ray study, history of recent exposure, and physician progress notes indicating a plan to rule out TB. A TB skin test is not recommended by the US Centers for Disease Control and Prevention.

DIF: Cognitive Level: Comprehension REF: Box 5.1: Special Tuberculosis Precautions OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection.

TOP: Assessment of Potential TB KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 06: Sterile Technique Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. When the following concepts are compared, which is most important in maintaining a safe,

aseptic environment? a. Performing a surgical hand scrub b. Applying a sterile gown c. Recognizing the importance of following aseptic principles d. Applying a mask and protective eyewear ANS: C

A nurse in an operating room follows a series of steps toward sterile technique, such as applying a mask, protective eyewear, and a cap; performing a surgical hand scrub; and applying a sterile gown and sterile gloves. In contrast, a nurse who is performing a sterile dressing change at a patient’s bedside or in the home setting may only wash the hands and apply sterile gloves. Regardless of the procedures followed or the setting, the nurse needs to recognize the importance of following strict aseptic principles.

DIF: Cognitive Level: Application REF: Principles for Practice OBJ: Identify the principles of surgical asepsis.

TOP: Aseptic Principles KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse is applying for a job at a local hospital. She wants to look her best for the interview

and decides to wear artificial nails. She does this knowing that artificial nails NURSINGTB.COM a. are appropriate in the critical care unit setting as long as the nurse washes her hands frequently. b. can lead to fungal growth under the nail. c. can actually lower the bacterial count on the hands because they cover the natural nail. d. are banned only in areas where patients are critically ill.

ANS: B

Numerous reports identify that fungal growth commonly occurs under artificial nails as a result of moisture becoming trapped between the natural nail and the artificial nail. Because of the risks for infection posed by artificial nail use, health care workers who have direct contact with patients at high risk (e.g., those in intensive care units or operating rooms) should not wear artificial nails. Health care workers who wear artificial nails or nail extenders are more likely to harbor gram-negative pathogens on their fingertips, both before and after handwashing. Many health care institutions have chosen to ban artificial nails and extenders in all clinical areas, with the rationale that all patients are at risk for infection.

DIF: Cognitive Level: Application REF: Evidence-Informed Practice OBJ: Identify the principles of surgical asepsis.

TOP: Artificial Nails KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. When removing the mask after an aseptic procedure, what should the nurse do first? a. Remove gloves. b. Untie top strings of mask.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY c. Untie bottom strings of mask. d. Untie top strings and let mask hang.

ANS: A

Remove gloves first, if worn. This prevents contamination of hair, neck, and facial area by contaminants on gloves. Untie the top strings of the mask after untying the bottom strings.

This prevents the top part of the mask from falling down over the clothing. If the mask falls and touches the clothing, it will be contaminated.

DIF: Cognitive Level: Application REF: Skill 6.1 OBJ: Apply and remove a cap, mask, and eyewear correctly.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Removing the Mask

4. An appropriate principle of surgical asepsis is that a. the entirety of a sterile package is sterile once it is opened. b. all of the draped table, top to bottom, is considered sterile. c. an object held below the waist is considered contaminated. d. if the sterile barrier field becomes wet, the dry areas are still sterile.

ANS: C

A sterile object or field out of the range of vision or an object held below a person’s waist is contaminated. Once a sterile package is opened, a 2.5-cm (1-inch) border around the edges is considered unsterile. Tables draped as part of a sterile field are considered sterile only at table level. A sterile barrier that has been permeated by punctures, tears, or moisture must be considered contaminated.

DIF: Cognitive Level: ApplicatiN onURSINRGETFB : .BCoO xM 6.1: Principles of Surgical Asepsis OBJ: Perform the following skills: applying sterile gloves using open glove method, preparing a sterile field, applying a sterile drape correctly.

TOP: Sterile Field KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. A patient requires a sterile dressing change for a mid-abdominal surgical incision. An

appropriate intervention for the nurse to implement in maintaining sterile asepsis is to a. put sterile gloves on before opening sterile packages. b. discard items that may have been in contact with the area below waist level. c. place the povidone-iodine bottle well within the sterile field. d. place sterile items on the very edge of the sterile drape.

ANS: B

A sterile object held below a person’s waist is considered contaminated. To maintain sterile asepsis, discard items that may have been in contact with the area below waist level. Sterile gloves are not put on before opening sterile packages, because the outside of the package is not sterile. The nurse uses hand hygiene and opens sterile packages while being careful to keep the inner contents sterile. Povidone-iodine and chlorhexidine are not considered sterile solutions and require separate work surfaces for prepping. The edges of a sterile field are considered to be contaminated. Sterile items should be placed in the middle of the sterile field to maintain sterile asepsis.

DIF: Cognitive Level: Application REF: Box 6.1: Principles of Surgical Asepsis OBJ: Perform the following skills: applying sterile gloves using open glove method, preparing a

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY sterile field, applying a sterile drape correctly.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Sterile Field

6. Which patient may the nurse suspect will be at risk for a latex allergy? a. Patient with food allergies b. Patient with diabetes c. Patient with arthritis d. Patient with hypertension ANS: A

Individuals at risk for latex allergy include those with a history of food allergies. Patients with diabetes, arthritis, and hypertension are not at increased risk for latex allergies.

DIF: Cognitive Level: Application REF: Box 6.2: Individuals at Risk for Latex Allergy OBJ: Identify individuals at risk for latex allergy.

TOP: Latex Allergy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. Which of the following is an appropriate technique for the nurse to use when performing

sterile gloving? a. Put the glove on the nondominant hand first. b. Interlock the hands after both gloves are applied. c. Pull the cuffs down on both gloves after gloving. d. Grasp the outside cuff of the other glove with the gloved hand.

ANS: B

After the second glove is on, interlock the hands above waist level. Be sure to touch only sterile sides. Gloving of the dom inR anSt I hN anGdTfiB rs.t C imOpMroves dexterity. The cuffs usually fall NU down after application. With a gloved dominant hand, slip fingers underneath the second glove’s cuff. The cuff protects gloved fingers. Sterile touching sterile prevents glove contamination.

DIF: Cognitive Level: Application REF: Skill 6.3 OBJ: Perform the following skills: applying sterile gloves using open glove method, preparing a sterile field, applying a sterile drape correctly.

TOP: Applying Sterile Gloves KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The nurse is preparing to insert a urinary catheter. The package is dry but shows signs of

yellowing inside the plastic wrapper, as if the package was wet at one time. What should the nurse do? a. Use the package because it is dry at present. b. Consider the outer package contaminated, but the inner package sterile. c. Discard the entire package as contaminated. d. Open the package and consider the 2.5 cm (1-inch) border as contaminated.

ANS: C

A sterile barrier that has been permeated by punctures, tears, or moisture must be considered contaminated. If there is any question or doubt of an item’s sterility, the item is considered to be unsterile. Once a sterile package has been opened, a 2.5-cm (1-inch) border around the edges is considered unsterile.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY DIF: Cognitive Level: Application REF: Box 6.1: Principles of Surgical Asepsis OBJ: Explain the importance of organization and caution when using surgical aseptic techniques.

TOP: Principles of Surgical Asepsis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. A type I hypersensitivity to latex is evident if the nurse assesses a. localized swelling. b. skin redness and itching. c. runny eyes and nose and cough. d. tachycardia, hypotension, and wheezing.

ANS: D

Type I allergic reaction is a true latex allergy that can be life threatening. Reactions vary on the basis of the type of latex protein and the degree of individual sensitivity, including local and systemic. Symptoms include hives, generalized edema, itching, rash, wheezing, bronchospasm, difficulty breathing, laryngeal edema, diarrhea, nausea, hypotension, tachycardia, and respiratory or cardiac arrest. Type IV hypersensitivity is a cell-mediated allergic reaction to chemicals used in latex processing. Reaction, including redness, itching, and hives, can be delayed up to 48 hours. Localized swelling, red and itchy or runny eyes and nose, and coughing may develop. Irritant dermatitis is a nonallergic response characterized by skin redness and itching.

DIF: Cognitive Level: Comprehension REF: Box 6.3: Levels of Latex Reactions OBJ: Identify individuals at risk for latex allergy.

TOP: Levels of Latex Reactions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. A nurse is preparing a sterile fiN elU dR foSr I aN drGeT ssB in. gCchOaMnge using surgical aseptic technique. The

nurse gathers supplies to prepare the sterile field using a packaged drape. Which option correctly describes how the nurse should set up the field? a. Don sterile gloves before opening the packaged drape. b. Clean the bottle of irrigation solution with alcohol before placing the bottle on the field. c. Avoid dropping sterile supplies close to the 2.5 cm (1-inch) border around the drape. d. Leave the sterile field unattended to obtain needed supplies.

ANS: C

The exterior border of the sterile drape is presumed contaminated, so all supplies must be kept within the sterile portion. Dropping supplies too close to the 2.5 cm (1-inch) border risks having them bounce off the sterile area. Nonsterile supplies are never to be placed on the sterile field. The sterile field is never to be out of the nurse’s line of sight. Sterile gloves will not be applied until the sterile field is set up, and items needed to deliver care are ready for use. Applying them earlier in the process risks having them become contaminated.

DIF: Cognitive Level: Application REF: Skill 6.2 OBJ: Perform the following skills: preparing a sterile field, applying sterile gloves using open-glove method, and applying a sterile drape correctly.

TOP: Using Surgical Asepsis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. Medical asepsis and surgical asepsis both begin with

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. b. c. d.

proper hand hygiene. applying gloves. donning a gown. applying a cap.

ANS: A

As with medical asepsis, proper hand hygiene with an appropriate cleaner or antiseptic is required before initiating any sterile procedure.

DIF: Cognitive Level: Understanding REF: Principles for Practice OBJ: Identify the principles of surgical asepsis.

TOP: Standard Precautions KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 12. Which order of the following steps is the appropriate sequence to use when applying sterile

attire?

1. Apply sterile gloves.

2. Secure hair.

3. Don protective eyewear.

4. Apply hair cover.

5. Wash hands.

6. Apply mask. a. 5, 2, 4, 6, 3, 1 b. 1, 2, 3, 4, 5, 6 c. 3, 2, 1, 4, 6, 5 d. 5, 3, 2, 4, 6, 1 ANS: A

The correct sequence is to washNU haRnS dsI, N seG cuTrB e. haCirO , aMpply hair cover, apply mask, don protective eyewear, and apply sterile gloves.

DIF: Cognitive Level: Application REF: Skill 6.1 OBJ: Perform the following skills: preparing a sterile field, applying sterile gloves using open-glove method, and applying a sterile drape correctly.

TOP: Sterile Attire KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Nurses commonly use surgical asepsis in which of the following situations? (Select all that

apply.) a. In labour and delivery areas b. When inserting an intravenous catheter c. When treating patients with surgical incisions or burns d. When inserting a urinary catheter e. When dressing a MRSA-positive wound ANS: A, B, C, D

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Although nurses commonly practice surgical asepsis in operating rooms, labour and delivery areas, and major diagnostic or special procedure areas, they use surgical aseptic techniques at the patient’s bedside in three primary situations: (1) during procedures that require intentional perforation of a patient’s skin (e.g., insertion of intravenous [IV] catheters), (2) when the skin’s integrity is broken as the result of a surgical incision or burns, and (3) during procedures that involve insertion of devices or surgical instruments into normally sterile body cavities (e.g., insertion of a urinary catheter). Dressing a wound positive for methicillin-resistant Staphylococcus aureus (MRSA) is not one of the three primary situations that affect skin integrity.

DIF: Cognitive Level: Application REF: Principles for Practice OBJ: Discuss settings where surgical aseptic techniques are necessary.

TOP: Surgical Asepsis KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 2. The patient has just had a tracheostomy tube placed and is expectorating copious amounts of

sputum that he coughs forcefully from his tracheostomy tube. The patient also is suspected of having methicillin-resistant Staphylococcus aureus (MRSA) in his sputum. The nurse is preparing to suction the patient to clear his airway. Which of the following will the nurse need to wear if following routine practices? (Select all that apply.) a. Mask b. Goggles c. Gown d. Gloves ANS: A, B, C, D

Routine practices are used for potential contact with blood and all body fluids. The use of GT routine practices calls for the wNeU arR inS gIoN fm asB ks.iC nO coMmbination with eye protection devices such as goggles or glasses with solid side shields whenever splashes, spray, splatter, or droplets of blood or other potentially infectious fluids may occur. These barriers keep the eyes, nose, and mouth free from exposure. Similarly, you wear gowns when there is risk of being splattered with blood or other infectious materials. All health care institutions need to provide to all employees at risk for exposure personal protective equipment and instructions for its use.

DIF: Cognitive Level: Synthesis REF: Skill 6.1 OBJ: Identify the principles of surgical asepsis.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Standard Precautions

3. A sterile field consists of which of the following? (Select all that apply.) a. Sterile tray b. Work surface draped with a sterile towel c. Table covered by a large sterile drape d. Patient’s bedside table ANS: A, B, C

A sterile field may consist of a sterile kit or tray, a work surface draped with a sterile towel or wrapper, or a table covered with a large sterile drape. A patient’s bedside table is not sterile but can be a work surface where a sterile field can be applied.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY DIF: Cognitive Level: Application REF: Principles for Practice OBJ: Perform the following skills: applying sterile gloves using open glove method, preparing a sterile field, applying a sterile drape correctly.

TOP: Sterile Field KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. When performing sterile aseptic procedures, the nurse must create a sterile field. Which of the

following are included in principles of surgical asepsis? (Select all that apply.) a. All items used within a sterile field must be sterile. b. A 5-cm border around the edges is considered unsterile. c. If two sterile objects touch, they are both considered unsterile. d. A sterile object or filed becomes contaminated by prolonged exposure to air.

ANS: A, D

Principles of surgical asepsis include the following: All items used within a sterile field must be sterile.

A sterile barrier that has been permeated by punctures, tears, or moisture must be considered contaminated.

Once a sterile package is opened, a 2.5-cm (1-inch) border around the edges is considered unsterile.

Tables draped as part of a sterile field are considered sterile only at table level.

If there is any question or doubt about the sterility of an item, the item is considered to be unsterile.

Sterile contacting sterile equals sterile; sterile contacting unsterile equals unsterile. Movement around and in the sterile field must not compromise or contaminate the field.

A sterile object or field out of the range of vision or an object held below a person's waist is contaminated.

NURSINGTB.COM A sterile object or field becomes contaminated by prolonged exposure to air; stay organized and complete any procedure as soon as possible.

DIF: Cognitive Level: Application REF: Box 6.1: Principles of Surgical Asepsis OBJ: Identify the principles of surgical asepsis.

TOP: Sterile Field KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 07: Vital Signs Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The patient is brought to the emergency department complaining of severe shortness of

breath. She is cyanotic and her extremities are cold. In an attempt to quickly assess the patient’s respiratory status, the nurse should a. remove the patient’s nail polish to get a pulse oximetry reading. b. use a forehead probe to get a pulse oximetry reading. c. use a finger probe to get a pulse oximetry reading. d. check the colour of the patient’s nail polish before attempting a reading.

ANS: B

Conditions that decrease arterial blood flow such as peripheral vascular disease, hypothermia, pharmacological vasoconstrictors, hypotension, or peripheral edema affect accurate determination of oxygen saturation in these areas. For patients with decreased peripheral perfusion, you can apply a forehead sensor. Assess for factors that influence measurement of SpO2 (e.g., oxygen therapy; respiratory therapy such as postural drainage and percussion; hemoglobin level; hypotension; temperature; nail polish; medications such as bronchodilators).

DIF: Cognitive Level: Analysis REF: Procedural Guideline 7.2 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations.

TOP: Pulse Oximetry KEY: Nursing Process Step: Implementation NURSINGTB.COM MSC: NCLEX: Physiological Integrity 2. A person’s core temperature is considered the most accurate because it is a. reflective of the surrounding environment. b. the same for everyone. c. controlled by the hypothalamus. d. independent of external influences.

ANS: C

The core temperature, or the temperature of the deep body tissues, is under the control of the hypothalamus and remains within a narrow range. Skin or body surface temperature rises and falls as the temperature of the surrounding environment changes, and it fluctuates dramatically. Body tissues and cells function best within a relatively narrow temperature range, from 36C to 38C (96.8F–100.4F), but no single temperature is normal for all people. For healthy young adults, the average oral temperature is 37C (98.6F). An acceptable temperature range for adults depends on age, gender, range of physical activity, hydration status, and state of health.

DIF: Cognitive Level: Analysis REF: Skill 7.1 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations.

TOP: Core Temperature KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 3. The nurse takes the patient’s temperature using an axillary electronic thermometer. The

temperature reading is 36.5C (97.7F). The nurse knows that this correlates with a. 37.0C (98.6F) rectally. b. 37.0C (98.6F) orally. c. 36.0C (97.7F) tympanic. d. 36.0C (97.7F) orally.

ANS: B

It generally is accepted that axillary and tympanic temperatures are usually 0.5C (0.9F) lower than oral temperatures. It generally is accepted that rectal temperatures are usually 0.5C (0.9F) higher than oral temperatures.

DIF: Cognitive Level: Analysis REF: Skill 7.1 OBJ: Discuss factors involved in selecting temperature measurement sites.

TOP: Temperature Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The patient has an order to be off the floor for 15 minutes every 2 hours to smoke a cigarette.

The patient has just returned from his “cigarette break.” The nurse is about to take the patient’s temperature orally and should a. wait about 15 minutes before taking his temperature. b. give him oral fluids to rinse the nicotine away before taking his temperature. c. give him a stick of chewing gum to chew and then take his temperature. d. take his oral temperature and record the findings.

ANS: A

The nurse should verify that the patient has not had anything to eat or drink in the past 20 NG Moked within the past 2 minutes before minutes and has not chewed guNmUfR orS5Im inT utB es.oCrOsm oral temperature is measured. Oral food and fluids and smoking and gum can alter temperature measurement.

DIF: Cognitive Level: Synthesis REF: Skill 7.1 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations.

TOP: Oral Temperature Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. When evaluating the patient’s temperature levels, the nurse expects the patient’s temperature

to be lower a. in the morning. b. after exercising. c. during periods of stress. d. during the preoperative period.

ANS: A

Temperature is lowest during early morning. Muscle activity and stress raise heat production.

Medications may impair or promote sweating, vasoconstriction, or vasodilation or may interfere with the ability of the hypothalamus to regulate temperature.

DIF: Cognitive Level: Comprehension REF: Skill 7.1 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations.

TOP: Temperature Assessment

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

6. When inserting a rectal thermometer, the nurse encounters resistance. The nurse should a. apply mild pressure to advance. b. ask the patient to take deep breaths. c. remove the thermometer immediately. d. remove the thermometer and reinsert it gently.

ANS: C

If resistance is felt during insertion, withdraw the thermometer immediately. Never force the thermometer. This prevents trauma to the mucosa. With the nondominant hand, separate the patient’s buttocks to expose the anus. Ask the patient to breathe slowly and relax. This fully exposes the anus for thermometer insertion and relaxes the anal sphincter for easier thermometer insertion.

DIF: Cognitive Level: Application REF: Skill 7.1 OBJ: Accurately assess a patient’s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures.

TOP: Rectal Temperature Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. An appropriate procedure for measurement of an adult’s temperature with a tympanic

membrane sensor is a. pulling the ear pinna down and back. b. moving into the ear in a figure-eight pattern. c. fitting the probe loosely into the ear canal. d. pointing the probe toward the mouth and chin.

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ANS: B

Move the thermometer in a figure-eight pattern. Pull the ear pinna backward, up, and out for an adult; fit the speculum tip snugly in the canal and do not move; and point the speculum tip toward the nose.

DIF: Cognitive Level: Application REF: Skill 7.1 OBJ: Accurately assess a patient’s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures.

TOP: Rectal Temperature Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The patient is a 1-year-old male infant who is admitted with possible sepsis. The patient is

irritable and agitates easily. What should the nurse do to assess the patient’s temperature? a. Take an oral temperature before doing anything else. b. Take an axillary temperature using the upper axilla. c. Place the child in Sims’ position for a rectal temperature. d. Take a rectal temperature as the last vital sign.

ANS: D

Critically ill children sometimes have cool skin but a high core temperature because of poor perfusion to the skin. Children may assume the prone position for rectal temperature measurement. With children who cry or are restless, it is best to take temperature as the last vital sign. Use axillary temperatures for screening purposes only, not to detect fevers in infants and young children. Use the lower axilla to record temperature in side-lying infants.

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DIF: Cognitive Level: Application REF: Pediatric (Skill 7.1) OBJ: Accurately assess a patient’s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures.

TOP: Temperature Assessment in Pediatric Patients KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The patient is returning from a cardiac catheterization. The puncture site is in the right femoral

artery. The patient is having vital signs assessed every 15 minutes. Along with vital signs, the nurse assesses the pedal pulses of the right and left feet. Which of the following would be of major concern? a. Both pedal pulses were bounding. b. The femoral artery could be palpated. c. The right pedal pulse was weaker than the left. d. The radial artery pulse was 88.

ANS: C

If a peripheral pulse distal to an injured or treated area of an extremity feels weak on palpation, the volume of blood reaching tissues below the affected area may be inadequate, and surgical intervention may be necessary. A full bounding pulse is an indication of increased volume. When the pulse wave reaches a peripheral artery, you can feel it by palpating the artery lightly against underlying bone or muscle. The pulse is the palpable bounding of the blood flow. The usual range for adults is 60 to 100 beats per minute.

DIF: Cognitive Level: Analysis REF: Skill 7.2 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations.

TOP: Pulse Assessment KEY: Nursing Process Step: EvaN luU atR ioS n INM EX: Physiological Integrity GSTCB: .NCCOLM 10. The patient has an order to be off the floor for 15 minutes every 2 hours to smoke a cigarette.

The patient has just returned from his “cigarette break.” The nurse is about to take the patient’s radial pulse and should a. wait about 15 minutes before taking his pulse. b. use her thumb to detect the pulse and get an accurate count. c. press hard to detect the pulse and get an accurate count. d. take his pulse for 15 seconds and multiply by 4.

ANS: A

If a patient has been smoking, wait 15 minutes before assessing pulse. Anxiety, activity, and smoking elevate heart rate. Assessing radial pulse rate at rest allows for objective comparison of values. Fingertips are the most sensitive parts of the hand for palpating arterial pulsation.

The nurse’s thumb has pulsation that interferes with accuracy. Pulse assessment is more accurate when moderate pressure is used. Too much pressure occludes pulse and impairs blood flow. If the pulse is regular, count the rate for 30 seconds and multiply the total by 2. If the pulse is irregular, count the rate for a full 60 seconds. Assess the frequency and the pattern of irregularity.

DIF: Cognitive Level: Analysis REF: Skill 7.2 OBJ: Accurately assess a patient’s radial and apical pulses.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

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TOP: Pulse Assessment

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 11. When evaluating the radial pulse measurement technique of the unregulated care provider

(UCP), the nurse identifies appropriate technique when the UCP a. has the patient’s arm elevated. b. positions the patient supine or sitting. c. applies significant pressure to the pulse site. d. counts the pulse for 15 seconds and multiplies by 4.

ANS: B

Assist the patient to assume a supine or sitting position. If the patient is supine, place the patient’s forearm straight alongside or across the lower chest or upper abdomen with the wrist extended straight. If the patient is sitting, bend the patient’s elbow 90 degrees and support the lower arm on the chair or on the nurse’s arm. Slightly extend or flex the wrist with the palm down until the strongest pulse is noted. Lightly compress against the radius, obliterate the pulse initially, and then relax pressure so the pulse becomes easily palpable. Pulse is assessed more accurately with moderate pressure. Too much pressure occludes the pulse and impairs blood flow. If the pulse is regular, count the rate for 30 seconds and multiply the total by 2. If the pulse is irregular, count the rate for 60 seconds. Assess frequency and pattern of irregularity.

DIF: Cognitive Level: Comprehension REF: Skill 7.2 OBJ: Accurately assess a patient’s radial and apical pulses.

TOP: Delegation of Pulse Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. The nurse is caring for an infant in the neonatal intensive care unit (NICU). While taking vital

signs, the nurse finds that the baby’s heart rate is 195. The nurse calls the physician, knowing that the normal heart rate should be a. 60 to 100 beats per minute.NURSINGTB.COM b. 100 to 160 beats per minute. c. 90 to 140 beats per minute. d. 220 beats per minute or higher.

ANS: B

The infant’s heart rate at birth ranges from 100 to 160 beats per minute at rest. By adolescence, the heart rate varies between 60 and 100 beats per minute and remains so throughout adulthood. By age 2, the pulse rate slows to 90 to 140 beats per minute.

DIF: Cognitive Level: Analysis REF: Skill 7.3 OBJ: Accurately assess a patient’s radial and apical pulses.

TOP: Assessing Apical Pulse KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. The patient has been in the hospital for several days for urosepsis. He has been responding

favorably to treatment, and his vital signs have been normal for 2 days. When the nurse takes his vital signs, however, the patient’s apical pulse is 152 and regular. The nurse suspects that the a. patient is having a reaction to his narcotic medication. b. patient may be suffering from hypothermia. c. patient’s fever may have returned. d. patient may be an athlete.

ANS: C

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Fever or exposure to warm environments increases heart rate. Large doses of narcotic analgesics and hypothermia can slow heart rate. A well-conditioned patient may have a slower than usual resting heart rate, which returns more quickly to resting rate after exercise.

DIF: Cognitive Level: Synthesis REF: Skill 7.3 OBJ: Accurately assess a patient’s radial and apical pulses.

TOP: Assessing Apical Pulse KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. What steps should the nurse take to conduct an assessment of a possible pulse deficit? a. A nurse measures the pulse after the patient exercises. b. Two nurses check the same pulse on opposite sides of the body. c. Two nurses assess the apical and radial pulses and determine the difference. d. The current pulse is compared with previous pulse measurements for differences.

ANS: C

Locate apical and radial pulse sites. One nurse auscultates the apical pulse, and one nurse palpates the radial pulse. Both nurses count the pulse rate for 60 seconds simultaneously.

Subtract the radial rate from the apical rate to obtain the pulse deficit. The pulse deficit reflects the number of ineffective cardiac contractions in 1 minute. If a pulse deficit is noted, assess for other signs and symptoms of decreased cardiac output.

DIF: Cognitive Level: Application REF: Skill 7.2 OBJ: Explain the implications of a pulse deficit.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Pulse Deficit

15. An appropriate method of assessing a patient’s respirations is for the nurse to a. place the bed flat.

NURSINGTB.COM b. remove all supplemental oxygen sources from documentation. c. explain to the patient that respirations are being assessed. d. gently place the patient’s hand in a relaxed position over the upper abdomen.

ANS: D

Place the patient’s arm in a relaxed position across the abdomen or lower chest, or place the nurse’s hand directly over the patient’s upper abdomen. Be sure the patient is in a comfortable position, preferably sitting or lying with the head of the bed elevated 45 to 60 degrees. Sitting erect promotes full ventilatory movement. A position of discomfort may cause the patient to breathe more rapidly. Documentation should include any supplemental oxygen that the patient is receiving. Inconspicuous assessment of respirations immediately after pulse assessment prevents the patient from consciously or unintentionally altering the rate and depth of breathing.

DIF: Cognitive Level: Application REF: Skill 7.4 OBJ: Accurately assess a patient’s respirations.

TOP: Respiratory Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 16. The nurse is about to take vital signs on a newborn patient in the nursery. She should a. assess respiratory rate after taking a rectal temperature. b. observe the child’s chest while the child is sleeping. c. call the physician if the rate is greater than 40. d. expect that the child will have short periods of apnea.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY ANS: D

An irregular respiratory rate and short apneic spells are normal for newborns. Assess respiratory rate before other vital signs or assessments are taken. Children up to age 7 breathe abdominally, so respirations are observed by abdominal movement. Average respiratory rate (breaths per minute) for newborns is 30 to 60; for infants (6 months to 1 year), 30 to 50; for toddlers (2 years), 25 to 32; and for children from 3 to 12 years, 20 to 30.

DIF: Cognitive Level: Analysis REF: Pediatric (Skill 7.4) OBJ: Accurately assess a patient’s respirations.

TOP: Pediatric Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. The nurse should report an assessment of a. 14; adult patient b. 16; 8-year-old patient c. 25; toddler d. 38; infants

respirations per minute for a(n)

.

ANS: B

Acceptable average respiratory rate (breaths per minute) for newborns is 35 to 40; for infants, 30 to 53; for toddlers (1–2 years), 22 to 37; and for children, 18 to 25. Adults average 12 to 20 respirations per minute.

DIF: Cognitive Level: Application REF: Skill 7.4 OBJ: Identify ranges of acceptable vital sign values for infant, child, and adult.

TOP: Respiratory Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

NURSINGTB.COM 18. During the normal cardiac cycle, blood pressure reaches a peak, followed by a trough, in the

cycle. What is the peak known as? a. Pulse pressure b. Systolic cycle c. Diastolic cycle d. Korotkoff phase ANS: B

Blood pressure is the force exerted by blood against the vessel walls. During a normal cardiac cycle, blood pressure reaches a peak, followed by a trough, or low point, in the cycle. The peak pressure occurs when the heart’s ventricular contraction, or systole, forces blood under high pressure into the aorta. The difference between systolic pressure and diastolic pressure is the pulse pressure. When the ventricles relax, the blood remaining in the arteries exerts a minimum or diastolic pressure. Diastolic pressure is the minimal pressure exerted against the arterial wall at all times. As the sphygmomanometer cuff is deflated, the five different sounds heard over an artery are called Korotkoff phases.

DIF: Cognitive Level: Understanding REF: Skill 7.5 OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation.

TOP: Systolic Blood Pressure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19. The patient is complaining of a severe headache. The nurse takes the patient’s blood pressure

and finds it to be 240/110. What is the pulse pressure?

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. b. c. d.

110 240 130 350

ANS: C

The difference between systolic pressure and diastolic pressure is the pulse pressure. For a blood pressure of 240/110, the pulse pressure is 130. The diastolic pressure is 110. The systolic pressure is 240. The sum of the systolic and diastolic pressures is 350.

DIF: Cognitive Level: Analysis REF: Skill 7.5 OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation.

TOP: Pulse Pressure KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. The patient is an 86-year-old woman who is being admitted for dehydration and pneumonia.

The patient is lying in bed but tells the nurse that she needs to go to the bathroom. The nurse tells the patient that she will stay with her and will help her get there. The patient states, “That’s okay. I can make it on my own.” The nurse should a. help the patient to the bathroom and stay with her. b. allow the patient to get up on her own and go to the bathroom. c. allow the patient to go to the bathroom and call for help if needed. d. insert a Foley catheter.

ANS: A

Orthostatic hypotension, also referred to as postural hypotension, occurs when a normotensive person develops symptoms (e.g., light-headedness and dizziness) and low blood pressure when rising to an upright positiNoU n.ROSrtIhN osGtaTtiB c. chCaO ngMes in vital signs are good indicators of blood volume depletion. In severe cases of orthostatic hypotension, loss of consciousness may occur. Foley catheters are believed to be a major source of urinary tract infection.

DIF: Cognitive Level: Synthesis REF: Hypotension OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation.

TOP: Orthostatic Hypotension KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 21. The nurse chooses a sphygmomanometer that has a circular gauge and a needle that registers

the millimetre calibrations. This type of device is known as a(n) a. mercury b. electronic c. aneroid d. direct (invasive) ANS: C

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manometer.

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The aneroid manometer has a glass-enclosed circular gauge containing a needle that registers millimeter calibrations. Metal parts in the aneroid manometer are subject to temperature expansion and contraction and must be recalibrated at least every 6 months to verify their accuracy. Before using the aneroid manometer, make sure the needle is pointing to zero. With mercury manometers, pressure created by inflation of the compression cuff moves the column of mercury up the tube against the force of gravity. Millimeter calibrations mark the height of the mercury column. Electronic or automatic blood pressure machines consist of an electronic sensor positioned inside a blood pressure cuff attached to an electronic processor. You measure arterial blood pressure either directly (invasively) or indirectly (noninvasively). The direct method requires electronic monitoring equipment and the insertion of a thin catheter into an artery. The risks associated with invasive blood pressure monitoring require use in an intensive care setting.

DIF: Cognitive Level: Understanding REF: Blood Pressure Equipment OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation.

TOP: Manometers KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 22. The nurse is working on the general surgical unit and is caring for a patient who has a right

total mastectomy. To take the patient’s vital signs and to accurately assess the patient’s blood pressure, it will be necessary to a. place the blood pressure cuff on the left upper arm. b. place the blood pressure cuff on the right upper arm. c. place the blood pressure cuff on the right lower arm. d. use direct (invasive) blood pressure measurement.

ANS: A

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Determine the best site for blood pressure assessment. Avoid applying the cuff to an extremity when intravenous fluids are infusing, an arteriovenous shunt or fistula is present, or breast or axillary surgery has been performed on that side. The risks associated with invasive blood pressure monitoring require use in an intensive care setting.

DIF: Cognitive Level: Application REF: Skill 7.5 OBJ: Describe factors involved in selecting an extremity to measure blood pressure.

TOP: Manometers KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. Which site is used to auscultate blood pressure? a. Radial b. Ulnar c. Brachial d. Temporal ANS: C

Place the stethoscope over the brachial artery to measure blood pressure. Use the radial site for the radial pulse, the ulnar site for the ulnar pulse, and the temporal site for the temporal pulse.

DIF: Cognitive Level: Application REF: Skill 7.5 OBJ: Describe factors involved in selecting an extremity to measure blood pressure.

TOP: Brachial Pulse KEY: Nursing Process Step: Implementation

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY MSC: NCLEX: Physiological Integrity 24. The nurse is caring for a 2-year-old child who is admitted with croup and crying. To take the

child’s vital signs, the nurse should a. place the pediatric blood pressure cuff on the left arm. b. place the blood pressure cuff on the right thigh. c. skip the blood pressure measurement. d. place the blood pressure cuff on the left thigh.

ANS: C

Blood pressure is not a routine part of assessment in children younger than 3 years. The right arm is preferred for blood pressure measurement in children older than 3. Thigh blood pressure is the least preferred and the most uncomfortable method for children.

DIF: Cognitive Level: Analysis REF: Pediatric (Skill 7.5) OBJ: Describe factors involved in selecting an extremity to measure blood pressure.

TOP: Teaching Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. When the benefits of the different types of blood pressure monitoring devices are compared,

which of the following patients would be the best candidate for noninvasive electronic blood pressure measurement? a. A 49-year-old postoperative patient with no history of heart disease on q15min vital signs b. A 22-year-old patient undergoing active grand mal seizures c. A 68-year-old patient with diagnosed peripheral vascular disease d. A 54-year-old patient with chronic atrial fibrillation

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ANS: A

These devices are used when frequent assessment is required, as in critically ill or potentially unstable patients; during or after invasive procedures; or when therapies require frequent monitoring. Patients with irregular heart rate, peripheral vascular disease, seizures, tremors, and shivering are not candidates for this device.

DIF: Cognitive Level: Analysis REF: Skill 7.5 OBJ: Discuss the benefits and disadvantages of using an automatic blood pressure machine.

TOP: Noninvasive Electronic Blood Pressure Measurement KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 26. The patient was found in an alley on a cold winter night and is admitted with hypothermia

from environmental exposure. She is elderly and is having difficulty breathing. Her breath sounds are diminished, and the tip of her nose is cyanotic. The nurse wants to assess the oxygen level in the patient’s blood. She decides to use the pulse oximeter. The best way to apply this to this patient would be with a(n) a. finger probe. b. earlobe sensor. c. forehead sensor. d. toe sensor.

ANS: C

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

In adults, you can apply reusable and disposable oximeter probes to the earlobe, finger, toe, bridge of the nose, or forehead. For patients with decreased peripheral perfusion, you can apply a forehead sensor. Conditions that decrease arterial blood flow such as peripheral vascular disease, hypothermia, pharmacological vasoconstrictors, hypotension, or peripheral edema affect accurate determination of oxygen saturation in these areas.

DIF: Cognitive Level: Analysis REF: Box 7.9: Characteristics of Pulse Oximeter Sensor Probes and Sites OBJ: Accurately assess a patient’s oxygenation status using pulse oximetry.

TOP: Oxygen Saturation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 27. The patient is admitted in a near comatose state with a blood glucose level of 42 mmol/L. His

respiratory rate is 42 breaths per minute, and his respiratory pattern is deep and regular. What is this type of breathing known as? a. Cheyne-Stokes respiration b. Biot’s respiration c. Bradypnea d. Kussmaul’s respiration ANS: D

Respirations are abnormally deep, regular, and increased in rate. This is common in diabetic ketoacidosis. With Cheyne-Stokes respirations, respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. The respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth. The pattern reverses, and breathing slows and becomes shallow, climaxing in apnea before respiration resumes. With Biot’s respirations, respirations are abnormally shallow for 2 to 3 OM breaths followed by an irregulaN rU peRriSoI dN ofGaTpB ne.a.CW ith bradypnea, the rate of breathing is regular but abnormally slow (fewer than 12 breaths per minute).

DIF: Cognitive Level: Analysis REF: Box 7.5: Alterations in Breathing Pattern OBJ: Accurately assess a patient’s respirations.

TOP: Breathing Patterns KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 28. What is a disadvantage of using the disposable sensor pad for pulse oximetry? a. It is less restrictive. b. It contains latex. c. It is less expensive to use. d. It is available in different sizes.

ANS: B

A disposable sensor pad can be applied to a variety of sites, including the earlobe of an adult and the nose bridge, palm, or sole of an infant. It is less restrictive for continuous SpO2 monitoring. It is expensive and contains latex, which some patients may not be able to tolerate. The skin under the adhesive may become moist and may harbor pathogens. It is available in a variety of sizes, and the pad can be matched to infant weight.

DIF: Cognitive Level: Application REF: Box 7.9: Characteristics of Pulse Oximeter Sensor Probes and Sites OBJ: Accurately assess a patient’s oxygenation status using pulse oximetry.

TOP: Oxygen Saturation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

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29. When heat loss mechanisms are unable to keep pace with heat production,

is

the result. a. hypothermia b. hyperthermia c. normothermia d. thermoregulation ANS: B

Fever, or hyperthermia, occurs when heat loss mechanisms are unable to keep pace with excess heat production, resulting in an abnormal rise in body temperature.

DIF: Cognitive Level: Analysis REF: Skill 7.1 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations.

TOP: Core Temperature KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 30. The nurse is taking a rectal temperature on an adult patient. She expects to insert the

thermometer a. 1.0 b. 3.5 c. 6.0 d. 9.0

_ cm.

ANS: B

Gently insert the thermometer into the anus in the direction of the umbilicus 3.5 cm (1.5 inches) for an adult. Do not force the thermometer.

NURSINGTB.COM DIF: Cognitive Level: Application REF: Skill 7.1 OBJ: Accurately assess a patient’s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures.

TOP: Rectal Temperature Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 31. The patient has been sleeping and has been lying on his right side. The nurse is ready to take

his temperature using a tympanic thermometer. Which ear should the nurse take the temperature in? a. Left ear b. Right ear c. Either ear; it doesn’t matter d. Neither ear; the nurse should take the temperature at a different site ANS: A

If the patient has been lying on one side, use the upper ear. Heat trapped in the ear facing down will cause a false high temperature reading.

DIF: Cognitive Level: Application REF: Skill 7.1 OBJ: Accurately assess a patient’s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures.

TOP: Tympanic Membrane Temperature Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 32. An irregular heartbeat, often found in children, that speeds up with inspiration and slows

down with expiration is known as a sinus a. dysrhythmia b. tachycardia c. bradycardia d. arrhythmia

.

ANS: A

Children often have a sinus dysrhythmia, which is an irregular heartbeat that speeds up with inspiration and slows down with expiration.

DIF: Cognitive Level: Analysis REF: Pediatric (Skill 7.2) OBJ: Accurately assess a patient’s radial and apical pulses.

TOP: Pulse Assessment—Pediatric Considerations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 33.

is the heart sound of the tricuspid and mitral valves closing at the end of ventricular filling. a. S1 b. S2 c. S3 d. S4 ANS: A

S1 is the heart sound of the tricuspid and mitral valves closing at the end of ventricular filling, just before systolic contraction begins.

DIF: Cognitive Level: ApplicatiN onURSINRGETFB : .SC kiO llM 7.3 OBJ: Accurately assess a patient’s radial and apical pulses.

TOP: Assessing Apical Pulse KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 34.

is the heart sound of the pulmonic and aortic valves closing at the end of the systolic contraction. a. S1 b. S2 c. S3 d. S4 ANS: B

S2 is the heart sound of the pulmonic and aortic valves closing at the end of the systolic contraction.

DIF: Cognitive Level: Application REF: Skill 7.3 OBJ: Accurately assess a patient’s radial and apical pulses.

TOP: Assessing Apical Pulse KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 35. An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral

pulse site creates a. an arrhythmia b. widened pulse pressure c. a pulse deficit d. pulseless electric activity

.

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ANS: C

An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a pulse deficit. Pulse deficits often are associated with dysrhythmias and warn of potentially decreased cardiac function.

DIF: Cognitive Level: Comprehension REF: Skill 7.3 OBJ: Accurately assess a patient’s radial and apical pulses.

TOP: Pulse Deficit KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 36. After applying the sphygmomanometer to the patient’s upper arm, the nurse inflates the cuff

to the proper level, and then, using a stethoscope, listens for the a. diastolic b. systolic c. Kussmaul d. Korotkoff

sounds.

ANS: D

The most common technique used for measuring blood pressure is auscultation with a sphygmomanometer and stethoscope. As the sphygmomanometer cuff is deflated, the five different sounds heard over an artery are called Korotkoff phases. The sound in each phase has unique characteristics. Blood pressure is recorded with the systolic reading (first Korotkoff sound) before the diastolic reading (beginning of the fifth Korotkoff sound).

DIF: Cognitive Level: Application REF: Fig 7.9 OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation.

TOP: Korotkoff Sounds KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological IntN egUriR tySINGTB.COM

occurs when the systolic blood pressure falls to 90 mm Hg or below.

37. a. b. c. d.

Hypotension Hypertension An irregular heart rate Cheyne-Stokes

ANS: A

Hypotension occurs when the systolic blood pressure falls to 90 mm Hg or below. Although some adults normally have a low blood pressure, for most people, low blood pressure is an abnormal finding associated with illness.

DIF: Cognitive Level: Understanding REF: Hypotension OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation.

TOP: Hypotension KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is preparing to take the patient’s temperature. Which of the following may cause

the temperature to fluctuate? (Select all that apply.) a. Age b. Stress c. Hormones

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY d. Medications ANS: A, B, C, D

Older persons have a narrower range of temperature than younger adults. A temperature within an acceptable range in an adult may reflect a fever in an older person. Undeveloped temperature-control mechanisms in infants and children cause temperature to rise and fall rapidly. Stress elevates temperature. Women have wider temperature fluctuations than men because of menstrual cycle hormonal changes; body temperature varies during menopause.

Some medications impair or promote sweating, vasoconstriction, or vasodilation or interfere with the ability of the hypothalamus to regulate temperature.

DIF: Cognitive Level: Analysis REF: Skill 7.1 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations.

TOP: Temperature Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. Which of the following processes are involved in respiration? (Select all that apply.) a. Ventilation b. Diffusion c. Oximetry d. Perfusion ANS: A, B, D

Three processes are involved in respiration: ventilation, mechanical movement of gases into and out of the lungs; diffusion, movement of O2 and CO2 between the alveoli and the red blood cells; and perfusion, distribution of red blood cells to and from the pulmonary capillaries.

NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Skill 7.4 OBJ: Accurately assess a patient’s respirations.

TOP: Respiratory Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse is about to teach the patient about risk factors for hypertension. Which of the

following are risk factors for hypertension? (Select all that apply.) a. Obesity b. Cigarette smoking c. High blood cholesterol d. Renal disease ANS: A, B, C, D

People with a family history of hypertension, premature heart disease, lipemia, or renal disease are at significant risk. Obesity, cigarette smoking, heavy alcohol consumption, high blood cholesterol and triglyceride levels, and continued exposure to stress from psychosocial and environmental conditions are factors linked to hypertension.

DIF: Cognitive Level: Understanding REF: Hypertension OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations.

TOP: Teaching Considerations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 4. The nurse is about to take a patient’s blood pressure. Which of the following conditions would

cause the nurse to obtain a false high reading? (Select all that apply.) a. Bladder or cuff too narrow b. Bladder or cuff too wide c. Patient’s arm below the level of the heart d. Inflating the cuff too slowly ANS: A, C, D

Bladder or cuff too narrow or too short, arm below heart level, or inflating the cuff too slowly will give a false high reading. A bladder or cuff too wide will give a false low reading.

DIF: Cognitive Level: Analysis REF: Box 7.6: Common Mistakes in Blood Pressure Assessment OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation.

TOP: Common Mistakes in Blood Pressure Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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Chapter 08: Health Assessment Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The nurse is visiting the patient for the first time this shift. She introduces herself and asks the

patient several questions related to his condition. While doing so, and without being obvious, she is looking at the colour of his eyes and is assessing his ears and nose for discharge and the symmetry of his mouth. Which assessment technique is the nurse using? a. Palpation b. Percussion c. Inspection d. Auscultation ANS: C

Inspection is the visual examination of body parts or areas. An experienced nurse learns to make multiple observations, almost simultaneously, while becoming very perceptive of abnormalities. Palpation uses the sense of touch. Percussion involves tapping the body with the fingertips to evaluate the size, borders, and consistency of body organs and to discover fluid in body cavities. Auscultation is listening with a stethoscope to sounds produced by the body.

DIF: Cognitive Level: Application REF: Inspection OBJ: Describe the techniques used with each physical assessment skill.

TOP: Inspection KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

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2. The patient is admitted with fever and acute lower abdominal pain. He has taken Tylenol but

says he still feels feverish. Before taking the patient’s temperature, the nurse may a. touch the patient’s skin with the dorsum of her hand. b. touch the patient’s skin with the pads of her fingers. c. palpate the skin using the bimanual method. d. tap the patient’s skin using the fingertips.

ANS: A

The dorsum (back) of the hand is more sensitive to temperature variations. The pads of the fingertips detect subtle changes in texture, shape, size, consistency, and pulsation of body parts. Bimanual palpation involves one hand placed over the other while pressure is applied.

The upper hand exerts downward pressure as the other hand feels the subtle characteristics of underlying organs and masses. Seek the assistance of a qualified instructor before attempting deep palpation. Percussion involves tapping the body with the fingertips to evaluate the size, borders, and consistency of body organs and to discover fluid in body cavities.

DIF: Cognitive Level: Application REF: Palpation OBJ: Describe the techniques used with each physical assessment skill.

TOP: Palpation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. What should the nurse do when preparing to complete an assessment for a 16-year-old

patient?

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. b. c. d.

Focus on illness behaviours.

Plan for a diminished energy level.

Treat the patient as an individual.

Have the parents present throughout.

ANS: C

Older children and adolescents tend to respond best when treated as adults and individuals and often can provide details about their health history and severity of symptoms. Routine examinations of children have a focus on health promotion and illness prevention, particularly in the care of well children with competent parenting and no serious health problems. The focus is on growth and development, sensory screening, dental examination, and behavioural assessment. Children who are chronically ill, disabled, in foster care, or foreign-born adopted may require additional assessment. The adolescent has a right to confidentiality. After talking with the parents about historical information, the nurse arranges to be alone with the adolescent to speak further privately and to perform the examination.

DIF: Cognitive Level: Application REF: Person-Centred Care OBJ: Describe how to conduct a physical examination on patients from diverse cultures.

TOP: Children and Adolescents KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. In providing a physical assessment of an 88-year-old patient, the nurse should a. do it as quickly as possible to prevent fatigue. b. assume that the patient will have disabilities. c. prepare to perform a mental status examination. d. always do the exam in the small exam room to prevent chills.

ANS: C

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Inclusion of a review of mental status is highly recommended when the nurse performs an examination of an older person. Allow extra time, and be patient, relaxed, and unhurried with older persons. Do not assume that aging is always accompanied by illness or disability. Older persons are able to adapt to change and to maintain functional independence. Provide adequate space for an examination, particularly if the patient uses a mobility aid.

DIF: Cognitive Level: Application REF: Physical Assessment of Various Age Groups: Older Persons OBJ: Describe how to conduct a physical examination on patients from diverse cultures.

TOP: Older Persons KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The general survey begins with a review of the patient’s primary health problems and an

evaluation of the patient’s vital signs, height and weight, general behaviour, and appearance.

It also provides information about the patient’s illness, hygiene, skin condition, body image, and emotional state. Which of the following cannot be delegated to unregulated care providers (UCP)? a. Reporting subjective signs and symptoms b. Measuring the patient’s height and weight c. Monitoring intake and output d. Obtaining initial vital signs ANS: D

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Because the initial set of vital signs are part of the general health assessment, they must be taken by the nurse. After that the UCP may take vital signs for a stable patient. The nurse directs UCP to report a patient’s subjective signs and symptoms to the nurse, to measure the patient’s height and weight, and to monitor oral intake and urinary output.

DIF: Cognitive Level: Application REF: Delegation and Collaboration (Skill 8.1) OBJ: Identify data to collect from the nursing history before an examination.

TOP: Delegation Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. Petechiae are noted on the patient as a result of the nurse finding a. bluish-black patches. b. tenting. c. pinpoint-sized red dots. d. large areas of raised, irritated skin.

ANS: C

Petechiae appear as tiny, pinpoint-sized, red or purple spots on the skin caused by small hemorrhages in the skin layers and may indicate a blood-clotting disorder, a medication reaction, or liver disease. Bluish-black patches are more indicative of malignant melanoma.

With reduced turgor, the skin remains suspended or “tented” for a few seconds before slowly returning to place. This indicates decreased elasticity and possible dehydration. Large areas of raised, irritated skin are not characteristic of petechiae.

DIF: Cognitive Level: Application REF: Skill 8.1 OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Petechiae KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological IntN egUriR tySINGTB.COM 7. The nurse is assessing the patient by grasping a fold of skin on his forearm. She notices that

the skin remains suspended for a longer than normal period. What could this indicate? a. Stage I pressure ulcer b. Increased blood flow to the area c. Localized vasodilation d. Dehydration ANS: D

With reduced turgor, the skin remains suspended or “tented” for a few seconds before slowly returning to place. This indicates decreased elasticity and possible dehydration. A stage I pressure ulcer may cause warmth and erythema (redness) of an area. Skin temperature reflects an increase or decrease in blood flow. Normal reactive hyperemia (redness) is a visible effect of localized vasodilation, the body’s normal response to lack of blood flow to underlying tissue.

DIF: Cognitive Level: Analysis REF: Skill 8.1 OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Assessment of Skin Hydration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. The nurse is preparing to examine a patient who has chronic lung disease. She realizes that the

patient most likely will need to be in which position for the examination? a. Sitting upright

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Position the patient sitting upright. This promotes full lung expansion during examination.

Patients with chronic respiratory disease will likely need to sit up throughout the examination because of shortness of breath. Only if the patient is unable to tolerate sitting would a supine position or a side-lying position be used.

DIF: Cognitive Level: Analysis REF: Skill 8.1 OBJ: Describe proper patient positioning during each phase of the examination.

TOP: Positioning for Examination of Thorax and Lungs KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. Which of the following may an unregulated care provider (UCP) be responsible for

determining? a. Vital signs b. Cranial nerve function c. Neck vein distension d. Auscultation of bowel sounds ANS: A

Unregulated care providers (UCP) can be trained to count apical pulse and peripheral pulses after the nurse’s initial assessment. UCP need to be instructed to recognize temperature and colour changes, along with changes in peripheral pulses. Comprehensive heart and neck vessel assessment should not bN eU deRleSgI atN edGtT oBU.CCPO .H Mowever, UCP should know to report the development of abdominal pain or changes in the patient’s bowel habits or dietary intake.

DIF: Cognitive Level: Comprehension REF: Delegation and Collaboration (Skill 8.4) OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Delegation KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 10. The nurse is caring for a patient who is recovering from an acute myocardial infarction. While

providing cardiac education, the nurse realizes that the patient needs more education when he a. describes changes in his behaviour that may improve cardiovascular function. b. describes the schedule, dosage, and purpose of his medication. c. states that he will take his medication when he has chest pain or when his heart rate is greater than 100. d. describes the benefits of taking his medication regularly.

ANS: C

The patient should not take medications for cardiovascular function intermittently. Medication should be taken on the regular prescribed schedule to prevent additional cardiac events.

Describing changes in his behaviour that may improve his cardiovascular function indicates that the patient understands steps he may take to improve his own health. The ability to accurately describe the schedule, dose, and purpose of his medication indicates that the patient understands his treatment. Understanding the benefits of taking his medication regularly should improve patient compliance with therapy.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY DIF: Cognitive Level: Analysis REF: Skill 8.4: Cardiovascular Assessment OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Cardiovascular Disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11. Which of the following is an expected outcome for a patient after cardiac assessment? a. Apical pulse rate equals 58 beats per minute b. Carotid bruits present c. Point of maximal impulse (PMI) palpable at left fifth intercostal space at

midclavicular line d. Jugular veins distended with patient in sitting position ANS: C

Locate the PMI by palpating with fingertips along the fifth intercostal space at the midclavicular line. Sinus bradycardia: Pulse rhythm is regular, but rate is slower than normal at 40 to 60 beats per minute. Place bell of stethoscope over each carotid artery while auscultating for blowing sounds (bruit). Ask the patient to hold a breath for a few heartbeats so that respiratory sounds will not interfere with auscultation. Narrowing of the carotid artery lumen by arteriosclerotic plaques causes disturbance in blood flow. Blood passing through the narrowed section creates turbulence and emits a blowing or swishing sound. Normal veins are flat when the patient is sitting, and pulsations become evident as the patient’s head is lowered.

DIF: Cognitive Level: Analysis REF: Skill 8.4: Cardiovascular Assessment OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Cardiovascular Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. Where is the pulmonic area forNaU usRcS ulI taN tioGnTfB ou.nCdO ?M a. Second intercostal space on the right side b. Second intercostal space on the left side c. Third intercostal space (Erb’s point) d. Fourth intercostal space along the sternum ANS: B

The pulmonic area is at the second intercostal space on the left side. The aortic area is at the second intercostal space on the patient’s right side. The second pulmonic area is found by moving down the left side of the sternum to the third intercostal space, also referred to as Erb’s point. The tricuspid area is located at the fourth left intercostal space along the sternum.

DIF: Cognitive Level: Application REF: Skill 8.4: Cardiovascular Assessment OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Heart Sounds KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. While performing a cardiovascular assessment on a patient with suspected left-sided

congestive heart failure, the nurse is unable to palpate the point of maximal impulse (PMI) with the patient lying supine. What might her next step be? a. Have the patient turn onto his left side. b. Have the patient lean forward. c. Have the patient move to a sitting position. d. Palpate the PMI to the right of the midclavicular line.

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If palpating the PMI is difficult, turn the patient onto the left side. This manoeuvre moves the heart closer to the chest wall. Different positions help clarify the types of sounds heard. Sitting position is best to hear high-pitched murmurs (if present). In the presence of serious heart disease, the PMI will be located to the left of the midclavicular line if related to an enlarged left ventricle. In chronic lung disease, the PMI is often to the right of the midclavicular line as a result of right ventricular enlargement.

DIF: Cognitive Level: Application REF: Skill 8.4: Cardiovascular Assessment OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Cardiovascular Disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. Which is the best position in which to place the patient to hear low-pitched cardiovascular

sounds? a. Supine b. Sitting up c. Dorsal recumbent d. Left lateral recumbent ANS: D

Different positions help clarify types of sounds heard. Sitting position is best to hear high-pitched murmurs (if present). Supine is a common position to hear all sounds. Left lateral recumbent is the best position to hear low-pitched sounds.

DIF: Cognitive Level: Application REF: Skill 8.4: Cardiovascular Assessment OBJ: Use physical assessment techniques and skills during routine nursing care.

GETYB: .NCuO TOP: Cardiovascular Disease NURSINK rsM ing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. What technique should the nurse implement for assessment of the carotid artery? a. Massaging the arteries briskly b. Using the diaphragm of the stethoscope c. Palpating each carotid artery separately d. Placing the patient in a supine position ANS: C

Palpate each carotid artery separately with index and middle fingers around the medial edge of the sternocleidomastoid muscle. Ask the patient to raise the chin slightly, keeping the head straight. Note rate and rhythm, strength, and elasticity of the artery. Also note if the pulse changes as the patient inspires and expires. Do not vigorously palpate or massage the artery.

Stimulation of the carotid sinus may cause a reflex drop in heart rate and blood pressure. Place the bell of the stethoscope over each carotid artery, auscultating for a blowing sound (bruit).

To assess venous pressure, have the patient recline at a 45-degree angle and slowly recline into the supine position, avoiding neck hyperextension or flexion. Measure the distance between the angle of Louis and the highest point of vein pulsation.

DIF: Cognitive Level: Application REF: Skill 8.4: Cardiovascular Assessment OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Assessment of Carotid Artery KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 16. Which of the following is an unexpected finding after a cardiac assessment? a. A pulse rate of 72 beats per minute b. Jugular vein pulsation with the patient supine c. PMI found at the midclavicular line d. A sustained swishing sound during systole or diastole ANS: D

Murmurs are sustained swishing or blowing sounds heard at the beginning, middle, or end of systole or diastole. They are caused by increased blood flow through a normal valve, forward flow through a stenotic valve or into a dilated vessel or chamber, or backward flow through a valve that fails to close. Expected outcomes after completion of procedure: Heart rate is between 60 and 100 beats per minute (adolescent through adult) and without extra sounds or murmurs; jugular veins distend when patient lies supine and flatten when patient is in sitting position; and point of maximal impulse (PMI) is palpable at fifth intercostal space at left midclavicular line in the adult.

DIF: Cognitive Level: Analysis REF: Skill 8.4: Cardiovascular Assessment OBJ: Use interprofessional collaboration to communicate abnormal findings to appropriate team members.

TOP: Murmurs KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 17. Which technique is most appropriate for a nurse to implement during the assessment of the

abdomen? a. Assessing painful areas first b. Auscultating for 5 minutes over each quadrant c. Positioning the patient in a supine position with the arms behind or over the head d. Palpating painful masses or organ enlargement deeply and firmly

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ANS: B

To auscultate bowel sounds, place the diaphragm of the stethoscope lightly over each of the four abdominal quadrants. Listen 5 minutes over each quadrant before deciding that bowel sounds are absent. Painful areas are assessed last. Manipulation of a body part can increase the patient’s pain and anxiety and can make the remainder of the assessment difficult to complete.

Placing the arms under the head or keeping the knees fully extended can cause the abdominal muscles to tighten. Tightening of muscles prevents adequate palpation. If masses are palpated, note size, location, shape, consistency, tenderness, mobility, and texture.

DIF: Cognitive Level: Comprehension REF: Skill 8.5 OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Abdominal Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. How should the nurse document an exaggeration of the posterior curvature of the thoracic

spine found during the assessment of a 90-year-old patient? a. Lordosis b. Osteoporosis c. Scoliosis d. Kyphosis ANS: D

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Kyphosis is an exaggeration of the posterior curvature of the thoracic spine (hunchback).

Lordosis is an increased lumbar curvature (swayback). Osteoporosis is a metabolic bone disease that causes a decrease in quality and quantity of bone. Scoliosis is a lateral curvature of the spine.

DIF: Cognitive Level: Application REF: Skill 8.7 OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Curvature of the Spine KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19. The patient is diagnosed with Bell’s palsy. The nurse assesses the patient and notices drooping

of the patient’s right eye and the right side of his mouth. When the functions of the following cranial nerves (CNs) are compared, the most likely cause of these symptoms would be a dysfunction of the a. facial nerve (CN VII). b. trigeminal nerve (CN V). c. oculomotor nerve (CN III). d. glossopharyngeal nerve (CN IX).

ANS: A

Assess CN VII (facial) by noting facial symmetry. Have the patient frown, smile, puff out their cheeks, and raise the eyebrows. Expressions should be symmetrical; Bell’s palsy causes drooping of the upper and lower face; cerebrovascular accident (CVA) causes asymmetry.

Assess CN V (trigeminal) by applying light sensation with a cotton ball to symmetrical areas of the face. Sensations should be symmetrical; unilateral decrease or loss of sensation possibly is due to a CN V lesion or a lesion in higher sensory pathways. Assess CNs III (oculomotor), IV (trochlear), and VI (abducens) by assessing extraocular movement (EOM) functioning.

Ask the patient to follow the mN ovUeR mSeI ntNoG fT yoBu. rC finOgMer through the six cardinal positions of gaze; measure pupillary reaction to light reflex and accommodation using a penlight. These cranial nerves are most likely to be affected by increasing intracranial pressure (ICP), which causes a change in pupil response or pupil size; sometimes pupils change shape (more oval) or react sluggishly. ICP impairs EOMs. Damage to CN IX causes impaired swallowing; damage to CN X causes loss of gag reflex, hoarseness, and a nasal voice. When the palate fails to rise and the uvula pulls toward the normal side, this indicates a unilateral paralysis.

DIF: Cognitive Level: Synthesis REF: Skill 8.7 OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Cranial Nerves KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 20. Measurement of the patient’s ability to differentiate between sharp and dull sensations over

the forehead tests which cranial nerve? a. Abducens b. Facial c. Trigeminal d. Oculomotor ANS: C

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The trigeminal nerve is tested by applying light sensation with a cotton ball to symmetrical areas of the face. Sensations should be symmetric; unilateral decrease or loss of sensation may be caused by a cranial nerve (CN) V lesion. Assess CNs III (oculomotor), IV (trochlear), and VI (abducens) by assessing extraocular movement (EOM) functioning. Ask the patient to follow the movement of your finger through the six cardinal positions of gaze; measure pupillary reaction to light reflex and accommodation using a penlight. The facial nerve is tested by having the patient smile, frown, puff out the cheeks, and raise and lower the eyebrows while you look for asymmetry. The oculomotor nerve is tested by assessing directions of gaze and by testing pupillary reaction to light and accommodation.

DIF: Cognitive Level: Application REF: Skill 8.7 OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Cranial Nerves KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 21. The nurse is assessing the neurological status of a patient. She uses the handle end of a reflex

hammer to stroke the lateral aspect of the sole of the foot. She notes that the great toe dorsiflexes and the other toes spread out like a fan. What does this indicate? a. A positive Romberg’s test b. A negative Babinski’s reflex c. A hyperactive patellar tendon reflex d. A normal reflex in a child younger than age 2 ANS: D

After the soles of the feet are stroked, if Babinski’s reflex is present, the great toe will dorsiflex, accompanied by fanning of the other toes. This indicates central nervous system (CNS) dysfunction. Dorsiflexion of the great toe and fanning of the others are normal findings in a child younger than age 2. RNoUmRbS erI g’NsGteTstB: .

HC avOeMthe patient stand with feet together, arms at sides, once with eyes open, and once with eyes closed (for 20–30 seconds each time).

Protect the patient’s safety by standing at their side; observe for swaying. Plantar response (Babinski’s reflex): Using the handle end of the reflex hammer, stroke the lateral aspect of the sole, from the heel to the ball of the foot. The toes should flex inward and downward. Knee reflex: Palpate the patellar tendon just below the patella. Tap the pointed end of the reflex hammer briskly on the tendon. Knee reflex is the most common DTR assessment performed.

The normal response is knee extension.

DIF: Cognitive Level: Synthesis REF: Skill 8.7 OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Babinski’s Reflex KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 22. How does a nurse appropriately measure intake and output? a. Recording 50% of ice chip consumption b. Checking urinary output every 24 hours c. Emptying the chest tube drainage every 2 hours d. Subtracting liquid medications from the total intake ANS: A

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All liquids consumed must be counted including liquids with meals, gelatin, custards, ice cream, popsicles, sherbets, and ice chips (recorded as 50% of measured volume [e.g., 100 mL of ice chips equals 50 mL of water]) for the intake record. Liquid medicines such as antacids are counted as fluid intake, as are fluids with medications. The output record must include all fluids leaving the body. Instruct the patient (or family) to call the nurse to empty contents of the urinal, urine hat, or commode each time it is used so the fluid may be measured. Blood collected in a wound drain is also counted. Chest tube drainage is emptied ONLY when the container is nearly full. A closed system is necessary to maintain lung re-expansion.

DIF: Cognitive Level: Application REF: Procedural Guideline 8.1 OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Intake KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. Which skin condition would cause a nurse to suspect chicken pox? a. Wheals b. Nodules c. Pustules d. Vesicles ANS: D

A vesicle is a circumscribed elevation of skin filled with serous fluid, smaller than 1 cm (e.g., herpes simplex and chicken pox). A wheal is an irregularly shaped, elevated area of superficial localized edema that varies in size (e.g., hive and mosquito bite); it is not characteristic of chicken pox. A nodule is an elevated solid mass, deeper and firmer than a papule, 1 to 2 cm (e.g., wart), and not characteristic of chicken pox. A pustule is a circumscribed elevation of skin similar to a vesicle but filled with pus; it varies in size (e.g., acne and staphylococcal infectiNoU n)RaS ndIN is GnT otBc. haCraOcM teristic of chicken pox.

DIF: Cognitive Level: Application REF: Box 8.5: Types of Skin Lesions OBJ: Discuss normal physical findings for patients across the life span.

TOP: Primary Skin Lesions KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 24. Which patient position maximizes the nurse’s ability to assess the patient’s body for

symmetry? a. Sitting b. Supine c. Prone d. Dorsal recumbent ANS: A

Sitting upright provides full expansion of the lungs and allows better visualization of symmetry of upper body parts. The supine position maximizes the nurse’s ability to assess pulse sites. The prone position is used only to assess extension of the hip joint. The dorsal recumbent position is used for abdominal assessment because it promotes relaxation of abdominal muscles.

DIF: Cognitive Level: Application REF: Skill 8.1 OBJ: Discuss normal physical findings for patients across the life span.

TOP: Positions for Physical Assessment KEY: Nursing Process Step: Assessment

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY MSC: NCLEX: Physiological Integrity 25. During assessment of a patient with anemia, a nurse is alert for the presence of a. pallor. b. jaundice. c. cyanosis. d. erythema.

ANS: A

Pallor is a decrease in colour caused by a reduced amount of oxyhemoglobin resulting from decreased blood flow caused by anemia or shock. Jaundice is caused by increased deposit of bilirubin in tissues caused by liver disease or destruction of red blood cells; it is not characteristic of anemia. Cyanosis is caused by an increased amount of deoxygenated hemoglobin caused by heart or lung disease or a cold environment; it is not characteristic of anemia. Erythema is caused by increased visibility of oxyhemoglobin as a result of dilation or increased blood flow because of fever, direct trauma, blushing, or alcohol intake; it is not characteristic of anemia.

DIF: Cognitive Level: Application REF: Skill 8.1 OBJ: Discuss normal physical findings for patients across the life span.

TOP: Skin Colour Variations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 26. A nurse is documenting a patient’s breath sounds. Fine crackles are heard as a. loud, low-pitched, coarse sounds. b. high-pitched, musical squeaks. c. dry, grating sounds on inspiration. d. high-pitched, fine sounds aN t tU heReSnI dNoG f iT nsBp. irC atO ioM n.

ANS: D

Fine crackles are high-pitched, fine, short, interrupted crackling sounds heard during the end of inspiration; they usually are not cleared with coughing. Rhonchi are loud, low-pitched, rumbling, coarse sounds heard most often during inspiration or expiration that may be cleared by coughing. Wheezes are high-pitched, continuous, musical sounds like a squeak heard continuously during inspiration or expiration; they are usually louder on expiration and do not clear with coughing. Pleural friction rub has a dry, grating quality heard best during inspiration; it does not clear with coughing and is heard loudest over the lower lateral anterior surface.

DIF: Cognitive Level: Application REF: Table 8.6: Adventitious Breath Sounds OBJ: Discuss normal physical findings for patients across the life span.

TOP: Adventitious Breath Sounds KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 27. A student nurse is working with a patient who has asthma. The primary nurse tells the student

that wheezes can be heard on auscultation. The student expects to hear a. coarse crackles and bubbling. b. high-pitched musical sounds. c. dry, grating noises. d. loud, low-pitched rumbling.

ANS: B

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Wheezes are high-pitched, continuous, musical sounds like a squeak heard continuously during inspiration or expiration; they are usually louder on expiration. Coarse crackles and bubbling are not descriptive of wheezes. Dry, grating noises are heard with a pleural friction rub. Loud, low-pitched rumbling is characteristic of rhonchi.

DIF: Cognitive Level: Application REF: Table 8.6: Adventitious Breath Sounds OBJ: Discuss normal physical findings for patients across the life span.

TOP: Adventitious Breath Sounds KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 28. A nurse is documenting a patient’s breath sounds. Rhonchi are heard as a. loud, low-pitched, coarse sounds. b. high-pitched, musical squeaks. c. dry, grating sounds on inspiration. d. high-pitched, fine sounds at the end of inspiration.

ANS: A

Rhonchi are loud, low-pitched, rumbling, coarse sounds heard most often during inspiration or expiration; they may be cleared by coughing. Wheezes are high-pitched, continuous, musical sounds like a squeak heard continuously during inspiration or expiration; they are usually louder on expiration and do not clear with coughing. Pleural friction rub has a dry, grating quality heard best during inspiration and does not clear with coughing; it is heard loudest over the lower lateral anterior surface. Fine crackles are high-pitched fine, short, interrupted crackling sounds heard during the end of inspiration; they usually are not cleared with coughing.

DIF: Cognitive Level: Application REF: Table 8.6: Adventitious Breath Sounds OBJ: Discuss normal physical fiN ndUinRgS s fIoN r pGaT tieBn. ts C acOroMss the life span.

TOP: Adventitious Breath Sounds KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 29. Which of the following is a major cause of lung cancer, cerebrovascular disease, heart disease,

and chronic lung disease? a. Diabetes b. UV exposure c. Radiation d. Smoking ANS: D

Smoking is a major cause of lung cancer, heart disease, and chronic lung disease (emphysema and chronic bronchitis).

DIF: Cognitive Level: Understanding REF: Skill 8.2 OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Smoking KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 30. When performing an assessment of the cardiovascular system, the nurse evaluates the skin

and nails of the patient. Inadequate tissue perfusion is known as a. ischemia b. anemia c. cyanosis

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY d. necrosis ANS: A

Inadequate tissue perfusion results in inadequate delivery of oxygen and nutrients to cells, a condition called ischemia. This is caused by constriction of vessels or by occlusion (blockage) from clot formation.

DIF: Cognitive Level: Understanding REF: Skill 8.4 OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Ischemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 31. The patient has been immobile at home after having had leg trauma in an automobile accident

and is now being admitted with calf pain and localized swelling of the calf muscle. One test that is contraindicated in assessment of this patient is testing for . a. equal pulses bilaterally b. capillary refill c. paresthesia d. Homans’ sign ANS: D

Homans’ sign is no longer considered a reliable indicator for the presence or absence of deep vein thrombosis (DVT) and should not be considered a reliable test. Trauma to the vein or muscle, reduced mobility, and increased blood clotting are reliable risk factors. If the calf is swollen, tender, or red, notify the patient’s health care provider for further assessment and evaluation. If there is a strong suspicion of DVT, testing for Homans’ sign is contraindicated.

If a clot is present, it may become dislodged from its original site during this test. This could result in a pulmonary embolismN.URSINGTB.COM DIF: Cognitive Level: Analysis REF: Skill 8.4 OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Deep Vein Thrombosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 32. The patient has been in the critical care unit after an acute myocardial infarction 3 days

earlier. During an initial assessment of the patient, the nurse detects a heart murmur that the patient did not have previously. The nurse should . a. realize that this is a normal finding b. notify the patient’s health care provider c. order an echocardiogram d. perform a 12-lead electrocardiogram (ECG) ANS: B

Impaired blood flow through the heart indicates the need for immediate medical attention.

Some murmurs are benign. Nurses cannot order an echocardiogram.

DIF: Cognitive Level: Analysis REF: Skill 8.4 OBJ: Use interprofessional collaboration to communicate abnormal findings to appropriate team members.

TOP: Murmurs KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 33. The patient is noted to have difficulty swallowing. The nurse realizes that the most probable

cause of this difficulty is damage to cranial nerve a. VII b. VIII c. IX d. X

.

ANS: C

Damage to cranial nerve (CN) IX causes impaired swallowing. When the palate fails to rise and the uvula pulls toward the normal side, this indicates a unilateral paralysis. Damage to CN VII affects taste; damage to CN VIII affects hearing; damage to CN X causes loss of gag reflex, hoarseness, and nasal voice.

DIF: Cognitive Level: Synthesis REF: Skill 8.7 OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Cranial Nerves KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 34. Increased visibility of oxyhemoglobin caused by dilation or increased blood flow is known as

. a. b. c. d.

erythema anemia cyanosis jaundice

ANS: A

Red skin (erythema) is caused by increased visibility of oxyhemoglobin caused by dilation or increased blood flow.

NURSINGTB.COM DIF: Cognitive Level: Application REF: Skill 8.1 OBJ: Discuss normal physical findings for patients across the life span.

TOP: Skin Colour Variations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 35. A late sign of decreased oxygen levels may cause a change in skin colour known as a. b. c. d.

. erythema anemia cyanosis jaundice

ANS: C

Bluish (cyanosis) colouring of the skin is caused by hypoxia (late sign of decreased oxygen levels).

DIF: Cognitive Level: Application REF: Skill 8.1 OBJ: Discuss normal physical findings for patients across the life span.

TOP: Skin Colour Variations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

is a yellow-orange skin colour seen with increased deposit of bilirubin in

36.

tissues.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. b. c. d.

Erythema Anemia Cyanosis Jaundice

ANS: D

Jaundice, a yellow-orange skin colour, is seen with increased deposits of bilirubin in tissues.

DIF: Cognitive Level: Understanding REF: Skill 8.1 OBJ: Discuss normal physical findings for patients across the life span.

TOP: Skin Colour Variations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The purpose of the physical assessment is to (Select all that apply.) a. compare the patient’s status with previous findings. b. help the nurse gather additional data. c. help select the best nursing measures. d. teach patients about better health promotion.

ANS: A, B, C, D

In acute care settings, you perform a brief physical assessment at the beginning of each shift to identify changes in the patient’s status for comparison with the previous assessment. After gathering data, the nurse groups significant findings into patterns of data that reveal actual or risk nursing diagnoses. Each abnormal finding directs the nurse to gather additional data. The information is useful in selecting the best nursing measures to manage the patient’s health problems. During the physical N asUseRsS smIeNnG t iT sB an.iC deOaM l time to offer patient teaching and encourage promotion of health practices, such as breast and genital self-examination.

DIF: Cognitive Level: Comprehension REF: Principles for Practice OBJ: Discuss the purposes of physical assessment.

TOP: Purpose of the Physical Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse is preparing to examine a comatose patient on a ventilator. Before beginning the

procedures, she (Select all that apply.) a. speaks to the patient to minimize anxiety. b. drapes the body parts not being examined. c. encourages the patient to ask questions. d. uses medical terms to let the patient know that she is professional.

ANS: A, B

Minimize patients’ anxiety and fear by conveying an open, receptive, and professional approach. Using simple terms, thoroughly explain what you will do, what the patient should expect to feel, and how the patient can cooperate. Even if the patient appears unresponsive, it still is essential to explain your actions. Provide access to body parts while draping areas that are not being examined.

DIF: Cognitive Level: Application REF: Person-Centred Care OBJ: List techniques to promote the patient’s physical and psychological comfort during an

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TOP: Preparing the Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The patient has come to the clinic complaining of bleeding from what she calls a “mole” on

her neck. She states that her mother died from skin cancer at a fairly early age because she was fair skinned and had a lot of exposure to the sun. The patient admits that she often forgets to wear sunscreen and spends a lot of time outside for work. The nurse prepares to examine the mole while being especially watchful for (Select all that apply.) a. uneven shape of the mole (asymmetry). b. ragged or blurred edges of the mole border. c. pigmentation that is not uniform. d. size of the mole.

ANS: A, B, C, D

The warning signs of skin cancer using the ABCD mnemonic include A for Asymmetry—look for uneven shape; B for Border irregularity—look for edges that are blurred, notched, or ragged; C for Colour—pigmentation is not uniform; blue, black, brown variegated, tan, or areas of unusual colour such as pink, white, grey, or red; and D for Diameter—greater than the size of a typical pencil eraser. Also, identify any skin lesion or nevus that starts to bleed or ooze or feels different (swollen, hard, lumpy, itchy, or tender to the touch).

DIF: Cognitive Level: Analysis REF: Box 8.4: Malignant Melanoma Mnemonics OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Melanoma KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. While performing a physical exNaU mR inSaI tioNnG , tThB e. nuCrsOeMincorporates health promotion by

teaching the patient about how to reduce the risk of lung cancer. The nurse explains that besides cigarette smoking, exposure to other substances may lead to this disease. Some of these substances are (Select all that apply.) a. arsenic. b. asbestos. c. radiation. d. air pollution.

ANS: A, B, C, D

Explain to patients that exposure to radiation, arsenic, and asbestos from occupational, medical, and environmental sources; air pollution; history of tuberculosis; and second-hand smoke contribute significantly to lung cancer.

DIF: Cognitive Level: Understanding REF: Skill 8.3 OBJ: Discuss ways to incorporate health promotion and health teaching into an assessment.

TOP: Lung Cancer KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

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Chapter 09: Specimen Collection Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. How should the nurse identify a patient before obtaining a laboratory specimen? a. Use at least two patient identifiers. b. Look at the chart before entering the room. c. Ask the patient his name. d. Check the patient’s armband twice.

ANS: A

Before obtaining a laboratory specimen, use at least two identifiers such as checking the identification number on the admission armband and asking the patient’s name. Patients who are confused or who have a language barrier may smile and not understand the question. The patient could also have the wrong armband on; checking it twice would not change that.

DIF: Cognitive Level: Application REF: Skill 9.1 OBJ: Identify measures to minimize anxiety and promote safety during specimen collection.

TOP: Positive Patient Identification KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. When discussing the collection of a clean-voided urine specimen, it is important for the nurse

to instruct the patient to a. use a clean specimen cup. b. collect 100 to 150 mL of urine for testing. c. void some urine first and thN enUR coSllI ecNt G thTeBsa.mCpOleM. d. wash the perineal area with soap and water immediately before voiding.

ANS: C

After the patient has initiated a urine stream, pass the urine specimen container into the stream and collect 90 to 120 mL of urine. A sterile specimen container is used. Pour antiseptic solution over cotton balls. A cotton ball or gauze is used to cleanse the perineum.

DIF: Cognitive Level: Application REF: Skill 9.1 OBJ: Use correct technique for collecting clean-voided, timed, and catheterized urine specimens.

TOP: Obtaining Urine Culture and Sensitivity (C&S) Specimen KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The nurse needs to obtain a sterile urine specimen for culture and sensitivity (C&S) from a

patient who has an indwelling catheter. The catheter was placed the night before. What must the nurse do to obtain the specimen? a. Obtain the urine from the drainage bag. b. Clamp the drainage tubing for 15 minutes. c. Draw urine using a 20-mL syringe. d. Insert the needle into the silicone catheter.

ANS: B

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Clamp the drainage tubing with a clamp or rubber band for 30 minutes to permit collection of fresh, sterile urine in the catheter tubing rather than draining into the bag. Do not collect a urine specimen for culture tests from a urine drainage bag unless it is the first urine to drain into a new sterile bag. Draw urine into a 3-mL syringe (for culture), or draw urine into a 20-mL syringe (for routine urinalysis). Proper volume is needed to perform the test. Do not puncture Silastic, silicone, or plastic catheters. These are not self-sealing.

DIF: Cognitive Level: Application REF: Skill 9.1 OBJ: Use correct technique for collecting clean-voided, timed, and catheterized urine specimens.

TOP: Obtaining Urine C&S Specimen from a Catheter KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. What should the nurse do first if a patient is unable to void on demand for a clean-voided

specimen? a. Perform Credé’s procedure for the suprapubic area. b. Catheterize the patient to obtain the specimen. c. Offer fluids, if allowed, and wait about 30 minutes. d. Notify the physician that the test cannot be completed.

ANS: C

If the patient is unable to urinate on demand, offer fluids if permitted. Allow more time for urine to accumulate in the bladder. Try obtaining a specimen after 30 minutes. If the patient has no urine in the bladder, Credé’s would not be useful. The risk for infection precludes the use of catheterization simply to obtain a specimen. If the patient is unable to void after several hours, the physician may need to be called to obtain a prescription for catheterization.

DIF: Cognitive Level: ApplicatiN onURSINRGETFB : .SC kiO llM 9.1 OBJ: Use correct technique for collecting clean-voided, timed, and catheterized urine specimens.

TOP: Obtaining Urine C&S Specimen from a Catheter KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. What must the nurse do to collect a midstream urine sample from an infant? a. Apply a sterile plastic collection bag to the perineum. b. Wring out diapers and collect the urine in a specimen container. c. Have the infant sit facing the back of the toilet. d. Catheterize the infant and collect the urine using sterile procedure.

ANS: A

Use a sterile plastic urine collecting bag that adheres to the perineum of a non–toilet-trained child. Special considerations for boys: Place the penis and scrotum inside the bag. Diapers may be contaminated. Seating on a toilet generally is not realistic for an infant.

Catheterization should be used as a last resort only.

DIF: Cognitive Level: Application REF: Pediatric (Skill 9.1) OBJ: Use correct technique for collecting clean-voided, timed, and catheterized urine specimens.

TOP: Obtaining Urine C&S Specimen from an Infant KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. What should the nurse do when a patient is required to provide a timed urine specimen?

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. Save all urine from the time the test began. b. Leave the collection bottle on the floor near the patient’s bed. c. Send notices along with the patient when leaving the unit to have all urine saved

and returned to the unit. d. Remove contaminants such as toilet paper from the urine before transferring it to the collection bottle.

ANS: C

Place signs on the patient’s door and toileting area, indicating that a timed urine specimen collection is in progress. If the patient leaves the unit for a test or procedure, be sure that personnel in that area collect and save all urine. The nurse discards the first specimen and then collects every successive specimen until the timed period has ended. Place a specimen collection container in the bathroom and, if indicated, in a pan of ice. The urine specimen is not to be contaminated with feces or toilet tissue.

DIF: Cognitive Level: Application REF: Procedural Guideline 9.1 OBJ: Use correct technique for collecting clean-voided, timed, and catheterized urine specimens.

TOP: Obtaining a Timed Urine Specimen KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. What instructions does the nurse provide to the patient to obtain a double-voided urine

specimen? a. Save two separate specimens from the first voiding in the morning. b. Add two specimens together from the morning voiding and the evening voiding. c. Discard the first sample, then wait a half hour and void again. d. Void first and then self-catheterize to obtain the specimens.

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ANS: C

A fresh specimen should be used because stagnant urine that has been in the bladder for several hours will not accurately reflect the serum glucose level at the time of testing. Ask the patient to collect a random urine specimen and discard, drink a glass of water, and collect another specimen 30 to 45 minutes later.

DIF: Cognitive Level: Application REF: Procedural Steps (PG 9.2) OBJ: Identify special conditions necessary for collection of each specimen.

TOP: Collecting a Double-Voided Specimen KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. An appropriate procedure for urine testing with reagent strips for chemical properties of the

sample is to a. obtain the first voided specimen in the morning. b. immerse the test strip in the urine and remove immediately. c. add a chemically active tablet to the urine and then test it with a reagent strip. d. wipe the strip with a sterile gauze after dipping.

ANS: B

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Immerse the strip briefly in the urine sample, and then remove it and tap it gently on the side of the container; prolonged exposure to excess urine can dilute reagents. Stagnant urine stored in the bladder overnight or for long periods does not reveal quantities of glucose and ketones excreted by the kidney at the time of testing. Kits that contain tablets do not also use strips; the tablet contains the reagent and changes colour to indicate chemical properties of the urine.

Tap the strip gently against the side of the container to shed excess urine; do not wipe it.

DIF: Cognitive Level: Application REF: Procedural Guideline 9.2 OBJ: Discuss nursing responsibilities for processing a specimen after collection.

TOP: Testing the Chemical Properties of Urine KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. A patient is concerned because her first guaiac test is positive. What information should the

nurse share with the patient? a. The patient probably has colorectal cancer. b. The test needs to be repeated after she eats some red meat. c. The test needs to be repeated at least three times. d. The patient needs a low-residue diet to reduce intestinal abrasions.

ANS: C

A single positive test result does not confirm bleeding or indicate colorectal cancer. For confirmed positive results, the test must be repeated at least three times while the patient is on a meat-free, high-residue diet. More in-depth diagnosis is needed with a positive result.

DIF: Cognitive Level: Application REF: Skill 9.2 OBJ: Provide patient education to promote patient cooperation during specimen collection.

NURSINKGETYB: .NCuO TOP: Guaiac Testing rsM ing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 10. When teaching a patient about home testing for occult blood, the nurse instructs the patient

that a. b. c. d.

positive results are indicative of bleeding. poultry and fish should be eaten before testing. testing should be done carefully during the menstrual cycle. two samples should be obtained from the same part of the stool specimen.

ANS: C

Specimens will be positive if contaminated by menstrual or hemorrhoidal blood or povidone-iodine. A single positive test result does not confirm bleeding or indicate colorectal cancer. Diets rich in meats, green leafy vegetables, poultry, and fish may produce false-positive results. Obtain a second fecal specimen from a different portion of the stool.

DIF: Cognitive Level: Application REF: Skill 9.2 OBJ: Provide patient education to promote patient cooperation during specimen collection.

TOP: Guaiac Testing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. A patient asks what food may be eaten before a stool specimen is obtained for occult blood.

What food should the nurse allow the patient to eat? a. Fish b. Apples

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY c. Red meats d. Green leafy vegetables ANS: B

Diets rich in meats, green leafy vegetables, poultry, and fish may produce false-positive results.

DIF: Cognitive Level: Comprehension REF: Skill 9.2 OBJ: Provide patient education to promote patient cooperation during specimen collection.

TOP: Guaiac Testing KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 12. The nurse evaluates that an expected outcome for analysis of gastric secretions is a. positive frank blood. b. negative occult blood. c. the presence of clumps or clots. d. the presence of brown, “coffee-ground” secretions.

ANS: B

An expected outcome after completion of the procedure is the test for occult blood. If frank red blood is observed or coffee-ground materials are seen, report these findings immediately.

This is an unexpected finding.

DIF: Cognitive Level: Comprehension REF: Skill 9.2 OBJ: Explain the rationale for the collection of each specimen.

TOP: Guaiac Testing of Gastric Contents KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

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13. An appropriate technique for the nurse to implement when obtaining throat cultures is to a. have the patient lie flat in the bed. b. do the culture before meals or an hour after meals. c. avoid touching the swab to any of the inflamed areas. d. place pressure on the tongue blade along the back of the tongue.

ANS: B

Plan to do the culture before mealtime or at least 1 hour after eating. This procedure often induces gagging; timing will decrease the patient’s chances of vomiting. Ask the patient to sit erect in bed or on a chair facing the nurse. Gently but quickly swab the tonsillar area from side to side, making contact with inflamed or purulent sites. Depress the anterior third of the tongue only; placement of a tongue blade along the back of the tongue is more likely to initiate a gag reflex.

DIF: Cognitive Level: Application REF: Skill 9.4 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Obtaining a Throat Culture KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. What step should the nurse take to obtain a vaginal specimen for a culture? a. Apply sterile gloves. b. Assist the patient to a side-lying position. c. Collect discharge from the perineum on the same swab. d. Insert the swab to 2.5 cm (1 inch) into the orifice and rotate before removal.

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ANS: D

Gently insert the swab to 2.5 cm (1 inch) into the vaginal orifice and rotate before removal.

Apply clean disposable gloves. The patient should be in dorsal recumbent position. If a discharge near the vagina appears different from the discharge along the perineum, collect separate specimens from each area.

DIF: Cognitive Level: Application REF: Skill 9.5 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Obtaining a Vaginal Culture KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. When using a commercially prepared tube to collect a culture, the nurse should a. take the swab and mix it in the reagent to check for colour changes. b. place the swab into the culture tube and then add a special reagent to the tube. c. crush the ampule at the end of the tube and put the tip of the swab into the solution. d. place the swab into the tube, close it securely, and keep it warm until it is sent to

the laboratory.

ANS: C

Immediately squeeze the end of the tube to crush the ampule, and push the tip of the swab into fluid medium.

DIF: Cognitive Level: Application REF: Equipment (Skill 9.4) OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Preparing a Culture Tub KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. A nurse suspects that the patienNt U mRaySI haNvG eT tuB be.rC cuOloMsis (TB). She sends a sputum sample to

the laboratory for testing. When the following tests are compared, which will best support the diagnosis of possible tuberculosis? a. Acid-fast bacillus (AFB) b. General cytology c. Chemical analysis d. Culture and sensitivity ANS: A

Sputum specimens are collected to identify cancer cells, for culture and sensitivity (C&S) to identify pathogens and determine the antibiotics to which they are sensitive, and for acid-fast bacillus to diagnose pulmonary tuberculosis. Cytological or cellular examinations of sputum may identify aberrant cells or cancer. Chemical analysis would indicate chemicals within the blood, not sputum. Sputum collected for culture and sensitivity testing is used to identify specific microorganisms and to determine which antibiotics are most sensitive. A definitive diagnosis of TB also requires a sputum culture and sensitivity.

DIF: Cognitive Level: Analysis REF: Skill 9.6 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Acid-Fast Bacilli KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 17. The patient has come to the emergency department complaining of coughing up bloody

sputum. The patient has a 30-year history of smoking and has lost 6.8 kg (15 pounds) in the past month. What will the nurse expect the sputum specimen to be evaluated for? a. Culture and sensitivity b. Acid-fast bacillus (AFB) c. Cytology d. Chemical analysis ANS: C

The patient is showing signs of cancer. Sputum specimens are collected to identify cancer cells. Sputum collected for culture and sensitivity testing is used to identify specific microorganisms. The AFB test is used to support the diagnosis of tuberculosis. Chemical analysis would indicate chemicals within the blood, not sputum.

DIF: Cognitive Level: Analysis REF: Skill 9.6 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Cytological Examination of Sputum KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 18. An appropriate technique that the nurse can tell the patient to implement before obtaining a

sputum specimen is to a. use mouthwash before the collection. b. splint the surgical incision before coughing. c. try to obtain a sample immediately after eating. d. take a deep breath, cough hard, and expectorate.

ANS: B

If the patient has a surgical inciNsiUoR nS orIlN ocGaT lizBe. dC arO eaMof discomfort, have the patient place hands firmly over the affected area, or place a pillow over the area. Splinting of painful areas minimizes muscular stretching and discomfort during coughing and thus makes cough more productive. The patient should not use mouthwash or toothpaste because it may decrease viability of microorganisms and culture results. Have the patient wait 1 to 2 hours after eating.

After a series of deep breaths, ask the patient to cough after full inhalation.

DIF: Cognitive Level: Application REF: Skill 9.6 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Obtaining Sputum Specimen KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. During a sputum collection, the patient becomes hypoxic. What action should the nurse take? a. Suction the patient thoroughly. b. Continue to complete the procedure quickly. c. Stop the procedure and provide oxygen, if prescribed. d. Have the patient lie down and take deep breaths before continuing with the

specimen collection.

ANS: C

If the patient becomes hypoxic, discontinue the procedure until stable and provide oxygen therapy as needed, if prescribed. Suctioning can decrease usable oxygen to the patient.

DIF: Cognitive Level: Application REF: Skill 9.6 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY TOP: Hypoxia During Suctioning MSC: NCLEX: Physiological Integrity

KEY: Nursing Process Step: Implementation

20. The nurse has delegated activities of daily living (ADL) care of a patient with a large wound

that is draining. Which of the following should the nurse instruct the unregulated care provider (UCP) to report back to her? a. The wound has a foul odour. b. Drainage is decreased. c. The patient’s temperature is slightly below normal. d. The patient does not complain of discomfort.

ANS: A

Report a foul odour, increased drainage, and increased temperature or complaints of discomfort.

DIF: Cognitive Level: Application REF: Delegation and Collaboration (Skill 9.7) OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Signs of Infection KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 21. An appropriate technique for the nurse to use when culturing wound drainage that is suspected

to contain anaerobic bacteria is to a. use older secretions for the specimen. b. add exudate from the skin to the wound specimen. c. aspirate 5 to 10 mL of exudate from a deep cavity wound. d. swab carefully and slowly in a back-and-forth motion across the wound.

ANS: C

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Take a swab from a special anaerobic culture tube, swab deeply into the draining body cavity, and rotate gently. Remove the swab and return it to the culture tube, or insert the tip of a syringe into the tube, and aspirate 5 to 10 mL of exudate. Cleanse the area around the wound edges with an antiseptic swab. This removes old exudate and skin flora, preventing possible contamination of the specimen. Never collect exudate from the skin unless it is a separate culture and is labeled as such.

DIF: Cognitive Level: Application REF: Skill 9.7 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Obtaining Anaerobic Wound Specimen KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. The patient is diagnosed with suspected bacteremia. The physician has prescribed blood

cultures from two different sites. The patient is complaining of chills and has an elevated temperature. What action should the nurse take in the presence of these symptoms? a. Delay drawing the blood cultures until symptoms subside. b. Draw blood from only one site to prevent further discomfort. c. Draw the blood cultures as ordered. d. Draw blood from the patient’s intravenous (IV) catheter.

ANS: C

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Because bacteremia may be accompanied by fever and chills, blood cultures should be drawn when the patient is experiencing these clinical signs. It is important that at least two culture specimens be drawn from two different sites. Bacteremia exists when both cultures grow the infectious agent. Because blood culture specimens obtained from an IV catheter are often contaminated, tests that use them should not be performed unless catheter sepsis is suspected.

DIF: Cognitive Level: Application REF: Skill 9.8 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Drawing Blood Cultures KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. When blood specimens are drawn, which of the following statements is true? a. Draw cryoglobulin levels using test tubes placed on ice. b. To test ammonia and ionized calcium levels, warm the test tubes. c. To draw for lactic acid levels, do not use a tourniquet. d. To draw for vitamin levels, use light to determine density.

ANS: C

Some specimens have special collection requirements before or after specimen collection, for example, for lactic acid levels, do not use a tourniquet. For cryoglobulin levels, use prewarmed test tubes. For ammonia and ionized calcium levels, place the tube in ice for delivery to the laboratory. For vitamin levels, avoid exposure of the test tube to light.

DIF: Cognitive Level: Analysis REF: Skill 9.8 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Drawing Blood KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

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24. A patient is to have a venipuncture to obtain a blood sample to check ammonia levels. What

should the nurse do when given this information? a. Use prewarmed test tubes. b. Keep the specimen out of the light. c. Avoid use of a tourniquet during the procedure. d. Place the samples on ice before sending them to the laboratory.

ANS: D

Some specimens have special collection requirements before or after specimen collection. For ammonia levels, tubes must be placed on ice for delivery to the laboratory. For cryoglobulin levels, use prewarmed test tubes. For vitamin levels, avoid exposure of the test tube to light.

For lactic acid levels, do not use a tourniquet.

DIF: Cognitive Level: Analysis REF: Skill 9.8 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Drawing Blood KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. The nurse is preparing to perform a venipuncture on a patient. Which of the following is an

appropriate action for the nurse to take? a. Apply the tourniquet until the distal pulse is no longer felt. b. Remove the tourniquet after 1 minute. c. Instruct the patient to vigorously open and close the fist. d. Do not use veins that rebound.

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ANS: B

Do not keep a tourniquet on the patient longer than 1 minute. Prolonged tourniquet application causes stasis, localized acidemia, and hemoconcentration. Palpate the distal pulse (e.g., brachial) below the tourniquet. If the pulse is not palpable, reapply the tourniquet more loosely. Ask the patient to open and close the fist several times, finally leaving the fist clenched. Instruct the patient to avoid vigorous opening and closing of the fist. Palpate for a firm vein that rebounds; a patent, healthy vein is elastic and rebounds on palpation.

DIF: Cognitive Level: Application REF: Skill 9.8 OBJ: Use correct technique to perform venipuncture.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Applying Tourniquet

26. An appropriate technique for the nurse to implement when preparing for a venipuncture is to a. tie the tourniquet in a knot. b. tie the tourniquet, so it can be easily removed. c. place the tourniquet 12 to 15 cm above the selected site. d. make the tourniquet tight enough to occlude the distal pulse.

ANS: B

Apply the tourniquet by encircling the extremity and pulling one end of the tourniquet tightly over the other, looping one end under the other, so it can be removed by pulling the end with a single motion. Apply the tourniquet 5 to 10 cm above the venipuncture site selected. Palpate the distal pulse below the tourniquet; if the pulse is not palpable, reapply the tourniquet more loosely.

DIF: Cognitive Level: ApplicatiN onURSINRGETFB : .SC kiO llM 9.8 OBJ: Use correct technique to perform venipuncture.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Applying Tourniquet

27. The nurse is drawing blood from a patient to determine the blood alcohol level. Which step is

an appropriate action for the nurse to take? a. Swab the area with an antiseptic swab. b. Swab the area with an alcohol swab. c. Do not swab the area at all. d. Apply the tourniquet for 5 minutes.

ANS: A

If drawing a sample for a blood alcohol level or blood culture, use only an antiseptic swab, not an alcohol swab. Do not keep a tourniquet on the patient longer than 1 minute.

DIF: Cognitive Level: Application REF: Skill 9.8 OBJ: Use correct technique to perform venipuncture.

TOP: Drawing Blood for Blood Alcohol Level KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 28. When performing a venipuncture, the nurse should a. inject with the needle at a 45-degree angle. b. select a vein that is rigid and cordlike and that rolls when palpated.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY c. perform the needle insertion immediately after cleansing the skin with alcohol. d. place the thumb of the nondominant hand about 2.5 cm (1 inch) below the site and

pull the skin taut.

ANS: D

Place the thumb or forefinger of the nondominant hand 2.5 cm (1 inch) below the site and gently pull the skin taut. Stretch the skin down until the vein is stabilized. Hold a syringe and needle at a 15- to 30-degree angle from the patient’s arm with the bevel up. Palpate for a firm vein that rebounds. Do not use veins that feel rigid or cordlike; a thrombosed vein is rigid, rolls easily, and is difficult to puncture. Allowing alcohol to dry completes its antimicrobial task and reduces the “sting” of venipuncture. Alcohol left on the skin can cause hemolysis of the sample.

DIF: Cognitive Level: Application REF: Skill 9.8 OBJ: Use correct technique to perform venipuncture.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Venipuncture

29. When obtaining a venipuncture sample for a blood culture, the nurse should a. recap the needles. b. shake the culture bottles well. c. use two different sites to draw samples. d. inoculate the aerobic culture bottle first.

ANS: C

Collect 10 to 15 mL of venous blood by venipuncture in a 20-mL syringe from each venipuncture site. Culture specimens must be obtained from two sites. Dispose of needles, syringe, and soiled equipment iNnUthReSpI roNpG erTcB on.tC aiO neMr. Do not cap the needles. Mix gently after inoculation. If both aerobic and anaerobic cultures are needed, inoculate the anaerobic culture first.

DIF: Cognitive Level: Analysis REF: Skill 9.8 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Blood Cultures KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 30. When teaching about the procedure for capillary puncture, the nurse instructs a patient to a. hold the finger upright. b. use the central tip of the finger. c. allow the antiseptic to dry completely. d. vigorously squeeze the end of the finger.

ANS: C

Clean the site with an antiseptic swab, and allow it to dry completely. Alcohol left on the skin can cause hemolysis of the sample. Hold the finger to be punctured in a dependent position while gently massaging the finger toward the puncture site to increase blood flow to the area before puncture. Select the lateral side of the finger; be sure to avoid the central top of the finger, which has a more dense nerve supply.

DIF: Cognitive Level: Application REF: Skill 9.9 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Capillary Puncture KEY: Nursing Process Step: Implementation

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY MSC: NCLEX: Physiological Integrity 31. Which of the following is the site of choice for obtaining samples for an arterial blood gas

(ABG)? a. Radial artery b. Brachial artery c. Femoral artery d. Popliteal artery ANS: A

The radial artery is the safest, most accessible site for puncture; it is superficial, is not adjacent to large veins, and usually has adequate collateral circulation by the ulnar artery. Its use is relatively painless if the periosteum is avoided, and it is used when Allen’s test is positive. The brachial artery has reasonable collateral blood flow but is less superficial, is more difficult to palpate and stabilize, and carries increased risk for venous puncture; its use results in increased discomfort. The femoral artery should not be used by nurses without specialized training. The popliteal artery usually is not used.

DIF: Cognitive Level: Application REF: Skill 9.10 OBJ: Use correct technique to perform arterial puncture for blood gas measurement.

TOP: Arterial Blood Gases KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 32. An appropriate technique for the nurse to implement when obtaining an arterial blood gas

(ABG) specimen is to a. insert the needle at a 45-degree angle. b. use a 19-gauge, 2.5-cm (1-inch) needle. c. leave 0.5 mL of heparin in N thU eR sySriInN geG. TB.COM d. aspirate blood after the puncture.

ANS: A

Hold the needle bevel up, and insert the needle at a 45-degree angle into the artery. Use a 23to 25-gauge needle. Aspirate 0.5-mL sodium heparin into a syringe, and then eject all heparin in the barrel out of the syringe. Allow arterial pulsations to pump 2 to 3 mL of blood into the heparinized syringe slowly to reduce the presence of air bubbles.

DIF: Cognitive Level: Application REF: Skill 9.10 OBJ: Use correct technique to perform arterial puncture for blood gas measurement.

TOP: Arterial Blood Gases KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 33. What should the nurse do after obtaining a sample for an arterial blood gas (ABG)? a. Maintain pressure over the site for 3 to 5 minutes. b. Check the artery proximal to or above the puncture site. c. Place the syringe into a plastic bag, and send it to the laboratory. d. Apply a cool compress to hematoma formation at the puncture site.

ANS: A

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Maintain continuous pressure on and proximal to the site for 3 to 5 minutes. Palpate the artery below or distal to the puncture site to determine whether pulse quality has changed, indicating alteration in arterial flow. Place a syringe in a cup of crushed ice. Failure to do this may result in decreased pH, arterial oxygen pressure (PaO2), and oxygen saturation. Apply warm compresses to enhance the absorption of blood.

DIF: Cognitive Level: Application REF: Skill 9.10 OBJ: Use correct technique to perform arterial puncture for blood gas measurement.

TOP: Arterial Blood Gases KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

organisms grow in superficial wounds exposed to the air.

34. a. b. c. d.

Aerobic Anaerobic Cyanotic Infectious

ANS: A

Aerobic organisms grow in superficial wounds exposed to the air.

DIF: Cognitive Level: Understanding REF: Skill 9.7 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Aerobic Organisms KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 35. The least traumatic method of obtaining a blood specimen is a. radial arterial puncture. b. femoral arterial puncture. NURSINGTB.COM c. capillary puncture. d. venipuncture.

ANS: C

Skin puncture, also called capillary puncture, is the least traumatic method of obtaining a blood specimen.

DIF: Cognitive Level: Understanding REF: Skill 9.9 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Skin/Capillary Puncture KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. When collecting specimens, the nurse should (Select all that apply.) a. wear gloves and perform hand hygiene. b. handle excretions discreetly. c. explain the procedure to the patient. d. allow patients to collect their own urine specimens.

ANS: A, B, C, D

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When collecting specimens, wear gloves, and perform hand hygiene. Also, handle excretions discreetly. Invasive collection procedures and fear of unknown test results often cause patients anxiety. Patients who receive a clear explanation about the purpose of the specimen and how the nurse will obtain it are more cooperative. Give patients proper instruction to collect their own specimens of urine, stool, and sputum, thus avoiding embarrassment.

DIF: Cognitive Level: Application REF: Principles for Practice OBJ: Identify measures to minimize anxiety and promote safety during specimen collection.

TOP: Specimen Collection KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. When obtaining laboratory specimens, the nurse needs to be aware that (Select all that apply.) a. specimen collection may cause anxiety and embarrassment. b. sociocultural variations may affect a patient’s compliance. c. contact isolation precautions are required for collection of blood. d. two identifiers, including room number, must be used.

ANS: A, B

The nurse should recognize that specimen collection may cause anxiety, embarrassment, or discomfort. Cultural considerations are important when collecting specimens and performing diagnostic procedures. Culture and beliefs may affect a patient’s response and willingness to participate in specimen collection. Use of a patient’s room number is not an acceptable identifier, and the nurse should follow routine practices when collecting specimens of blood or other body fluids.

DIF: Cognitive Level: Application REF: Person-Centred Care OBJ: Identify measures to minimize anxiety and promote safety during specimen collection.

UeRnS GETYB: .NCuO TOP: Obtaining Laboratory SpecNim s INK rsM ing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. A timed urine collection can be used for which of the following? (Select all that apply.) a. Glucose b. Adrenocorticosteroids c. Bacteria count d. Colour ANS: A, B

Some tests of renal function and urine composition require urine to be collected over 2 to 72 hours. The 24-hour timed collection is most common. These tests measure for elements such as amino acids, creatinine, hormones, glucose, and adrenocorticosteroids, whose levels fluctuate throughout the day. A timed urine collection also can serve as a means to measure the concentration or dilution of urine. Bacteria count and colour can be determined through a routine urinalysis.

DIF: Cognitive Level: Understanding REF: Procedural Guideline 9.1 OBJ: Use correct technique for collecting clean-voided, timed, and catheterized urine specimens.

TOP: Obtaining a Timed Urine Specimen KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. Hemoccult testing helps reveal blood that is visually undetectable. This test is a useful

diagnostic tool for which of the following conditions? (Select all that apply.)

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. b. c. d.

Colon cancer Upper gastrointestinal (GI) ulcers Localized gastric parasites Large polyps

ANS: A, B, C, D

This test is a useful diagnostic tool for conditions such as colon cancer, upper gastrointestinal ulcers, and localized gastric parasitic infection or intestinal irritation. The amount of bleeding increases with the size of the polyp and the stage of cancer. People with small polyps (less than 1 cm in diameter) bleed scarcely more than those without polyps.

DIF: Cognitive Level: Comprehension REF: Skill 9.2 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Guaiac Testing KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 5. The nurse is caring for a patient who has had a craniotomy. The patient appears to need

endotracheal suctioning. The nurse is aware that this can be of concern because suctioning can cause which of the following? (Select all that apply.) a. Violent coughing b. Aspiration of stomach contents c. Increased intracranial pressure d. Bradycardia or tachycardia ANS: A, B, C, D

Sometimes suctioning provokes violent coughing, causes vomiting and aspiration of stomach contents, and induces constriction of pharyngeal, laryngeal, and bronchial muscles. In addition, suctioning may causeNhU ypRoSxI em gaOl M overload, resulting in cardiopulmonary NiGa TorBv.aC compromise and increased intracranial pressure.

DIF: Cognitive Level: Comprehension REF: Skill 9.6 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Suctioning KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 6. In explaining to the patient about obtaining a sputum specimen to diagnose tuberculosis, the

nurse explains which of the following? (Select all that apply.) a. Specimens are best obtained in the early morning. b. Acid-fast bacillus (AFB) smears require three consecutive morning samples. c. Bacteria accumulate as secretions pool. d. Specimens should be obtained at bedtime.

ANS: A, B, C

Specimens for AFB require three consecutive morning samples, and cultures can take up to 8 weeks. The ideal time to collect sputum is early morning because bronchial secretions tend to accumulate during the night. Bacteria also accumulate as secretions pool.

DIF: Cognitive Level: Comprehension REF: Skill 9.3 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Cultures for Acid-Fast Bacilli and C&S for Tuberculosis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

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Chapter 10: Diagnostic Procedures Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. A nurse should contact the physician to postpone intravenous moderate sedation if the patient a. has been nothing by mouth (NPO) for 1 hour. b. has a history of substance abuse. c. has no history of latex allergy. d. has demonstrated an understanding of the procedure.

ANS: A

Verify that the patient has not ingested food or fluids, except for oral medications, for at least 4 hours. Verify specific employer requirements. Because a risk of moderate sedation is loss of airway protection, an empty stomach reduces the risk for aspiration. A history of substance abuse is not a contraindication to the procedure, although it usually requires dose adjustment of the sedative. With no history of latex allergy, allergic reactions are not a concern. An understanding of the procedure implies that consent was informed.

DIF: Cognitive Level: Application REF: Skill 10.2 OBJ: Explain nursing responsibilities related to the use of intravenous sedation during diagnostic/surgical procedures.

TOP: Moderate Sedation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. Which action should the nurse take after a procedure requiring intravenous moderate

sedation?

NURSINGTB.COM a. Report to the physician a Ramsay sedation score that is less than 3. b. Monitor airway patency and vital signs every 5 minutes for 30 minutes. c. Take vital signs every 15 minutes for the next 2 hours. d. Take vital signs every 30 minutes until stable.

ANS: B

After the procedure, monitor airway patency, vital signs, SpO2, pain score, and level of consciousness every 5 minutes for at least 30 minutes, then every 15 minutes for an hour, and then every 30 minutes until the patient meets the discharge criteria on the employer’s designated scoring system. Report to the physician only a Ramsay sedation score higher than 3.

DIF: Cognitive Level: Application REF: Skill 10.2 OBJ: Explain nursing responsibilities related to the use of intravenous sedation during diagnostic/surgical procedures.

TOP: Moderate Sedation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. Under which circumstances should a nurse contact the physician to postpone an angiography? a. If a patient has been nothing by mouth (NPO) for only 1 hour. b. If a patient’s femoral site has been shaved and cleansed with an antiseptic. c. If the patient received diphenhydramine (Benadryl) as a preprocedure medication. d. When test results reveal a blood urea nitrogen (BUN) level of 15 mg/100 mL and a

creatinine level of 0.8 mg/mL. ANS: A

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A patient needs to be NPO for 2 to 8 hours before the procedure to prevent possible aspiration because the patient is sedated. The site of catheter insertion needs to be shaved and prepped with antiseptic just before the procedure. Diphenhydramine is used prophylactically to block histamine and decrease allergic responses. Elevated BUN or creatinine levels would place patients at risk for renal failure induced by contrast media.

DIF: Cognitive Level: Application REF: Skill 10.2 OBJ: Assist health care providers with angiogram, cardiac catheterization, intravenous pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy.

TOP: Postponing Angiography KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 4. What action should the nurse take after an angiography? a. Limit the patient’s fluid intake. b. Have the patient ambulate as soon as possible. c. Apply a pressure dressing to the vascular site. d. Maintain the patient in a sitting position while he or she is in bed.

ANS: C

A total of 5 to 15 minutes of manual pressure is often enough to stop active site bleeding.

However, a certain amount of bed rest is needed to achieve reliable hemostasis. Check employer policy for postprocedure bed rest requirements. This is often up to 6 hours when no vascular closure device is used. Encourage patient to drink 1 to 2 L of fluid after the procedure. Emphasize the need to lie flat for 6 to 12 hours.

DIF: Cognitive Level: Application REF: Skill 10.2 OBJ: Perform appropriate physical and psychosocial assessments before, during, and after diagnostic procedures.

TOP: PostN -AUnR giS ogIraNpG hyTPBro.cC edOuM re KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse is alert to a possible delayed reaction to the dye injected during an angiography. For

which response should she monitor the patient? a. Pallor b. Dyspnea c. Thirst d. Numbness and tingling ANS: B

Assess the patient for a possible delayed reaction to iodine dye, seen as dyspnea, hives, tachycardia, and rash. This reaction occurs up to 6 hours after injection of dye. Thirst, by itself, is not a major warning sign of reaction to the dye. Pallor, by itself, is not a major warning sign of reaction to the dye. A patient’s report of any feelings of pain, dyspnea, numbness or tingling, or other untoward symptoms may indicate cardiac complications or procedure site complications, but not a reaction to the dye.

DIF: Cognitive Level: Application REF: Skill 10.2 OBJ: Perform appropriate physical and psychosocial assessments before, during, and after diagnostic procedures.

TOP: Reaction to IV Dye KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 6. The nurse is preparing to assist with a bone marrow aspiration on a 3-month-old infant. The

nurse may expect that the physician will use which site to perform the aspiration? a. Sternum b. Anterior iliac crest c. Proximal tibia d. Posterior iliac crest ANS: C

In children, the anterior or posterior iliac crest is used, and in infants, the proximal tibia is used.

DIF: Cognitive Level: Application REF: Skill 10.3 OBJ: Assist health care providers with angiogram, cardiac catheterization, intravenous pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy.

TOP: Bone Marrow Aspiration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The nurse is discussing the patient’s upcoming elective lumbar puncture and explains that the

patient will probably need to undergo computed tomography of the brain before the procedure is done. What is the reason for this? a. Diagnose central nervous system (CNS) infection. b. Rule out increased intracranial pressure. c. Visualize cerebrospinal fluid. d. Measure pressure in the subarachnoid space.

ANS: B

In elective lumbar puncture (LP), preprocedure computed tomography (CT) results are reviewed for evidence of brainNshUifRt S toIrN ulG eT ouBt.inCcO reMased intracranial pressure. The purpose of the LP procedure itself is to measure pressure in the subarachnoid space; obtain cerebrospinal fluid (CSF) for visualization and laboratory examination; and inject anesthetic, diagnostic, or therapeutic agents. A CT scan will not allow adequate visualization of these structures.

DIF: Cognitive Level: Application REF: Skill 10.3 OBJ: Assist health care providers with angiogram, cardiac catheterization, intravenous pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy.

TOP: Lumbar Puncture KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. The patient is a 56-year-old man who has terminal cirrhosis and severe ascites. He is lethargic

but is demonstrating signs of discomfort and respiratory distress. The physician has spoken with the patient’s wife and has obtained consent to perform an abdominal paracentesis on the patient. After the physician leaves to prepare for the procedure, the wife asks the nurse whether the procedure is really necessary. The nurse should respond by saying this a. is the first step in the patient’s recovery. b. may help the patient feel better. c. is needed to detect increased intracranial pressure. d. is needed to analyze pleural fluid.

ANS: B

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

The patient is diagnosed as terminal. Paracentesis is a palliative measure used to provide temporary relief of abdominal and respiratory discomfort caused by severe ascites.

Intracranial pressure is assessed with computed tomography. Thoracentesis, not paracentesis, is performed to analyze or remove pleural fluid.

DIF: Cognitive Level: Application REF: Skill 10.3 OBJ: Assist health care providers with angiogram, cardiac catheterization, intravenous pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy.

TOP: Abdominal Paracentesis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. Which is the appropriate patient position for a lumbar puncture? a. Prone b. Supine c. Sims’ d. Lateral recumbent ANS: D

Position the patient in a lateral recumbent (fetal) position with the head and neck flexed. This provides spinal column full curvature. The spinal column is flexed as much as possible to allow maximal space between vertebrae.

DIF: Cognitive Level: Application REF: Skill 10.3 OBJ: Assist health care providers with angiogram, cardiac catheterization, intravenous pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy.

TOP: Positioning for Lumbar Puncture KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

NURSINGTB.COM 10. In which position is the patient usually placed for a thoracentesis? a. Dorsal recumbent position b. Supine with the arms over the head c. Sims’ position on the affected side d. Sitting and leaning over a bedside table ANS: D

Place the patient in the orthopneic position (upright position with arms and shoulders raised and supported on a padded over-bed table). If the patient is unable to tolerate this position, assist the patient to a side-lying position with the affected lung positioned upward. This expands the intercostal space for needle insertions.

DIF: Cognitive Level: Application REF: Skill 10.3 OBJ: Assist health care providers with angiogram, cardiac catheterization, intravenous pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy.

TOP: Positioning for Thoracentesis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. When explaining about a lumbar puncture, the nurse informs the patient that during the

procedure, he or she will be asked to a. remain very still. b. cough during the fluid aspiration. c. change position. d. breathe deeply during the needle insertion.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

ANS: A

Emphasize the importance of remaining immobile during the procedure to prevent trauma, especially with the lumbar puncture, because sudden movement is a risk for spinal cord nerve root damage. Also, instruct the patient not to cough, sneeze, or breathe deeply during the procedure because these actions increase the risks for needle displacement and damage to other structures.

DIF: Cognitive Level: Application REF: Skill 10.3 OBJ: Assist health care providers with angiogram, cardiac catheterization, intravenous pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy.

TOP: Lumbar Puncture KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. When explaining what to expect during a bronchoscopy, the nurse informs the patient that a. an anesthetic solution will be swallowed. b. the tube will be passed through the nose. c. nothing will be given by mouth for 2 to 3 hours before. d. no food or fluid will be provided until the gag reflex returns.

ANS: D

Do not allow the patient to eat or drink until the tracheobronchial anesthesia has worn off and the gag reflex has returned—usually for 2 hours. Instruct the patient not to swallow the local anesthetic. The bronchoscope is introduced into the mouth, to the pharynx, to pass through the glottis. The patient should have taken nothing by mouth for at least 8 hours before a bronchoscopy.

DIF: Cognitive Level: Application REF: Skill 10.4 NURSINGTB.COM OBJ: Assist health care providers with angiogram, cardiac catheterization, intravenous pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy.

TOP: Bronchoscopy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. The physician needs to visually examine a patient’s esophagus, stomach, and duodenum. The

nurse anticipates that the physician will prescribe a. endoscopic retrograde cholangiopancreatography (ERCP). b. esophagoscopy. c. esophagogastroduodenoscopy (EGD). d. proctoscopy.

ANS: C

EGD permits visualization of the esophagus, stomach, and duodenum in a single examination.

ERCP is performed for visualization of the hepatobiliary tree and pancreatic ducts.

Esophagoscopy is used to examine the esophagus only. Proctoscopy offers a visual examination of the lower gastrointestinal tract.

DIF: Cognitive Level: Application REF: Skill 10.5 OBJ: Assist health care providers with angiogram, cardiac catheterization, intravenous pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy.

TOP: Esophagogastroduodenoscopy (EGD) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 14. A patient who is a candidate for an upper gastrointestinal endoscopy has a. been nothing by mouth (NPO) for 8 hours. b. evident respiratory distress. c. active gastrointestinal bleeding. d. an esophageal diverticulum.

ANS: A

Verify that the patient has been NPO for at least 8 hours. Evident respiratory distress will increase risk, and the procedure may have to be delayed. This test is contraindicated in patients with severe upper gastrointestinal tract bleed, Zenker’s diverticulum, or a large aortic aneurysm.

DIF: Cognitive Level: Application REF: Skill 10.5 OBJ: Assist health care providers with angiogram, cardiac catheterization, intravenous pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy.

TOP: Esophagogastroduodenoscopy (EGD) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. For an upper gastrointestinal endoscopy, a nurse should a. remove the patient’s dentures. b. suction the patient every 5 minutes. c. place the patient in high-Fowler’s position. d. provide fluids immediately after the test is finished.

ANS: A

Remove the patient’s dentures and other dental appliances to prevent dislodgement of dental structures during the intubationNpUhR asSe.IPNoG siT tioBn.tC heOtM ip of the cannula in the patient’s mouth for easy access to drain oral secretions; suction as needed. Help the patient maintain left lateral Sims’ position. Instruct the patient not to eat or drink after the procedure until the gag reflex returns, which is usually about 2 hours after the procedure.

DIF: Cognitive Level: Application REF: Skill 10.5 OBJ: Assist health care providers with angiogram, cardiac catheterization, intravenous pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy.

TOP: Gastrointestinal Endoscopy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. During an electrocardiogram, the patient should anticipate that a. chest pain may occur. b. the electrode sites will be cleaned with alcohol. c. talking and moving around will be allowed. d. the electrodes are attached with ties or rubber straps.

ANS: B

Clean and prepare the skin; wipe the sites with alcohol to help remove oils that would prevent adherence of the electrodes. Although the procedure is painless, it is important to document and note whether the patient is experiencing any chest discomfort during the procedure.

Instruct the patient to lie still without talking. Electrodes are self-sticking.

DIF: Cognitive Level: Application REF: Skill 10.2 OBJ: Perform appropriate physical and psychosocial assessments before, during, and after diagnostic

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY procedures.

TOP: Electrocardiogram (ECG) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. The nurse is caring for a patient who underwent a cardiac catheterization. The sheaths have

just been removed. You should assess the patient carefully for what potential complication? a. Vasovagal reaction b. Hypertension c. Tachycardia d. Allergic reaction ANS: A

Before removing the catheter sheath, check the health care provider’s prescriptions for instructions on treating a vasovagal reaction. Manual pressure applied to the groin/femoral area can stimulate the baroreceptors and cause a vasovagal reaction in which the patient becomes bradycardic and hypotensive. Vasovagal reactions are usually brief and self-limited.

When applying pressure to the groin after sheath removal, be alert for a vasovagal reaction and be prepared to treat it by lowering the head of the bed to the flat position and giving a bolus of intravenous (IV) fluids.

DIF: Cognitive Level: Application REF: Skill 10.2 OBJ: Perform appropriate physical and psychosocial assessments before, during, and after diagnostic procedures.

TOP: Cardiac Catheterization KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. The nurse is caring for a patient who has received moderate sedation for a procedure at the

bedside. Which task can be delN egUaR teS dI toNtG heTuBn. reCgO ulM ated care provider (UCP) during this procedure? a. Assessing sedation score b. Obtaining blood pressure c. Monitoring respiratory rate d. Recording urine output ANS: D

The task of assisting with intravenous (IV) moderate sedation, including the preprocedure assessment, cannot be delegated to a UCP. In most agencies, a registered nurse (RN) or health care provider assesses and monitors a patient’s level of sedation, airway patency, and level of consciousness. Roles in monitoring depend on scope-of-practice guidelines as determined by provincial/territorial regulations (see employer policy). You could delegate to a UCP the task of recording urine output.

DIF: Cognitive Level: Application REF: Delegation and Collaboration OBJ: Describe the health care team collaboration and teamwork required before, during, and after procedures, including delegation to unregulated care providers (UCPs).

TOP: Conscious Sedation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 19. Which of the following is a medication-induced depression of consciousness during which

patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. In addition, no interventions are required to maintain a patent airway, and spontaneous ventilation is adequate.

NURSING TEST BANK

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. b. c. d.

Mild sedation Moderate sedation Deep sedation Therapeutic coma

ANS: B

Moderate sedation/analgesia produces a minimally depressed level of consciousness induced by the administration of pharmacological agents in which a patient retains a continuous and independent ability to maintain protective reflexes and a patent airway and is aroused by physical or verbal stimulation.

DIF: Cognitive Level: Understanding REF: Skill 10.1 OBJ: Perform appropriate physical and psychosocial assessments before, during, and after diagnostic procedures.

TOP: Moderate Sedation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 20. The removal of a small amount of the liquid organic material in the medullary canals of

selected bones, in particular the sternum and the posterior superior iliac crests in adults, is known as . a. lumbar puncture b. bone marrow aspiration c. angiogram d. paracentesis ANS: B

Bone marrow aspiration is the removal of a small amount of the liquid organic material in the medullary canals of selected bones, in particular the sternum and the posterior superior iliac crests in adults.

NURSINGTB.COM DIF: Cognitive Level: Understanding REF: Skill 10.3 OBJ: Identify physiological indications for diagnostic procedures.

TOP: Bone Marrow Aspiration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 21. A

involves the introduction of a needle into the subarachnoid space of the spinal column. The purpose of this test is to measure pressure in the subarachnoid space; obtain cerebrospinal fluid (CSF) for visualization and laboratory examination; and inject anesthetic, diagnostic, or therapeutic agents. a. lumbar puncture b. bone marrow aspiration c. angiogram d. paracentesis ANS: A

A lumbar puncture (LP), called a spinal puncture or spinal tap, involves the introduction of a needle into the subarachnoid space of the spinal column. The purpose of this test is to measure pressure in the subarachnoid space; obtain CSF for visualization and laboratory examination; and inject anesthetic, diagnostic, or therapeutic agents.

DIF: Cognitive Level: Understanding REF: Skill 10.3 OBJ: Identify physiological indications for diagnostic procedures.

TOP: Lumbar Puncture KEY: Nursing Process Step: Assessment

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The patient will be undergoing moderate intravenous (IV) sedation. The nurse needs to assess

which of the following during the procedure? (Select all that apply.) a. Airway compromise b. Hemodynamic instability c. Agitation d. Combativeness ANS: A, B, C, D

Patient risks during IV sedation include hypoventilation, airway compromise, hemodynamic instability, and/or altered levels of consciousness that include an overly depressed level of consciousness or agitation and combativeness. Emergency equipment appropriate for the patient’s age and size and staff with skill in airway management, oxygen delivery, and use of resuscitation equipment are essential. During and after the procedure, patients need continuous monitoring of vital signs, oxygen saturation, heart rhythm, lung sounds, and level of consciousness.

DIF: Cognitive Level: Application REF: Skill 10.1 OBJ: Explain nursing responsibilities related to the use of intravenous sedation during diagnostic/surgical procedures.

TOP: Moderate Sedation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The patient has undergone a cardiac catheterization. It has been 2 hours since the catheter and

sheath have been removed. WhNicUhRoS f tIhN eG foT llB ow .iCngOw Mould be a concern for the nurse recovering the patient after the procedure? (Select all that apply.) a. Swelling and hardness at the catheter insertion site b. Complaints of itching and urticaria c. Urine output less than 30 mL/hr d. Low back pain radiating to both sides of the body ANS: A, B, C, D

If hematoma or hemorrhage is present at the catheter insertion site, apply pressure over the insertion site, and notify the health care provider or physician if interventions do not stop the bleeding or if the patient demonstrates symptoms of acute blood loss (hypotension, tachycardia). If the patient has an allergic reaction to contrast medium manifested by symptoms of flushing, itching, and urticaria, continue monitoring the patient and assess for anaphylaxis. Notify the health care provider. Renal toxicity from contrast can be detected by monitoring intake and output. Urine output of less than 30 mL/hr is a sign of renal toxicity.

Low back pain radiating to both sides of the body is a hallmark sign of retroperitoneal bleeding.

DIF: Cognitive Level: Analysis REF: Skill 10.2 OBJ: Perform appropriate physical and psychosocial assessments before, during, and after diagnostic procedures.

TOP: Reaction to IV Dye KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. Both aspiration and biopsy diagnose and differentiate which of the following? (Select all that

apply.)

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. b. c. d.

Leukemia Certain malignancies Heart disease Thrombocytopenia/anemia

ANS: A, B, D

Both aspiration and biopsy diagnose and differentiate leukemia, certain malignancies, anemia, and thrombocytopenia. Heart disease is not diagnosed with these studies.

DIF: Cognitive Level: Comprehension REF: Skill 10.3 OBJ: Identify physiological indications for diagnostic procedures.

TOP: Bone Marrow Biopsy/Aspiration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse is caring for a patient who has just undergone a bronchoscopy and has been in

recovery for the past 15 minutes. The nurse should be especially watchful for which of the following? (Select all that apply.) a. Return of the gag reflex b. Laryngospasm c. Respiratory status d. Facial or neck crepitus ANS: B, C, D

Laryngospasm with bronchospasm evidenced by sudden, severe shortness of breath is an unexpected and potentially lethal outcome. Call the health care provider or physician immediately, prepare emergency resuscitation equipment, and anticipate a possible cricothyrotomy. Observe respiratory status closely, particularly for facial or neck crepitus.

This is an early sign of bronchiN alUpRerSfoIrN atG ioT n.BT.hC eO gaMg reflex does not normally return until 2 hours after the procedure.

DIF: Cognitive Level: Application REF: Skill 10.4 OBJ: Perform appropriate physical and psychosocial assessments before, during, and after diagnostic procedures.

TOP: Evaluation of Patient Undergoing Bronchoscopy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

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Chapter 11: Safe Patient Handling, Transfer, and Positioning Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. A nurse should be aware of safety measures to prevent personal injury when lifting or moving

patients. An appropriate principle to follow is a. bend at the waist for lifting. b. tighten the stomach muscles and pelvis. c. keep the weight to be lifted away from the body. d. carry or hold the weight 30 to 60 cm (1–2 feet) above the waist.

ANS: B

Tighten the stomach muscles and tuck the pelvis; this provides balance and protects the back.

Bend at the knees; this helps maintain the nurse’s centre of gravity and lets the strong muscles of the legs do the lifting. Keep the weight to be lifted as close to the body as possible; this action places the weight in the same plane as the lifter and close to the centre of gravity for balance.

DIF: Cognitive Level: Application REF: Box 11.1: Principles of Safe Body Mechanics OBJ: Describe principles of safe patient handling, transfer, and positioning.

TOP: Principles of Lifting KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The most prevalent and debilitating occupational health hazard among nurses is a. footdrop.

NURSINGTB.COM b. pressure ulcers. c. musculoskeletal disorders. d. contractures.

ANS: C

Musculoskeletal disorders are the most prevalent and debilitating occupational health hazard among nurses. Little improvement has been noted in the incidence of musculoskeletal injuries among health care workers. In 2016 the health care and social services industry averaged more than 43?836 lost time claims in Canada. Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. Pressure ulcers and contractures are complications that can develop in patients who do not maintain correct body alignment.

DIF: Cognitive Level: Comprehension REF: Evidence-Informed Practice OBJ: Describe principles of safe patient handling, transfer, and positioning.

TOP: Risks for Nurses KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The patient is an older person with severe kyphosis who is immobile from a stroke several

years earlier. He has been admitted for severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize? a. This patient should be turned onto his back for meals. b. This patient may have to be turned more frequently than every 2 hours. c. This patient may be allowed to remain in his favorite position as long as he doesn’t complain of discomfort.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY d. Skin breakdown is not an issue for this patient.

ANS: B

Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the centre of gravity is not aligned. Cluttered hallways and bedside areas increase the patient’s risk for falling.

Dehydration or edema may require more frequent position changes because patients are at risk for skin breakdown.

DIF: Cognitive Level: Application REF: Safety Guidelines OBJ: Describe principles of safe patient handling, transfer, and positioning.

TOP: Repositioning KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. Why does a nurse move a patient who has been confined to bed for a few days slowly from a

sitting to a standing position? a. Fatigue b. Muscle injury c. Sensory disorientation d. Orthostatic hypotension ANS: D

A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop in blood pressure) when transferred.

DIF: Cognitive Level: Comprehension REF: Skill 11.1 OBJ: Describe principles of safeNpU atR ieS ntIhN anG dlTinBg. , tC raO nsM fer, and positioning.

TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual

has the greatest potential for injury during transfers? a. Diabetes mellitus b. Myocardial infarction c. A cerebrovascular accident d. An upper extremity fracture ANS: C

Certain conditions increase a patient’s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus, myocardial infarction, or upper extremity fracture does not increase the patient’s risk for injury to the same extent.

DIF: Cognitive Level: Application REF: Skill 11.1 OBJ: Describe transfer and positioning procedures to follow to ensure patient and nurse safety.

TOP: Cerebrovascular Accident KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the bed.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY b. Raise the head of the bed 30 degrees. c. Turn the patient onto the side facing away from the nurse. d. Move the patient’s legs over the side of the bed.

ANS: B

With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient and the nurse to raise the patient to a sitting position.

The bed should be in the low position. The patient is turned to face the nurse after the head of the bed is raised 30 degrees. The patient’s legs are positioned over the edge of the bed after the head of the bed is raised and the patient is turned to face the nurse.

DIF: Cognitive Level: Application REF: Skill 11.1 OBJ: Describe the procedures for helping a patient move up in bed, helping a patient to a sitting position, logrolling a patient, and transferring a patient from a bed to a chair.

TOP: Assisting Patient to a Sitting Position on Side of Bed KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a

chair, what should the nurse do? a. Grab the patient under the axilla to lift. b. Have the patient move forward with the weak side. c. Have the patient put on shoes with nonskid soles. d. Place the chair in a position 90 degrees opposite the bed.

ANS: C

Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Always have thNeUpR atS ieI ntNw r s.hC oeOsMduring transfer; bare feet increase the risk GeTaB for falls. Patients should never be lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patient’s strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.

DIF: Cognitive Level: Application REF: Skill 11.1 OBJ: Describe the procedures for helping a patient move up in bed, helping a patient to a sitting position, logrolling a patient, and transferring a patient from a bed to a chair.

TOP: Assisting Patient to a Sitting Position on Side of Bed KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to

assist. Of the following, which would be the best technique for transferring the patient? a. Using three nurses and a slide board b. Using the three-person lift technique c. Raising the head 30 degrees d. Having the patient keep arms to the side ANS: A

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can tolerate. This maintains alignment of the spinal column. Cross the patient’s arms on the chest to prevent injury to the arms during transfer.

DIF: Cognitive Level: Application REF: Skill 11.1 OBJ: Describe principles of safe patient handling, transfer, and positioning.

TOP: Normal Body Alignment for Sitting Position KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. An appropriate technique for the nurse to implement when moving a patient out of bed to a

chair with a mechanical lift is to a. lower the height of the bed. b. lower the head of the bed. c. place the sling from shoulders to knees. d. keep the check valve open when the patient is seated in the chair.

ANS: C

The sling should extend from shoulders to knees (hammock) to support the patient’s body weight equally. Raise the bed to a high position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released.

If the valve is left open, the boom may continue to lower and injure the patient.

DIF: Cognitive Level: ApplicatiN onURSINRGETFB : .SC kiO llM 11.1 OBJ: Describe principles of safe patient handling, transfer, and positioning.

TOP: Normal Body Alignment for Sitting Position KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. When preparing to move a patient in bed, the nurse should a. expect that the patient’s comfort level will decrease. b. make sure that all pillows used in the previous position stay in position. c. raise the bed to a comfortable working height. d. plan on moving the patient herself because other nurses are busy.

ANS: C

Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse’s centre of gravity and reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient’s comfort level should increase. The nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.

DIF: Cognitive Level: Application REF: Skill 11.2 OBJ: Describe principles of safe patient handling, transfer, and positioning.

TOP: Planning Patient Move KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 11. An appropriate procedure to use when moving a patient up in bed is for the nurse to a. raise the head of the bed. b. start by flexing the patient’s knees and hips. c. place a pillow under the patient’s shoulders. d. instruct the patient to inhale and hold still.

ANS: B

When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables the nurse to assess body alignment and reduces the pull of gravity on the patient’s upper body. The nurse should remove the pillow from under the patient’s head and shoulders and place the pillow at the head of the bed. This prevents striking the patient’s head against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out, thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in moving up in bed, and increases patient cooperation. Breathing out avoids Valsalva’s manoeuvre.

DIF: Cognitive Level: Application REF: Skill 11.2 OBJ: Describe principles of safe patient handling, transfer, and positioning.

TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished,

the patient is in a supported Fowler’s position with the head of the bed elevated 45 degrees.

Also important for positioning this patient is to a. support his calves with pillows. b. place a large pillow behindNhU isRhS eaIdNtoGpTrB ev.eC ntOeM xtension. c. place a pillow behind his upper back. d. avoid using pillows if the patient does not have use of the hands and arms.

ANS: A

Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the heels. This sometimes is referred to as “floating” heels. Rest the patient’s head against the mattress or on a small pillow. This prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment. Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion contractures of arms and wrists.

DIF: Cognitive Level: Application REF: Skill 11.2 OBJ: Describe principles of safe patient handling, transfer, and positioning.

TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. To position a patient with hemiplegia in Fowler’s position, the nurse should a. elevate the head of the bed 15 to 30 degrees. b. place the patient in the prone position. c. position a spastic hand with the fingers extended using hand rolls.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY d. position the patient’s head with slight hyperextension of the neck.

ANS: C

Position a spastic hand with the wrist in neutral position or slightly extended; fingers should be extended with the palm down or may be left in relaxed position with the palm up. Position the patient in supine position. Elevate the head of the bed 45 to 60 degrees. This increases comfort, improves ventilation, and increases the patient’s opportunity to relax. Adjust the head of the bed according to the patient’s condition. For example, those with increased risk for pressure ulcers will remain at a 30-degree angle. Position the head on a small pillow with the chin slightly forward. If the patient is totally unable to control head movement, avoid hyperextension of the neck. Too many pillows under the head may cause or worsen neck flexion contracture.

DIF: Cognitive Level: Application REF: Skill 11.2 OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions.

TOP: Supporting a Hemiplegic Patient in Fowler’s Position KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. In positioning the patient in the prone position, one way to improve breathing is to a. support the arms in a flexed position level at the shoulders. b. place a pillow under the lower legs. c. place a small pillow under the patient’s abdomen. d. support the patient’s head with a small pillow.

ANS: C

Placing a small pillow under thN eU paRtiSeI ntN ’sGaT bdBo.mCeO nM below the level of the diaphragm reduces pressure on the breasts of some female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body alignment and reduces the risk for joint dislocation but does not improve breathing. Supporting the lower legs with pillows to elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes but does not directly improve breathing. Turning the patient’s head to one side and supporting it with a small pillow is designed to reduce flexion or hyperextension of the cervical vertebrae.

Although it may help with breathing, this is not the primary purpose.

DIF: Cognitive Level: Application REF: Skill 11.2 OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions.

TOP: Prone position KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. A postoperative patient has been instructed by a nurse about the importance of moving in bed

but is still avoiding movement. The nurse should a. avoid moving the patient until he or she is motivated. b. have family members move the patient around. c. decrease the frequency of movement to be performed. d. medicate the patient with a prescribed analgesic before moving.

ANS: D

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If the patient avoids moving, medicate with analgesia as prescribed by the physician to ensure the patient’s comfort before moving. Allow pain medication to take effect before proceeding.

If the patient does not move, he or she is at risk for developing complications of immobility.

Family members are not trained in proper moving techniques and can cause injury to the patient or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.

DIF: Cognitive Level: Application REF: Skill 11.1 OBJ: Describe principles of safe patient handling, transfer, and positioning.

TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. The patient is an older person who has just been admitted for a probable cerebrovascular

accident. The patient is nonverbal and does not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should a. allow the patient to lie on his right side continuously because he seems comfortable. b. prevent the patient from lying on his right side until he no longer wishes to lie on that side. c. frequently assess the patient and turn him more often. d. allow the patient to lie on his right side until a pressure ulcer develops and he can no longer lie on that side.

ANS: C

Patients who have maintained bed rest for a long time may revert back to a favorite position.

Frequently assess these patientN s, U anRdStI urNnGthTeB m.mCoOreMoften as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort.

The purpose of assessment and turning is to prevent complications of immobility.

DIF: Cognitive Level: Analysis REF: Skill 11.2 OBJ: Describe principles of safe patient handling, transfer, and positioning.

TOP: Turning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. The nurse is preparing to reposition the patient. Which of the following is a principle of safe

patient transfer and positioning? a. The wider the base of support, the greater the stability of the nurse. b. The higher the centre of gravity, the greater the stability of the nurse. c. Facing in the opposite direction of movement prevents twisting. d. Using either the arms or the legs reduces the risk for back injury.

ANS: A

The wider the base of support, the greater the stability of the nurse. The lower the centre of gravity, the greater the stability of the nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs reduces the risk for back injury.

DIF: Cognitive Level: Comprehension

REF: Box 11.1: Principles of Safe Body Mechanics

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY OBJ: Describe principles of safe patient handling, transfer, and positioning.

TOP: Principles of Safe Patient Transfer and Positioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse

place the trochanter roll? a. Under the small of the back b. Behind the knees when supine c. Alongside the ilium to mid-thigh d. In the palm of the hand with fingers flexed ANS: C

The nurse should place the trochanter roll alongside the ilium to mid-thigh. The trochanter roll is a rolled wedge, pillow, or sandbag placed by the lateral aspect of the leg between the iliac crest and the knees to prevent external hip rotation.

DIF: Cognitive Level: Application REF: Skill 11.2 OBJ: Describe principles of safe patient handling, transfer, and positioning.

TOP: Trochanter Rolls KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. Plantar flexion contracture, otherwise known as

, is caused when the force of gravity pulls an unsupported, weakened foot into a plantar-flexed position. a. footdrop b. pressure ulcers c. musculoskeletal disorders d. contractures NURSINGTB.COM ANS: A

Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at walking.

DIF: Cognitive Level: Comprehension REF: Skill 11.2 OBJ: Describe transfer and positioning procedures to follow to ensure patient and nurse safety.

TOP: Footdrop KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 20. Which of the following best describes proprioceptive function? a. The ability to detect pain b. The ability to see peripheral vision c. Awareness of posture and changes in equilibrium d. Awareness of numbness and tingling ANS: C

Proprioceptive function is the awareness of posture and changes in equilibrium. Assess a patient’s proprioceptive function when determining the stability of the patient’s balance for transfer.

DIF: Cognitive Level: Comprehension REF: Skill 11.1 OBJ: Describe principles of safe patient handling, transfer, and positioning.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY TOP: Proprioceptive Function MSC: NCLEX: Physiological Integrity

KEY: Nursing Process Step: Assessment

MULTIPLE RESPONSE 1. Patients at risk for complications or injury from improper positioning include patients with

which of the following? (Select all that apply.) a. Poor nutrition b. Loss of sensation c. Impaired muscle development d. Poor circulation ANS: A, B, C, D

Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer. Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility, and impaired muscle development.

DIF: Cognitive Level: Comprehension REF: Principles for Practice OBJ: Describe principles of safe patient handling, transfer, and positioning.

TOP: Risks for Complications KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible.

This is because the nurse realizes that mobilization (Select all that apply.) a. improves joint motion. b. decreases circulation.

NURSINGTB.COM c. increases social activity. d. enhances mental stimulation.

ANS: A, C, D

Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient’s rehabilitation.

DIF: Cognitive Level: Analysis REF: Skill 11.2 OBJ: Describe principles of safe patient handling, transfer, and positioning.

TOP: Mobilization KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse prevents self-injury by using which of the following when transferring a patient?

(Select all that apply.) a. Correct posture b. Maximal muscle strength c. Effective body mechanics d. Effective lifting techniques ANS: A, C, D

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The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting techniques. Consider individual patient problems during transfer.

DIF: Cognitive Level: Comprehension REF: Box 11.1: Principles of Safe Body Mechanics OBJ: Describe transfer and positioning procedures to follow to ensure patient and nurse safety.

TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. Proper alignment for a patient in sitting position includes which of the following? (Select all

that apply.) a. Head erect b. 10-centimeter (4-inch) space between edge of seat and popliteal space c. Vertebrae straight d. Both feet elevated ANS: A, C

In proper alignment for the sitting position, the head is erect and vertebrae are in straight alignment. Body weight is evenly distributed on buttocks and thighs. Thighs are parallel and in the horizontal plane. Both feet are supported on the floor, and ankles are comfortably flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior surface of the knee.

DIF: Cognitive Level: Application REF: Procedural Guideline 11.1 OBJ: Describe principles of safe patient handling, transfer, and positioning.

TOP: Normal Body Alignment for Sitting Position KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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5. Which of the following risk factors contribute to complications of immobility? (Select all that

apply.) a. Paralysis b. Traction c. Arterial insufficiency d. Incontinence e. Constipation ANS: A, B, C, D

Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned more frequently. Paralysis impairs movement; muscle tone changes, and sensation is affected. Because of difficulty in moving and poor awareness of the involved body part, the patient is unable to protect and position the body part for self.

Traction, bone fractures, surgery, or arthritic changes of the affected extremity result in decreased range of motion. Decreased circulation predisposes the patient to pressure ulcers.

Premature and young infants require frequent turning because their skin is fragile. Normal physiological changes associated with aging predispose older persons to greater risks for developing complications of immobility. Constipation is not a risk factor for immobility.

DIF: Cognitive Level: Comprehension REF: Skill 11.2 OBJ: Describe principles of safe patient handling, transfer, and positioning.

TOP: Risk Factors That Contribute to Complications of Immobility KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 6. Positioning of patients to maintain correct body alignment is essential to prevent which of the

following complications? (Select all that apply.) a. Thrombus b. Pressure ulcer c. Kyphosis d. Contractures ANS: B, D

Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates proper body alignment.

DIF: Cognitive Level: Comprehension REF: Skill 11.2 OBJ: Describe principles of safe patient handling, transfer, and positioning.

TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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Chapter 12: Exercise & Mobility Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The patient has been admitted for hypertension. His blood pressure is normally in the 160/90

range. He has been on bed rest for the past few days, and the doctor has started him on a new blood pressure medication. The nurse is assisting the patient to move from the bed to the chair for breakfast, but when the patient tries to sit up on the side of the bed, he complains of being dizzy and nauseous. The nurse lays the patient down and takes his vital signs. His pulse is 124. His blood pressure is 130/80. This blood pressure is indicative of what? a. A normal blood pressure for this patient b. Orthostatic hypotension c. Orthostatic hypertension d. Effective baroreceptor function ANS: B

Orthostatic hypotension is a drop in blood pressure that occurs when the patient changes from a horizontal to a vertical position. It traditionally is defined as a drop in systolic or diastolic blood pressure of 20 or 10 mm Hg, respectively. Those at higher risk are immobilized patients, those undergoing prolonged bed rest, the older-adult patient, those receiving antihypertensive medications, and those with chronic illness, such as diabetes mellitus or cardiovascular disease. Signs and symptoms of orthostatic hypotension include dizziness, light-headedness, nausea, tachycardia, pallor, and even fainting. Orthostatic hypertension would be an increase in blood pressure. Physiological changes associated with aging and prolonged bed rest may reduceNthUeReS ffI ecNtiG veTnB es.s CoO f tM he baroreceptors. In these patients, moving to the dangling position may cause a gravity-induced drop in blood pressure; thus it is recommended to raise the head of the bed and allow a few minutes before dangling.

DIF: Cognitive Level: Analysis REF: Principles for Practice OBJ: Identify significant assessment data to be noted before assisting with exercise and ambulation.

TOP: Orthostatic Hypotension KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The patient is an older person who has been on bed rest for the past several days. When

getting the patient up, the nurse should a. tell the patient not to move his legs when dangling. b. tell the patient to hold his breath while dangling. c. raise the head of the bed and allow a few minutes before dangling. d. have the patient stand without dangling.

ANS: C

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Physiological changes associated with aging and prolonged bed rest may influence the effectiveness of the baroreceptors. For these patients, moving to the dangling position may cause a gravity-induced drop in blood pressure; thus it is recommended to raise the head of the bed and allow a few minutes before dangling. Interventions to minimize orthostatic hypotension include movement of the legs and feet in the dangling position to promote venous return via intermittent contraction and relaxation of the skeletal leg muscles and asking the patient to take several deep breaths before and during dangling. Dangling a patient before standing is an intermediate step that allows assessment of the individual before changing positions to maintain safety and prevent injury to the patient.

DIF: Cognitive Level: Application REF: Safety Guidelines OBJ: Identify significant assessment data to be noted before assisting with exercise and ambulation.

TOP: Dangling KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. An appropriate technique for the nurse to use when performing range-of-motion (ROM)

exercises is to a. repeat each five times during the exercise. b. perform the exercises quickly and firmly. c. support the proximal portion of the extremity being exercised. d. continue the exercise slightly beyond the point of resistance.

ANS: A

Each movement should be repeated five times during an exercise period. Be sure that ROM exercises are performed slowly and gently. When performing active-assisted or passive ROM exercises, support the joint by holding the distal portion of the extremity or by using a cupped hand to support the joint. Discontinue exercise if the patient complains of discomfort or if you N.URSINGTB.COM note resistance or muscle spasm DIF: Cognitive Level: Application REF: Procedural Guideline 12.1 OBJ: Demonstrate assisting with ambulation, assisting with ambulation with the use of an assistive device, assisting with range-of-motion exercises, and applying elastic stockings and sequential compression device.

TOP: Range of Motion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. A patient is admitted to the medical unit after a cerebrovascular accident (CVA). Evidence of

left-sided hemiparesis is noted, and the nurse will be following up on range-of-motion (ROM) and other exercises performed in physical therapy. The nurse should correctly teach the patient and family members which of the following principles of ROM exercises? a. Flex the joint to the point of discomfort. b. Medicate the patient after the ROM exercise session. c. Move the joints quickly. d. Provide support for distal joints.

ANS: D

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When performing active-assisted or passive ROM exercises, support the joint by holding the distal portion of the extremity, or by using a cupped hand to support the joint. The joint should be flexed to the point of resistance, not to the point of discomfort. Assess the patient’s level of comfort (on a scale of 0 to 10, with 10 being the worst pain) before performing exercises.

Before beginning ROM exercises, determine whether the patient would benefit from pain medication. Joints should be moved slowly through the ROM. Quick movement could cause injury.

DIF: Cognitive Level: Application REF: Procedural Guideline 12.1 OBJ: Demonstrate assisting with ambulation, assisting with ambulation with the use of an assistive device, assisting with range-of-motion exercises, and applying elastic stockings and sequential compression device.

TOP: Range of Motion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. A nurse encourages a patient to prevent venous stasis by a. crossing the legs when sitting in a chair. b. wearing thigh-length nylon stockings or garters. c. elevating the legs on pillows while in bed. d. increasing early ambulation.

ANS: D

Prevention is the best method to reduce the risk for deep vein thrombosis (DVT) secondary to immobility. Early ambulation remains the most effective preventive measure. Discourage patients from activities that promote venous stasis (e.g., crossing legs, wearing garters, and elevating legs on pillows).

DIF: Cognitive Level: ComprehN enUsiRoS n INRGETFB : .SC kiO llM 12.1 OBJ: Discuss risk factors related to the development of deep vein thrombosis.

TOP: Venous Stasis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. Graduated compression stockings are prescribed for the patient on bed rest after surgery. The

nurse explains to the patient that the primary purpose for the elastic stockings is to a. keep the skin warm and dry. b. prevent abnormal joint flexion. c. apply external pressure. d. prevent bleeding.

ANS: C

The primary purpose of graduated compression stockings is to maintain external pressure on the muscles of the lower extremities and thus promote venous return. The primary purpose of graduated compression stockings is not to keep the skin warm and dry, prevent abnormal joint flexion, or prevent bleeding. They are used to prevent clot formation as a result of venous stasis.

DIF: Cognitive Level: Comprehension REF: Procedural Guideline 12.3 OBJ: Demonstrate assisting with ambulation, assisting with ambulation with the use of an assistive device, assisting with range-of-motion exercises, and applying elastic stockings and sequential compression device.

TOP: Antiembolic Stockings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

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7. When assessing the patient for risk for deep vein thrombosis (DVT), the nurse should consider

which of the following an indicator of increased risk? a. A positive Homans’ sign b. Pallor to the distal area c. Edema noted in the extremity d. Fever or dehydration ANS: D

Indicators in Virchow’s triad include clotting disorders, fever, and dehydration. Additionally, a swollen extremity, pain, and warm cyanotic skin indicate an elevated risk. Less than 20% of patients exhibit a positive Homans’ sign. Edema of the extremity may or may not occur.

Pallor to the distal area is a sign of arterial insufficiency, not deep vein thrombosis.

DIF: Cognitive Level: Application REF: Procedural Guideline 12.3 OBJ: Discuss risk factors related to the development of deep vein thrombosis.

TOP: DVT KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. An appropriate procedure for the nurse to use when applying an elastic stocking is to a. remove the stockings every 24 hours. b. keep the tops of the stockings rolled down slightly. c. turn the stocking inside out to apply from the toes up. d. wash stockings daily and dry in a dryer.

ANS: C

Turn elastic stocking inside out by placing one hand into the sock, holding the toe of the sock with the other hand, and pullingN.UTR hiSs IalNloGwTsBe. asC ieO rM application of the stocking. Elastic stockings should be removed and reapplied at least twice a day. Instruct the patient not to roll the socks partially down. Rolling the socks partially down has a constricting effect and can impede venous return. Instruct the patient to launder elastic stockings every 2 days with mild detergent and lay flat to dry.

DIF: Cognitive Level: Application REF: Procedural Guideline 12.3 OBJ: Demonstrate assisting with ambulation, assisting with ambulation with the use of an assistive device, assisting with range-of-motion exercises, and applying elastic stockings and sequential compression device.

TOP: Applying Elastic Stockings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. When using a sequential compression device (SCD), the nurse should a. apply powder to the patient’s skin if redness and itching are present. b. leave a two-finger space between the patient’s leg and the compression stocking. c. keep the patient connected to the compression device when transferring into and

out of bed. d. remove the elastic stockings before putting on the sequential pneumatic

compression stockings.

ANS: B

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Check the fit of SCD sleeves by placing two fingers between the patient’s leg and the sleeve.

Observe for signs, symptoms, and conditions that might contraindicate the use of elastic stockings or SCD: Elastic stockings and SCD sleeves may aggravate a skin condition or cause it to spread. Remove SCD sleeves when transferring the patient into and out of bed to prevent injury. If the patient is wearing elastic stockings, eliminate any wrinkles and folds before applying SCD sleeves. Wrinkles lead to increased pressure and alter circulation.

DIF: Cognitive Level: Comprehension REF: Procedural Guideline 12.3 OBJ: Demonstrate assisting with ambulation, assisting with ambulation with the use of an assistive device, assisting with range-of-motion exercises, and applying elastic stockings and sequential compression device.

TOP: Applying SCD Sleeves KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. The patient is a paraplegic who possesses good arm and hand strength. When the following

devices are compared, which would be most appropriate for this patient? a. Axillary crutch b. Platform crutch c. Lofstrand crutch d. Standard crook cane ANS: C

The Lofstrand crutch has a handgrip and a metal band that fits around the patient’s forearm.

Both the metal band and the handgrip are adjusted to fit the patient’s height. This type of crutch is useful for patients with a permanent disability such as paraplegia. The axillary crutch commonly is used by patients of all ages on a short-term basis. The platform crutch is used by patients who are unable to bear weight on their wrists. It has a horizontal trough on which SrIisNtsGaTndB. patients can rest their forearmsNaU ndRw a vCeOrtM ical handle for the patient to grip. The standard crook cane provides the least support and is used by patients who require only minimal assistance to walk.

DIF: Cognitive Level: Analysis REF: Skill 12.2 OBJ: Develop teaching plans for safety in the home while using an ambulation aid, applying and monitoring effects of elastic stockings and sequential compression devices, and performing range-of-motion.

TOP: Crutches KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11. An appropriate way for the nurse to measure a patient for crutches is to a. have a flexion of 45 degrees at both of the patient’s elbows. b. have a space of two to three fingers between the top of the crutch and the axilla. c. place the crutch tips 1 foot to each side of the patient’s feet, and observe the

positioning of the crutches. d. place the crutch tips 1 foot (30 cm) to the front of the patient’s feet, and observe

the positioning of the crutches.

ANS: B

Following correct crutch adjustment, two to three fingers should fit between the top of the crutch and the axilla. Following correct crutch adjustment, elbows should be flexed 15 to 30 degrees. Elbow flexion is verified with a goniometer. Position the crutches with the crutch tips at 15 cm (6 inches) to the side and 15 cm (6 inches) in front of the patient’s feet, and the crutch pads 5 cm (2 inches) below the axilla.

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DIF: Cognitive Level: Comprehension REF: Skill 12.2 OBJ: Demonstrate assisting with ambulation, assisting with ambulation with the use of an assistive device, assisting with range-of-motion exercises, and applying elastic stockings and sequential compression device.

TOP: Crutches KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. The patient has been using crutches for the past 2 weeks. When she comes for her follow-up

examination, she complains of tingling and numbness in her hands and upper torso. Which of the following is a possible cause of these symptoms? a. The patient’s elbows are flexed 15 to 30 degrees when using the crutches. b. The crutch pad is approximately 5 cm (2 inches) below the patient’s axilla. c. The patient holds the cane 10 to 15 cm (4–6 inches) to the side of her foot. d. The handgrip does not allow for elbow flexion.

ANS: D

Instruct the patient to report any tingling or numbness in the upper torso, which may mean that the crutches are being used incorrectly or that they are the wrong size. If the handgrip is too low, radial nerve damage can occur even if overall crutch length is correct because the extra length between the handgrip and the axillary bar can force the bar up into the axilla as the patient stretches down to reach the handgrip. After correct crutch adjustment, two to three fingers must fit between the top of the crutch and the axilla. Adequate space prevents crutch palsy. Proper fit is when the crutch pad is approximately 5 cm (2 inches) or two to three finger widths under the axilla, with the crutch tips positioned 15 cm (6 inches) lateral to the patient’s heel.

DIF: Cognitive Level: Analysis REF: Skill 12.2 N U R S I N OBJ: Demonstrate assisting with ambulationG, T asBsi. stC inO gM with ambulation with the use of an assistive device, assisting with range-of-motion exercises, and applying elastic stockings and sequential compression device.

TOP: Crutches KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. The patient has a leg injury and is being fitted for a cane. The patient should be taught to a. hold the cane on the uninvolved side. b. hold the cane on the weaker side. c. extend the cane 38 cm (15 inches) from the foot when used. d. maintain approximately 60 degrees of elbow flexion.

ANS: A

The patient holds the cane on the uninvolved side, 10 to 15 cm (4–6 inches) to the side of the foot. This offers the most support when the cane is placed on the stronger side of the body.

The cane and the weaker leg work together with each step. The cane extends from the greater trochanter to the floor while the cane is held 15 cm (6 inches) from the foot. Allow approximately 15 to 30 degrees of elbow flexion. As weight is taken on by the hand and the affected leg is lifted off the floor, complete extension of the elbow is necessary.

DIF: Cognitive Level: Comprehension REF: Skill 12.2 OBJ: Demonstrate assisting with ambulation, assisting with ambulation with the use of an assistive device, assisting with range-of-motion exercises, and applying elastic stockings and sequential compression device.

TOP: Cane Measurement KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 14. While ambulating, the patient becomes light-headed and starts to fall. What should the nurse

do first? a. Call for help. b. Try to reach for a chair. c. Ease the patient down to the floor. d. Push the patient back toward the bed.

ANS: C

If the patient begins to fall, gently ease the patient to the floor by holding firmly onto the gait belt; stand with the feet apart to provide a broad base of support, extend the leg, and let the patient gently slide to the floor. As the patient slides, the nurse bends the knees to lower the body. The nurse can cause more damage to self and patient by trying to catch the patient. The nurse certainly will call for help, but this is not the first priority. The nurse must ensure the patient’s safety before getting help by easing him to the floor.

DIF: Cognitive Level: Application REF: Procedural Steps (PG 12.3) OBJ: Demonstrate assisting with ambulation, assisting with ambulation with the use of an assistive device, assisting with range-of-motion exercises, and applying elastic stockings and sequential compression device.

TOP: Patient Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. When the four gaits listed below are compared, which is the most stable of the crutch gaits? a. Four-point gait b. Three-point gait c. Two-point gait d. Swing-to gait

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ANS: A

Four-point gait is the most stable of crutch gaits because it provides at least three points of support at all times. The patient must be able to bear weight on both legs. Each leg is moved alternately with each opposing crutch, so that three points of support are on the floor all the time. This gait is often used when the patient has some form of paralysis, such as for spastic children with cerebral palsy. This is less stable than four-point gait because it requires the patient to bear all weight on one foot. Weight is borne on the uninvolved leg and then on both crutches. The affected leg does not touch the ground during the early phase of three-point gait.

This gait may be useful for patients with a broken leg or a sprained ankle. This is less stable than four-point gait because it requires at least partial weight bearing on each foot. It is faster than four-point gait and requires better balance because only two points support the body at any one time. This is the easier of the two swinging gaits. It is less stable than four-point gait because it requires the ability to partially bear body weight on both legs. This gait is often used by patients whose lower extremities are paralyzed or who wear weight-supporting braces on their legs.

DIF: Cognitive Level: Analysis REF: Skill 12.2 OBJ: Demonstrate assisting with ambulation, assisting with ambulation with the use of an assistive device, assisting with range-of-motion exercises, and applying elastic stockings and sequential compression device.

TOP: Crutch Gaits KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 16. The nurse is caring for a patient who has just been treated for a broken leg. She needs to teach

the patient how to use crutches. Which crutch gait is most appropriate for this patient? a. Four-point gait b. Three-point gait c. Two-point gait d. Swing-to gait ANS: B

The three-point gait requires the patient to bear all weight on one foot. Weight is borne on the uninvolved leg and then on both crutches. The affected leg does not touch the ground during the early phase of three-point gait. It is useful for patients with a broken leg or a sprained ankle. The four-point gait is the most stable of crutch gaits because it provides at least three points of support at all times. The patient must be able to bear weight on both legs. Each leg is moved alternately with each opposing crutch, so that three points of support are on the floor all the time. The two-point is used when the patient has some form of paralysis, such as for spastic children with cerebral palsy. This gait requires at least partial weight bearing on each foot. It requires better balance because only two points support the body at one time. This is the easier of the two swinging gaits. It requires the ability to partially bear body weight on both legs. The swing-to gait is used by patients whose lower extremities are paralyzed or who wear weight-supporting braces on their legs.

DIF: Cognitive Level: Analysis REF: Skill 12.2 OBJ: Demonstrate assisting with ambulation, assisting with ambulation with the use of an assistive device, assisting with range-of-motion exercises, and applying elastic stockings and sequential compression device.

TOP: Crutch Gaits KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

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17. When teaching the use of a three-point crutch gait, the nurse should instruct the patient to

move a. both crutches and the affected leg first, then the stronger leg. b. the right crutch, left foot, left crutch, and right foot in sequence. c. the left crutch and right foot, then move the right crutch and left foot. d. both crutches, then lift and swing the legs forward as far as the crutches.

ANS: A

The proper sequence for the three-point crutch gait is as follows: Begin in tripod position, advance both crutches and the affected leg, and then move the stronger leg forward, stepping on the floor. This is the proper sequence for the four-point gait, the two-point gait, and the swing-to gait.

DIF: Cognitive Level: Comprehension REF: Skill 12.2 OBJ: Demonstrate assisting with ambulation, assisting with ambulation with the use of an assistive device, assisting with range-of-motion exercises, and applying elastic stockings and sequential compression device.

TOP: Crutch Gaits KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. A patient with left hemiparesis is using a quad cane for ambulation. Which of the following is

the correct technique for the nurse to use in teaching the patient? a. Use the cane on the right side, with the cane moving forward first.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY b. Use the cane on the left side, with the left leg moving forward with the cane. c. Use the cane in either hand, with the right leg moving forward first. d. Use the cane in either hand, with the left leg moving beyond the forward

placement of the cane.

ANS: A

To correctly use a quad cane, the patient places the cane on the side opposite the involved leg.

This provides added support for the weak or impaired side. Ambulation then begins by moving the cane forward 15 to 25 cm (6–10 inches), keeping body weight on both legs. The weak leg is then brought forward even with the cane while the body weight is supported by the strong leg and the cane. The strong leg is then advanced past the cane. Moving a leg and the cane forward at the same time will compromise balance and increase risk of fall.

DIF: Cognitive Level: Comprehension REF: Skill 12.2 OBJ: Demonstrate assisting with ambulation, assisting with ambulation with the use of an assistive device, assisting with range-of-motion exercises, and applying elastic stockings and sequential compression device.

TOP: Ambulation with a Cane KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. A drop in blood pressure that occurs when the patient changes position from a horizontal to a

vertical position is known as a. orthostatic hypertension b. orthostatic hypotension c. venous wall damage d. blood flow stasis ANS: B

.

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Orthostatic hypotension is a drop in blood pressure that occurs when the patient changes position from a horizontal to a vertical position.

DIF: Cognitive Level: Comprehension REF: Procedural Guideline 12.4 OBJ: Identify significant assessment data to be noted before assisting with exercise and ambulation.

TOP: Orthostatic Hypotension KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 20. The patient is performing range-of-motion (ROM) exercises independently. These are known

as a. b. c. d.

exercises. graduated compression continuous passive motion passive range-of-motion active range-of-motion

ANS: D

ROM exercises may be active, passive, or active-assisted. They are active if the patient is able to perform the exercises independently and passive if the exercises are performed for the patient by the caregiver. The exercises are active-assisted if the patient is able to perform some of the actions independently with support and assistance from the caregiver.

DIF: Cognitive Level: Understanding REF: Procedural Guideline 12.1 OBJ: Discuss indications for performing ROM and isometric exercises.

TOP: Active Range of Motion KEY: Nursing Process Step: Implementation

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY MSC: NCLEX: Physiological Integrity 21. Virchow’s triad (hypercoagulability of blood, venous wall damage, and stasis of blood flow)

has been found to contribute to a. diabetes b. heart disease c. cancer d. deep vein thrombosis

.

ANS: D

Three elements (commonly referred to as Virchow’s triad) contribute to the development of deep vein thrombosis (DVT): hypercoagulability of the blood, venous wall damage, and stasis of blood flow.

DIF: Cognitive Level: Comprehension REF: Procedural Guideline 12.3 OBJ: Demonstrate assisting with ambulation, assisting with ambulation with the use of an assistive device, assisting with range-of-motion exercises, and applying elastic stockings and sequential compression device.

TOP: Deep Vein Thrombosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The patient had a stroke and is currently immobile. The nurse realizes that increasing mobility

is critical because immobility can result in alterations in which of the following? (Select all that apply.) a. Cardiovascular function b. Pulmonary function NURSINGTB.COM c. Skin integrity d. Elimination ANS: A, B, C, D

When mobility is altered, many body systems are at risk for impairment. Impaired mobility can result in altered cardiovascular functioning, disruption of normal metabolic functioning, increased risk for pulmonary complications, the development of pressure ulcers, and urinary elimination alterations.

DIF: Cognitive Level: Comprehension REF: Principles for Practice OBJ: Describe the evidence that supports early activity and exercise in patient care.

TOP: Complications of Immobility KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse is applying a continuous passive motion (CPM) machine to the patient’s leg. To do

so, she must (Select all that apply.) a. provide analgesia 1 hour before starting the CPM. b. only activate the machine for 1 hour per day or less. c. align the patient’s joint with the CPM’s mechanical joint. d. secure the patient’s extremity tightly with Velcro straps.

ANS: B, C

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Provide analgesia 20 to 30 minutes before CPM is needed. A CPM is usually prescribed to be on from 1.5 to 24 hours a day, depending on surgeon’s preference and patient’s condition.

Align the patient’s joint with the mechanical joint of the CPM. DIF: Cognitive Level: Application REF: Procedural Guideline 12.2 OBJ: Demonstrate assisting with ambulation, assisting with ambulation with the use of an assistive device, assisting with range-of-motion exercises, and applying elastic stockings and sequential compression device.

TOP: CPM Machine KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. Factors that contribute to the development of deep vein thrombosis (DVT) are (Select all that

apply.) a. elevated sodium (Na+) levels. b. hypercoagulability of the blood. c. venous wall damage. d. stasis of blood flow.

ANS: B, C, D

Three elements (commonly referred to as Virchow’s triad) contribute to the development of DVT: hypercoagulability of the blood, venous wall damage, and stasis of blood flow.

DIF: Cognitive Level: Comprehension REF: Box 12.1: Risk Factors for Deep Vein Thrombosis OBJ: Discuss risk factors related to the development of deep vein thrombosis.

TOP: Deep Vein Thrombosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 13: Support Surfaces and Special Beds Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The patient is admitted to the unit with a stage 3 pressure injury. When the different types of

support surfaces are compared, which would be most therapeutic for this patient? a. Foam mattress b. Gel overlay c. Air-fluidized bed d. Air mattress ANS: C

Air-fluidized beds are recommended for use for patients with stage 3 and stage 4 pressure injuries. Foam support surfaces are recommended to reduce the risk of the patient developing pressure injuries. Gel overlay support surfaces are recommended for patients who are wheelchair dependent and those who are at risk for developing pressure injuries. Nonpowered air-filled mattresses are recommended for patients who are able to reposition themselves.

DIF: Cognitive Level: Analysis REF: Table 13.1: Support Surfaces OBJ: Identify the different types of support surfaces and specialty beds used for pressure redistribution.

TOP: Pressure Injuries KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. What is the most important factor in preventing and treating pressure injuries? a. Proper use of foam or air mattresses b. Proper use of an air-fluidizeNdUbReS d INGTB.COM c. Frequent repositioning of the patient d. Proper use of a low-air-loss bed ANS: C

Frequent repositioning, which temporarily relieves pressure, is the backbone of preventive protocols. It is the nurse’s responsibility to use appropriate turning schedules for patients in bed or on a chair. No bed or mattress totally eliminates the need for competent nursing care.

DIF: Cognitive Level: Comprehension REF: Principles for Practice OBJ: Explain why preventive nursing care is still essential when using support surfaces and specialty beds. TOP: Repositioning KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. What is the primary purpose for the use of a support surface? a. To reduce pressure b. To promote patient comfort c. To increase circulation d. To facilitate patient movement ANS: A

Support surfaces aid in reducing pressure on the patient’s skin. Promoting patient comfort may happen, but it is not the primary purpose of the support mattress. A support mattress does not increase patient circulation, nor does it facilitate patient movement.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY DIF: Cognitive Level: Comprehension REF: Principles for Practice OBJ: Describe guidelines for placing patients on support surfaces and specialty beds.

TOP: Patient Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. When working with a patient who is being placed on an air mattress/overlay, the nurse should a. apply the preinflated overlay over the standard mattress. b. bring any plastic strips or flaps around the corners of the bed mattress. c. administer an analgesic after the patient is moved onto the mattress. d. keep clamps or pins attached to the sheets to keep them in place over the mattress.

ANS: B

When preparing an air mattress/overlay, bring any plastic strips or flaps around the corners of the bed mattress. This secures the air mattress in place. Apply a deflated mattress flat over the surface of the bed mattress. The decision to administer analgesic would be based on the patient’s condition rather than on the procedure. Pins and other sharps should not be used, to avoid puncturing an air mattress.

DIF: Cognitive Level: Application REF: Procedural Guideline 13.1 OBJ: Describe guidelines for placing patients on support surfaces and specialty beds.

TOP: Air Mattress/Overlay KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The patient requires a support surface to help prevent pressure injuries. He has a large open

wound on his leg that is dressed daily. The nurse must choose which support surface would be most appropriate. What does the nurse realize when comparing the different types of support surfaces? a. Water mattresses are betterNfoUrRpS atI ieN ntGs T wBit. hC opOeM n wounds. b. Air-surface beds cannot be used if the patient needs cardiopulmonary resuscitation (CPR). c. Water mattresses make it hard to regulate patient body temperature. d. Air mattresses reduce shear and friction.

ANS: D

Water mattresses are no longer used regularly because they harbour organisms in the water, leaks in the mattress are risky for patients with open wounds, and the structural integrity of the building does not always support the weight of the mattress. An air mattress reduces shear and friction and so is a good choice for this patient. Air-surface beds are equipped with a CPR switch to instantly lower the head section from an elevated position and to deflate the mattress to provide a firm surface for chest compressions. Follow the manufacturer’s directions regarding the temperature of the water. Proper water temperature prevents loss of body heat as the patient lies on the mattress.

DIF: Cognitive Level: Analysis REF: Table 13.1: Support Surfaces OBJ: Describe guidelines for placing patients on support surfaces and specialty beds.

TOP: Comparison of Support Surfaces KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. The patient is admitted with a large stage 4 pressure injury on his coccyx. After comparing the

benefits of the following support surfaces, the nurse would choose which of the following as most appropriate for this patient?

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. b. c. d.

Water mattress Gel overlay Foam overlay Air-fluidized bed

ANS: D

If a patient has large stage 3 or stage 4 pressure injury on multiple turning surfaces, a low-air-loss bed or air-fluidized bed may be indicated. The use of water mattresses has been reduced considerably because they harbour organisms in the water, and leaks in the mattress are risky for patients with open wounds. Gel overlays are used for moderate- to high-risk patients, not for patients who have stage 4 injuries. They are useful for patients who are wheelchair dependent. Foam overlays are used for moderate- to high-risk patients, not for those with stage 4 injuries.

DIF: Cognitive Level: Analysis REF: Table 13.1: Support Surfaces OBJ: Describe the steps for correct placement of a patient on a special bed or a support surface mattress.

TOP: Air-Fluidized Beds KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 7. An air-suspension bed is contraindicated for the patient with a. burns. b. traction. c. osteoporosis. d. respiratory insufficiency.

ANS: B

Changes in pressure and position from an air-suspension bed are contraindicated for patients with an unstable spine or tractiN onUw nM in alignment. An air-suspension bed is not RhSoImNuGstTrBem .aCiO contraindicated for patients with burns, osteoporosis, and respiratory insufficiency.

DIF: Cognitive Level: Application REF: Table 13.1: Support Surfaces OBJ: Describe the steps for correct placement of a patient on a special bed or a support surface mattress.

TOP: Air-Suspension Beds KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 8. Of the following problems that may occur with the use of an air-fluidized bed, which is of

greatest concern to the nurse? a. Nausea b. Anxiety c. Slight disorientation d. Insensible fluid loss ANS: D

Diaphoresis often goes undetected, and thus insensible fluid loss is not always evident until a patient develops fluid and electrolyte imbalances. This individual often is already compromised in relation to hydration, fluids, and electrolytes; therefore the nurse needs to carefully monitor the patient’s fluid balance status. Some nausea, disorientation, and anxiety can occur, but they are not as critical as insensible fluid loss.

DIF: Cognitive Level: Evaluation REF: Skill 13.2 OBJ: Describe the steps for correct placement of a patient on a special bed or a support surface mattress.

TOP: Air-Fluidized Beds

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

9. The nurse is caring for a patient who is in an air-fluidized bed. He or she places the patient in

semi-Fowler’s position using foam wedges, even though he or she realizes that a. patients gain the greatest benefit from the prone position in an air-fluidized bed. b. for resuscitation, he or she may have to increase the air pressure of the bed to do cardiopulmonary resuscitation (CPR). c. he or she may have to increase the air pressure of the bed to turn the patient. d. the foam wedges may decrease the effects of the bed.

ANS: D

Although the use of foam wedges as needed is recommended (e.g., elevating the head of the patient for position changes), areas supported by the foam wedges do not benefit from pressure relief of the bed’s surface. Do not position a patient in a prone (face-down) position on an air-fluidized bed. Suffocation may occur. In emergencies when resuscitation is required, press the CPR switch and unplug the unit to defluidize the bed immediately. To turn patients, position bedpans, or perform other therapies, stop fluidization. Once the procedure is complete, set to continuous fluidization. Stopping fluidization provides firm, moulded support that facilitates turning and handling of the patient. Continuous fluidization provides permanent fluid support.

DIF: Cognitive Level: Application REF: Skill 13.2 OBJ: Describe the steps for correct placement of a patient on a special bed or a support surface mattress.

TOP: Use of Foam Wedges KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. A patient is on bed rest after suN stU aiR niSnI gN inG juTriB es.iC nO aM car accident. Which nursing action helps

prevent complications of immobility? a. Decreasing fluid intake to ease dependent edema b. Turning the patient every 2 hours and providing a low-air-loss mattress c. Raising the head of the bed to maximize the patient’s lung inflation d. Bathing and feeding the patient to decrease energy expenditure ANS: B

To avoid pressure injuries in an immobilized patient, the nurse must assess the skin thoroughly and use such preventive measures as regular turning, a low-air-loss mattress, and a trapeze (if the patient’s condition allows). The nurse should increase, not decrease, the patient’s fluid intake to help prevent renal calculi, which may result from immobility. To prevent atelectasis, another complication of immobility, having the patient cough, deep breathe, and use an incentive spirometer would be more effective than raising the head of the bed. Instead of bathing and feeding the patient, the nurse should promote independent self-care activities whenever possible to prepare the patient for a return to the previous health status.

DIF: Cognitive Level: Analysis REF: Principles for Practice OBJ: Explain why preventive nursing care is still essential when using support surfaces and specialty beds. TOP: Use of a Low-Air-Loss Mattress KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 11. After comparing the following support surfaces, the nurse realizes that an extremely obese

patient should benefit from the use of a(n) a. bariatric bed. b. foam mattress. c. water mattress. d. air-fluidized bed.

ANS: A

A valuable resource in the care of the morbidly obese patient (a person who weighs more than 45.3 kg [100 pounds] above ideal weight) is the bariatric bed, which provides a safe, adaptable surface. The foam or water mattress and the air-fluidized bed are not designed specifically for the obese patient.

DIF: Cognitive Level: Analysis REF: Table 13.1: Support Surfaces OBJ: Describe the steps for correct placement of a patient on a special bed or a support surface mattress.

TOP: Bariatric Bed KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. Which of the following is a limitation of the bariatric bed? a. Lack of an in-bed scale b. Narrowness of the bed c. Lack of pressure reduction d. Increased liability to the institution ANS: C

A limitation of this bed is the lack of pressure reduction or relief in the mattress. The at-risk obese patient needs to have som prTesBs. urC eO reMdistribution mattress placed on the NeUtRypSeIoNf G bariatric bed. The bariatric bed possesses an in-bed scale that provides the nurse with a means of obtaining accurate weights and thus improves health care and patient dignity. The bed is slightly wider than a standard hospital bed, yet it is within the guidelines for standard door width, allowing movement into and out of a room without difficulty. A full- or double-wide bariatric bed can accommodate a patient up to 453 kg (1000 pounds). However, when using a full- or double-wide bariatric bed, you must assemble it in the patient’s room and must not use it for transfers, because this bed is too large to fit through standard hospital doorways.

Because the bariatric bed is capable of supporting weights up to 385 kg (850 pounds), it provides a stable, balanced surface that limits hospital liability should the standard bed frame collapse or the electric motor burn out.

DIF: Cognitive Level: Comprehension REF: Table 13.1: Support Surfaces OBJ: Describe the steps for correct placement of a patient on a special bed or a support surface mattress.

TOP: Bariatric Bed KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. After comparing the benefits of the following support surfaces, the nurse realizes that a patient

with multiple traumas and/or spinal cord injury is expected to be placed on a(n) a. Rotokinetic bed. b. bariatric bed. c. flotation mattress. d. air-fluidized mattress.

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY ANS: A

The Rotokinetic bed provides skeletal alignment and constant rotation and is used for patients with multiple trauma and spinal cord injury. Use of the bariatric bed is contraindicated in patients with spinal cord injury. Flotation mattresses and air-fluidized mattresses are contraindicated for patients with an unstable spine.

DIF: Cognitive Level: Analysis REF: Table 13.1: Support Surfaces OBJ: Describe the steps for correct placement of a patient on a special bed or a support surface mattress.

TOP: Rotokinetic Bed KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. When teaching about the use of the Rotokinetic bed, the nurse informs the patient that the a. bed will be stopped in one position most of the time. b. amount of rotation will be greater in the beginning. c. patient may experience a sensation of falling or light-headedness. d. bed is moved manually all of the time and will rotate head over feet.

ANS: C

Inform the patient that there will be a sensation of light-headedness or falling. However, reassure the patient that he or she will not fall because the pads will prevent this and are checked by two people to ensure proper placement. It is recommended that the Rotokinetic bed stay in rotation mode for 20 hours a day. The bed rotates constantly when set on rotation mode. The Rotokinetic bed rotates automatically from side to side.

DIF: Cognitive Level: Application REF: Skill 13.2 OBJ: Describe the steps for correct placement of a patient on a special bed or a support surface mattress.

TOP: RotoNkU inR etS i cI BN edGTB.COM KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. Use of the low-air-loss bed is contraindicated in patients with a. skin breakdown on more than one surface b. diabetic ulcers c. a spinal cord injury d. a history of cardiac surgery

.

ANS: C

Use of this bed is contraindicated in patients with spinal cord injury. The low-air-loss bed can be used for patients who have skin breakdown on more than one surface. There are no contraindications for patients with diabetic ulcers or a history of cardiac surgery.

DIF: Cognitive Level: Comprehension REF: Skill 13.2 OBJ: Describe the steps for correct placement of a patient on a special bed or a support surface mattress.

TOP: Low-air-loss bed KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. The

bed rotates and improves skeletal alignment with constant side-to-side rotation up to 90 degrees. a. Rotokinetic b. low-air-loss

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY c. air-fluidized d. gel-overlay ANS: A

The Rotokinetic bed improves skeletal alignment with constant side-to-side rotation up to 90 degrees.

DIF: Cognitive Level: Comprehension REF: Table 13.1: Support Surfaces OBJ: Describe the steps for correct placement of a patient on a special bed or a support surface mattress.

TOP: Rotokinetic Bed KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. It is recommended that the Rotokinetic bed stay in the rotation mode for at least

hours a day. a. 12 b. 18 c. 20 d. 22 ANS: C

It is recommended that the Rotokinetic bed stay in the rotation mode for at least 20 hours a day.

DIF: Cognitive Level: Comprehension REF: Skill 13.2 OBJ: Describe the steps for correct placement of a patient on a special bed or a support surface mattress.

TOP: Rotokinetic Bed KEY: Nursing Process Step: Implementation NURSINGTB.COM MSC: NCLEX: Physiological Integrity 18. The major cause of pressure injuries is a. malnutrition b. impaired mobility c. unrelieved pressure d. aging skin

.

ANS: C

The major cause of pressure injuries is unrelieved pressure. The greater the pressure and the longer the pressure is applied, the greater the likelihood that a pressure injury will develop.

Malnutrition, impaired mobility, and aging skin are all factors contributing to pressure injury.

DIF: Cognitive Level: Comprehension REF: Principles for Practice OBJ: Explain why preventive nursing care is still essential when using support surfaces and specialty beds. TOP: Pressure Injuries KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Factors that contribute to pressure injury formation include which of the following? (Select all

that apply.) a. Friction b. Shear

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY c. Turning every 2 hours d. Malnutrition e. Impaired mobility ANS: A, B, D, E

Factors that contribute to pressure injury formation are both extrinsic (e.g., moisture, friction, and shear) and intrinsic (e.g., malnutrition, loss of sensation, impaired mobility, aging skin, impaired mental status, infection, incontinence, and low arteriolar pressure). Turning every 2 hours is a measure to prevent injury formation, not a factor that contributes to it.

DIF: Cognitive Level: Comprehension REF: Principles for Practice OBJ: Explain why preventive nursing care is still essential when using support surfaces and specialty beds. TOP: Risk Factors for Pressure Injuries KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The patient is admitted to the hospital. Part of the patient assessment will include (Select all

that apply.) a. use of an appropriate pressure injury risk scale. b. assessment of the patient’s nutritional status. c. assessment of the patient’s mobility status. d. assessment of the patient’s fluid status.

ANS: A, B, C, D

A complete patient assessment includes the use of appropriate pressure injury risk scales; the presence of shear and friction; and the patient’s nutritional, fluid, mobility, and continence status.

DIF: Cognitive Level: ApplicatiN onURSINRGETFB : .PC riO ncM iples for Practice OBJ: Describe guidelines for placing patients on support surfaces and specialty beds.

TOP: Patient Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. Air-fluidized beds require the nurse to assess for which of the following? (Select all that

apply.) a. Patient’s fluid and electrolyte status b. Patient’s financial status c. Structural strength of the room where the bed will be d. Room temperature ANS: A, B, C, D

Air-fluidized beds provide continuous circulation of warm, dry air, which may increase patient risk for dehydration. The bed also may increase room temperature, making it uncomfortable for the patient and possibly leading to overheating of the equipment. Another concern is that the bed is heavy and expensive. Unless the patient has a physician prescription, third-party payment may not be available.

DIF: Cognitive Level: Application REF: Skill 13.2 OBJ: Describe the steps for correct placement of a patient on a special bed or a support surface mattress.

TOP: Air-Fluidized Beds KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 4. The patient will be going home but still requires an air-fluidized bed. Before discharge, it will

be necessary for the company that is leasing the bed to inspect the home for which of the following? (Select all that apply.) a. Accessibility b. Structural support c. Smoke detectors d. A lift to get patient off bed to perform cardiopulmonary resuscitation (CPR) ANS: A, B

Beds weigh up to 950 kg (2100 pounds); therefore the company that is leasing the bed needs to inspect the home for accessibility and structural support. Smoke detectors should be in every home, but this is not relevant to the air-fluidized bed. The bed can be deflated if CPR needs to be performed, and the patient would not need to be lifted off the surface.

DIF: Cognitive Level: Application REF: Care in the Community (Skill 13.2) OBJ: Describe the steps for correct placement of a patient on a special bed or a support surface mattress.

TOP: Home Care Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 14: Patient Safety Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The patient is admitted to the hospital with prescriptions for activity as tolerated. He is

wheelchair bound at home and has brought his own electric wheelchair and battery charger to help him maintain mobility. The nurse realizes that a. patients are not allowed to bring in an electric wheelchair. b. electrical equipment is banned from all hospitals. c. the charger needs to be checked by hospital engineers. d. electrical devices are not a cause for concern.

ANS: C

The third (longer) prong in an electrical plug is the ground. If a patient brings an electrical device to the hospital, an engineer inspects the device for safe wiring and function before use.

Many patients with disabilities use battery chargers for mobility equipment function. These devices need to be inspected by hospital engineers. Fires in health care settings typically are electrical or anaesthetic related.

DIF: Cognitive Level: Comprehension REF: Procedural Guideline 14.1 OBJ: Describe methods used to evaluate safety interventions.

TOP: Fire/Electrical Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. On entering the patient’s room, the nurse sees a fire burning in the trashcan next to the bed.

Mhat is the nurse’s next action?

The nurse removes the patient N anUdRreSpI orNtsGtT heBf.irC e.OW a. Extinguish the fire. b. Remove all other patients from the unit. c. Close all doors of patient rooms. d. Move the trashcan into the bathroom.

ANS: C

Using the RACE acronym, the next action the nurse should take is to confine the fire by closing doors and windows and turning off oxygen and electrical equipment (Rescue, Activate, Contain, and Evacuate). Extinguish the fire by using an extinguisher after ensuring patient and individual safety after closing the doors of patient rooms. After activating the alarm, the nurse should close all the doors, not remove all the other patients from the unit.

Moving the trashcan would not be an appropriate action because the nurse could get burned in this attempt.

DIF: Cognitive Level: Application REF: Procedural Guideline 14.1 OBJ: Describe nursing interventions performed in the event of fire, electrical shock, or chemical spill. TOP: Fire Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. In a long-term care facility, an elderly patient drops his burning cigarette into a trashcan and

starts a fire. A type fire extinguisher is the most appropriate type of fire extinguisher for the nurse to use in this situation. a. A

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY b. B c. C d. D ANS: A

Type A fire extinguishers are used for ordinary combustibles such as wood, cloth, paper, and plastic. A trashcan fire would require a type A fire extinguisher. Type B fire extinguishers are used for flammable liquids such as gasoline, grease, paint, and anaesthetic gas. Type C fire extinguishers are used for electrical fires. There is no type D fire extinguisher.

DIF: Cognitive Level: Comprehension REF: Fire OBJ: Describe nursing interventions performed in the event of fire, electrical shock, or chemical spill. TOP: Fire Extinguishers KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. Given the most common causes of hospital fires, which of the following choices are most

appropriate in preventing patient injury? a. Ensure that all electrical devices are checked by engineering. b. Assist patients who smoke to a safe area to smoke. c. Prop fire doors open for easier patient access. d. Educate patients on the importance of smoking cessation.

ANS: A

Fires in health care settings are usually electrical or anaesthetic related, so ensuring all electrical devices are inspected will greatly reduce the risk of fire. Look for inspection labels verifying recent inspection for all electrical devices. Fire doors should never be propped open.

Although educating patients on smoking cessation is a good idea, it will have little effect on immediate hospital safety. AlthNoU ugRhSsI mN okGiT ngBi.s C noOlMonger allowed in the hospital setting, smoking-related fires continue to pose a risk because of unauthorized smoking in bed or the bathroom.

DIF: Cognitive Level: Analysis REF: Procedural Guideline 14.1 OBJ: Describe nursing interventions performed in the event of fire, electrical shock, or chemical spill. TOP: Fire Extinguishers KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. After recognizing that a patient has received an electrical shock and removing the source of

the shock, what should the nurse do next? a. Call for assistance. b. Immediately start cardiopulmonary resuscitation (CPR). c. Obtain emergency equipment. d. Assess for the presence of a pulse.

ANS: D

If the patient receives an electrical shock, immediately assess for the presence of a pulse.

Electrical shock can cause cardiac arrest or asystole. Do not leave the patient. Only if the patient is pulseless will the nurse institute cardiopulmonary resuscitation. If the patient has a pulse and remains alert and oriented, obtain vital signs and assess the skin for signs of thermal injury. Electrical current will cause burn at points of entry and exit from the body.

DIF: Cognitive Level: Application REF: Procedural Guideline 14.1 OBJ: Describe nursing interventions performed in the event of fire, electrical shock, or chemical

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY spill. TOP: Electrical Shock MSC: NCLEX: Physiological Integrity

KEY: Nursing Process Step: Implementation

6. The patient is an older person who is admitted for a medical problem. While doing his

admission assessment, the nurse learns that the patient gets up two to three times a night to use the restroom. The institution has only beds with four side rails. Which of the following is the appropriate rationale for leaving one of the lower side rails down? a. Falls rarely happen in the inpatient setting. b. Having all side rails raised increases the occurrence of falling. c. Side rails have no bearing on whether or not a patient falls. d. Patient falls rarely result in physical injury.

ANS: B

Having all four side rails raised often increases the occurrence of falling, because patients try to climb over the rails to reach a chair or bathroom and often fall farther as a result. Leaving three side rails up (two upper and one lower) on a bed with four side rails is safer for the patient. Leaving the lower side rail down on the side of the bed the patient will exit the bed from to access the bathroom reduces the risk of falls.

DIF: Cognitive Level: Comprehension REF: Person-Centred Care OBJ: Discuss the importance of a fall-risk assessment in providing for patient safety.

TOP: Falls Prevention KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 7. A patient is taking a medication that has the potential to cause orthostatic hypotension. Which

of the following nursing interventions is appropriate for this patient? a. Have the patient sit slowly and dangle. b. Refer the patient to physicaN lU thR erS apIyN. GTB.COM c. Keep the side rails up at all times. d. Obtain a walker or a cane for patient use.

ANS: A

Dangling allows adjustment to orthostatic hypotension, permitting blood pressure to stabilize before ambulating. Have the patient dangle his or her feet for a few minutes before standing, walk slowly, and ask for help if dizzy or weak. The nurse would confer with physical therapy on the feasibility of gait training and muscle-strengthening exercise. Check employer policies regarding side rail use. Side rails are a restraint device if they immobilize or reduce the ability of a patient to move his or her arms, legs, body, or head freely. Keep one side rail up in a two-rail system, and keep three of four rails up (one lower rail down) in a four-rail system, with the bed in low position and wheels locked, when you are not administering patient care.

This allows the patient to manoeuvre and get out of bed safely. Do not assume that the patient requires a walker or a cane. Evaluate the need for assistive devices such as walker, cane, or bedside commode. Assistive devices may provide greater stability and may help the patient assume a more active role.

DIF: Cognitive Level: Application REF: Skill 14.1 OBJ: Describe nursing interventions specific for reducing patients’ risks for falls.

TOP: Orthostatic Hypotension KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 8. What should the nurse do to promote patient understanding and security in the health care

setting? a. Restrain the patient as necessary. b. Explain all procedures to the patient. c. Allow the patient more time alone. d. Restrict activity as much as possible.

ANS: B

Orient patient and family to surroundings, introduce to staff, and explain all treatments and procedures. This promotes patient understanding and cooperation. The use of restraints is one safety strategy that can protect patients from injury, but restraints must be used with extreme caution. Physical restraints should be the last resort and should be used only when reasonable alternatives have failed. Isolation may increase anxiety. Encourage family and friends to stay with the patient. Sitters or companions may be used. In some institutions, volunteers can be effective companions. Patient anxiety is reduced and safety is increased when one person provides care and supervision is constant. Constant activity may irritate the patient, yet the lack of activity may create anxiety and/or boredom. Meaningful diversional activities provide distraction, help reduce boredom, and provide tactile stimulation. Minimize occurrences of wandering.

DIF: Cognitive Level: Comprehension REF: Person-Centred Care OBJ: Describe steps in the design of a restraint-free environment.

TOP: Alternatives to Physical Restraint KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 9. As part of an attempt to implement a restraint-free environment, the nurse a. provides constant activity for the patient. b. covers or camouflages tubeN sU anRdSdI raNinGsT . B.COM c. changes caregivers as often as possible. d. reduces visiting hours and times in therapy.

ANS: B

Position intravenous (IV) catheters, urinary catheters, and tubes/drains out of patient view, or use camouflage by wrapping the IV site with bandage or stockinette, placing undergarments on patients with a urinary catheter, or covering abdominal feeding tubes/drains with a loose abdominal binder. This helps maintain medical treatment and reduces patient access to tubes/lines. Provide scheduled ambulation, chair activity, and toileting. Organize treatments so the patient has long uninterrupted periods throughout the day. Provide for sleep and rest periods. Constant activity may irritate the patient. Provide the same caregivers to the extent possible. This increases familiarity with individuals in the patient’s environment, decreasing anxiety and restlessness. Encourage family and friends to stay with the patient. Sitters or companions may be used. In some institutions, volunteers can be effective companions.

Patient anxiety is reduced and safety is increased when one person provides care and supervision is constant.

DIF: Cognitive Level: Application REF: Skill 14.2 OBJ: Describe steps in the design of a restraint-free environment.

TOP: Alternatives to Physical Restraint KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 10. A patient is well known to the hospital staff from previous admissions and is prone to

wandering at night. For patient safety, the physician writes a prescription for “belt restraint prn.” What should the nurse do on reviewing this prescription? a. Apply a belt restraint on the patient as needed. b. Have the patient sign an informed consent form. c. Inform the physician that prn restraint prescriptions are unacceptable. d. Obtain a signed informed consent from a family member.

ANS: D

The use of mechanical or physical restraints should be part of a patient’s prescribed medical treatment. A physician’s time-limited prescription is necessary. The patient’s or family member’s informed consent is necessary in the long-term care setting.

DIF: Cognitive Level: Application REF: Skill 14.2 OBJ: Discuss steps in the design of a restraint-free environment.

TOP: Applying Physical Restraints KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. To promote patient safety, government standards regarding mechanical and physical restraints

state that a. alternative measures are to be implemented before restraints are used. b. the nurse’s judgment is all that is required for restraint use. c. restraints should be used immediately for all patients who may need them. d. restraints cannot be used except to prevent others from being harmed.

ANS: A

The use of mechanical or physical restraints must be part of the prescribed medical treatment, all less-restrictive interventionsNm t bIeNtrGieTdBf. irsCt,OoM ther disciplines must be applied, and UuRsS supporting documentation must be provided. If the alternatives fail, the nurse may consider use of a restraint to prevent injury. Determine the patient’s need for restraint if other less-restrictive measures fail to prevent interruption of therapy or injury to self or others.

Confer with the physician or primary health care provider, who must write the prescription for restraints. Restraints may be needed for the confused or combative patient to prevent interruption of therapy or injury to self or others.

DIF: Cognitive Level: Application REF: Skill 14.2 OBJ: Discuss steps in the design of a restraint-free environment.

TOP: Applying Physical Restraints KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 12. When applying a belt restraint to a patient, it is important for the nurse to a. apply the belt under the hospital gown. b. place the restraint around the abdomen. c. have the patient in a sitting position. d. apply the belt as tightly as possible.

ANS: C

Have the patient in a sitting position. Remove wrinkles or creases in clothing. Bring ties through slots in a belt. Apply a belt over clothes, gown, or pyjamas to prevent damage to the skin. Make sure to place the restraint at the waist, not at the chest or abdomen. Avoid applying the belt too tightly.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY DIF: Cognitive Level: Application REF: Skill 14.3 OBJ: Discuss precautions used to prevent injury in patients who are restrained.

TOP: Belt Restraints KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. When caring for a patient who has been restrained, how often will the nurse perform an

assessment? a. Every 15 minutes b. Every 30 minutes c. Every hour d. Every 2 hours ANS: A

After application, evaluate the patient’s condition every 15 minutes for signs of injury.

Frequent assessments prevent injury to the patient and allow removal of the restraint at the earliest possible time. Observation and frequent assessments prevent complications such as suffocation, skin breakdown, and impaired circulation. The Joint Commission recommends that the patient’s condition be evaluated every 15 minutes. If the nurse restrains the patient in an emergency situation because of violent or aggressive behaviour that presents an immediate danger, a face-to-face physician assessment within 1 hour is needed to determine the patient’s continued need for restraints. Restraints should be removed at least every 2 hours. If the patient is violent or noncompliant, remove one restraint at a time or have staff assistance while removing restraints. Removal provides an opportunity to change the patient’s position, offer nutrients, perform full range of joint motion (ROJM), and toilet and exercise the patient.

DIF: Cognitive Level: Comprehension REF: Skill 14.3 OBJ: Discuss precautions used to prevent injury in patients who are restrained.

GETYB: .NCuO TOP: Evaluation of Patient CondNitU ioR n SINK rsM ing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. When caring for a patient who has an arm or leg restraint in place, how often will the nurse

remove the restraint? a. Every 15 minutes b. Every 30 minutes c. Every hour d. Every 2 hours ANS: D

Restraints should be removed at least every 2 hours. If the patient is violent or noncompliant, remove one restraint at a time and/or have staff assistance while removing restraints. Removal provides an opportunity to change the patient’s position, offer nutrients, perform full range of motion (ROM), and toilet and exercise the patient. After application, evaluate the patient’s condition for signs of injury every 15 minutes. Frequent assessments prevent injury to the patient and allow removal of the restraint at the earliest possible time. If the patient shows no sign of impaired circulation or other complications, the restraint does not need to be removed at this time. If the nurse restrains a patient in an emergency situation because of violent or aggressive behaviour, this presents an immediate danger; a face-to-face physician assessment is needed within 1 hour to determine the patient’s need for the restraint.

DIF: Cognitive Level: Comprehension REF: Skill 14.3 OBJ: Discuss precautions used to prevent injury in patients who are restrained.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY TOP: Evaluation of Patient Condition MSC: NCLEX: Physiological Integrity

KEY: Nursing Process Step: Implementation

15. When assessing a patient, a nurse notes that the skin distal to a restraint is pale and cool to the

touch. Which of the following interventions will the nurse perform first? a. Remove the restraint. b. Loosen the restraint. c. Obtain a larger restraint. d. Reapply the restraint with more padding.

ANS: A

If a patient has altered neurovascular status of an extremity, such as cyanosis, pallor and coldness of skin, or complaints of tingling, pain, or numbness, remove the restraint immediately, and notify the physician. Loosening the restraint may not effectively restore adequate circulation. An improperly sized restraint may not provide the protection needed for the patient.

DIF: Cognitive Level: Application REF: Skill 14.3 OBJ: Discuss precautions used to prevent injury in patients who are restrained.

TOP: Altered Neurovascular Status of an Extremity KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. A nurse enters the room of a patient who is sitting in a chair and the patient begins to have a

seizure. To promote patient safety, which nursing intervention will the nurse initially perform? a. Immediately call for assistance. b. Assist the patient to the flooNrU . RSINGTB.COM c. Put the patient back into the bed. d. Insert a padded tongue blade into the patient’s mouth.

ANS: B

When the seizure begins, position the patient safely. If the patient is standing or sitting, guide the patient to the floor and protect the head by cradling in the nurse’s lap or placing a pillow under the head. Clear the surrounding area of furniture. If the patient is in bed, raise the side rails and pad and put the bed in a low position. Stay with the patient, and observe the sequence and timing of seizure activity. Continued observation ensures adequate ventilation during and after a seizure and will assist in documentation, diagnosis, and treatment of a seizure disorder. If possible, turn the patient onto one side, with the head tilted slightly forward. This allows the tongue to fall away from the airway, permitting drainage of saliva and vomitus, and prevents aspiration. Do not force any objects, such as fingers, medicine, a tongue depressor, or an airway, into the patient’s mouth when the teeth are clenched. This could cause injury to the mouth and stimulate gagging, which could lead to aspiration.

DIF: Cognitive Level: Application REF: Skill 14.1 OBJ: Describe nursing interventions for a patient who experiences generalized seizures.

TOP: Seizures KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. What should the nurse do to prevent a patient from aspirating during a seizure? a. Insert an oral airway.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY b. Restrain the patient securely. c. Sit the patient upright. d. Turn the patient onto his or her side.

ANS: D

If possible, turn the patient onto the side, with the head flexed slightly forward. This position prevents the tongue from blocking the airway and promotes drainage of secretions, thus reducing the risk for aspiration. Do not force any objects, such as fingers, medicine, a tongue depressor, or an airway, into the patient’s mouth when the teeth are clenched. This could cause injury to the mouth and could stimulate gagging, leading to possible aspiration. Do not restrain the patient. Loosen clothing to prevent musculoskeletal injury and airway obstruction.

When a seizure begins, position the patient safely. If the patient is standing or sitting, guide the patient to the floor and protect the head by cradling in the nurse’s lap or placing a pillow under the head. Clear the surrounding area of furniture. If the patient is in bed, raise the side rails and pad, and put the bed in a low position.

DIF: Cognitive Level: Application REF: Skill 14.4 OBJ: Describe nursing interventions for a patient who experiences generalized seizures.

TOP: Aspiration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. Health care facilities must provide employees with access to information about the properties

of particular chemicals and information for handling substances in a safe manner. Facilities do this by providing . a. safety data sheets (SDS) b. the Workplace Hazardous Materials Information System (WHMIS) c. personal protective equipment (PPE) d. fire extinguishers

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ANS: A

Health care facilities provide employees access to a material safety data sheet (SDS) for each hazardous chemical. An SDS is a form that contains data about the properties of a particular chemical and information for handling a substance in a safe manner (e.g., storage, disposal, protective equipment, and spill handling procedures).

DIF: Cognitive Level: Comprehension REF: Procedural Guideline 14.1 OBJ: Describe methods used to evaluate safety interventions.

TOP: Safety Data Sheets (SDS) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19. A thumbless device used to restrain patients’ hands to prevent them from dislodging invasive

equipment, removing dressings, or scratching is known as a(n) a. freedom splint b. mitten restraint c. belt restraint d. extremity restraint

.

ANS: B

A mitten restraint is a thumbless mitten device that restrains patients’ hands and prevents patients from dislodging invasive equipment, removing dressings, or scratching, yet it allows greater movement than is permitted with a wrist restraint.

DIF: Cognitive Level: Comprehension

REF: Skill 14.3

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY OBJ: Discuss precautions used to prevent injury in patients who are restrained.

TOP: Mitten Restraints KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. Continuous seizure activity that lasts longer than 30 minutes is known as a. focal onset seizure b. generalized onset seizure c. status epilepticus d. unknown onset seizure

.

ANS: C

Continuous seizure activity that lasts longer than 30 minutes is status epilepticus, which is a medical emergency.

DIF: Cognitive Level: Understanding REF: Skill 14.4 OBJ: Describe nursing interventions for a patient who experiences generalized seizures.

TOP: Status Epilepticus KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. A safe health care environment is one in which (Select all that apply.) a. the patient’s basic needs are met. b. physical hazards are reduced. c. transmission of microorganisms is reduced. d. sanitary measures are carried out.

ANS: A, B, C, D

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A safe environment is one in which the patient’s basic needs are met, physical hazards are reduced or eliminated, transmission of microorganisms is reduced, and sanitary measures are carried out.

DIF: Cognitive Level: Comprehension REF: Safety Guidelines OBJ: Describe methods used to evaluate safety interventions.

TOP: Safe Environment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. Effective fall prevention programs include which of the following? (Select all that apply.) a. Risk assessment b. Medication reviews c. Use of assistive devices d. Exercise and strength training ANS: A, B, C, D

Evidence shows that hospital-based fall prevention programs that focus on a multifactorial approach reduce fall rates. Effective fall prevention programs include risk assessment, medication reviews with necessary modifications, use of assistive devices, exercise and strength training, and education for home safety.

DIF: Cognitive Level: Comprehension REF: Skill 14.1 OBJ: Discuss current evidence in fall prevention.

TOP: Fall Prevention Programs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 3. Which of the following fall prevention strategies should the nurse perform on all hospitalized

patients? (Select all that apply.) a. Conduct hourly rounds. b. Provide the patient regular toileting. c. Assess the patient’s comfort needs. d. Evaluate the effectiveness of pain medication.

ANS: A, B, C, D

A recent study shows that hourly nurse rounds are an effective strategy for reducing falls.

Combining hourly rounds with activities such as regular toileting and assessing the patients’ comfort needs manages those factors that often prompt patients to get out of bed without assistance. In the hospital setting, a variety of fall-risk screening tools are available. Because multiple risk factors for falls are known, no single assessment tool is sensitive and specific for analyzing fall risk.

DIF: Cognitive Level: Comprehension REF: Skill 14.1 OBJ: Describe nursing interventions specific for reducing patients’ risks for falls.

TOP: Fall Prevention Programs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. Which of the following alternatives to physical restraints should the nurse use to promote

patient safety? (Select all that apply.) a. Environmental modifications b. Less frequent patient observation c. Involvement of family during visitation d. Frequent reorientation of the patient ANS: A, C, D

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Many alternatives to the use of restraints are available, and you should try all of them before using restraints. Modification of the environment is an effective alternative to restraints. More frequent observation of patients, involvement of family during visitation, and frequent reorientation are helpful measures.

DIF: Cognitive Level: Application REF: Skill 14.2 OBJ: Describe steps in the design of a restraint-free environment.

TOP: Alternatives to Physical Restraint KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The use of restraints has been associated with which of the following complications? (Select

all that apply.) a. Pressure injuries b. Pneumonia c. Constipation d. Death ANS: A, B, C, D

The use of restraints is associated with several serious complications, including pressure ulcers, hypostatic pneumonia, constipation, incontinence, and death.

DIF: Cognitive Level: Comprehension REF: Skill 14.3 OBJ: Discuss precautions used to prevent injury in patients who are restrained.

TOP: Applying Physical Restraints KEY: Nursing Process Step: Assessment

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY MSC: NCLEX: Physiological Integrity 6. When working with a patient who has a new seizure disorder, the nurse is alerted to the need

for further instruction when the patient tells the nurse: (Select all that apply.) a. “I will avoid alcohol because it can react with my medications and make me sleepy.” b. “I have the medications that I take listed on this card that I carry with me.” c. “I will be sure to take my medications as prescribed by my provider.” d. “I will visit my physician right after I return home from my next trucking job.”

ANS: B, D

Patients should wear a medical alert bracelet or carry an identification card noting the presence of seizure disorder and listing medications taken. A seizure condition usually imposes driving limitations. It is recommended that a waiting period of 1 seizure-free year elapses before the patient attempts to drive or operate dangerous equipment.

DIF: Cognitive Level: Application REF: Skill 14.4 OBJ: Describe nursing interventions for a patient who experiences generalized seizures.

TOP: Teaching Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 15: Emergency Preparedness and Disaster Management Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. A patient has been exposed to a toxic chemical. The nurse’s first priority is a. b. c. d.

. determining the exact toxic chemical decontamination providing the antidote obtaining a full set of vital signs

ANS: B

Suspect a toxic chemical event when large numbers of ill people present who have unexplained yet similar symptoms. The primary objective for initial care is decontamination, the process used to remove harmful contaminants from the surface of the skin. You achieve this by removing clothing, scrubbing the skin, and performing hydrolysis, a process of chemical dilution in which large volumes of water are used.

DIF: Cognitive Level: Comprehension REF: Skill 15.2 OBJ: Discuss guidelines for patient care in the event of mass casualty care.

TOP: Decontamination KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. Personal protective equipment (PPE) is categorized by the level of safety provided. Standard

work uniforms or work clothes offer what level of protection?

NURSINGTB.COM a. Level A b. Level B c. Level C d. Level D ANS: D

Standard work uniforms or work clothes offer level D protection. There is no respiratory protection. Routine practices and additional precautions are important to take when level D protection is used. Level A protection provides maximum protection because it offers self-contained breathing apparatus, fully encloses the individual, and includes chemical-resistant boots and gloves. Level B protection provides respiratory protection but less skin protection. Used by trained responders, this PPE includes self-contained breathing apparatus; a hooded chemical-resistant suit; and face, boot, and glove protection. First responders (those emergency personnel first on the scene) and hospital personnel are trained and fitted to use level C protection. As with level A and B protection, level C protection presents danger to the user, primarily for dehydration and hyperthermia.

DIF: Cognitive Level: Comprehension REF: Safety Guidelines OBJ: Identify actions to take in the event of biological, chemical, and radiation exposure.

TOP: Levels of Safety KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 3. The most recently labeled level of protection is BioPPE. The use of BioPPE requires which of

the following items?

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. b. c. d.

Self-contained breathing apparatus Respiratory protection but less skin protection Chemical-resistant boots and gloves Standard work clothes and contact- and respiratory-protective devices

ANS: D

The most recently labeled level of protection is BioPPE. BioPPE requires the use of standard work clothes, along with contact and respiratory protection. Double gloving and an N95 mask or a better respirator is recommended. Level A protection provides maximum protection in that it offers a self-contained breathing apparatus, fully encapsulates the individual, and includes chemical-resistant boots and gloves. BioPPE protection is not adequate when caring for patients exposed to toxic chemicals; however, it provides adequate protection against radiological and biological agents.

DIF: Cognitive Level: Application REF: Safety Guidelines OBJ: Identify actions to take in the event of biological, chemical, and radiation exposure.

TOP: BioPPE KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. On arriving at a mass causality scene, health care providers using the START approach will

initiate triage by doing which of the following first? a. Assess breathing. b. Instruct ambulatory patients to move to a designated area. c. Assess respiratory rate, perfusion, and mental status. d. Differentiate between those triaged as red and yellow.

ANS: B

In the START process, step 1, N triUagReS, I beNgG inT sB by.iC nO strMucting all ambulatory patients to move to a designated area, the “green area.” Those patients that are able to do this are tagged green (minor). Step 2: Assess breathing; if the patient is breathing, move to step 3. If the patient is not breathing, attempt to open the airway. Step 3: Assess respiratory rate, perfusion, and mental status.

DIF: Cognitive Level: Comprehension REF: Person-Centred Care OBJ: Discuss guidelines for patient care in the event of mass casualty care.

TOP: Triage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. Disaster nursing differs from general nursing because when caring for patients during a

disaster a. the focus is on caring for the sickest people first. b. using a colour tag system reduces the amount of emotional stress on the nurse. c. the focus is no longer on airway, breathing, and circulation. d. the focus is on caring for those most likely to survive.

ANS: D

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Disaster nursing differs from general nursing in that the focus shifts from caring for the sickest people first to saving the greatest number of lives. Triage sorts the victims into groups with colour-coded tags that identify status—black for the dead or mortally injured, red for those in need of immediate attention to survive, yellow for those seriously injured but more stable than individuals coded red, and green for those with minimal injuries, This allows the rescue teams to direct resources in a most effective manner to save the greatest number of lives.

DIF: Cognitive Level: Comprehension REF: Person-Centred Care OBJ: Discuss guidelines for patient care in the event of mass casualty care.

TOP: Disaster Nursing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. The nurse has arrived at the scene of a natural disaster and is assigned to care for four patients.

To which patient should the nurse provide care first? a. Patient with a closed head injury with no changes in level of consciousness b. Patient with a 3-cm laceration to the forearm c. Patient who is breathing 8 times per minute d. Patient with a displaced wrist fracture ANS: C

Nursing care should be prioritized when multiple patients are cared for at once. ABCs (airway, breathing, and circulation) should always take precedence. The patient who is breathing only 8 times per minute is in need of immediate nursing care. The goal of triage is to sort, assess, and perform life-saving measures as quickly as possible for large numbers of victims.

DIF: Cognitive Level: AnalysisNURSINRGETFB : .PC erO soMn-Centred Care OBJ: Discuss guidelines for patient care in the event of mass casualty care.

TOP: Disaster Nursing KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The patient is brought into the emergency department as part of a mass casualty incident

(MCI). The patient has white powder on his clothes, and it is suspected that the patient has been exposed to anthrax. What should the nurse do first? a. Cut off the patient’s clothing and place it in a plastic bag. b. Have the patient remove his sweater by pulling it over his head. c. Avoid using oxygen that could decrease the patient’s oxygen drive. d. Provide the patient with appropriate antibiotics.

ANS: A

If you suspect anthrax, remove the patient’s clothing and place it in a labeled plastic biohazard bag. Do not have the patient pull clothing off over the head, but rather cut off clothing.

Administer oxygen therapy. Various biological agents (e.g., pulmonary anthrax) commonly cause respiratory symptoms that will result in an altered gas exchange. Exposure to these agents is commonly treated with ciprofloxacin and/or doxycycline, and botulism requires supportive care and use of an antitoxin.

DIF: Cognitive Level: Application REF: Skill 15.1 OBJ: Identify actions to take in the event of biological, chemical, and radiation exposure.

TOP: Anthrax KEY: Nursing Process Step: Implementation

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY MSC: NCLEX: Physiological Integrity 8. Which of the following biological agent requires the use of an antitoxin if exposure occurs? a. Anthrax b. Plague c. Botulism d. Typhoid ANS: C

Botulism requires supportive care and use of an antitoxin. Attack with various biological agents (e.g., anthrax, plague, and typhoidal tularemia) is commonly treated with ciprofloxacin and/or doxycycline.

DIF: Cognitive Level: Application REF: Table 15.1: Summary of Selected Class A Biological Warfare Agents OBJ: Identify actions to take in the event of biological, chemical, and radiation exposure.

TOP: Botulism KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The patient is admitted to the emergency department with possible smallpox exposure. The

patient has never had a smallpox immunization. The nurse prepares to administer a smallpox vaccination, realizing that vaccination a. within 4 days of exposure should prevent the disease. b. is effective only if received before exposure. c. 4 to 7 days after exposure will completely prevent the disease. d. within 3 days will offer only some protection from disease.

ANS: A

NURSINGTB.COM

In the event that smallpox is the biological weapon, the best treatment is prevention by immunization with vaccine before the onset of symptoms. Vaccination within 3 days of exposure should prevent the disease or will significantly reduce its effect. Vaccination 4 to 7 days after exposure offers some protection from disease or will decrease the severity of disease.

DIF: Cognitive Level: Application REF: Skill 15.1 OBJ: Identify actions to take in the event of biological, chemical, and radiation exposure.

TOP: Smallpox KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. If a patient is receiving radiation using gamma rays, the nurse would be watching for which of

the following? a. Severe pain during administration b. Development of an allergy to shellfish c. Severe burns or internal injury d. Confusion and lethargy ANS: C

Gamma rays pose the greatest health risk because the waves penetrate deeply, causing severe burns and internal injury. Radiation does not cause patients to develop an allergy to shellfish and is painless during administration. Confusion and lethargy are not known side effects of radiation.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY DIF: Cognitive Level: Analysis REF: Skill 15.3 OBJ: Identify actions to take in the event of biological, chemical, and radiation exposure.

TOP: Gamma Rays KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11. After a suspected radiological exposure, the initial scan of the patient’s extremities is positive.

What will be the next step in this patient’s care? a. Washing the skin with soap and water while taking care not to irritate or abrade the skin b. Removing clothing to eliminate 70% to 90% of the contamination c. Isolating and covering up any skin that is positive for radiation using a plastic wrap d. Conducting a thorough survey of the patient’s entire body with the radiation sensing equipment ANS: D

If the initial assessment of the patient’s face, hands, and feet is positive for radiation exposure, the specially trained technician will conduct a more thorough assessment of the patient’s entire body. Determining the amount and level of radiation is important in determining the level of danger to the caretaker and the level of care required for the patient. This determination precedes any other care.

DIF: Cognitive Level: Application REF: Skill 15.3 OBJ: Identify actions to take in the event of biological, chemical, and radiation exposure.

TOP: Assessment of Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. How is a disaster best defined? a. Any event or situation that N GuTltBip.leCcOaM reU suRltSs I inNm sualties and/or deaths b. A catastrophic and/or destructive event that disrupts normal functioning c. An industrial accident and unplanned release of nuclear waste d. An event that results in human casualties that overwhelm available health care

resources ANS: B

A disaster is defined as a catastrophic and/or destructive event that disrupts normal functioning; it may include any anticipated or unexpected event whose effects lead to significant destruction and/or adverse consequences. Any event or situation that results in multiple casualties and/or deaths is called a mass casualty incident (MCI). An industrial accident with unplanned release of nuclear waste is classified as a technological disaster. A medical disaster is a catastrophic event that results in human casualties that overwhelm available health care resources.

DIF: Cognitive Level: Comprehension REF: Principles for Practice OBJ: Discuss the characteristics of different types of disasters. TOP: Disasters KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. Dispersal of biological agents is a real and psychological terrorist threat. Which of the

following organisms has the potential to cause the greatest harm? a. Anthrax b. Ricin c. Salmonella

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY d. Hantavirus ANS: A

Class A biological warfare agents are considered the greatest threat because they can be transmitted easily from person to person and can cause high mortality with a potential for major public health impact. Of the organisms listed here, only anthrax (Bacillus anthracis) is considered a class A agent.

DIF: Cognitive Level: Comprehension REF: Table 15.1: Summary of Selected Class A Biological Warfare Agents OBJ: Discuss the characteristics of different types of disasters.

TOP: Potential Organisms for Bioterrorism by CDC Category KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. Canada’s Emergency Management Framework has four components. They are a. prevention, preparedness, response, and recovery. b. prevention, preparedness, reaction, and mitigation. c. strengths, weaknesses, opportunities, and threats. d. opportunities, threats, response, and recovery.

ANS: A

Canada’s Emergency Management Framework has four components: prevention/mitigation, preparedness, response, and recovery from potential threats and disaster events.

DIF: Cognitive Level: Comprehension REF: Principles for Practice OBJ: Describe elements of emergency preparedness and disaster management, including prevention/mitigation, preparedness, response, and recovery.

TOP: Canada’s Emergency Management Framework NURSINGTB.COM KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15. Conditions determined by physical, social, economic, and/or environmental factors or

processes, which increase the susceptibility of a community to the effects of hazards, are considered a(n) a. threat. b. vulnerability. c. emergency. d. hazard.

ANS: B

A vulnerability is defined as conditions determined by physical, social, economic, and/or environmental factors or processes, which increase the susceptibility of a community to the effects of hazards.

DIF: Cognitive Level: Comprehension REF: Box 15.1: Disaster Definitions and Types OBJ: Discuss the characteristics of different types of disasters. TOP: Epidemic KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 16. Which households should own an emergency preparedness/disaster kit? a. Those located in areas of frequent natural disasters b. Those who are currently experiencing a disaster c. None—only hospitals should have emergency preparedness/disaster kits. d. All households should have emergency preparedness/disaster kits.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY ANS: D

Every household should prepare should have an emergency preparedness kit/disaster kit that includes basic items (water, can opener, utility knife, food, first-aid kit, identification, etc.) and items unique to members of the household, like hearing aid batteries or an extra pair of glasses.

DIF: Cognitive Level: Comprehension REF: Care in the Community (Skill 15.1) OBJ: Discuss the characteristics of different types of disasters. TOP: Disaster Supply Kit KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 17. The

_ outlines a plan that addresses preparedness planning related to equipment, systems, and protocols necessary to achieve integrated voice and data communications in the event of a disaster. a. Incident Command System (ICS) b. Emergency Act c. Canadian Red Cross d. World Health Organization (WHO) ANS: A

The Incident Command System (ICS) outlines a plan that addresses preparedness planning related to equipment, systems, and protocols necessary to achieve integrated voice and data communications in the event of a disaster.

DIF: Cognitive Level: Comprehension REF: Principles for Practice OBJ: Describe elements of emergency preparedness and disaster management, including prevention/mitigation, preparedness, response, and recovery.

TOP: Incident Command Systems KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

NURSINGTB.COM

18. Hurricane Zee has caused severe flooding and loss of power throughout the east coast. The

local community has a stockpile of supplies that will help it get through the next 72 hours.

Beyond this, once local and federal authorities confirm the need, supplies will be issued from the . a. Incident Command System (ICS) b. Strategic National Stockpile (SNS) c. Canadian Red Cross d. National Emergency Strategic Stockpile (NESS) ANS: D

The Public Health Agency of Canada funds the National Emergency Strategic Stockpile (NESS), which provides health and social service supplies quickly to provinces and territories when their own resources are depleted during an emergency. There is a central depot in Ottawa, with several supply centres located across Canada. The SNS is the U.S. version of NESS. DIF: Cognitive Level: Application REF: Principles for Practice OBJ: Discuss guidelines for patient care in the event of mass casualty care.

TOP: National Emergency Strategic Stockpile (NESS) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19.

is the sorting of individuals by the seriousness of their condition and the likelihood of their survival.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. b. c. d.

Assessment Planning Implementation Triage

ANS: D

Triage is the sorting of individuals by the seriousness of their condition and the likelihood of their survival.

DIF: Cognitive Level: Understanding REF: Person-Centred Care OBJ: Discuss guidelines for patient care in the event of mass casualty care.

TOP: Triage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. For safety reasons, rescue workers should be upwind and uphill from a toxic chemical disaster

scene to avoid exposure. The exception is when _ is lighter than air. a. anthrax b. varicella c. cyanide gas d. brucellosis

has been released, because it

ANS: C

For safety reasons, rescue workers should be upwind and uphill from a toxic chemical disaster scene to avoid exposure. The exception is when cyanide gas has been released. Cyanide is lighter than air and thus will travel uphill. It has the unique smell of bitter almonds; however, it is often odourless.

NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Skill 15.2 OBJ: Discuss guidelines for patient care in the event of mass casualty care.

TOP: Cyanide Gas KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Which of the following should make the nurse suspect a biological event? (Select all that

apply.) a. Large numbers of ill people with unexplained similar symptoms b. Unexplained deaths among young and healthy populations c. A patient population with symptoms suggestive of a common agent d. An unusual geographical pattern associated with the symptoms ANS: A, B, D

You should suspect a biological event when large numbers of ill people present who have unexplained yet similar symptoms; when unexplained deaths occur, particularly among young and healthy populations; when an unusual pattern (e.g., geographical, season, and patient population) is associated with the symptoms; when the patient fails to respond to traditional therapy; and when a single patient presents with symptoms suggestive of an uncommon agent (e.g., anthrax and smallpox). Once you suspect a biological event, notify incident command immediately.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY DIF: Cognitive Level: Comprehension REF: Skill 15.1 OBJ: Identify actions to take in the event of biological, chemical, and radiation exposure.

TOP: Bioterrorism KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. Why are children particularly vulnerable to environmental toxins? (Select all that apply.) a. They have stronger immune systems. b. They take in proportionally larger doses of toxins from food, water, and the air. c. Their organ systems are less able to remove toxins than adult organ systems. d. They have a greater number of years of life expectancy.

ANS: B, C, D

Children are particularly vulnerable to environmental toxins because, pound for pound, they take in larger doses of toxins than adults; their organ systems are less able to remove the toxins than those of adults; and they have a greater number of years of life expectancy over which to develop complications from the toxic exposure.

DIF: Cognitive Level: Comprehension REF: Pediatric (Skill 15.1) OBJ: Discuss guidelines for patient care in the event of mass casualty care.

TOP: Psychological Status KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The patient is admitted with exposure to an unknown chemical. His clothing appears to be

grossly contaminated. What should the nurse do? (Select all that apply.) a. Avoid touching contaminated parts of clothing. b. Pull off the patient’s tee shirt over his head. c. Cut off the patient’s clothes. d. Wash the patient with largeNaU mRoS unItsNoGfTsoBa. pCanOdMwater.

ANS: A, C, D

Remove all of the patient’s clothing, but do not pull it over the patient’s head; instead, cut garments off. Act quickly, and avoid touching contaminated parts of clothing as much as possible. Decontaminate the patient using large amounts of soap and water to wash the patient thoroughly.

DIF: Cognitive Level: Application REF: Skill 15.2 OBJ: Discuss guidelines for patient care in the event of mass casualty care.

TOP: Decontamination KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 16: Pain Assessment and Management Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The nurse is caring for a patient who is a devout Orthodox Jew. The patient is on a

patient-controlled analgesia (PCA) pump. What accommodations might the nurse have to make to conform to the patient’s cultural needs? a. Ask the patient whether he will need alternative forms of medication for the Sabbath. b. Ask the patient specific questions because Jews tend to be stoic regarding pain. c. Medicate the patient “around the clock” instead of as needed (prn). d. Understand that Jews believe that suffering is a consequence of actions in a previous life.

ANS: A

Orthodox or Observant Jews may not use electrical equipment during the Sabbath and on Holy Days; therefore the staff should program the PCA pump to achieve optimum pain relief.

Alternative methods will be needed during these times. Cultures vary regarding when to recognize pain, what words to use in expressing pain, when to seek treatment, and what treatments are desirable. The nurse should ask the patient about his preferences.

DIF: Cognitive Level: Comprehension REF: Person-Centred Care OBJ: Evaluate the effectiveness of pain-management techniques.

TOP: Cultural Considerations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

NURSINGTB.COM

2. The patient is admitted with persistent pain. She states that nothing takes the pain away

totally, but that “Dilaudid works best.” The fact that the patient calls the medication by name should alert the nurse to a. suspect that the patient is drug seeking. b. expect that the patient may need smaller doses than normal. c. assess the patient’s acceptable level of comfort. d. accept the fact that nothing will help this patient’s pain.

ANS: C

It is important to assess the patient’s acceptable level of comfort so that both you and the patient are striving for the same outcome. Some patients with prior pain conditions can alert the nurse to pain-relieving measures that were successful. Patients with persistent pain are often familiar with the names and actions of medications, including opioid medications. This should not cause you to view the patient negatively or with suspicion. Patients currently receiving opioids for persistent pain often require higher doses of analgesics to alleviate new pain. Do not accept that “there is nothing that will help this patient’s pain.” Learn the institutional policy for how to proceed in this situation.

DIF: Cognitive Level: Application REF: Person-Centred Care OBJ: Understand the components of a pain assessment.

TOP: Assessment of Comfort Level KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 3. The nurse frequently must assess a patient who is experiencing pain. When assessing the

intensity of the pain, the nurse should a. ask whether there are any precipitating factors. b. question the patient about the location of the pain. c. offer the patient a pain scale to objectify the information. d. use open-ended questions to find out about the sensation.

ANS: C

Descriptive scales are an objective means of measuring pain intensity. Use a pain intensity scale appropriate to the patient’s age, developmental level, and comprehension, and ask the patient to rate the pain. An appropriate pain rating scale is reliable, easily understood, and easy to use, and it reflects changes in pain intensity. Asking the patient what precipitates the pain does not assess intensity but rather assesses the pain pattern. Asking the patient about the location of pain does not assess the intensity of the patient’s pain. To determine the quality of the patient’s pain, the nurse may ask open-ended questions to find out about the sensation experienced (e.g., “Tell me what your pain feels like”). This approach assists in identifying the underlying pain mechanism (e.g., somatic or neuropathic pain), but it may not reveal intensity or changes in intensity.

DIF: Cognitive Level: Application REF: Skill 16.1 OBJ: Understand the components of a pain assessment.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Assessing Pain Intensity

4. The nurse who is caring for a patient postoperatively notes that he is expressing discomfort

and is diaphoretic. Which of the following interventions is most appropriate? a. Straighten the bed linens. NURSINGTB.COM b. Change the saturated surgical dressing. c. Administer prescribed pain medications. d. Check for displaced equipment underneath the patient.

ANS: C

Administer pain-relieving medications as prescribed. Analgesics are the cornerstone of pain management. Smoothing wrinkles in bed linens may reduce pressure and irritation to the skin; however, pain-relieving medication should be given first. Changing a wet surgical dressing might not be needed if the patient has received a wet-to-dry dressing as treatment or if not changing the dressing will reduce irritation to the skin but will not address the discomfort.

Reposition underlying tubes, wires, or equipment that may apply pressure directly to dependent skin surfaces. Removing these stimuli may maximize the response to pain-relieving interventions such as medication, but pain-relieving medication should be administered first.

DIF: Cognitive Level: Application REF: Box 16.1: The Canadian Pain Society’s Position Statement OBJ: Describe how an initial pain assessment allows you to provide a patient basic comfort measures.

TOP: Treatment of Pain KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 5. The patient’s family is concerned that the patient may get too much pain medication after

surgery and become addicted to the medication if he is placed on a patient-controlled analgesia (PCA) pump. They also voice concern about the effectiveness of the PCA. The nurse should instruct the family and the patient that a. pain relief with the PCA pump is not as good as when the nurse provides it, but it does save on nursing time. b. pain relief is good when the medication peaks, but less so when the levels drop, and that is when the patient will know that he needs more. c. because the device provides medication as soon as the patient needs it, he will probably use less of the medication. d. the patient will be kept in bed for several days after surgery to make sure it is safe to ambulate.

ANS: C

Because the device provides medication on demand as soon as the patient feels the need, the total amount of opioid use is reduced. Because the blood level stays within a narrow range of the minimum effective analgesia concentration for the individual, pain relief is enhanced, and the incidence of side effects, such as sedation and respiratory depression, is decreased. The PCA has several advantages. It allows more constant serum levels of the opioid and, as a result, avoids the peaks and troughs of a large bolus. An advantage of PCA is that when used postoperatively, fewer complications arise because earlier and easier ambulation occurs as a result of effective pain relief.

DIF: Cognitive Level: Comprehension REF: Skill 16.2 OBJ: Describe the process for delivering medication through a patient-controlled analgesia (PCA) device.TOP: Patient-Controlled Analgesia (PCA) KEY: Nursing Process Step: Implementation NURSINGTB.COM MSC: NCLEX: Physiological Integrity 6. The nurse caring for a patient who has a patient-controlled analgesia (PCA) knows that it a. allows the family to participate in pain management for the patient. b. prevents mistakes in medication administration. c. can be used by all hospitalized patients. d. provides a more constant level of medication.

ANS: D

PCA allows more constant serum levels of the opioid, and, as a result, it avoids the peaks and troughs of a large bolus. Because the blood level is maintained within a narrow range of the minimum effective analgesia concentration for the individual, pain relief is enhanced and the incidence of side effects, such as sedation and respiratory depression, is decreased. Potential concerns involving PCA use are pump failure and operator errors. Patients may misunderstand how PCA therapy works, may mistake the PCA button for the nurse call button, or may have family members who operate the demand button. Instruct the family not to push the timing device for the patient unless the patient is unable to push the button him- or herself, and the nurse has instructed the family to do so. Use of a PCA pump does not prevent mistakes. The pump may fail to deliver medication on demand, may have a faulty alarm or a low battery, or may lack free-flow protection. Operators may incorrectly program the dose, concentration, or rate. Not all patients are candidates for PCA. Assess the patient’s cognitive ability to determine the appropriateness of PCA pain management.

DIF: Cognitive Level: Comprehension

REF: Skill 16.2

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY OBJ: Describe the process for delivering medication through a patient-controlled analgesia (PCA) device.TOP: Patient-Controlled Analgesia (PCA) KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 7. When evaluating the effects of patient-controlled analgesia (PCA), the nurse notes that the

patient is sedated and is difficult to arouse. What step should the nurse take next? a. Insert an airway. b. Turn patient to the side. c. Stop the PCA. d. Expect this as a patient outcome of the therapy.

ANS: C

If the patient is sedated and is not readily arousable, stop the PCA. As long as the patient has spontaneous respirations, instruct him or her to take deep breaths. Apply oxygen at 2 L via nasal cannula. Elevate the head of the bed 30 degrees, unless contraindicated, to facilitate respirations. Heavy sedation is not an expected outcome of PCA therapy. Evaluate for the presence of analgesic side effects. Maintain a slightly drowsy, easily aroused patient.

DIF: Cognitive Level: Application REF: Skill 16.2 OBJ: Describe the process for delivering medication through a patient-controlled analgesia (PCA) device.TOP: Patient-Controlled Analgesia (PCA) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The patient is scheduled for surgery late in the afternoon. His postoperative prescriptions

include patient-controlled analgesia (PCA) therapy. Which of the following nursing interventions is appropriate to perform? a. Teach the patient about PCN AUaR fteSrIthNeGpT atB ie. ntCcOoM mes out of recovery. b. Teach the patient about PCA before surgery and before preoperative medication administration. c. Tell the patient not to use PCA unless he can no longer tolerate the pain. d. Inform the patient’s family to watch him carefully and to depress the PCA administration button whenever they think he needs it.

ANS: B

Instruct surgical patients preoperatively. Encourage the patient to push the button on the timing unit whenever he feels pain. Tell the patient not to delay if he is experiencing pain.

Pain is easier to prevent than to treat. Inform the patient and family that the patient cannot overdose with PCA if only the patient pushes the button. The family should not push the button unless instructed to do so by the nurse.

DIF: Cognitive Level: Application REF: Skill 16.2 OBJ: Describe the process for delivering medication through a patient-controlled analgesia (PCA) device.TOP: Patient-Controlled Analgesia (PCA) Teaching Consideration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The nurse knows that an advantage of intraspinal analgesia is the a. smaller doses of epidural than intrathecal medication. b. lack of significant patient complications. c. systemic distribution of morphine faster than fentanyl. d. ability to achieve appropriate analgesia with smaller dosages.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

ANS: D

Because opioids are delivered close to their site of action, the central nervous system (CNS), they have greater bioavailability and thus require much smaller doses to achieve adequate pain relief. Epidural and intrathecal doses are not equivalent. Intrathecal doses are much smaller than epidural doses. As an example, the epidural dose of morphine is 10 to 20 times greater than that required for an intrathecal dose. The catheter poses a threat to patient safety because of its anatomical location, its potential for migration through the dura, and its proximity to spinal nerves and vessels. Migration of an epidural catheter into the subarachnoid space can produce medication levels too high for intrathecal use. Fentanyl and sufentanil are hydrolipid, which causes them to have a quicker onset and a shorter duration of action (2 hours).

Morphine and hydromorphone are hydrophilic, resulting in a longer onset and a longer duration of action (up to 24 hours with a single bolus dose).

DIF: Cognitive Level: Comprehension REF: Skill 16.3 OBJ: Assess a patient receiving epidural analgesia.

TOP: Intraspinal Analgesia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 10. The patient is in the hospital undergoing major abdominal surgery. When the patient returns

from the recovery room, the nurse expects that he most likely will be receiving pain medication a. by mouth. b. intramuscularly. c. via the epidural route. d. intravenously.

ANS: C

Research shows the epidural roN uU teRtoSbIeNmGoTstBe.ffC ecOtiMve in managing postoperative pain from thoracic and abdominal surgeries.

DIF: Cognitive Level: Comprehension REF: Skill 16.3 OBJ: Assess a patient receiving epidural analgesia.

TOP: Intraspinal Analgesia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 11. While reviewing a patient’s medication history, the nurse determines that intraspinal analgesia

is contraindicated as a result of a. previous spinal anaesthesia. b. recent administration of anticoagulants. c. a history of cardiac problems. d. a diagnosis of advanced cancer.

ANS: B

Recent anticoagulants sometimes contraindicate the placement of an epidural catheter because of the risk for epidural hematoma at the insertion site. Certain conditions may make epidural analgesia the method of choice for pain control: after surgery, for patients with trauma or advanced cancer that is not responsive to other pain management modalities, and those predisposed to cardiopulmonary complications because of a pre-existing medical condition or surgery. Previous spinal anaesthesia is not a contraindication for receiving subsequent spinal anaesthesia.

DIF: Cognitive Level: Analysis REF: Skill 16.3 OBJ: Assess a patient receiving epidural analgesia.

TOP: Intraspinal Analgesia

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

12. A nurse checks the continuous intravenous (IV) infusion for the intraspinal analgesia. The IV

setup should be changed if a. tubing with a Y-port is attached. b. an infusion pump is attached. c. the tubing connections are all taped. d. a diluted, preservative-free medication is used.

ANS: A

Use tubing without Y-ports for continuous infusions. Use of tubing without Y-ports prevents accidental injection or infusion of another medication meant for vascular space into epidural space. Normal equipment used for intraspinal infusion includes an infusion pump and compatible tubing without Y-ports. Catheter and injection cap or infusion pump tubing should be securely taped and labeled. Closed, intact systems prevent entry of pathogens and disruption of the flow of medication. Medication should be prediluted, preservative-free opioid, or local anaesthetic as prescribed by the physician and prepared for use in an IV infusion pump (usually prepared by pharmacy). Preservatives may be toxic to nerve tissue.

DIF: Cognitive Level: Application REF: Skill 16.3 OBJ: Assess a patient receiving epidural analgesia.

TOP: Intraspinal Analgesia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 13. Before administering an epidural medication, the nurse aspirates and suspects that the catheter

has migrated into the subarachnoid space when a. clear drainage is noted. b. no drainage is noted. c. purulent drainage is noted. NURSINGTB.COM d. redness, warmth, and edema are noted.

ANS: A

Aspiration of more than 1 mL of clear fluid or bloody return means that the catheter may have migrated into the subarachnoid space or into a vessel. Do not inject the medication. Notify the physician. Purulent drainage is a sign of infection, indicating that local inflammation and superficial skin infection at the insertion site have occurred. Redness, warmth, and edema are signs of inflammation, indicating that local inflammation at the insertion site has occurred.

DIF: Cognitive Level: Analysis REF: Skill 16.3 OBJ: Assess a patient receiving epidural analgesia.

TOP: Catheter Migration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. A nurse is evaluating the epidural catheter insertion site and suspects that the intraspinal

catheter has punctured the dura when a. clear drainage is b. bloody drainage is c. purulent drainage is d. redness, warmth, and swelling are ANS: A

noted.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Clear drainage may indicate puncture of the dura. Bloody drainage may indicate that the catheter has entered the blood vessel. Purulent drainage is a sign of infection. Redness, warmth, and swelling are signs of inflammation. Local inflammation and superficial skin infection can occur at the insertion site.

DIF: Cognitive Level: Analysis REF: Skill 16.3 OBJ: Assess a patient receiving epidural analgesia.

TOP: Evaluating Epidural Site KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15. When assessing a local infusion pump site, the nurse notes that which of the following

requires an intervention? a. The device is labeled, indicating that an anaesthetic is being used. b. The catheter connections are loose. c. Surgical dressings are dry and intact. d. No blood backup is present in the tubing.

ANS: B

Assess the catheter connections; all should be firmly attached. If connections become detached, do not reattach because infection could occur. Notify the physician. The label on the device provides information regarding type of anaesthetic, concentration, volume, flow rate, date and time prepared, and the name of the person who prepared it. The nurse should read this label. The dressing should be dry and intact. If not, stop the infusion and notify the physician. The catheter may not be placed properly. Assess for blood backing up in the tubing. If blood is present, stop the infusion and notify the physician. This indicates possible displacement of the catheter into a blood vessel.

DIF: Cognitive Level: Analysis REF: Safety Guidelines N U R S I N OBJ: Assess a patient receiving a peripheralGnT erB ve.bCloOcM k.

TOP: Assessment of Local Anaesthetic Infusion Pump KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 16. The patient had knee-replacement surgery and has a local infusion pump to provide a local

anaesthetic to the surgical site. The patient puts on the call light and complains that pain at the site is more intense than it has ever been and is getting worse. The nurse checks the site and finds that the dressing is damp but intact. The infusion pump is pumping, and there is medication in the bag. The most probable cause of the problem might be the a. catheter may be clogged. b. pump may be releasing too much medication into the site. c. catheter may be displaced. d. patient may be exaggerating the pain.

ANS: C

Assess the surgical dressing and the site of catheter insertion. The dressing should be dry and intact. Determine whether the catheter is properly placed. If the catheter is clogged, infusion of medication will stop. Pain levels will increase but the dressing will be dry, and the pump should alarm. If the pump is releasing too much medication, the nurse should expect to see symptoms of local anaesthetic adverse reaction. It is not the patient’s responsibility to convince the nurse that he has pain; it is the nurse’s responsibility to believe the patient.

DIF: Cognitive Level: Analysis REF: Skill 16.4 OBJ: Assess a patient receiving a peripheral nerve block.

TOP: Unexpected Outcomes

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

17. A nonpharmacological approach that the nurse may implement for patients who are

experiencing pain that focuses on diverting the patient’s attention away from the pain sensation by promoting pleasurable and meaningful stimuli is a. massage. b. heat/cold. c. guided imagery. d. distraction.

ANS: D

Distraction is a technique that diverts an individual’s attention away from the pain sensation.

By introducing meaningful stimuli, the nurse helps the patient refocus attention. Distraction directs a patient’s attention to something else and thus can reduce awareness of pain and even increase tolerance. A proper massage not only blocks the perception of pain impulses but also helps relax muscle tension and spasm that otherwise might increase pain. Massage hastens the elimination of wastes stored in muscles, improves oxygenation of tissues, and stimulates the relaxation response in the nervous system. Heat produces vasodilation, reduced blood viscosity, reduced muscle tension, and increased tissue metabolism. Heat helps relieve muscle spasms and joint stiffness. Cold produces vasoconstriction, reduced cell metabolism, and increased blood viscosity. Cold is effective for inflamed joints and muscles. The goal of imagery is to have the patient use one or several of the senses to create an image of the desired result. This image creates a positive psychophysiological response. Guided imagery can be used as a distraction technique.

DIF: Cognitive Level: Comprehension REF: Distraction OBJ: Assess and implement nonpharmacological measures to relieve pain.

NURSINGTB.COM TOP: Distraction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. Offering the patient a backrub before preparing for sleep can promote relaxation and comfort.

An effective backrub takes a. 1 to 2 minutes. b. 3 to 6 minutes. c. 7 to 10 minutes. d. 11 to 15 minutes.

ANS: B

Massage hastens the elimination of wastes stored in the muscles, improves oxygenation of tissues, and stimulates the relaxation response in the nervous system. An effective backrub takes 3 to 6 minutes.

DIF: Cognitive Level: Comprehension REF: Massage OBJ: Assess and implement nonpharmacological measures to relieve pain.

TOP: Massage: Backrub KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. The patient is admitted for persistent pain. He states that morphine sulphate has been used to

relieve his pain, but recently he has needed to use more of the medication to relieve pain. This patient’s plan of care will have to incorporate interventions to deal with which of the following?

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. b. c. d.

Addiction Pseudoaddiction Tolerance Physical dependence

ANS: C

Tolerance is defined as a state of adaptation in which exposure to a medication induces changes that result in diminution of one or more of the medication’s effects over time.

Addiction is defined as a primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors that influence its development and manifestations. It is characterized by behaviours that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. Pseudoaddiction is a term that describes patient behaviour that may occur when pain is undertreated. Patients with unrelieved pain may focus on obtaining medications, may “clock watch,” or otherwise may seem inappropriately “drug seeking.” Even such behaviours as illicit drug use and deception can occur in the patient’s efforts to obtain relief. Pseudoaddiction can be distinguished from true addiction in that behaviours resolve when pain is effectively treated. Physical dependence is a state of adaptation that often includes tolerance and is manifested by a drug class–specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreased blood level of the drug, and/or administration of an antagonist.

DIF: Cognitive Level: Analysis REF: Box 16.4: Opioid Use Disorder and Pain Treatment OBJ: Evaluate the effectiveness of pain-management techniques.

TOP: Terminology Related to Drug Dependency KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

NURSINGTB.COM

20. Which of the following patient conditions is categorized as a neurobiological disease? a. Physical dependence b. Addiction c. Pseudoaddiction d. Tolerance ANS: B

Addiction is defined as a primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors that influence its development and manifestations. It is characterized by behaviours that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. Physical dependence is a state of adaptation that often includes tolerance and is manifested by a drug class–specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreased blood level of the drug, and/or administration of an antagonist. Pseudoaddiction is a term that describes patient behaviour that may occur when pain is undertreated. Patients with unrelieved pain may focus on obtaining medications, may “clock watch,” or otherwise may seem inappropriately “drug seeking.” Even such behaviours as illicit drug use and deception can occur in the patient’s efforts to obtain relief. Pseudoaddiction can be distinguished from true addiction in that behaviours resolve when pain is effectively treated. Tolerance is defined as a state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drug’s effects over time.

DIF: Cognitive Level: Analysis

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY REF: Box 16.4: Opioid Use Disorder and Pain Treatment OBJ: Assess adverse effects of analgesics.

TOP: Terminology Related to Drug Dependency KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. Which of the following statements about evaluating patients in pain is true? a. The best judge of the existence of pain is the nurse. b. Visible signs always accompany pain. c. Patients often are hesitant to report pain. d. Nonpharmacological interventions are better than pain medications.

ANS: C

Patients often are hesitant to report pain for fear of being labeled as complainers, hypochondriacs, or addicts. The patient’s self-report is the most reliable indicator of the existence and intensity of pain. Even with severe pain, periods of physiological and behavioural adaptation occur, leading to periods of minimal or no observable signs of pain.

Lack of pain expression does not necessarily mean lack of pain. Nonpharmacological interventions are synergistic with medications but are not a substitute for pharmacological management of pain.

DIF: Cognitive Level: Comprehension REF: Table 16.1: Misconceptions: Barriers to the Assessment and Treatment of Pain OBJ: Understand the components of a pain assessment.

TOP: Misconceptions of Pain KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. a. b. c. d.

has an identifiabN leUcR auSsI eN anGdTraBp. idCoOnM set and generally disappears with healing.

Acute pain Persistent pain Cancer pain Neuropathic pain

ANS: A

Acute pain or transient pain has an identifiable cause, has a rapid onset, varies in intensity, is of short duration, and generally disappears with healing.

DIF: Cognitive Level: Understanding REF: Purpose OBJ: Understand the components of a pain assessment.

TOP: Acute Pain KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 23. Pain that extends beyond the period of healing and often lacks an identified pathological cause

is known as a. acute pain b. persistent pain c. cancer pain d. neuropathic pain ANS: B

.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Persistent pain extends beyond the period of healing, often lacks an identified pathological cause, rarely has autonomic signs, does not provide a protective function, disrupts sleep and activities of daily living, degrades the health and function of an individual, and may be cancerous or noncancerous/nonmalignant in origin.

DIF: Cognitive Level: Understanding REF: Purpose OBJ: Understand the components of a pain assessment.

TOP: Chronic Pain KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 24.

is an interactive method of pain management that permits patient control over pain through self-administration of analgesics. a. Around-the-clock analgesia b. Transcutaneous analgesia c. Epidural analgesia d. Patient-controlled analgesia (PCA) ANS: D

PCA is an interactive method of pain management that permits patient control over pain through self-administration of analgesics.

DIF: Cognitive Level: Understanding REF: Skill 16.2 OBJ: Describe the process for delivering medication through a patient-controlled analgesia (PCA) device.TOP: Patient-Controlled Analgesia (PCA) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. The

is a potential space between the vertebral bones and the dura mater, the outermost meninges coverin aiG nT anBd.sC piO naMl cord.

NgUtRheSbIrN a. subdural space b. dural space c. subarachnoid space d. epidural space ANS: D

The epidural space is a potential space between the vertebral bones and the dura mater, the outermost meninges covering the brain and spinal cord.

DIF: Cognitive Level: Understanding REF: Skill 16.3 OBJ: Assess a patient receiving epidural analgesia.

TOP: Epidural Space KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 26. Catheter migration into the

can produce dangerously high medication levels.

Only physicians and nurse anaesthetists administer medications in this space. a. subdural space b. dural space c. subarachnoid space d. epidural space ANS: C

Only physicians and nurse anaesthetists administer spinal medications in the subarachnoid space because of the increased risk associated with the procedure.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY DIF: Cognitive Level: Understanding REF: Skill 16.3 OBJ: Assess a patient receiving epidural analgesia.

TOP: Epidural Space KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Which of the following are characteristics of cancer pain? (Select all that apply.) a. It may be acute. b. It may be persistent. c. It usually is related to tumour recurrence or treatment. d. It often is of less intensity than the patient reports.

ANS: A, B, C

Cancer pain may be acute, persistent, or intermittent, and it usually is related to tumour recurrence or treatment. The patient is the only one who knows whether pain is present and what the experience is like. It is not the patient’s responsibility to convince the nurse that he has pain; it is the nurse’s responsibility to believe the patient.

DIF: Cognitive Level: Comprehension REF: Box 16.1: The Canadian Pain Society’s Position Statement OBJ: Understand the components of a pain assessment.

TOP: Cancer Pain KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The patient has morphine sulphate prescribed for pain every 4 hours as needed (prn). The

patient complains of severe pain and usually requests more morphine an hour before it is due.

The nurse should (Select all that apply.) a. request a “placebo prescription” from the physician.

NURSINGTB.COM b. offer the patient medication around the clock instead of prn. c. offer the patient massage between medication doses. d. offer the patient a nonopioid medication between morphine doses if prescribed.

ANS: B, C, D

Some patients exhibit drug-seeking behaviours when in fact they are seeking pain relief.

Occasionally, a physician will prescribe a placebo to discredit a patient’s report of pain. This is unethical and should be avoided. Timely administration before a patient’s pain becomes severe is crucial to ensure optimal relief. Pain is easier to prevent than to treat. In most circumstances, administration of pharmacological agents around the clock rather than on an as-needed” (prn) basis is preferable. Often a combination of nonopioids and opioids is effective in managing pain. Using an integrated approach that considers both pharmacological and nonpharmacological therapies in managing pain is recommended.

DIF: Cognitive Level: Application REF: Skill 16.1 OBJ: Understand the components of a pain assessment.

TOP: Pain Treatment Strategies KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The patient voices concern to the nurse regarding his patient-controlled analgesia (PCA)

pump. He states that he is afraid of getting an overdose if he pushes the button too many times. The nurse reassures the patient that (Select all that apply.) a. there is a time delay (lockout) between patient doses. b. there is a maximum dose the patient can receive. c. the patient has a right to be concerned and needs to be careful.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY d. the patient could be put on a continuous infusion instead because it is safer.

ANS: A, B

PCA prevents overdosing by interposing a preprogrammed delay time or “lockout” (usually 6–16 minutes) between patient-initiated doses. In addition, the prescriber may limit the total amount of opioid that the patient may receive in 1 to 4 hours. Use basal (continuous) infusions cautiously because studies have not shown superior analgesic benefit. Continuous infusion increases the risk for opioid overdose.

DIF: Cognitive Level: Comprehension REF: Skill 16.2 OBJ: Describe the process for delivering medication through a patient-controlled analgesia (PCA) device.TOP: Patient-Controlled Analgesia (PCA) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The patient states that the patient-controlled analgesia (PCA) is not controlling his pain. The

nurse checks the infusion setup and intravenous (IV) site and then evaluates the patient’s ability to use the system. All looks in order. The nurse should notify the physician to (Select all that apply.) a. report suspected drug-seeking behaviour. b. possibly change the medication being used. c. adjust the dosage of the medication being used. d. request placebo medication to evaluate true pain.

ANS: B, C

Instruct the patient to check with the nurse or physician with questions and concerns or if medication is not controlling the pain. The medication may have to be changed, or the dosage may need to be adjusted.

NURSINGTB.COM DIF: Cognitive Level: Application REF: Skill 16.2 OBJ: Describe the process for delivering medication through a patient-controlled analgesia (PCA) device.TOP: Patient-Controlled Analgesia (PCA) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. Medications administered in the epidural space spread by (Select all that apply.) a. diffusion through the dura mater. b. transport through blood vessels. c. absorption by fat. d. absorption through muscle.

ANS: A, B, C

A medication administered in the epidural space spreads (1) by diffusion through the dura mater into the cerebrospinal fluid (CSF), where it acts directly on receptors in the dorsal horn of the spinal cord; (2) via blood vessels in the epidural space for systemic delivery; and/or (3) by means of absorption by fat in the epidural space, creating a depot where the medication is released slowly into the systemic circulation.

DIF: Cognitive Level: Comprehension REF: Skill 16.3 OBJ: Assess a patient receiving epidural analgesia.

TOP: Epidural Space KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 6. Pain is experienced differently by different people, because pain perception is based on which

of the following? (Select all that apply.) a. Past pain experiences b. Personal values c. Cultural expectations d. Emotions ANS: A, B, C, D

Because higher centers in the brain influence perception greatly, the pain experience is a product of a person’s past pain experiences, values, cultural expectations, and emotions.

DIF: Cognitive Level: Comprehension REF: Patient-Centred Care OBJ: Understand the components of a pain assessment.

TOP: Pain Perception KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

NURSINGTB.COM

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 17: Palliative Care Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The patient has a history of terminal cancer but is being admitted for treatment of a pressure

ulcer. The patient’s wife has been caring for him at home and refuses to discuss admission to a nursing home. The wife looks extremely tired and is near the point of exhaustion. What could the nurse suggest? a. A consult for respite care b. Continuing with the plan of care as is c. That the doctor orders the patient into a nursing home d. That the wife stays away while the patient is hospitalized ANS: A

Respite is one option for family caregivers experiencing caregiver fatigue. Palliative and hospice care place a primary focus on the patient’s values, quality of life, and care preferences.

DIF: Cognitive Level: Application REF: Care in the Community (Skill 17.1) OBJ: Explain the philosophy and principles of an integrated palliative approach to care.

TOP: Respite Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. Grief that occurs before an actual loss or death and involves gradual disengagement from

what is being lost is known as which type of grief?

NURSINGTB.COM a. Anticipatory b. Complicated c. Uncomplicated d. Normal ANS: A

Grief that occurs before an actual loss or death and involved gradual disengagement from what is being lost is anticipatory grief. Normal or uncomplicated grief is evidenced by feelings, behaviours, and reactions associated with loss such as sadness, anger, crying, resentment, and loneliness. Complicated grief occurs when a person experiences distress related to the loss.

DIF: Cognitive Level: Comprehension REF: Grief OBJ: Describe the nurse’s role in assisting patients and families in grief associated with serious illness and death.

TOP: Loss KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 3. The nurse recognizes that anticipatory grieving can be most beneficial for a patient or family

because it can a. be done in a private setting. b. be discussed with other individuals. c. promote separation of the ill patient from the family. d. allow time for the process of grief.

ANS: D

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

The benefit of anticipatory grief is that it allows for a gradual disengagement from the loss.

Anticipatory grief may help people move through the stages of grief, allowing time to grieve in private, to discuss the anticipated loss with others, and then to “let go” of the loved one.

DIF: Cognitive Level: Comprehension REF: Grief OBJ: Describe the nurse’s role in assisting patients and families in grief associated with serious illness and death.

TOP: Grief KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse is preparing to assist the patient at the end stage of her life. To provide comfort for

the patient in response to anticipated symptom development, the nurse plans to a. decrease the patient’s fluid intake. b. limit the use of pain medication. c. provide larger meals with more seasoning. d. determine patient wishes and select appropriate therapies.

ANS: D

Have the patient identify what she wants to accomplish, and use strategies to conserve energy for meeting those goals. This provides the patient with a sense of well-being and purpose to meet important personal goals. Decreasing the patient’s fluid intake may make the terminally ill patient more prone to dehydration and constipation. The nurse should take measures to help maintain oral intake, such as administering antiemetics, applying topical analgesics to oral lesions, and offering ice chips. The use of analgesics should not be limited. Controlling the terminally ill patient’s level of pain is a primary concern in promoting comfort. Nausea, vomiting, and anorexia may increase the terminally ill patient’s likelihood of inadequate nutrition. The nurse should serve smaller portions and bland foods, which may be more palatable.

NURSINGTB.COM

DIF: Cognitive Level: Analysis REF: Patient-Centred Care OBJ: Describe approaches to optimizing comfort and quality of life.

TOP: Caring for the Dying Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. A nurse-initiated or independent activity for promotion of respiratory function in a terminally

ill patient is to a. limit oral fluid intake. b. position the patient in semi-Fowler’s or Fowler’s position. c. reduce narcotic analgesic use. d. administer bronchodilators.

ANS: B

Position the patient in semi-Fowler’s or Fowler’s position. This promotes maximal ventilation, lung expansion, and drainage of secretions. Limiting fluids may not promote respiratory function, and unless a patient is on a fluid-restricted diet, the nurse should not do so. Reducing narcotic analgesic use is not a nurse-initiated activity to promote respiratory function. To prevent further respiratory depression, respiratory rate should be assessed before narcotics are administered. Management of air hunger involves judicious administration of morphine and anxiolytics for relief of respiratory distress. The administration of bronchodilators would require a physician’s prescription. It is not an independent nursing activity.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY DIF: Cognitive Level: Application REF: Skill 17.1 OBJ: Describe approaches to optimizing comfort and quality of life.

TOP: Caring for the Dying Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. When caring for a patient who is an appropriate candidate for organ or tissue donation, the

nurse knows that consent for donation a. is mandated by Canadian federal law. b. can be presumed, rather than explicit. c. must be explicit; it cannot be presumed. d. can never be given by next of kin.

ANS: C

Although the Canadian federal government is responsible for ensuring the safety of donated organs, provinces and territories have specific guidelines, procedures, and laws regarding consent. Explicit, rather than presumed, consent is required in Canada and donors can give prior consent by indicating this on their health card, driver’s license, or through a registry. In the absence of prior consent, the next of kin can give consent.

DIF: Cognitive Level: Application REF: Skill 17.2 OBJ: Discuss the nurse’s role in facilitating autopsy and organ and tissue donation requests.

TOP: Organ Donation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. The patient is on a ventilator and has a heartbeat but has been declared “brain dead.” The

family has agreed to organ donation. The nurse realizes that which of the following organ donations would require that the patient be left on life support? a. Eyes NURSINGTB.COM b. Bone c. Kidney d. Skin ANS: C

In the case of vital organ donation (e.g., heart, lungs, liver, pancreas, and kidneys), the patient must remain on life support until the organs are removed surgically. Tissues such as eyes, bone, and skin are commonly retrieved from deceased patients who are not on life support.

DIF: Cognitive Level: Application REF: Skill 17.2 OBJ: Discuss the nurse’s role in facilitating autopsy and organ and tissue donation requests.

TOP: Organ Donation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. An appropriate technique for the nurse to implement when caring for a patient’s body after

death is to a. remove the patient’s identification band and put a new gown on the patient. b. cover the patient with a sheet and transfer him or her to the morgue. c. inquire about particular cultural or spiritual practices. d. remove tubes and lines if the patient is to be autopsied.

ANS: C

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Respect the individuality of the patient and family and support their right to have cultural or religious values and beliefs upheld. Identify and tag the body, leaving identification on the body as directed by employer policy to ensure proper identification of the body for delivery to the morgue or mortuary. After viewing, remove linens and gown, per employer policy. Place the body in a shroud provided by the agency. The shroud protects from injury to the skin, avoids exposure of the body, and provides a barrier against potentially contaminated body fluids. Removal of tubes and lines is contraindicated if an autopsy is planned.

DIF: Cognitive Level: Application REF: Skill 17.2 OBJ: Describe the process of postmortem care.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Postmortem Care

9. After the death of a patient and before other nursing interventions are implemented, the nurse

should a. place the patient in a supine position and straighten the limbs. b. wait an hour to prepare the patient for viewing. c. place the patient in a side-lying position to allow drainage. d. exclude the family while the body is being prepared.

ANS: A

Immediately after death and before other activities are begun, place the body in supine position and elevate the head of the bed 30 degrees to decrease rigor mortis. Ask family members if they have requests for preparation or viewing of the body (such as position of the body, special clothing, and shaving). Determine whether they wish to be present or assist with care of the body. This provides closure for those who wish to assist with body preparation.

DIF: Cognitive Level: ApplicatiN onURSINRGETFB : .SC kiO llM 17.2 OBJ: Describe the process of postmortem care.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Postmortem Care

10. Before allowing the family of a deceased patient to view the body, the nurse should a. insert the patient’s dentures. b. lower the head of the bed. c. fold the arms and hands over the chest. d. leave all of the old dressings and tape in place.

ANS: A

If the person wore dentures, reinsert them. If the mouth fails to close, and if it is culturally appropriate to close the mouth, place a rolled-up towel under the chin. Dentures maintain the patient’s natural facial expression. Place a small pillow or a folded towel under the head. This prevents pooling of blood in the face and subsequent discolouration. Avoid placing one hand on top of the other. Placing one hand on top of the other can lead to discolouration of the skin.

Remove soiled dressings and replace with clean gauze dressings. Use paper tape. Paper tape minimizes skin trauma. Changing dressings helps control odours caused by microorganisms and creates a more acceptable appearance.

DIF: Cognitive Level: Application REF: Skill 17.2 OBJ: Describe the process of postmortem care.

KEY: Nursing Process Step: Implementation

TOP: Postmortem Care

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY MSC: NCLEX: Physiological Integrity 11. A new staff member is working with a patient who is dying. A nurse evaluates that this new

employee requires additional teaching when he or she is observed a. limiting the family’s visiting hours. b. staying with the patient and family as much as possible. c. finding a quiet place for family members to gather. d. asking the family if they would like to help with preparing the body.

ANS: A

Some cultures require silence at the time of death; others express grief with loud wailing, “falling out,” or hysteria. Do not rush any grieving process. Give family members and friends a private place to gather. Allow them time to ask questions. This creates a safe environment for the grieving family. Questions provide information about how they are coping with loss and their needs. Ask family members if they have requests for preparation or viewing of the body (such as position of the body, special clothing, or shaving). Determine whether they wish to be present or assist with care of the body. This may provide closure for those who wish to assist with body preparation.

DIF: Cognitive Level: Application REF: Skill 17.2 OBJ: Describe the process of postmortem care.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Postmortem Care

12. The patient was a practicing Hindu when he died. Knowing this, the nurse realizes that a. the body should be covered with a cotton sheet. b. anointing of the sick is performed even after death.

SaIshNG c. family members often prefeNrU toRw thT eB bo.dCyOaM fter death. d. the body should be buried within 24 hours.

ANS: C

With Hinduism, family members prefer to wash the body after death and are present to chant, pray, and use incense. In Buddhism, when the person has died, the body should be covered with a cotton sheet. Others should not touch the body, and the mouth and eyes of the deceased are left open. Christians in the Roman Catholic tradition often request sacraments of penance and anointing of the sick and Holy Communion at the end of life. In Orthodox Judaism, a family member remains with the body until burial, which takes place within 24 hours, although not on the Sabbath.

DIF: Cognitive Level: Application REF: Box 17.2: Select Religious and Cultural Practices Near and at the time of Death OBJ: Describe the process of postmortem care.

TOP: Postmortem Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. For a patient in the final stages of dying, a nurse expects to a. keep the patient’s room cool. b. avoid catheterizing the patient. c. elevate the head of the bed as tolerated. d. encourage the patient to eat and drink more.

ANS: C

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Poor circulation of body fluids, immobilization, and inability to expectorate secretions cause rattles and bubbling. Elevate the head with a pillow or raise the head of the bed; gently turn the head to the side to drain secretions. Coolness, colour, and temperature change in the hands, arms, legs, and feet. Place socks on the feet. Cover with a light cotton blanket. Keep warm blankets on the patient. Decreased muscle tone and consciousness may lead to incontinence of urine or bowel. Change bedding as appropriate. Use an indwelling catheter for patient comfort. Do not force the patient to eat or drink; give ice chips, soft drinks, or juice, as possible. Provide mouth care.

DIF: Cognitive Level: Application REF: Skill 17.2 OBJ: Explain physiological changes typical of impending death.

TOP: Physical Signs and Symptoms in the Final Stages of Dying KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. Nurses provide

, which is defined as care of the body after death in a manner consistent with the patient’s religious and cultural beliefs. a. premortem care b. postmortem care c. palliative care d. hospice care ANS: B

Nurses provide postmortem care, which is defined as care of the body after death in a manner consistent with the patient’s religious and cultural beliefs.

DIF: Cognitive Level: Comprehension REF: Skill 17.2 UR TOP: Postmortem Care OBJ: Describe the process of poN stm orS teI mNcaGreT. B.COM KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 15.

grief (symptoms lasting longer than 6 months) occurs when a person experiences significant distress related to the loss. a. Anticipatory b. Complicated c. Uncomplicated d. Normal ANS: B

Criteria for a person experiencing complicated grief may include inability to accept the death of a loved one, anger, depression, or inability to maintain social relationships and intense longing for the deceased. Complicated grief occurs when a person experiences distress related to the loss. Grief that occurs before an actual loss or death and involves gradual disengagement from what is being lost is anticipatory grief. Normal or uncomplicated grief is evidenced by feelings, behaviours, and reactions associated with loss such as sadness, anger, crying, resentment, and loneliness.

DIF: Cognitive Level: Comprehension REF: Grief OBJ: Describe the nurse’s role in assisting patients and families in grief associated with serious illness and death.

TOP: Loss KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY MULTIPLE RESPONSE 1. The World Health Organization’s (2018) definition of palliative care includes which of the

following? (Select all that apply.) a. An approach that improves the quality of life of individuals and their families facing life-threatening illness b. The prevention and relief of suffering c. Early identification and impeccable assessment and treatment d. End-of-life care only ANS: A, B, C

The World Health Organization defines palliative care as an approach that “improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual” (WHO, 2018, paragraph 1).

DIF: Cognitive Level: Understanding REF: Palliative Care in Canada OBJ: Explain the philosophy and principles of an integrated palliative approach to care.

TOP: Palliative Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. Which of the following statements is true about advance care plans (ACPs)? (Select all that

apply.) a. A substitute decision maker (SDM) should be appointed in advance. b. The original version of the ACP should be placed in the patient chart. c. ACPs often include decisions about whether or not to initiate cardiopulmonary NURSINGTB.COM resuscitation (CPR). d. ACPs only take place in the context of illness.

ANS: A, C

Goals of care conversations (not ACPs) take place in the context of illness. Advance care plans (ACPs) often include decisions about whether to initiate CPR. ACPs involve conversations with significant others about values and health care preferences and the appointment of a substitute decision maker in advance of events that might result in people being unable to make decisions for themselves. A copy of the ACP should be placed on the medical record (see employer policy), and the person should be encouraged to provide a copy to the primary care provider and family.

DIF: Cognitive Level: Comprehension REF: Communication and Collaborative Care Planning OBJ: Discuss approaches to goals of care conversations.

TOP: Advance Directives KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 18: Personal Hygiene and Bed Making Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The nurse is aware that normal flora that does not cause disease but does prevent

disease-causing microorganisms from reproducing is known as a. sebum. b. the epidermis. c. resident bacteria. d. the dermis.

ANS: C

Bacteria reside on the skin’s outer surface. Resident bacteria constitute normal flora that does not cause disease but does prevent disease-causing microorganisms from reproducing. Sebum, secreted from hair follicles from sebaceous glands, provides an acidic coating. This acid coating protects the epidermis against penetration from chemicals and microorganisms. It also minimizes loss of water and plasma proteins. It is not alive, however, and is not considered flora. The epidermis, or outer skin layer, is the first line of defense from external injury and infection. It contains several thin layers of cells undergoing different stages of maturation.

Resident bacteria live on its surface and protect it. Three primary layers make up the skin: the epidermis, the dermis, and subcutaneous tissue. The dermis lies underneath the epidermis and is not considered flora.

DIF: Cognitive Level: Comprehension REF: The Skin OBJ: Discuss clinical guidelines to use for providing personal hygiene to patients.

NURSINGTB.COM TOP: Resident Bacteria KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. In relation to hygiene and the acute care setting, the nurse knows that which of the following

statements is true? a. The disposable bath is a less desirable form of bathing than the traditional basin bath. b. The disposable bath is a more desirable form of bathing than the traditional basin bath. c. The disposable bath is more desirable for patients who can bathe independently. d. The disposable bath is not an acceptable form of bathing in the acute care setting.

ANS: B

Prepackaged disposable bath products have been shown to decrease the spread of infection.

The disposable bath is a desirable form of bathing for patients who are unable to bathe themselves in critical care and long-term care settings; it is even preferable to the traditional basin bath.

DIF: Cognitive Level: Analysis REF: Procedural Guideline 18.2 OBJ: Discuss clinical guidelines to use for providing personal hygiene to patients.

TOP: The Disposable Bath KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 3. The nurse is caring for a ventilated patient in the critical care unit (CCU) who has just

undergone coronary artery bypass. The nurse is concerned that the patient may be at risk for ventilator-acquired pneumonia (VAP). What step will he or she take to minimize this risk? a. Be careful not to provide oral hygiene because this may cause bacterial contamination of the airway. b. Be careful not to use chlorhexidine in oral care because it provides a medium for bacterial growth. c. Be careful not to use chlorhexidine in oral care because it enhances the rate at which VAP develops. d. Include the use of a chlorhexidine rinse as part of oral hygiene to delay the development of VAP. ANS: D

Guidelines for oral care in ventilator patients and those who need assistance with oral hygiene often include the use of a chlorhexidine rinse as a part of oral hygiene. Chlorhexidine early in the postintubation period may help delay the onset or development of VAP. Presently, chlorhexidine is recommended during the postoperative period for patients undergoing cardiac surgery. Ventilator-associated pneumonia results from the colonization of bacteria in the oral pharynx. These microorganisms then migrate from the mouth into the lungs. Dental plaque is also a reservoir for microorganisms causing VAP. Because of this evidence, guidelines for oral care in ventilator patients and those who need assistance with oral hygiene often include the use of a chlorhexidine rinse as a part of oral hygiene.

DIF: Cognitive Level: Application REF: Skill 18.3 OBJ: Discuss clinical guidelines to use for providing personal hygiene to patients.

TOP: Chlorhexidine KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

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4. The nurse plans to give the patient a therapeutic bath. Which of the following is considered

therapeutic? a. Bed bath b. Sponge bath at the sink c. Sitz bath d. Bag bath ANS: C

The sitz bath cleanses and reduces pain and inflammation in perineal and anal areas. It is used for a patient who has undergone rectal or perineal surgery or childbirth or has local irritation from hemorrhoids or fissures. There are two categories of baths: cleansing and therapeutic.

Cleansing baths include the bed bath, tub bath, sponge bath at the sink, shower, and bag bath.

DIF: Cognitive Level: Analysis REF: Box 18.1: Types of Baths OBJ: Discuss clinical guidelines to use for providing personal hygiene to patients.

TOP: Therapeutic Baths KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. What should the nurse do before starting a patient’s bed bath? a. Lower the bed. b. Offer the bedpan or urinal. c. Partially undress the patient. d. Place the head of the bed in high-Fowler’s position.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

ANS: B

The patient will feel more comfortable after voiding, and this will prevent interruption of the bath. The bed should be raised to a comfortable working height to aid the nurse’s access to the patient and to minimize strain on the nurse’s back muscles. The patient’s gown or pyjamas are removed and the bath blanket is used to cover the patient. This provides full exposure of body parts during bathing. The head of the bed is raised 30 to 45 degrees if the patient’s condition allows.

DIF: Cognitive Level: Application REF: Skill 18.1 OBJ: Administer a complete bed bath.

TOP: Providing Comfort During the Bed Bath KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. The nurse is preparing to provide a complete bed bath to a patient who has a running

intravenous (IV) line. He or she places a bath blanket over the patient and a. removes the gown from the arm with the IV first. b. removes the gown from the arm without the IV first. c. removes the gown after the bath to keep the patient warm. d. readjusts the IV rate before removing the gown.

ANS: B

If the patient has an IV line, remove the gown from the arm without the IV first. Then remove the gown from the arm with the IV. Remove the IV from the pole, and slide the IV container and tubing through the arm of the patient’s gown. Rehang the IV container; check the flow rate and regulate if necessary. Removing the patient’s gown or pyjamas before the bath provides full exposure of body parts during bathing. Rehang the IV container after changing the gown. Check the flow rate.NItUmRaSyIhN avGeTcB ha.nC geOdMwith all the manipulation of the gown change. Regulate if necessary.

DIF: Cognitive Level: Application REF: Skill 18.1 OBJ: Administer a complete bed bath.

TOP: Changing the Hospital Gown KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. While washing the patient’s face, the nurse should a. wash the eyes using soap and warm water. b. wash the eyes from outer canthus to inner canthus. c. wash the eyes with plain warm water. d. use the same portion of the washcloth.

ANS: C

Wash the patient’s eyes with plain warm water, using a clean area of cloth for each eye, bathing from inner to outer canthus. Soap irritates eyes. Use of separate sections of the mitt reduces infection transmission. Bathing the eye gently from inner to outer canthus prevents secretions from entering the nasolacrimal duct.

DIF: Cognitive Level: Application REF: Skill 18.1 OBJ: Administer a complete bed bath.

TOP: Washing the Eyes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 8. When bathing a patient, which sequence is the correct approach to use? a. Wash the feet after the legs. b. Wash the eyes after the face. c. Wash the legs before the abdomen. d. Wash the back area before the extremities.

ANS: A

When washing the patient, the nurse will try to work from the most soiled area to the least soiled area. Therefore the legs are washed before the feet, the eyes are washed before the face, the abdomen is washed before the legs, and the back is washed after the extremities.

DIF: Cognitive Level: Application REF: Skill 18.1 OBJ: Administer a complete bed bath.

TOP: Sequence of the Bed Bath KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. What should hygienic care of the patient with dry skin include? a. Use of moisturizers b. Use of ultraviolet light c. Application of antiseptic lotion d. Lowering of bathwater temperature ANS: A

Apply body lotion to the skin as needed and topical moisturizing agents to dry, flaky, reddened, or scaling areas. Dry skin results in reduced pliability and cracking. Moisturizers help prevent skin breakdown. Ultraviolet light and antiseptic lotion are not used to treat dry skin. Decreased bath water temperature causes chilling.

NURSINGTB.COM DIF: Cognitive Level: Application REF: Skill 18.1 OBJ: Administer a complete bed bath.

TOP: Dry Skin KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. While giving the patient a bed bath, the nurse notices a reddened area on the patient’s coccyx.

The nurse should a. decrease the temperature of the bath water. b. massage the reddened area to decrease the redness. c. apply topical moisturizing agents to the area. d. ignore the redness because it will return to normal soon.

ANS: C

Apply body lotion to the skin as needed and topical moisturizing agents to dry, flaky, reddened, or scaling areas. Decreased bath water temperature causes chilling. Do not massage any reddened area on the patient’s skin. Reddened areas, especially over bony prominences, indicate localized injury to the skin and/or underlying tissue and cannot be ignored.

DIF: Cognitive Level: Application REF: Skill 18.1 OBJ: Administer a complete bed bath.

TOP: Reddened Areas KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. The optimal position for a female patient for the provision of perineal care is

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. b. c. d.

prone. side-lying. high-Fowler’s. dorsal recumbent.

ANS: D

The dorsal recumbent position provides full exposure of the female genitalia. Side-lying, prone, and high-Fowler’s positions do not allow adequate exposure of the female genitalia.

DIF: Cognitive Level: Comprehension REF: Procedural Guideline 18.1 OBJ: Administer a complete bed bath.

TOP: Perineal Care for the Female KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. While evaluating the hygienic care practices of a female patient, the nurse recognizes that

additional instruction is necessary if the patient a. washes the perineal area from back to front. b. washes the labia majora before the labia minora. c. avoids tension on the indwelling catheter. d. uses separate sections of the washcloth for each cleansing stroke.

ANS: A

The patient should wash downward from the pubic area toward the rectum in one smooth stroke. She should use a separate section of the cloth for each stroke.

DIF: Cognitive Level: Application REF: Procedural Guideline 18.1 OBJ: Identify principles of aseptic technique applied while administering a bed bath.

TOP: Perineal Care for the Female KEY: Nursing Process Step: Implementation NURSINGTB.COM MSC: NCLEX: Physiological Integrity 13. In providing perineal care for a male patient, the nurse realizes that the patient has not been

circumcised. The nurse should a. retract the foreskin after care has been completed. b. place the patient in prone position. c. replace the foreskin to its natural position after care has been provided. d. have the patient adduct his legs.

ANS: C

After administering perineal care for uncircumcised male patients, make sure that the foreskin is in its natural position. This is extremely important for those patients with decreased sensation in the lower extremities. Tightening of the foreskin around the shaft of the penis causes local edema, discomfort, and, if not corrected, permanent urethral damage. Assist the patient to a supine position and have him abduct his legs.

DIF: Cognitive Level: Application REF: Procedural Guideline 18.1 OBJ: Administer a complete bed bath.

TOP: Perineal Care for the Male Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. The home care nurse is getting ready to help the patient prepare a tub bath. What should the

nurse be sure to do? a. Instruct the patient to use safety bars.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY b. Use the patient’s favourite bath oil for aroma therapy. c. Instruct the patient to stay in the tub no longer than 30 minutes. d. Check on the patient every 20 minutes.

ANS: A

Instruct the patient to use safety bars when getting into and out of the tub or shower. Caution the patient against the use of bath oil in tub water. This could lead to falls. Instruct the patient not to remain in the tub longer than 20 minutes. Check on the patient every 5 minutes.

DIF: Cognitive Level: Application REF: Procedural Guideline 18.2 OBJ: Explain precautions to take when assisting patients with a tub bath or shower.

TOP: Preparing for a Tub Bath KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. When teaching parents how to provide oral care to their child, the nurse instructs them to a. give bottles with juice at bedtime. b. begin dental visits after the child is 8 years old. c. allow the preschool child to floss his teeth without parental supervision. d. limit snacks to three or four per day.

ANS: D

Limit snacks to three or four per day. Avoid sugary snacks and drinks and sticky candy. Teach parents that the infant should not be put to bed with a bottle; this causes tooth decay and ear infection. Children should have their first dental examination at 1 year or sooner if needed.

Then children need to have a dental examination every 6 months. Young children will need parenteral assistance and supervision to learn to floss correctly.

DIF: Cognitive Level: ApplicatiN onURSINRGETFB : .SC kiO llM 18.2 OBJ: Identify clinical guidelines to follow when administering oral hygiene.

TOP: Pediatric Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. The nurse is about to provide oral hygiene to an unconscious patient. To do so, he or she

places the patient in which position? a. Fowler’s b. Semi-Fowler’s c. Sims’ d. Supine ANS: C

Unless contraindicated (e.g., head injury and neck trauma), lower the side rail and position the patient on the side (Sims’ position) with the head turned well toward the dependent side and the head of the bed lowered. Raise the side rail. This allows secretions to drain from the mouth instead of collecting in the back of the pharynx and prevents aspiration. This position allows secretions to drain toward the lungs as a result of gravity.

DIF: Cognitive Level: Application REF: Skill 18.2 OBJ: Explain differences in providing oral hygiene to dependent versus unconscious patients.

TOP: Oral Hygiene for an Unconscious Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 17. A nurse recognizes that a shampoo may be contraindicated for a bed-bound patient with a. heart disease. b. diabetes mellitus. c. a neck injury. d. a bleeding disorder.

ANS: C

Caution is needed with patients who have suffered neck injuries because flexion and hyperextension of the neck could cause further injury. Heart disease does not mean that a shampoo is contraindicated. A shampoo is not contraindicated for patients with diabetes mellitus or a bleeding disorder.

DIF: Cognitive Level: Comprehension REF: Procedural Guideline 18.5 OBJ: Identify clinical guidelines for administering hair, nail, and foot care.

TOP: Washing the Hair of Patients with Neck Injuries KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 18. Shaving with a disposable razor is contraindicated for a patient with a. heart disease. b. diabetes mellitus. c. a head injury. d. a bleeding disorder.

ANS: D

Before shaving, assess whether the patient has a bleeding tendency. Review medical history or laboratory values (e.g., platelet counts and prothrombin time). Determine the need to use an electric razor for the patient’s safety because of the potential for bleeding. Shaving with a disposable razor is not contrainN diUcR atS edIfN orGpTaB tie.nC tsOwMith heart disease, diabetes mellitus, or a head injury.

DIF: Cognitive Level: Analysis OBJ: Shave a patient safely.

KEY: Nursing Process Step: Assessment

REF: Procedural Guideline 18.4 TOP: Shaving a Male Patient MSC: NCLEX: Physiological Integrity

19. When evaluating the shaving of a patient done by a family member, the nurse determines that

the technique is done appropriately when a. long strokes are used. b. the razor is held at a 45-degree angle to the skin. c. shaving is done against the direction of hair growth. d. a cool cloth is used on the skin before the shave.

ANS: B

The razor should be held in the dominant hand at a 45-degree angle to the patient’s skin.

Begin by shaving across one side of the patient’s face using short, firm strokes in the direction the hair grows. Use the nondominant hand to gently pull the skin taut while shaving. Check with the patient, and ask whether he feels comfortable. Use a warm cloth. A warm cloth helps soften the skin and beard, and the sensation of warmth can be relaxing.

DIF: Cognitive Level: Application REF: Procedural Guideline 18.4 OBJ: Shave a patient safely.

TOP: Shaving a Male Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

20. The nurse is providing nail care for the patient who wants his fingernails “done.” The nurse

should a. clip the fingernails gently to prevent injury. b. clean under the nails using an orange stick. c. soak the fingernails no longer than 10 minutes. d. clean under the nails using the end of a cotton swab.

ANS: C

Unless the patient has diabetes, allow the patient’s feet and fingernails to soak no longer than 10 minutes. The goal is to soften the skin and debris beneath the nails, without causing excessive dryness. Obtain a physician’s prescription for cutting the nails (required by most agencies). The patient’s skin may be cut accidentally. Certain patients are more at risk for infection, depending on their medical condition. Check employer policy for appropriate process for cleaning beneath the nails. Do not use an orange stick or the end of a cotton swab; both of these splinter and can cause injury.

DIF: Cognitive Level: Application REF: Skill 18.4 OBJ: Safely administer nail care.

TOP: Nail Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. The nurse assesses the patient’s skin and notices an abrasion. Which of the following best

describes this type of skin abnormality? a. A papulopustular skin eruption b. Rough texture on the skin surface c. Erythema and scaly, oozing areas d. A scraping away of the epidermis

NURSINGTB.COM

ANS: D

An abrasion is a scraping or rubbing away of the epidermis; it may result in localized bleeding and later weeping of serous fluid. Acne is defined as a papulopustular skin eruption. Rough texture may indicate dry skin, not an abrasion. Scaly, oozing erythematous areas may indicate contact dermatitis.

DIF: Cognitive Level: Comprehension REF: Table 18.1: Common Skin Problems OBJ: Discuss clinical guidelines to use for providing personal hygiene to patients.

TOP: Skin Problems KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 22. The nurse is caring for a male patient who has dry skin. When the following interventions are

compared, which would be most appropriate for this patient? a. Limiting the frequency of bathing b. Using a fat-free soap for washing c. Using warm water and moisturizers d. Bathing with hot water to increase blood flow ANS: C

Effective treatment for dry skin does not include limiting the frequency of bathing but lies in bathing with warm, not hot, water and using moisturizers. Super-fatted soap (e.g., Dove) should be used for cleansing. The body should be rinsed well of all soap, because residue left can cause irritation and breakdown. Moisture should be added to the air through the use of a humidifier. Fluid intake should be increased when the skin is dry.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

DIF: Cognitive Level: Application REF: Skill 18.1 OBJ: Discuss clinical guidelines to use for providing personal hygiene to patients.

TOP: Treatment for Dry Skin KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. The patient confides in the nurse that she is bothered by the fact that she has alopecia. How

should the nurse respond to this information? a. Shave hair off of the affected area. b. Use permethrin. c. Offer the patient access to scarves or wigs. d. Place a drop of oil on the area.

ANS: C

Alopecia is balding patches in the periphery of the hairline. Offer patients access to scarves, hairpieces, or wigs. Stop hair-care practices that damage hair. Shaving hair off of the affected area is the treatment for pediculosis pubis (crab lice). Permethrin is the treatment for pediculosis capitis (head lice). Ticks are removed by placing a drop of oil or ether on the tick, causing it to suffocate.

DIF: Cognitive Level: Application REF: Table 18.2: Hair and Scalp Problems OBJ: Identify clinical guidelines for administering hair, nail, and foot care.

TOP: Alopecia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. The patient requires postural drainage three times a day. Which of the following bed positions

would be most appropriate for this task? a. Fowler’s position NURSINGTB.COM b. Trendelenburg’s position c. Reverse Trendelenburg’s position d. Semi-Fowler’s position ANS: B

With Trendelenburg’s position, the entire bed frame is tilted, with the head of the bed down.

This position facilitates postural drainage and venous return in patients with poor peripheral perfusion. In Fowler’s position, the head of the bed is raised to an angle of 45 to 90 degrees or more. This position is preferred while the patient eats, is used during nasogastric tube insertion and nasotracheal suction, and promotes lung expansion. In reverse Trendelenburg’s position, the entire bed frame is tilted, with the foot of the bed down. It is used infrequently, promotes gastric emptying, and prevents esophageal reflux. In semi-Fowler’s position, the head of the bed is raised approximately 30 to 45 degrees. This promotes lung expansion and relieves strain on abdominal muscles.

DIF: Cognitive Level: Application REF: Table 18.4: Common Bed Positions OBJ: Identify clinical guidelines for administering hair, nail, and foot care.

TOP: Bed Positions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. The a. liver b. brain c. heart

is the largest human organ.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY d. skin ANS: D

Skin, the largest human body organ, protects us from heat, light, injury, and infection, and serves to (1) help regulate body temperature; (2) store water, vitamin D, and fat; (3) help sense pain and other stimuli; and (4) prevent the entry of bacteria.

DIF: Cognitive Level: Understanding REF: The Skin OBJ: Discuss clinical guidelines to use for providing personal hygiene to patients.

TOP: Skin KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 26. The first line of defense against external injury and infection contains several thin layers of

cells undergoing different stages of maturation. This first line of defense is known as the . a. sebum b. epidermis c. resident bacteria d. dermis ANS: B

The epidermis, or outer skin layer, is the first line of defense against external injury and infection. It contains several thin layers of cells undergoing different stages of maturation.

DIF: Cognitive Level: Comprehension REF: The Skin OBJ: Discuss clinical guidelines to use for providing personal hygiene to patients.

TOP: The Epidermis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological IntN egUriR tySINGTB.COM 27.

provides an acidic coating to protect the skin against penetration from chemicals and microorganisms; it also minimizes loss of water and plasma proteins. a. Sebum b. The epidermis c. Resident bacteria d. The dermis ANS: A

Sebum, secreted from hair follicles from sebaceous glands, provides an acidic coating. This acidic coating protects the epidermis against penetration from chemicals and microorganisms.

It also minimizes loss of water and plasma proteins.

DIF: Cognitive Level: Comprehension REF: The Skin OBJ: Discuss clinical guidelines to use for providing personal hygiene to patients.

TOP: Sebum KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

is defined as excessive growth of body and facial hair.

28. a. b. c. d.

Petechiae Epidermis Hirsutism Alopecia

ANS: C

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Hirsutism is defined as excessive growth of body and facial hair, especially in women.

DIF: Cognitive Level: Understanding REF: Table 18.2: Hair and Scalp Problems OBJ: Discuss clinical guidelines to use for providing personal hygiene to patients.

TOP: Hirsutism KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

is balding patches in the periphery of the hairline.

29. a. b. c. d.

Petechiae Epidermis Hirsutism Alopecia

ANS: D

Alopecia is balding patches in the periphery of the hairline. Hair becomes brittle and broken.

Alopecia can be caused by diseases, as a medication side effect, or after improper use of hair-care products and hair-styling devices.

DIF: Cognitive Level: Understanding REF: Table 18.2: Hair and Scalp Problems OBJ: Discuss clinical guidelines to use for providing personal hygiene to patients.

TOP: Alopecia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The skin, the largest human body organ, protects us from heat, light, injury, and infection and

does which of the following? (Select all that apply.) a. Helps regulate body temperNaU tuR reSINGTB.COM b. Stores water, vitamin D, and fat c. Helps sense pain d. Prevents the entry of bacteria ANS: A, B, C, D

Skin, the largest human body organ, protects us from heat, light, injury, and infection and serves to (1) help regulate body temperature; (2) store water, vitamin D, and fat; (3) help sense pain and other stimuli; and (4) prevent the entry of bacteria.

DIF: Cognitive Level: Comprehension REF: The Skin OBJ: Discuss clinical guidelines to use for providing personal hygiene to patients.

TOP: Skin KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. Critically ill patients on a ventilator are at risk for ventilator-associated pneumonia (VAP).

Sources of VAP include (Select all that apply.) a. bacteria in the oral pharynx. b. dental plaque. c. chlorhexidine rinses. d. frequent oral hygiene.

ANS: A, B

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

VAP results from the colonization of bacteria in the oral pharynx. These microorganisms then translocate from the mouth into the lungs. Dental plaque is also a reservoir for microorganisms causing VAP. Because of this, guidelines for oral care in ventilator patients and in those who need assistance with oral hygiene often include the use of a chlorhexidine rinse as part of oral hygiene. Chlorhexidine early in the postintubation period may help delay the onset or development of VAP. DIF: Cognitive Level: Comprehension REF: Skill 18.2 OBJ: Discuss clinical guidelines to use for providing personal hygiene to patients.

TOP: Oral Hygiene KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. When taking a shower in the home setting, the patient at risk for falls may benefit from (Select

all that apply.) a. installation of grab bars. b. adhesive strips applied to the tub floor. c. addition of a shower chair or stool. d. a hydraulic lift.

ANS: A, B, C

Patients at risk for falls may benefit from the installation of grab bars in the shower, the application of adhesive strips to the shower or tub floor, and the addition of a shower chair or placement of a chair or stool. Hydraulic lifts are useful in bathtubs.

DIF: Cognitive Level: Application REF: Care in the Community (Skill 18.1) OBJ: Explain precautions to take when assisting patients with a tub bath or shower.

TOP: Preparing for a Shower KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological IntN egUriR tySINGTB.COM 4. Patients at greatest risk for developing serious foot problems include those with (Select all

that apply.) a. peripheral neuropathy. b. peripheral vascular disease. c. pancreatitis. d. diabetes.

ANS: A, B, D

Patients at greatest risk for developing serious foot problems are those with peripheral neuropathy and peripheral vascular disease. These two disorders, commonly found in patients with diabetes, cause reduction in blood flow to the extremities and loss of sensory, motor, and autonomic nerve function. As a result, the patient is unable to feel heat and cold, pain, pressure, and the position of the foot. This reduction in blood flow impairs healing and promotes risk for infection.

DIF: Cognitive Level: Analysis REF: Skill 18.4 OBJ: Identify risk factors for foot and nail problems.

TOP: Foot Problems KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. The development of diabetic foot ulcers is dependent on which of the following? (Select all

that apply.) a. Peripheral neuropathy

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY b. Tissue ischemia c. Trauma to the foot d. Pain in the affected extremity ANS: A, B, C

The development of diabetic foot ulcers is multifactorial; three contributing factors are (1) peripheral neuropathy (changes in the function and efficiency of the nerves), (2) ischemia (decrease in blood flow related to plaque formation in the arteries), and (3) a pivotal event (e.g., trauma caused by banging the toe or stepping on a foreign object).

DIF: Cognitive Level: Comprehension REF: Skill 18.4 OBJ: Identify risk factors for foot and nail problems.

TOP: Diabetic Foot Ulcers KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. A patient is admitted with the diagnosis of pediculosis capitis (head lice). Proper treatment for

this condition would include which of the following? (Select all that apply.) a. Use of medicated shampoo or permethrin b. Use of products containing lindane c. Combing the hair with a nit comb for 2 to 3 days after treatment d. Washing linens in cold water for 30 minutes ANS: A, C

Use medicated shampoo available as a cream rinse for eliminating lice, or permethrin. Caution against the use of products containing lindane, because this ingredient is toxic and is known to cause adverse reactions. Remove the patient’s clothing before treatment, and apply new clothing after treatment. Repeat treatment according to product directions. Check the hair for nits, and comb with a nit comb for 2 to 3 days until you are sure all lice and nits have been Mhen treatment has failed. Vacuum removed. Manual removal of liN ceUiR sS thIe N bG esT t oBp.tiC onOw infested areas of the home. Wash linens in hot water, and dry for at least 30 minutes.

DIF: Cognitive Level: Analysis REF: Skill 18.2 OBJ: Identify clinical guidelines for administering hair, nail, and foot care.

TOP: Lice KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 19: Care of the Eye and Ear Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The nurse decides that unregulated care providers can provide care to a patient with contact

lenses when the unregulated care provider states: a. “If I am in a hurry, I will use tap water for rinsing the lenses.” b. “Gloves aren’t necessary; the eye is a clean organ.” c. “I will check with the patient to see if the lenses are disposable.” d. “It is normal for contact lens wearers to have red, teary eyes.”

ANS: C

Let the patient be a resource in the care of each device. Although it is the nurse’s responsibility to ensure that patients do not damage their devices or injure themselves, patients familiar with their devices are likely to have an established routine and helpful tips.

The replacement schedule is determined by the type of lenses the patient wears; the patient can provide that information. Tap water can contain microorganisms and may be absorbed into the lens, making it uncomfortable to wear. Clean, powder-free gloves are used to prevent the spread of microorganisms during care of contact lenses. Pain, tearing, discomfort, and redness can indicate conjunctivitis and should be referred to the patient’s provider if symptoms persist.

DIF: Cognitive Level: Comprehension REF: Procedural Guideline 19.2 OBJ: Identify person-centred guidelines used in caring for eye and ear prostheses.

TOP: Contact Lenses rsM ing Process Step: Assessment NURSINKGETYB: .NCuO MSC: NCLEX: Physiological Integrity 2. When providing eye care for the unconscious patient, the nurse should a. place the patient in a prone position for easier access. b. use a different corner of the washcloth for each eye. c. wipe each eye from outer to inner canthus. d. use a sterile medicine cup to instill lubricant.

ANS: B

Use a separate, clean cotton ball or corner of the washcloth for each eye. Place the patient in supine position. Gently wipe each eye from inner to outer canthus. Use an eyedropper to instill the prescribed lubricant (e.g., saline, methylcellulose, and liquid tears) as prescribed.

DIF: Cognitive Level: Application REF: Procedural Guideline 19.1 OBJ: Identify person-centred guidelines used in caring for eye and ear prostheses.

TOP: Eye Care for a Comatose Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. In caring for a patient with contact lenses, the nurse should be aware that a. rigid gas-permeable (RGP) lenses are no longer used. b. soft contact lenses are smaller than the cornea. c. all lenses must be removed periodically. d. extended wear lenses can be used for only 6 nights.

ANS: C

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

It is important to remember that all lenses must be removed periodically to prevent infection and corneal damage, and that proper cleaning is necessary before a lens is reinserted. Two basic types of contact lenses are used today: RGP and soft. Rigid contact lenses are made of firm, durable plastic and are smaller than the cornea. Soft contact lenses are made of a flexible hydrogel plastic and cover the entire cornea and a small rim of the sclera. Although the limit for extended wear lenses is usually 6 nights, certain soft lenses have been approved for continuous wear up to 30 nights.

DIF: Cognitive Level: Application REF: Procedural Guideline 19.2 OBJ: Identify person-centred guidelines used in caring for eye and ear prostheses.

TOP: Contact Lenses KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. Which of the following nursing interventions would the nurse perform first after a patient

sustained a chemical splash injury to the eye? a. Assess visual acuity. b. Flush the eye with large amounts of irrigation fluid. c. Assess level of pain. d. Determine whether the pupils are equal, round, and reactive to light and accommodation (PERRLA).

ANS: B

The first thing the nurse should do when caring for a patient who has sustained a chemical injury to the eye is flush the eye with large amounts of irrigation fluid. Assessment of visual acuity, pain, and PERRLA will be performed after the eye has been irrigated appropriately.

DIF: Cognitive Level: Application REF: Skill 19.1 OBJ: Correctly perform eye andNeaUrR irS rigIaN tioGnT s.B.COM KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Splash to Eye

5. The nurse caring for an unconscious patient determines that he is wearing contact lenses.

Which of the following nursing interventions will the nurse use when removing the contact lenses? a. Put on snug, powdered, clean gloves. b. Ask the patient to look down to expose the lower eyeball. c. Use the fingernail to slide the lens off of the cornea. d. Inspect the eye after the lenses have been removed.

ANS: D

After the lenses have been removed, inspect the eye for redness, pain, swelling of the eyelids or conjunctivae, discharge, or excess tearing. Perform hand hygiene. Don snug, powder-free, clean gloves, and place a towel just below the patient’s face. With the pad of the index finger of the same hand, slide the lens off the cornea down onto the lower sclera. Use of the pad rather than the fingernail prevents injury to the cornea and damage to the lens.

DIF: Cognitive Level: Application REF: Procedural Guideline 19.2 OBJ: Correctly remove, store, clean, and insert a contact lens. TOP: Removal of Contact Lenses KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 6. When removing a soft contact lens, the nurse finds that it is sticking together. What should the

nurse do next? a. Rub the lens briskly. b. Soak the lens in saline. c. Place cleansing solution on the lens. d. Pry the lens apart with the fingertips.

ANS: B

If the lens edges stick together, place the lens in the palm and soak thoroughly in saline; gently roll the lens back and forth with the index finger. If this is unsuccessful in restoring the shape of the lens, placing the lens in cleansing solution would be the next step. Brisk rubbing may damage the lens. Prying the lens apart could damage it.

DIF: Cognitive Level: Application REF: Procedural Guideline 19.2 OBJ: Correctly remove, store, clean, and insert a contact lens. TOP: Removal of Contact Lenses KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. The patient is brought to the emergency department after receiving a chemical burn to his

eyes. The doctor prescribes immediate eye irrigations. Of the following solutions, which would be the most beneficial for this patient? a. Lactated Ringer’s solution b. Albumin c. Tap water d. Dextrose and water ANS: A

Controversy continues over theNbUeR stSsoIluNtG ioT nBfo.rCirO riM gating the eye in a health care setting.

When a choice of normal intravenous (IV) solutions is available, lactated Ringer’s solution is more effective than normal saline in restoring pH after a chemical burn to the eye. Often cool tap water is recommended for emergency eye flushing because it is effective and immediately available for first aid. Dextrose and water, and albumin usually are not used for eye irrigation.

DIF: Cognitive Level: Analysis REF: Skill 19.1 OBJ: Correctly perform eye and ear irrigations.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Eye Irrigation

8. When providing care to a patient who has splashed bleach into his eye, the nurse will a. remove the patient’s contacts immediately. b. flush the eye from the outer to the inner canthus. c. reinsert contacts as soon as irrigation is done. d. irrigate toward the lower conjunctival sac.

ANS: D

Ask the patient to look toward the brow. Gently irrigate with a steady stream toward the lower conjunctival sac. This will minimize the force of the stream on the cornea and will flush irritant out of the eye and away from the other eye and nasolacrimal duct. In an emergency such as first aid for a chemical burn, do not delay flushing by removing the patient’s contact lens before irrigation. Do not remove the contact unless rapid swelling is occurring. Flush the eye from the inner to the outer canthus. Advise the patient to consult the prescriber before reusing the contact lens.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

DIF: Cognitive Level: Application REF: Skill 19.2 OBJ: Correctly perform eye and ear irrigations.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Eye Irrigation

9. The patient is found to have impacted cerumen in his ear canal. The nurse most likely will a. instill 1 to 2 drops of mineral oil. b. instill the irrigation under pressure. c. occlude the ear canal when irrigating. d. straighten the ear canal.

ANS: A

If the patient is found to have impacted cerumen, instill 1 to 2 drops of mineral oil or over-the-counter softener into the ear twice a day for 2 to 3 days before irrigation to loosen cerumen and ensure easier removal during irrigation. The greatest danger during administration of ear irrigation is rupture of the tympanic membrane. Fluids must not be instilled under pressure or with the irrigating device occluding the ear canal. Always attempt to remove foreign objects in the ear by first simply straightening the ear canal. Cerumen, however, is wax buildup and is not a foreign object.

DIF: Cognitive Level: Application REF: Skill 19.2 OBJ: Correctly perform eye and ear irrigations.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Ear Irrigation

10. How should the nurse position the ear when performing ear irrigation for a 2-year-old patient? a. Instill the irrigating solutionNU quRicSkI lyNaG ndTB fo. rcCefOuM lly. b. Pull the pinna up and back. c. Direct the fluid toward the anterior aspect of the ear canal. d. Pull the pinna down and back.

ANS: D

In children age 3 years or younger, pull the pinna down and back. Slowly instill irrigating solution by holding the tip of the syringe 1 cm (0.39 inch) above the opening to the ear canal.

Allow fluid to drain out during instillation into the basin. Continue until the canal is cleansed or the solution is used. Slow instillation prevents buildup of pressure in the ear canal and ensures contact of the solution with all canal surfaces. For adults and children older than age 3 years, gently pull the pinna up and back. Direct the fluid toward the superior aspect of the ear canal.

DIF: Cognitive Level: Application REF: Skill 19.2 OBJ: Correctly perform eye and ear irrigations.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Ear Irrigation

11. How does the nurse assess that a hearing aid is operating correctly? a. Speaking very softly behind the patient b. Covering the patient’s unaffected ear and speaking c. Determining the patient’s response to a normal tone of voice d. Removing the hearing aid and sending it to be checked by an audiologist

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY ANS: C

To determine whether the patient can hear clearly using the hearing aid, turn your back to the patient and ask a question slowly and clearly in a normal tone of voice. Depending on your position, the patient may be able to read your lips. The prostheses are limited by the function of the ear structures. The hearing aid may not be the problem in this case.

DIF: Cognitive Level: Comprehension REF: Skill 19.3 OBJ: Describe techniques that determine whether a hearing aid functions properly.

TOP: Assessing the Function of the Hearing Aid KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. The nurse is preparing to clean the patient’s hearing aid. The nurse realizes that he or she must a. make sure the hearing aid volume is turned on before removing the hearing aid. b. hold the hearing aid over the sink when cleansing. c. insert a paper clip into the receiver port to cleanse cerumen buildup. d. make sure the pressure equalization channel is clear.

ANS: D

The pressure equalization channel is a tiny hole through the entire length of the ear mould; it should be clear for the entire length. Before removing the hearing aid, turn the volume off to prevent feedback (whistling) during removal. Hold the hearing aid over a towel, and wipe the exterior with tissue to remove the cerumen. This prevents breakage if dropped. The receiver port is easily damaged. Never insert anything into the receiver port.

DIF: Cognitive Level: Application REF: Skill 19.3 OBJ: Correctly remove, clean, and reinsert a hearing aid.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological IntN egUriR tySINGTB.COM

TOP: Cleaning the Hearing Aid

13. When instructing a patient on correct technique for inserting a hearing aid into the ear, the

nurse will include which of the following instructions? a. Pull the outer ear up and out. b. Hold the aid with the long portion upright. c. Fit the aid snugly in the midline of the canal. d. Turn the aid to the desired sound level before insertion.

ANS: C

Hold the hearing aid in the dominant hand and insert the pointed end of the ear mould into the ear canal while following the natural contours of the canal. Pulling up and out on the outer ear has little effect on hearing aid insertion. Instead, hold the hearing aid in the dominant hand and insert the pointed end of the ear mould into the ear canal while following the natural contours of the canal. Turn the volume slowly to high to prevent damage to the hearing aid.

DIF: Cognitive Level: Application REF: Skill 19.3 OBJ: Correctly remove, clean, and reinsert a hearing aid.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Inserting the Hearing Aid

14. The elderly patient is instructed to store his hearing aid in a(n) a. cold place. b. container that keeps out moisture. c. easy to reach place.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY d. a cup of water.

ANS: B

Hearing aids and batteries should be stored in a dry container with desiccant or in an electronic dryer to prolong life, minimize repairs, and preserve batteries. Advise the patient to avoid exposing the hearing aid to extremes of temperature. Batteries are toxic if swallowed; keep them away from pets and children. Advise the patient to protect the hearing aid from water, alcohol, hair spray or cologne, perspiration, rain, and snow.

DIF: Cognitive Level: Application REF: Skill 19.3 OBJ: Correctly remove, clean, and reinsert a hearing aid.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Storage of Hearing Aid

15. The patient is brought into the emergency department after a motor vehicle accident. The

patient is unresponsive. The nurse is concerned about whether or not the patient wears contact lenses because contact lenses that are not removed a. can be damaged. b. can cause corneal injury. c. can set off the magnetic resonance imaging (MRI) machine. d. can get stuck.

ANS: B

It is extremely important to determine whether patients wear contact lenses, particularly when patients are admitted to hospitals or agencies in an unresponsive or confused state. If a seriously ill patient is wearing contact lenses and this fact goes undetected, severe corneal injury can result.

NURSINGTB.COM DIF: Cognitive Level: Application REF: Procedural Guideline 19.2 OBJ: Identify person-centred guidelines used in caring for eye and ear prostheses.

TOP: Contact Lenses KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is preparing to provide eye care for an unconscious patient. The nurse realizes that

unconscious patients do not have natural protective mechanisms to protect the cornea. These protective mechanisms include (Select all that apply.) a. blinking. b. squinting. c. lubrication. d. dilation.

ANS: A, C

Comatose patients do not have the natural protective mechanisms to protect the cornea. These protective mechanisms include blinking and lubrication of the eye. When patients are in a coma, the nurse is responsible for providing this care.

DIF: Cognitive Level: Comprehension REF: Procedural Guideline 19.1 OBJ: Identify person-centred guidelines used in caring for eye and ear prostheses.

TOP: Protective Mechanisms KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 20: Safe Medication Preparation Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The prescribed dose of Tylenol is given to a patient. The nurse recognizes the name Tylenol

as which of the following? a. Chemical name b. Trade name c. Generic name d. Canadian Compendium of Pharmaceuticals and Specialties ANS: B

A medication trade name or brand name is used to market the medication. The trade name has the symbol  at the upper right of the name, indicating a manufacturer’s trademark for the name (e.g., Panadol, Tempra, and Tylenol). The chemical name describes the medication’s composition and molecular structure, such as N-acetyl-para-aminophenol, commonly known as Tylenol. The chemical name rarely is used in clinical practice. A manufacturer who first develops a medication gives the generic name of a medication.

Acetaminophen is the generic name for Tylenol. The generic name is the official name that is listed in official publications such as the Canadian Compendium of Pharmaceuticals and Specialties (CPS). The CPS is a drug book that lists all medications by generic name.

DIF: Cognitive Level: Understanding REF: Medication Names OBJ: Discuss factors that contribute to medication errors.

TOP: Medication Names KEY: Nursing Process Step: AssN esU sm e nt M S C : N C L EX: Physiological Integrity RSINGTB.COM 2. The nurse is aware that a patient with liver disease and a decreased albumin level may develop

which of the following effects? a. Toxicity on normal doses of medication b. Less active medication available in the body c. Reduction in therapeutic effect d. Accelerated biotransformation of the medication ANS: A

Most medications bind to albumin to some extent. When medications bind to albumin, they are unable to exert pharmacological activity. Only the unbound or “free” medication is active.

Older persons and patients with liver disease or malnutrition have reduced albumin, which increases their risk for medication toxicity. With less albumin to bind with the medication, more “free” or active medication is present in the body. This would result in an increase in therapeutic effect and possibly in toxicity. Most biotransformation occurs in the liver, although the lungs, kidneys, blood, and intestines also play a role. Patients are at risk for medication toxicity if their organs that metabolize medications do not function correctly (e.g., elderly, those with chronic disease).

DIF: Cognitive Level: Application REF: Pharmacokinetics OBJ: Differentiate among different types of medication actions.

TOP: Protein Binding KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 3. During the admission process, the patient states that he stopped taking daily aspirin because of

nausea. The nurse documents the nausea as which of the following? a. Nonadherence b. Toxic effects of the medication c. Side effects of the medication d. Allergic reaction to the medication ANS: C

Side effects are predictable and often unavoidable secondary effects produced at a usual therapeutic medication dose. For example, some antihypertensive medications cause erectile dysfunction in male patients. Nonadherence or noncompliance refers to the patient behaviour of not following the prescribed medication regimen. In this case noncompliance would be the result of the patient’s nausea, but the nausea itself would not be considered noncompliance.

Toxic effects develop after prolonged intake of a medication, when a medication accumulates in the blood because of impaired metabolism or excretion, or when too high a dose is given.

Allergic reactions are unpredictable responses to a medication. Exposure to an initial dose of a medication causes a patient to become sensitized immunologically. The medication acts as an antigen, and this causes antibodies to be produced. Nausea is not an antigen–antibody response.

DIF: Cognitive Level: Application REF: Side Effects OBJ: Differentiate among different types of medication actions.

TOP: Side Effects KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. An 80-year-old patient who complains of feeling “anxious” is given lorazepam. The patient

becomes agitated and delirious. The nurse documents this reaction to lorazepam as which of NURSINGTB.COM the following? a. Toxicity b. Side effect c. Idiosyncratic reaction d. Allergic reaction ANS: C

Medications often cause unpredictable effects such as an idiosyncratic reaction, in which a patient overreacts or underreacts to a medication or has a reaction different from normal.

Predicting which patients will have an idiosyncratic response is impossible. For example, lorazepam (Ativan), an antianxiety medication, when given to an older person, may cause agitation and delirium. Toxic effects develop after prolonged intake of a medication, when a medication accumulates in the blood because of impaired metabolism or excretion, or when too high a dose is given. Side effects are predictable and often unavoidable secondary effects produced at a usual therapeutic medication dose. Allergic reactions are unpredictable responses to a medication. The medication acts as an antigen, and this causes antibodies to be produced. With repeated administration, the patient develops an allergic response. Sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, severe wheezing, and shortness of breath are characteristic of severe or anaphylactic reactions. Some patients become severely hypotensive, necessitating emergency resuscitation measures. Anaphylaxis is potentially fatal.

DIF: Cognitive Level: Application REF: Idiosyncratic Reactions OBJ: Differentiate among different types of medication actions.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY TOP: Idiosyncratic Reactions MSC: NCLEX: Physiological Integrity

KEY: Nursing Process Step: Assessment

5. A patient admitted to the hospital with pneumonia has intravenous (IV) antibiotics prescribed.

He receives the first dose with no problem, but during the second dose, he begins to complain of shortness of breath and difficulty breathing. The nurse notes wheezes throughout the lung fields. The nurse documents these symptoms as which of the following? a. Idiosyncratic reaction b. Toxic effect of the antibiotic c. Side effect of the medication d. Anaphylactic reaction ANS: D

An allergic reaction ranges from mild to severe, depending on the patient and the medication.

Among the different classes of medications, antibiotics cause a high incidence of allergic reactions. Sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, severe wheezing, and shortness of breath are characteristic of severe or anaphylactic reactions.

Some patients become severely hypotensive, necessitating emergency resuscitation measures.

Anaphylaxis is potentially fatal. Medications often cause unpredictable effects, such as an idiosyncratic reaction, in which a patient overreacts or underreacts to a medication or has a reaction that is different from normal. However, the symptoms displayed by this patient are classic anaphylactic symptoms. Toxic effects develop after prolonged intake of a medication, when a medication accumulates in the blood because of impaired metabolism or excretion, or when too high a dose is given. Two doses of a medication usually are not enough to develop toxic effects. Side effects are predictable and often unavoidable secondary effects produced at a usual therapeutic medication dose. Anaphylaxis is usually unpredictable initially and is avoided after the first reaction N byUlR isS tinIgNtG heTcBa. usCeOoM f the anaphylaxis in the allergy alert section of the patient record.

DIF: Cognitive Level: Application REF: Allergic Reactions OBJ: Differentiate among different types of medication actions.

TOP: Allergic Reactions KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. A patient with persistent back pain has been taking oral morphine sulphate for the past 2

years. On admission to the hospital, the patient receives morphine sulphate for back pain but reports no pain relief. The nurse notifies the health care provider, recognizing that the reason for the lack of pain relief is which of the following? a. Side effect of the morphine b. Medication dependence c. Idiosyncratic response to the morphine d. Medication tolerance ANS: D

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Medication tolerance is a decreased physiological response that occurs after repeated administration of a medication. Side effects are predictable and often unavoidable secondary effects produced at a usual therapeutic medication dose. Medication dependence can be physical or psychological. In psychological dependence, patients have an emotional desire for a medication to maintain an effect. A person believes that a desirable effect will result when taking the medication. Physical dependence is a physiological adaptation to a medication that manifests itself by intense physical disturbance when the medication is withdrawn.

Medications often cause unpredictable effects, such as an idiosyncratic reaction, in which a patient overreacts or underreacts to a medication or has a reaction that is different from normal.

DIF: Cognitive Level: Analysis REF: Medication Tolerance and Dependence OBJ: Differentiate among different types of medication actions.

TOP: Medication Tolerance KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. A patient is receiving vancomycin intravenously (IV) every 8 hours at 0800, 1600, and 2400.

A serum peak and trough level is prescribed after the third dose, which will be given at 1600.

When should the nurse draw up the trough level? a. 1630 b. 1800 c. 2330 d. 2400 ANS: C

The point at which the lowest amount of medication is in the serum is the trough concentration. Some medication doses (e.g., vancomycin and gentamicin) are based on peak and trough serum levels. A patiNeU ntR ’sStrIoN ugGhTleBv.elCiO sM drawn as a blood sample 30 minutes before the medication is administered, and the peak level is drawn whenever the medication is expected to reach its peak concentration. The third dose will be given at 1600, which means that the lowest level of medication will be present 30 minutes before the fourth dose at midnight. A patient’s trough level is drawn as a blood sample 30 minutes before the medication is administered; 1630 is 30 minutes after the medication is administered, and 1800 is 2 hours after the medication is administered. If the medication reaches its peak concentration in 2 hours, this could be a peak concentration, because the peak level is drawn whenever the medication is expected to reach its peak concentration. The next dose is due at 2400. A patient’s trough level is drawn as a blood sample 30 minutes before the medication is administered.

DIF: Cognitive Level: Application REF: Medication Dose Responses OBJ: Differentiate among different types of medication actions.

TOP: Trough ConcentrationKEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The hospital uses a unit-dose system for medication distribution. The nurse recognizes that

this system includes which safety feature? a. All medications are kept in the patient’s drawer. b. Liquids are kept in multidose containers to prevent spillage. c. Narcotics are kept in an area separate from the patient’s regular medications. d. The nurse is responsible for restocking the medication drawers daily.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY ANS: C

Controlled substances are not kept in the individual patient drawer; they are kept in a larger locked drawer to keep them secure. The unit dose is the prescribed dose of medication that the patient receives at one time. Each tablet or capsule is wrapped in a foil or paper container.

Liquid doses come in prepackaged foil or paper cups. At a designated time each day, the pharmacist or a pharmacy technician refills the drawers in the cart with a fresh supply.

DIF: Cognitive Level: Understanding REF: Unit Dose OBJ: Discuss factors that contribute to medication errors.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Unit Dose

9. The nurse is calculating a medication dosage using the metric system. A vial contains 1 mL of

fluid, and the nurse calculates the correct dosage to be half of the medication in the vial. How should the nurse document the correct dosage? a. mL b. .5 mL c. 0.5 mL d. 0.50 mL ANS: C

When writing medication dosages in metric units, convert fractions to decimals. Always include a zero before a decimal point (e.g., 0.1 mL is correct). Never use a trailing zero (e.g., 1.0 mL is incorrect).

DIF: Cognitive Level: Application REF: Systems of Medication Measurement OBJ: Identify the system of measurement for a given prescribed medication.

NURSINKGETYB: .NCuO TOP: The Metric System rsM ing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. The nurse is teaching a patient how to measure medication dosages at home. The prescription

is written for 30 mL of the medication. Which household measurement will the nurse teach the patient to use? a. Drops b. Teaspoon c. Tablespoon d. Cup ANS: C

The equivalents of measurement are as follows: 15 drops = 1 mL, 1 teaspoon = 5 mL, 1 tablespoon = 15 mL, and 1 cup = 240 mL; therefore a tablespoon is most appropriate, with 2 tablespoons = 30 mL. DIF: Cognitive Level: Application REF: Household Measurement OBJ: Identify the system of measurement for a given prescribed medication.

TOP: Household Measurement KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 11. The patient is complaining of severe leg pain. No pain medication is prescribed, so the nurse

calls the health care provider. A prescription for Tylenol with Codeine prn is given, in addition to a one-time prescription for morphine sulphate to be given stat. Which action by the nurse is most appropriate? a. Give the morphine sulphate and Tylenol with Codeine immediately. b. Give the Tylenol with Codeine now. c. Give the morphine sulphate immediately. d. Ask the patient which medication he would like first.

ANS: C

Types of prescriptions based on frequency and/or urgency of medication administration include prn prescriptions (given only when a patient requires it) and stat prescriptions (given immediately and only once).

DIF: Cognitive Level: Application REF: Medication Prescriptions (Orders) OBJ: List and discuss the 10 rights of medication administration.

TOP: Medication Orders KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The nurse is preparing to administer medication to a patient who is alert and oriented. When

medications are reviewed with the patient, the patient states that he does not take metoprolol.

Which action by the nurse is most appropriate? a. Ignore the patient’s statement and give the medication. b. Withhold the medication. c. Convince the patient that the doctor prescribed it, and he should take it. d. Give the medication and check the prescription afterward.

ANS: B

NURSINGTB.COM

If a patient questions the medication a nurse prepares, it is important not to ignore these concerns. An alert patient will know whether a medication is different from those received before. Withhold the medication until you are able to recheck the preparation against the prescription. If a medication prescription seems incorrect or inappropriate, always consult the prescriber.

DIF: Cognitive Level: Application REF: Person-Centred Care OBJ: List and discuss the 10 rights of medication administration.

TOP: Medication Orders KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. The nurse is preparing a liquid medication. Which action is most appropriate? a. Pour the liquid medication toward the label. b. Draw the liquid slowly into a syringe. c. Pour the medication into a medication cup on a flat surface at eye level. d. Measure the poured liquid to the top of the meniscus.

ANS: B

Draw liquid medication into a syringe (without a needle) slowly to prevent air bubbles from entering the syringe. Air displaces medications, which leads to inaccurate measurement of doses. Nurses are no longer encouraged to pour medications into graduated cups because of the risk of medication errors. The amount of poured liquid should be even with the base of the meniscus. Pour liquid medications away from a label to ensure that liquid will not run down a label, making it difficult to read.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

DIF: Cognitive Level: Application REF: Right Dose OBJ: List and discuss the 10 rights of medication administration.

TOP: Right Dose KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. The nurse enters the patient’s room to give medications. Which action is most appropriate to

identify the “right patient”? a. Ask the patient to state her name. b. Ask the patient to state her name and birth date. c. Ask the primary nurse to identify the patient. d. Say the patient’s name and date of birth and request patient validation.

ANS: B

Before giving a medication to a patient, always use at least two patient identifiers. Acceptable patient identifiers include the patient’s name, an identification number assigned by the health care facility, and the date of birth.

DIF: Cognitive Level: Application REF: Right Patient OBJ: List and discuss the 10 rights of medication administration.

TOP: Right Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. When medications are administered, which action by the nurse is appropriate? a. Administering medications prepared by another nurse b. Using sterile technique for nonparenteral medications c. Leaving medication at the bedside when the patient is in the bathroom d. Documenting the reason foN rm edSicIaN tioGnTrB ef. usCaO l iM n the nurse’s notes UR ANS: D

When a patient refuses a medication, determine the reason for it and take action. Document refusal of medications, and notify the prescriber. Never administer a medication prepared by another nurse. Use good medical aseptic technique and perform hand hygiene before preparing a dose of medication. Avoid touching tablets and capsules. Use sterile technique for parenteral medications. Remain with the patient as the patient takes the medication. Provide assistance if necessary (e.g., for the patient who is weak and unable to administer eyedrops).

Do not leave medications at a patient’s bedside without a prescription to do so.

DIF: Cognitive Level: Application REF: Right to Refuse OBJ: Identify guidelines for safe administration of medications.

TOP: Medication Preparation/Medication Administration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. When controlled substances are administered, which action is required by the nurse? a. Discard and sign for unused quantities. b. Count the amount of medication daily. c. Keep narcotics to be given with other patient medications. d. Have a second nurse witness disposal of unused portions and sign the record.

ANS: D

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

If you give only part of a premeasured dose of a controlled substance, a second nurse must witness disposal of the unused portion. Both nurses sign their names on the required form.

Store all narcotics in a locked, secure cabinet separate from the patient’s routine medications.

(Computerized, locked cabinets are preferred.) The computerized dispensing system should maintain the inventory of medications.

DIF: Cognitive Level: Application REF: Box 20.1: Guidelines for Safe Opioid Administration and Control OBJ: Identify guidelines for safe administration of medications.

TOP: Controlled Substances KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. To prevent medication errors, which action should be taken by the nurse? a. Clarify illegible prescriptions with the prescriber. b. Document the medication before administration. c. Read medication labels two times when preparing. d. Prepare all of the patient’s medications for the shift at the same time.

ANS: A

Do not interpret illegible handwriting; clarify illegible prescriptions with the prescriber.

Document all medications as soon as they are given. Be sure to read labels at least three times (comparing medication administration record [MAR] with label): before, during, and after administering the medication. Prepare medications at the time prescribed, and document all medications as soon as they are given.

DIF: Cognitive Level: Application REF: Right Documentation OBJ: Identify guidelines for safe administration of medications.

SoIcN GeTnB TOP: Medication Prescriptions/RNigUhR tD um tat. ioCnOM KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. The patient is to receive a medication via the sublingual route. Which action by the nurse is

appropriate? a. Placing the medication under the tongue b. Crushing the medication before administration c. Offering the patient a glass of orange juice after administration d. Using sterile technique to administer the medication ANS: A

Administering a medication by the sublingual route involves placing the solid medication in the mouth under the tongue until the medication dissolves. Crushing the medication is not necessary because it is designed to dissolve under the tongue. Patients are not to take any liquids with medications given by sublingual administration or immediately afterward. The mouth is not sterile. Sterile technique is not necessary for sublingual administration.

DIF: Cognitive Level: Application REF: Table 20.4: Routes of Medication Administration OBJ: Identify guidelines for safe administration of medications.

TOP: Routes of Medication Administration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 19. The nurse is caring for several patients. The patient in which situation can safely receive oral

medications? a. Nausea with frequent episodes of vomiting b. Taking a daily dose of vitamins c. Nasogastric tube connected to suction d. Diagnosed with an esophageal stricture ANS: B

Avoid giving oral medications to patients with alterations in gastrointestinal function (e.g., nausea and vomiting), reduced motility (after general anaesthesia or inflammation of the bowel), or surgical resection of a portion of the gastrointestinal tract. Oral medications cannot be given when the patient has gastric suctioning and are contraindicated in patients before some tests or surgery. Oral administration is contraindicated in patients who are nothing by mouth (NPO) and unable to swallow (e.g., patients with neuromuscular disorders, esophageal strictures, or lesions of the mouth).

DIF: Cognitive Level: Application REF: Table 20.5: Factors Influencing Choice of Administration Routes OBJ: Identify guidelines for safe administration of medications.

TOP: Factors Influencing Choice of Administration Routes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. The nurse receives a prescription to give a medication parenterally. The nurse will administer

this medication by which route? a. Oral b. Topical c. Sublingual d. Intramuscular ANS: D

Parenteral medications can be intramuscular, subcutaneous, intradermal, epidural, or intravenous. Medications given orally are given by mouth. Topical medications are applied on the skin (as a cream or patch) and as eyedrops or eardrops. Sublingual medications are given under the tongue.

DIF: Cognitive Level: Application REF: Table 20.4: Routes of Medication Administration OBJ: Identify guidelines for safe administration of medications.

TOP: Routes of Medication Administration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. The intended or desired physiological response to a medication is known as its a. b. c. d.

. pharmacotherapeutic effect therapeutic effect adverse effect side effect

ANS: B

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Each medication has a therapeutic effect—the intended or desired physiological response to a medication. For example, the nurse administers morphine sulphate, an analgesic, to relieve a patient’s pain.

DIF: Cognitive Level: Understanding REF: Therapeutic Effects OBJ: Differentiate among different types of medication actions.

TOP: Therapeutic Effects KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 22.

are predictable and often unavoidable secondary effects of a medication produced at a usual therapeutic medication dose. a. Pharmacotherapeutic effects b. Therapeutic effects c. Adverse effects d. Side effects ANS: D

Side effects are predictable and often unavoidable secondary effects produced at a usual therapeutic medication dose. For example, some antihypertensive medications cause impotence in male patients.

DIF: Cognitive Level: Understanding REF: Side Effects OBJ: Differentiate among different types of medication actions.

TOP: Side Effects/Adverse Effects KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 23. The patient reports taking an opioid medication in large dosages for the past several years.

While in the hospital, the patienNtUisRnSoI t pNrG esTcrBib.eC dO thMe medication and develops tachycardia, hypertension, sweating, and tremors. He becomes confused and experiences visual hallucinations. The nurse recognizes these signs as indicative of . a. pharmacotherapeutic effects b. physical dependence c. tolerance d. addiction ANS: B

Medication dependence can be physical or psychological. Physical dependence is manifested by intense physical disturbance when the medication is withdrawn.

DIF: Cognitive Level: Application REF: Medication Tolerance and Dependence OBJ: Differentiate among different types of medication actions.

TOP: Medication Tolerance and Dependence KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 24. A medication interaction in which the combined effect of medications is greater than the sum

of the effects of each individual agent acting independently is known as a _ a. metabolic effect b. pharmacotherapeutic effect c. synergistic effect d. dependence effect ANS: C

.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

A synergistic effect is a medication interaction in which the combined effect of two medications is greater than the sum of the effects of each individual agent acting independently. In other words, 1 + 1 = 3 or more. The use of a combination of medications to treat hypertension is an example of synergism. Each medication lowers blood pressure but in a different way; the summed effect produces a greater reduction in hypertension than is produced by the effects of each medication.

DIF: Cognitive Level: Understanding REF: Medication Interactions OBJ: Differentiate among different types of medication actions.

TOP: Medication Interactions KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 25. The prescriber orders an intravenous (IV) antibiotic every 8 hours. The nurse administers the

medication at 0900. The medication’s onset of action is 5 minutes, peak action is 30 minutes, and duration is 6 to 24 hours. A prescription for peak and trough levels is written. The nurse will have the peak level drawn at . a. 0900 b. 0930 c. 1000 d. 1500 ANS: B

The highest level is called the peak concentration. The peak level is drawn whenever the medication is expected to reach its peak concentration.

DIF: Cognitive Level: Application REF: Medication Dose Responses OBJ: Differentiate among different types of medication actions.

GETYB: .NCuO TOP: Medication Dose ResponseNsURSINK rsM ing Process Step: Assessment MSC: NCLEX: Physiological Integrity 26. The nurse administers 100 mg of a medication at 0800. The medication’s biological half-life

is 4 hours. A serum medication level is drawn at 1600. The nurse should anticipate mg will be left in the body at 1600? a. 10 b. 25 c. 50 d. 100 ANS: B

Biological half-life is the time it takes for excretion processes to lower the serum medication concentration by half. After the first half-life (1200), 50 mg will be left in the body. After the second half-life (1600), 25 mg will be left in the body. Each half-life lowers the amount of medication in the body by half.

DIF: Cognitive Level: Application REF: Medication Dose Responses OBJ: Differentiate among different types of medication actions.

TOP: Medication Dose Responses KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 27. A patient reports a pain level of 7 out of 10 and receives 10 mg of morphine intravenously.

The nurse knows that intravenous morphine has an onset of 1 to 2 minutes, a peak of 20 minutes, and a duration of 4 to 5 hours. The patient asks when he will start to feel some pain relief. The nurse should respond that relief should begin in . a. 1 to 2 minutes b. 20 minutes c. 30 minutes d. 4 hours ANS: A

The time it takes after a medication is administered for it to produce a therapeutic effect is known as the onset of medication action.

DIF: Cognitive Level: Application REF: Medication Dose Responses OBJ: Differentiate among different types of medication actions.

TOP: Onset of Medication Action KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 28. The nurse administers 650 mg of acetaminophen orally to a patient with a pain level of 4 out

of 10. The nurse is aware that the onset of action is 30 minutes to 1 hour, the peak action is 1 to 3 hours, and the duration of action is 3 to 8 hours. After , the nurse should assess the patient to determine the maximum effectiveness of the medication. a. 1 to 3 minutes b. 30 minutes to 1 hour c. 1 to 3 hours d. 4 to 6 hours ANS: C

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Peak action is the time it takes for a medication to reach its highest effective peak concentration.

DIF: Cognitive Level: Application REF: Medication Dose Responses OBJ: Differentiate among different types of medication actions.

TOP: Peak Action KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 29. A patient is prescribed diltiazem tablets, which have an onset of 30 minutes, a peak of 2 to 3

hours, and a duration of 6 to 8 hours. The nurse anticipates that the medication will be prescribed _ times per day. a. 1 to 2 b. 3 to 4 c. 5 to 6 d. 8 to 9 ANS: B

Duration of action is the length of time during which the medication is present in a concentration great enough to produce a therapeutic effect. A medication with a duration of action of 6 to 8 hours will usually be given 3 to 4 times daily to maintain therapeutic effects.

DIF: Cognitive Level: Application REF: Medication Dose Responses OBJ: Differentiate among different types of medication actions.

TOP: Duration of Action KEY: Nursing Process Step: Assessment

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY MSC: NCLEX: Physiological Integrity 30. The patient is to receive 200 mg of a medication. There are 100-mg scored tablets available.

The nurse prepares a. 2 b. 2.5 c. 4 d. 4.5

tablets.

ANS: A

The dose prescribed is the amount of medication prescribed (e.g., 200 mg). The dose on hand is the dose (e.g., mg, mL, units) of medication supplied by the pharmacy (in this case, 100-mg tablets). The amount on hand is the weight or volume of medication available and supplied by the pharmacy. It appears on the medication label as the contents of a tablet or capsule, or as the amount of medication dissolved per unit volume of liquid. The amount on hand is the basic quantity of the medication that contains the dose on hand. For solid medications, the amount on hand is often one capsule; the amount of liquid on hand is often 1 mL or 1 L (in this case, it is 1 tablet). The amount to be administered (e.g., mL, mg) is always expressed in the same measure as the amount on hand.

DIF: Cognitive Level: Application REF: Right Dose N U R S I N OBJ: Accurately calculate medication dosesG . TB.COM KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Dosage Calculations

31. The dose prescribed for a patient is 75 mg intramuscularly (IM). The medication is available

in a 50-mg/mL solution. The nurse prepares a. 0.5 b. 0.75 c. 1.0 d. 1.5

mL.

ANS: D

The dose prescribed is the amount of medication prescribed (e.g., 75 mg). The dose on hand is the dose (e.g., mg, mL, units) of medication supplied by the pharmacy (in this case, a 50-mg solution). The amount on hand is the weight or volume of medication available and supplied by the pharmacy. It appears on the medication label as the contents of a tablet or capsule, or as the amount of medication dissolved per unit volume of liquid. The amount on hand is the basic quantity of the medication that contains the dose on hand. The amount of liquid on hand is often 1 mL or 1 L (in this case, it is 1 mL). The amount to administer (e.g., mL, mg) is always expressed in the same measure as the amount on hand.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

DIF: Cognitive Level: Application REF: Dosage Calculations OBJ: Accurately calculate medication doses.

TOP: Dosage Calculations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 32. The nurse calculates that the proper dosage of a medication is 2 tsp. The nurse prepares

mL to administer to the patient. a. b. c. d.

0.5 5 10 100

ANS: C

Conversion: 1 tsp = 5 mL; 2 tsp = 10 mL. DIF: Cognitive Level: Application REF: Dosage Calculations OBJ: Accurately calculate medication doses.

TOP: Equivalents of Measurement KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE

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1. A patient with a history of renal failure and liver disease has been receiving morphine

sulphate every 4 hours for the past 2 weeks. The nurse finds the patient lethargic with a respiratory rate of 6 breaths per minute. The health care provider prescribes naloxone. The nurse anticipates which effects when naloxone is given? (Select all that apply.) a. Increase in alertness b. Decrease in urine output c. Complaints of pain d. Increase in respiratory rate ANS: A, C, D

Toxic effects develop after prolonged intake of a medication, when a medication accumulates in the blood as the result of decreased clearance by the liver and/or kidneys (because of impaired metabolism or excretion), or when too high a dose is given. Respiratory depression and sedation are known effects of opioid toxicity. Naloxone reverses the effects of opioids, including pain relief.

DIF: Cognitive Level: Application REF: Toxic Effects OBJ: Differentiate among different types of medication actions.

TOP: Toxic Effects KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. When do most medication errors occur? (Select all that apply.) a. During hospital admission b. During transfer from one unit to another

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY c. During discharge home d. During discharge to another facility ANS: A, B, C, D

Most medication errors occur at patient care transition points such as during hospital admission, transfer from one unit to another, and discharge to home or another facility.

DIF: Cognitive Level: Understanding REF: Right Medication OBJ: Discuss factors that contribute to medication errors.

TOP: Safe Medication Administration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse recognizes that patients with which conditions will have a reduction in the

distribution of medications? (Select all that apply.) a. Peripheral vascular disease b. Heart failure c. Liver disease d. Obesity ANS: A, B

The rate and extent of distribution depend on circulation, cell membrane permeability, and protein binding. Peripheral vascular disease and heart failure result in a decrease in circulation, which reduces distribution. Liver disease causes a reduction in plasma proteins, which results in more free active medication that is distributed more readily. Obesity does not affect distribution.

DIF: Cognitive Level: Application REF: Pharmacokinetics OBJ: Differentiate among differN enU t tR ypSeI sN ofGmTeB di. caC tioOnMactions.

TOP: Pharmacokinetics KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 4. The hospital has implemented a computerized physician order entry system (CPOE) to

eliminate the need for written prescriptions. The benefits of this system include which of the following? (Select all that apply.) a. Automatic medication allergy checks b. Automatic dosage indications c. Identification of potential medication interactions d. Reduced number of medical errors ANS: A, B, C, D

Decision support software, integrated into a CPOE system, allows for automatic medication allergy checks, dosage indications, and identification of potential medication interactions. Use of CPOE systems may significantly reduce medication errors by as much as 55% to 83%.

DIF: Cognitive Level: Understanding REF: Computerized Provider Order Entry OBJ: Describe the safety features of medication delivery systems.

TOP: Computerized Provider Order Entry KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 5. The nurse reviews a medication administration record for an anticoagulant that is prescribed at

0900 daily. The medication record indicates that the medication was given at the following times over the past 4 days. Which times follow the “right time” of medication administration?

(Select all that apply.) a. 0800 b. 0830 c. 0930 d. 1000 ANS: B, C

Time-critical medications such as anticoagulants must be administered within 30 minutes of the scheduled time. Non–time-critical medications can be given 1 to 2 hours before or after the scheduled time.

DIF: Cognitive Level: Application REF: Right Time OBJ: List and discuss the 10 rights of medication administration.

TOP: Right Time KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. Medication errors include which of the following? (Select all that apply.) a. Administration of the wrong medication b. Administration via the wrong route c. Inaccurate prescribing d. Failing to administer a medication ANS: A, B, C, D

Medication errors include inaccurate prescribing and administering the wrong medication, by the wrong route, and in the wroNnU gR tim eN inG teT rvBa. l, C anOdMadministering extra doses or failing to SI administer a medication.

DIF: Cognitive Level: Understanding REF: Safe Medication Administration OBJ: Identify guidelines for safe administration of medications.

TOP: Reporting Medication Errors KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The nurse administers a medication to the wrong patient but the patient suffers no harm from

the medication error. What actions should the nurse take? (Select all that apply.) a. Prepare a written incident report. b. Document in the nurses’ notes that an incident report was completed. c. Report the incident to a manager only if the patient is harmed. d. Notify the prescriber.

ANS: A, D

When a medication error occurs, the nurse assesses the patient and notifies the prescriber as soon as possible. When the patient is stable, the nurse notifies the appropriate person in the institution (e.g., manager and supervisor). The nurse is responsible for preparing a written incident report usually within 24 hours of the incident. To legally protect the nurse and the institution, the incident report is not referred to in the nurses’ notes. All medication errors, including those that do not cause obvious or immediate harm, should be reported.

DIF: Cognitive Level: Application REF: Reporting Medication Errors OBJ: Discuss medication error disclosure requirements.

TOP: Reporting Medication Errors

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 21: Nonparenteral Medications Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The nurse is administering a buccal medication. Which instruction should be given to the

patient? a. Hold the medication under the tongue. b. Swallow the medication after 30 seconds. c. Chew the medication before swallowing. d. Hold the medication against the cheek membranes.

ANS: D

Buccal medication is placed between the upper or lower molar teeth and the cheek area and is allowed to dissolve. The sublingual route is used to administer medication under the tongue.

Medication is dissolved rather than swallowed using the buccal route.

DIF: Cognitive Level: Application REF: Box 21.1: Examples of Topical Medication Routes OBJ: Safely and correctly administer a medication by oral, enteral, and topical routes.

TOP: Buccal Medication KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse is preparing to administer a medication. Which of the following is the most critical

to assess before medication administration? a. Diet history b. Allergy history c. Surgical history d. Medication tolerance ANS: B

Medication allergies should be listed on each page of the medication administration record (MAR), prominently displayed on the patient’s medical record, and the patient should be wearing the facility’s allergy bracelet. Assessment for medication allergies is necessary before medication is administered. A patient’s diet, surgical, and medication histories are important to assess, but they are not as critical as allergy history, which can reveal life-threatening conditions.

DIF: Cognitive Level: Application REF: Safety Guidelines OBJ: Identify guidelines for administering oral, enteral, and topical medications.

TOP: Allergy History KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The nurse is preparing oral medications for administration. Which action by the nurse is

appropriate? a. Using a cutting device to cut scored tablets b. Unwrapping all of the medications to be given and placing them together in a cup c. Crushing capsules and enteric-coated medication for easier swallowing d. Holding the medication cup at eye level to pour a liquid dosage ANS: A

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

If you have to break a medication to administer half the dosage, use a clean, gloved hand to break the tablet or cut it with a cutting device. Tablets that are to be broken in half must be prescored by a manufactured line that transverses the centre of the tablet. Tablets that are not prescored cannot be broken into equal halves, and the result will be an inaccurate dose. Using a cutting device results in a more even split of the tablet. Wrappers maintain the cleanliness of medications and identify medication name and dose. Not all medications can be crushed (e.g., capsules, enteric-coated, and long-acting/slow-release medications). The coating of these medications protects the stomach from irritation or protects the medication from destruction by stomach acids. Liquid medications poured from a stock bottle should be poured into a medication cup that is placed at eye level on a flat surface.

DIF: Cognitive Level: Application REF: Skill 21.1 OBJ: Safely and correctly administer a medication by oral, enteral, and topical routes.

TOP: Cutting Tablets KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The nurse is caring for four patients who require medications at 0900. Which action by the

nurse adheres to the 10 rights of medication administration? a. Prepare medications for all of the patients at once and keep the cups separate. b. Ask the supervisor to clarify an unclear medication prescription. c. Give the prescribed anticonvulsant between 0830 and 0930. d. Leave each patient’s medications at the bedside and return within 30 minutes to make sure they have been taken.

ANS: C

Time-critical medications such as anticonvulsants must be given within 30 minutes of the prescribed time. Prepare medications for one patient at a time. Keep all pages of the medication administration recoN rdU(R MSAIRN)GfoTrBo. neCpOaM tient together. This prevents preparation errors. Unclear prescriptions should be clarified with the prescriber before administration.

Stay with each patient until the medication is swallowed completely or is taken by the prescribed route.

DIF: Cognitive Level: Application REF: Skill 21.1 OBJ: Safely and correctly administer a medication by oral, enteral, and topical routes.

TOP: Administering Oral Medication KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. What should the nurse do to assist a patient who is having difficulty swallowing tablets? a. Administer the medication with less fluid. b. Insert a nasogastric tube and instill the medication. c. Crush the medications and administer with a small amount of food. d. Administer the tablets one at a time with plenty of water.

ANS: C

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

If the patient has difficulty swallowing, use a pill-crushing device to crush the tablets. Mix the ground tablet in a small amount of soft food (custard or applesauce). Large tablets are often difficult to swallow. A ground tablet mixed with palatable soft food is usually easier to swallow. Not all medications can be crushed (e.g., capsules, enteric-coated, and long-acting/slow-release medications). The coating of these medications protects the stomach from irritation or protects the medication from destruction by stomach acids. Administration of medication with less fluid could make it more difficult for the patient to swallow. Insertion of a nasogastric tube requires a prescription from the health care provider. A patient who is having difficulty swallowing may not be safe when swallowing large capsules or tablets even one at a time. Thin liquids such as water are more readily aspirated than thickened liquids.

DIF: Cognitive Level: Application REF: Skill 21.1 OBJ: Safely and correctly administer a medication by oral, enteral, and topical routes.

TOP: Crushing MedicationsKEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. The nurse is preparing to administer a pediatric dose of liquid medication to an infant. Which

action by the nurse is appropriate? a. Empty the unit-dose container into a plastic cup. b. Gently shake the multidose bottle before pouring the medication. c. Draw the medication into a syringe with a needle. d. Use an oral syringe to measure liquid dosages greater than 25 mL. ANS: B

If the liquid medication is in a multidose bottle, gently shaking the bottle ensures that the correct amount of medication, not just the solvent, is measured for the dose. If the medication is in a unit-dose container in the correct amount to be administered, no further preparation is .eCdOicMation, use an oral syringe. Do not use a necessary. If giving less than 1N 0U mR LSoI fN liqGuT idBm syringe with a needle. The medication may be accidentally given parenterally, or the needle may become dislodged and aspirated during administration.

DIF: Cognitive Level: Application REF: Skill 21.1 OBJ: Safely and correctly administer a medication by oral, enteral, and topical routes.

TOP: Pediatric Liquid Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. The patient is unable to sit upright for medication administration. The nurse should assist the

patient to which position to decrease the risk for aspiration? a. Prone b. Supine c. Side-lying d. Dorsal recumbent ANS: C

Assist the patient to a side-lying position if sitting is contraindicated by the patient’s condition. This decreases the risk for aspiration during swallowing. Swallowing is difficult or impossible in the prone position. The risk for aspiration is increased when the patient is swallowing in the supine position or in the dorsal recumbent position.

DIF: Cognitive Level: Application REF: Skill 21.1 OBJ: Safely and correctly administer a medication by oral, enteral, and topical routes.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY TOP: Positioning of Patient MSC: NCLEX: Physiological Integrity

KEY: Nursing Process Step: Implementation

8. The nurse is preparing to give sublingual nitroglycerin to a patient complaining of chest pain.

The nurse instructs the patient not to swallow the medication. Why is this instruction important? a. The effects of the medication will be nullified if swallowed. b. Sublingual medications begin to dissolve when placed on the tongue. c. The medication needs to be held against the cheek membranes until dissolved. d. The patient may aspirate on the water used for these medications.

ANS: A

If swallowed, the medication is destroyed by gastric juices or is detoxified so rapidly by the liver that therapeutic blood levels are not attained. Orally disintegrating formulations begin to dissolve when placed on the tongue. Sublingually administered medications are placed under the tongue and are allowed to dissolve completely. Water is not needed with these medications.

DIF: Cognitive Level: Application REF: Skill 21.1 OBJ: Safely and correctly administer a medication by oral, enteral, and topical routes.

TOP: Sublingual Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The nurse is preparing a medication for a small child. The medication comes in pill or liquid

form, but the liquid preparation has a bitter taste. Which action by the nurse is most appropriate? a. Give the pill form. b. Mix the liquid with honey. NURSINGTB.COM c. Mix the liquid in milk. d. Mix the liquid in applesauce.

ANS: D

Children will refuse bitter or distasteful oral preparations. Mix the medication with a small amount (about 1 tsp) of a sweet-tasting substance such as jam, applesauce, sherbet, ice cream, or fruit puree. Offer the child juice or a flavoured ice pop after medication administration.

Liquid forms of medication are safer to swallow to avoid aspiration of small pills. Do not use honey in infants because of the risk for botulism. Do not place medication in an essential food item such as milk or formula; the child may refuse the food at a later time.

DIF: Cognitive Level: Application REF: Skill 21.1 OBJ: Safely and correctly administer a medication by oral, enteral, and topical routes.

TOP: Pediatric Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. The nurse is preparing to administer aspirin to a patient via an enteral feeding tube. Which

form is appropriate for the nurse to administer? a. Crushed chewable aspirin b. Liquid aspirin c. Enteric-coated aspirin d. Sustained-release aspirin capsule ANS: B

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Preferably, medications administered by enteral tubes should be given in liquid form. If liquid form is not available, you will have to modify the form of the medication tablet by crushing or dissolving it. However, you cannot crush sustained-release, chewable, long-acting, or enteric-coated tablets and capsules. Therefore do not administer these medications by enteral tubes. Consult with the hospital pharmacy when in doubt.

DIF: Cognitive Level: Understanding REF: Skill 21.2 OBJ: Safely and correctly administer a medication by oral, enteral, and topical routes.

TOP: Enteral Feeding Tubes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. The nurse is preparing to administer a medication via a jejunostomy tube to a patient who is

receiving continuous tube feedings. The medication needs to be given on an empty stomach and comes only in tablet form. What action should the nurse take first? a. Add the medications directly to the tube feeding. b. Flush the tubing before the medication is given. c. Stop the feeding 30 minutes before medication administration. d. Dissolve the medication in cold water.

ANS: C

If the patient needs to take the medication on an empty stomach, stop the feeding 30 minutes before medication administration to facilitate absorption of the medication. Never add crushed medications directly to the tube feeding. Whenever possible, use liquid medications instead of crushed tablets, but if you have to crush tablets, the tubing must be flushed before and after the medication is given to prevent the medication from adhering to the inside of the tube.

Dissolve in at least 30 mL of warm water. Cold water causes gastric cramping.

DIF: Cognitive Level: ApplicatiN onURSINRGETFB : .SC kiO llM 21.2 OBJ: Safely and correctly administer a medication by oral, enteral, and topical routes.

TOP: Instilling Crushed Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The nurse is to administer several medications to a patient via a nasogastric (NG) tube. What

should the nurse do first? a. Add the medications to the tube feeding being given. b. Crush all tablets and capsules before administration. c. Administer all of the medications mixed together. d. Check for placement of the NG tube.

ANS: D

Check the placement of the feeding tube by observing gastric contents and checking the pH of aspirated contents. Gastric pH should be 4 or less. This ensures proper tube placement and reduces the risk of introducing fluids into the respiratory tract. Never add medications directly to the tube feeding. Not all tablets can be crushed, such as sustained-release tablets, nor should all capsules be opened. Medications should be reviewed carefully before a tablet is crushed or a capsule is opened. To administer more than one medication, give each separately, and flush between medications with 10 mL of water. Keeping the medications separate allows for accurate identification of medication if a dose is spilled. In addition, some medications are not compatible with each other, and this may cause clogging of the tube.

DIF: Cognitive Level: Application

REF: Skill 21.2

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY OBJ: Safely and correctly administer a medication by oral, enteral, and topical routes.

TOP: Administering Several Medications via NG Tube KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. When preparing to administer medication via a nasogastric tube, the nurse aspirates 275 mL

of gastric residual. What is the first action the nurse should take? a. Wait 1 hour and recheck the residual. b. Administer the medication with more fluid. c. Return the aspirate and withhold the medication. d. Attach the nasogastric tube to suction to remove additional volume.

ANS: C

Return aspirated contents to the stomach unless a single volume exceeds 500 mL or two measurements taken 1 hour apart each exceed 250 mL. When gastric residual is greater than 250 mL, the medication is withheld and the residual is rechecked in 1 hour. Large-volume aspirates indicate delayed gastric emptying and place the patient at risk for aspiration.

Additional fluid would not be administered if the patient had a large residual. Use of suction would require a prescription from the health care provider.

DIF: Cognitive Level: Application REF: Skill 21.2 OBJ: Safely and correctly administer a medication by oral, enteral, and topical routes.

TOP: Gastric Residual KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. The patient is to receive three different medications via a nasogastric tube. What is the total

amount of water the nurse should prepare to administer? a. 30 mL of water NURSINGTB.COM b. 60 mL of water c. 90 mL of water d. 250 mL of water ANS: C

Before the medications, 30 mL of water is administered; 15 to 30 mL of water is administered after each of the first two medications, and 30 to 60 mL is administered after the third medication, so 90 to 150 mL of water is needed.

DIF: Cognitive Level: Analysis REF: Skill 21.2 OBJ: Safely and correctly administer a medication by oral, enteral, and topical routes.

TOP: Flushing the NG Tube KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. The nurse is applying a new nitroglycerin transdermal patch. Which action by the nurse is

appropriate? a. Instructing the patient to wear the patch 24 hours a day every day b. Applying the new patch to the same site as the previous patch c. Cutting the patch in half when a change of dose is prescribed d. Instructing the patient to avoid heat sources over the patch ANS: D

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Heat sources over a transdermal patch can increase the rate of absorption, leading to potentially serious adverse effects. It is recommended to have a daily “patch-free” interval of 10 to 12 hours because tolerance develops if patches are used 24 hours a day every day. The patch should not be applied to previously used sites for at least 1 week. Transdermal patches are never to be cut in half. A change in dosage requires a new prescription.

DIF: Cognitive Level: Application REF: Skill 21.3 OBJ: Safely and correctly administer a medication by oral, enteral, and topical routes.

TOP: Applying Topical Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. The nurse is teaching a patient how to use a topical medication. Which statement indicates an

understanding of the procedure? a. “If the patch starts to come off, I can secure it with tape.” b. “If the patch falls off, I will put a new one on in the same place.” c. “If my skin is irritated, I will cleanse it using water only.” d. “I can dispose of used materials in the household trash as usual.”

ANS: C

If skin is inflamed, instruct patients to use only warm water rinse without soap for cleansing.

Instruct the patient on how to manage a transdermal patch that begins to peel off before the next dose is due. Rather than tape the patch or cover it, instruct the patient to remove the patch, clean the skin, and apply a new patch to a different area. Instruct the patient to wrap applicators, used patches, and similar materials and dispose of them into cardboard or plastic disposable containers. Careful disposal is necessary to ensure the safety of the patient, other adults, pets, and children.

DIF: Cognitive Level: ApplicatiN onURSINRGETFB : .SC kiO llM 21.3 OBJ: Safely and correctly administer a medication by oral, enteral, and topical routes.

TOP: Applying Topical Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. The patient is prescribed an ophthalmic medication via an intraocular disc. Which action by

the nurse is appropriate when administering the medication? a. Place the disc in the conjunctival sac. b. Apply sterile gloves before placing the disc. c. Pull on the patient’s upper eyelid and ask the patient to look up. d. Instruct the patient that the disc will be changed daily.

ANS: A

Medications delivered by disc resemble a contact lens, but the disc is placed in the conjunctival sac, not on the cornea. Clean gloves are used to place and remove the disc. The lower eyelid is pulled down and the patient is asked to look up. The disc remains in place for up to 1 week.

DIF: Cognitive Level: Application REF: Skill 21.4 OBJ: Differentiate types of topical administration that require sterile technique from those that require medical aseptic technique.

TOP: Instilling Eye and Ear Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 18. The patient has eyedrops prescribed daily to both eyes. Which action by the nurse is

appropriate when administering the medication? a. Carefully place the drop on the cornea. b. Wipe the eye with a tissue after placing the eyedrop. c. Hold the eyedropper about 1 to 2 cm above the eye. d. Instruct the patient to squeeze the eye shut after instillation.

ANS: C

Holding the eyedropper approximately 1 to 2 cm above the conjunctival sac of the eye prevents accidental contact of the eyedropper with the eye and reduces risk for injury and transfer of microorganisms to the dropper. The cornea is very sensitive. If drops were instilled onto the cornea, this would stimulate the blink reflex. The tissue should be placed just below the lower eyelid so medication that escapes the eye is absorbed. Wiping the eye removes too much of the medication. Squinting or squeezing the eyelids after instillation forces the medication from the conjunctival sac.

DIF: Cognitive Level: Application REF: Skill 21.4 OBJ: Safely and correctly administer a medication by oral, enteral, and topical routes.

TOP: Instilling Eye and Ear Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. The nurse is preparing to administer an eye ointment to the patient. Which action by the nurse

is appropriate? a. Clean away drainage or crusts by wiping from the outer to the inner canthus. b. Instruct the patient to keep the eye open for 2 minutes after instillation. c. Apply a thin ribbon evenly along the inner edge of the lower eyelid. d. Instruct the patient to avoid wiping the eye after instillation.

NURSINGTB.COM

ANS: C

While holding the ointment applicator above the lower lid margin, apply a thin ribbon of ointment evenly along the inner edge of the lower eyelid on the conjunctiva from the inner canthus to the outer canthus. This distributes medication evenly across the eye and lid margin.

Eyes are cleansed from the inner to the outer canthus to avoid entry of microorganisms into the lacrimal duct. After instillation, the patient is instructed to close the eye and rub the lid lightly in a circular motion, if not contraindicated, to distribute the medication. If excess medication is on the eyelid, it can be gently wiped from the inner to the outer canthus.

DIF: Cognitive Level: Application REF: Skill 21.4 OBJ: Safely and correctly administer a medication by oral, enteral, and topical routes.

TOP: Instilling Eye and Ear Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. A patient is experiencing a systemic effect from eyedrops. Which assessment finding by the

nurse is indicative of this? a. Headache b. Reddened eyes c. Darkened conjunctiva d. Elevated pulse and blood pressure ANS: D

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

An unexpected outcome is noted when the patient experiences systemic effects from drops (e.g., increased heart rate and blood pressure from epinephrine, decreased heart rate and blood pressure from timolol). Local side effects include headache, bloodshot eyes, and local eye irritation.

DIF: Cognitive Level: Analysis REF: Skill 21.4 OBJ: Identify guidelines for administering oral, enteral, and topical medications.

TOP: Unexpected Outcomes of an Eye Medication KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 21. A nurse is preparing to administer eardrops to an adult patient. Which action should be taken

by the nurse? a. Warm the medication to room temperature using warm water. b. Pull the pinna down and back to straighten the ear canal. c. Apply gentle pressure or massage to the pinna of the ear. d. Remove cerumen from the inner ear canal with a cotton-tipped applicator.

ANS: A

Internal ear structures are very sensitive to temperature extremes. Failure to instill a solution at room temperature can cause vertigo (severe dizziness) or nausea and can debilitate a patient for several minutes. Pulling the pinna down and back is the procedure for children aged 3 years and younger. Do not massage the pinna of the ear; instead massage the tragus. Gentle pressure or massage to the tragus of the ear moves medication inward. Cerumen is removed from the outer canal only.

DIF: Cognitive Level: Application REF: Skill 21.5 OBJ: Safely and correctly administer a medication by oral, enteral, and topical routes.

GETYB: .NCuO TOP: Instilling Eye and Ear MedNicU atR ioS nsINK rsM ing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. The nurse administers eardrops in the patient’s left ear. Which of the following positions is

appropriate after instillation of the drops? a. Prone b. Upright c. Right lateral d. Dorsal recumbent with hyperextension of the neck ANS: C

The patient should remain in the side-lying position, with the treated ear upward for a few minutes. Upright, prone, and dorsal recumbent positions are not recommended after administration of eardrops. The eardrops would run out of the ear canal.

DIF: Cognitive Level: Application REF: Skill 21.5 OBJ: Safely and correctly administer a medication by oral, enteral, and topical routes.

TOP: Administering Eye and Ear Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. How should the nurse position the patient to administer nose drops to the maxillary sinus? a. Sitting upright with the head tilted backward toward the side to be treated b. Supine with a small pillow under the shoulders and the head tilted backward c. Supine with the head tilted backward and turned to the unaffected side

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY d. Head tilted back over the edge of the bed and turned toward the side to be treated ANS: D

For access to the frontal and maxillary sinus, tilt the head back over the edge of the bed or pillow with the head turned toward the side to be treated. This position allows medication to drain into the affected sinus. For access to the posterior pharynx, tilt the patient’s head backward. For access to the ethmoid or sphenoid sinus, tilt the head back over the edge of the bed or place a small pillow under the patient’s shoulder and tilt the head back.

DIF: Cognitive Level: Application REF: Skill 21.6 OBJ: Safely and correctly administer a medication by oral, enteral, and topical routes.

TOP: Positioning to Administer Nose Drops to Maxillary Sinus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. The nurse is teaching a mother how to administer nasal drops to her infant. What should be

included in the teaching plan? a. Over-the-counter nasal drops can be saved and used later. b. Nasal decongestants are safe and have no serious side effects. c. Infants should receive nose drops 20 to 30 minutes before feedings. d. Infants are mouth breathers, so nasal medications are well tolerated.

ANS: C

Infants are nose breathers, and the possible congestion caused by nasal medications may inhibit their sucking. Administer nose drops 20 to 30 minutes before feedings.

Over-the-counter nasal sprays or nose drops should be used for only one illness; bottles become easily contaminated with bacteria. Nasal decongestants can enter the systemic circulation by way of the nasalNmUuR coSsI aN orGtT heBg.aC stO roM intestinal tract if swallowed, causing restlessness, nervousness, tremors, or insomnia in some patients. Long-term use can worsen nasal congestion through a rebound effect.

DIF: Cognitive Level: Application REF: Pediatric (Skill 21.6) OBJ: Prepare a teaching plan regarding medication use for a selected patient.

TOP: Teaching and Pediatric Considerations Relative to Nasal Medication KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. Several patients have been prescribed inhalation medications. The nurse is aware that a spacer

will be beneficial for which patient? a. A young child using a dry powder inhaler b. An elderly patient who uses a metered-dose inhaler c. A teenager who has just started using a nebulizer d. A young child who needs medication several times per day ANS: B

Because use of a metered-dose inhaler (MDI) requires coordination during the breathing cycle, many patients spray only the back of their throat and fail to receive a full dose. The inhaler must be depressed to expel medication just as the patient inhales. This ensures that the medication reaches the lower airways. Poor coordination can be solved by the use of spacer devices. Coordination is not necessary with dry powder inhalers or nebulizers. The use of a spacer is not dependent on the schedule of administration.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY DIF: Cognitive Level: Application REF: Skill 21.7 OBJ: Instruct patients in the proper use of a metered-dose inhaler (MDI), a dry powder inhaler (DPI), and a small-volume nebulizer.

TOP: Using Metered-Dose Inhalers KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 26. The nurse is teaching a patient how to use a metered-dose inhaler without a spacer. Which

action by the patient demonstrates correct use of the device? a. Being careful not to shake the canister b. Positioning the mouthpiece in front of the mouth while not touching the lips c. Depressing the canister fully, waiting 3 to 5 seconds, then inhaling slowly and deeply d. Taking another puff of the medication within 10 seconds ANS: B

The best way to deliver medication without a spacer is to position the mouthpiece 2 to 4 cm in front of a widely opened mouth with the opening of the inhaler toward the back of the throat.

The lips should not touch the inhaler. Shaking the inhaler before administration is the correct procedure; it mixes the medication within the canister. The correct procedure is to depress the canister fully while inhaling slowly and deeply through the mouth for 3 to 5 seconds. A wait of 20 to 30 seconds is advised between doses of the same medication; 2 to 5 minutes is the standard time between doses of different medications.

DIF: Cognitive Level: Application REF: Skill 21.7 OBJ: Instruct patients in the proper use of a metered-dose inhaler (MDI), a dry powder inhaler (DPI), and a small-volume nebulizer.

TOP: Metered-Dose Inhalers KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 27. The patient has a bronchodilatoNr U anRdSaInNinGhT alB ed.sCteOrM oid scheduled for the same time. What

teaching should the nurse provide to the patient about administering these medications? a. Inhale the bronchodilator, wait 20 to 30 seconds, then inhale the steroid. b. Inhale the bronchodilator, wait 2 to 5 minutes, then inhale the steroid. c. Inhale the steroid, wait 20 to 30 seconds, then inhale the bronchodilator. d. Inhale the steroid, wait 2 to 5 minutes, then inhale the bronchodilator.

ANS: B

Medications must be inhaled sequentially. If bronchodilators are administered with inhaled steroids, the bronchodilators should be given first to dilate the airway passages for the second medication. The patient is instructed to wait 2 to 5 minutes between inhalations when different medications are being given. The patient is instructed to wait 20 to 30 seconds between inhalations if the same medication is being taken.

DIF: Cognitive Level: Application REF: Skill 21.7 OBJ: Prepare a teaching plan regarding medication use for a selected patient.

TOP: Bronchodilators and Steroids KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 28. The nurse is administering a beta-adrenergic medication via a small-volume nebulizer. Which

assessment finding requires the nurse to withhold the medication immediately? a. Episodes of coughing b. Rapid and shallow respirations c. Wheezing noted on auscultation of the lungs

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY d. Irregular pulse with light-headedness ANS: D

If the patient experiences cardiac dysrhythmias (light-headedness, syncope), especially if receiving beta-adrenergics, withhold all additional doses of medication, assess vital signs, and notify the prescriber regarding reassessment of the type of medication and delivery method.

Coughing, rapid and shallow respirations, and wheezing would be assessed and recorded, but this would not necessarily require discontinuation of treatment. The prescriber would be notified to reassess the type of medication and delivery system.

DIF: Cognitive Level: Application REF: Skill 21.8 OBJ: Identify conditions contraindicating the administration of medications by various oral and topical routes.

TOP: Dysrhythmias KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 29. The patient is receiving vaginal suppositories for a vaginal infection. Which assessment

finding by the nurse indicates a desired outcome of the treatment? a. The patient reports pruritus and burning. b. The vaginal walls are bright red in colour. c. White curdlike patches appear on the vaginal walls. d. Vaginal discharge the same colour of the medication is noted.

ANS: D

Some vaginal discharge that is the same colour as the medication is an expected outcome after vaginal instillation. Local pruritus and burning indicate inflammation or infection and is an unexpected outcome. Bright red vaginal walls or white curdlike patches are signs of a possible yeast infection.

NURSINGTB.COM DIF: Cognitive Level: Application REF: Skill 21.9 OBJ: Safely and correctly administer a medication by oral, enteral, and topical routes.

TOP: Vaginal Instillations KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 30. The nurse is preparing to administer a rectal suppository to a patient. The patient should be

assisted to which position for insertion of the rectal suppository? a. Prone b. Supine c. Dorsal recumbent d. Left Sims’ position ANS: D

Left side-lying Sims’ position exposes the anus and helps the patient relax the external anal sphincter, while lessening the likelihood that the suppository or feces will be expelled. Supine and dorsal recumbent positions would make access to the anus difficult and would allow the suppository to slip out. The prone position would make inserting the suppository difficult.

DIF: Cognitive Level: Application REF: Skill 21.10 OBJ: Safely and correctly administer a medication by oral, enteral, and topical routes.

TOP: Inserting a Suppository KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 31. The nurse is preparing to administer a rectal suppository to an adult patient. Which action

should be taken by the nurse? a. Apply sterile gloves before handling the suppository. b. Apply extra lubricant to the suppository if there is active rectal bleeding. c. Insert the suppository past the internal sphincter, against the rectal wall, about 15 to 25 cm (6–10 inches). d. Instruct the patient to remain lying flat or on the side for 5 minutes after insertion of the suppository.

ANS: D

Lying flat or on the side for 5 minutes after the suppository is inserted prevents it from being expelled. Administering a suppository is not a sterile procedure; clean examination gloves are used. A suppository is contraindicated in the presence of active bleeding. The suppository is inserted 10 cm (4 inches).

DIF: Cognitive Level: Application REF: Skill 21.10 OBJ: Safely and correctly administer a medication by oral, enteral, and topical routes.

TOP: Inserting a Suppository KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 32. The easiest and most desirable way to administer medications is via the a. Nasogastric feeding tube b. Oral c. Buccal d. Sublingual

route.

ANS: B

The oral route is the easiest andNm osS tI deNsiGraTbB le.wCaO yM to administer medications. Patients UR usually ingest or self-administer oral medication with few problems.

DIF: Cognitive Level: Understanding REF: Skill 21.1 OBJ: Describe factors to assess before administering medications.

TOP: Oral Route of Medication Administration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse receives prescriptions on several patients for oral medications. The nurse will

question the prescription on patients with which conditions? (Select all that apply.) a. History of asthma and difficulty breathing b. Inability to swallow food c. Decreased level of consciousness d. Use of gastric suction ANS: B, C, D

Certain situations contraindicate receiving medications by mouth, such as nausea/vomiting, inability to swallow, bowel inflammation, reduced peristalsis, recent gastrointestinal surgery, gastric suction, and decreased level of consciousness. Alterations in gastrointestinal (GI) function can interfere with absorption, distribution, and excretion of the medication. Impaired swallowing and decreased level of consciousness increase the risk for aspiration. A history of asthma and difficulty breathing is not a contraindication to oral medications.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

DIF: Cognitive Level: Application REF: Skill 21.1 OBJ: Describe factors to assess before administering medications.

TOP: Oral Route of Medication Administration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse is preparing several topical medications for a patient. The nurse identifies which of

the following as ways to administer a topical medication? (Select all that apply.) a. Administering through an enteral tube placed in the jejunum b. Inhaling an aerosol spray into the lungs c. Spraying a mist into the nose d. Dissolving a medication under the tongue ANS: B, C, D

Topical medications can be applied by direct application of liquid (eyedrops, gargling, and swabbing the throat), insertion of a medication into a body cavity (rectal or vaginal suppositories, vaginal creams or foams), instillation of fluid into a body cavity (fluid is retained; eardrops, nose drops, bladder, and rectal instillation), irrigation of a body cavity (fluid is not retained; flushing eye, ear, vagina, bladder, or rectum with medicated fluid), spraying (instillation into nose or throat or under the tongue), and inhalation of medicated aerosol spray or dry powder medication (distributes medication throughout the nasal passages and the tracheobronchial airway). Medication may be directly applied to the skin or mucosa (lotion, ointment, cream, powder, foam, spray, patch, and disc), or it may be given by the sublingual (medication placed under the tongue and allowed to dissolve) or buccal (medication placed between the upper or lower molar teeth and cheek area and allowed to dissolve) route. Medications placed in the gastrointestinal tract via an enteral tube are not topical medications.

DIF: Cognitive Level: Understanding REF: Skill 21.3 OBJ: Safely and correctly administer a medication by oral, enteral, and topical routes.

TOP: Topical Medications KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse is preparing to administer medications to a patient with an enteral tube. The nurse

can safely give the medications through which types of enteral tube? (Select all that apply.) a. Nasogastric feeding tube b. Percutaneous endoscopic gastrostomy tube c. Jejunostomy tube d. Nasogastric decompression tube ANS: A, B, C

A nasogastric feeding tube, a percutaneous endoscopic gastrostomy (PEG) tube, and a jejunostomy tube are used to administer enteral feedings and can also be used to administer medications. Do not administer medications into nasogastric tubes that are inserted for decompression.

DIF: Cognitive Level: Application REF: Skill 21.2 OBJ: Safely and correctly administer a medication by oral, enteral, and topical routes.

TOP: Enteral Feeding Tubes KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 4. The nurse is teaching a patient with asthma about using a metered-dose inhaler to administer

albuterol. Which statements should the nurse include in the teaching plan? (Select all that apply.) a. This medication can produce systemic effects such as tachycardia and tremors. b. After inhaling the medication, hold your breath for about 10 seconds. c. After inhaling the medication and holding your breath, exhale slowly through an open mouth. d. After the last dose, do not rinse your mouth or drink any water for at least 1 hour.

ANS: A, B

Inhaled medications are designed to produce local effects; for example, bronchodilators open narrowed bronchioles. However, because these medications are absorbed rapidly through the pulmonary circulation, some have the potential for producing systemic side effects. Holding the breath for 10 seconds after inhalation allows the aerosol to penetrate deeper areas of the lung. Exhalation should occur slowly through the nose or pursed lips to keep the small airways open during exhalation. About 2 minutes after the last dose, the mouth should be rinsed with warm water because inhaled bronchodilators may cause dry mouth and taste alterations.

DIF: Cognitive Level: Application REF: Skill 21.7 OBJ: Prepare a teaching plan regarding medication use for a selected patient.

TOP: Metered-Dose Inhalers KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 22: Parenteral Medications Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The nurse is preparing an injection of 0.45 mL of medication for a pediatric patient. Which

syringe is most appropriate? a. Tuberculin syringe b. Insulin syringe c. 3-mL syringe d. 10-mL syringe ANS: A

The tuberculin syringe is calibrated in hundredths of a millilitre and has a capacity of 1 mL. It is used to prepare small amounts of medication such as small, precise doses for infants or young children. It is also used for intradermal and subcutaneous injections. An insulin syringe is used to administer insulin and is calibrated in units. A 3-mL syringe and a 10-mL syringe are calibrated in 0.2 of a millilitre and are not accurate for small volumes.

DIF: Cognitive Level: Application REF: Fig 22.5: Examples of types of syringes OBJ: Explain the importance of selecting the proper-size syringe and needle for an injection.

TOP: Syringes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse is preparing to administer an intramuscular (IM) injection to a 6-month-old infant.

Which injection site is the most appropriate for this patient?

NURSINGTB.COM a. Deltoid muscle b. Dorsogluteal injection site c. Vastus lateralis d. Abdomen 5 cm (2 inches) away from the umbilicus ANS: C

On the basis of the evidence, the vastus lateralis is the recommended site for pediatric IM injections for infants up to 12 months of age. The deltoid is the recommended site for children 18 months of age and older. The dorsogluteal site should not be used as an IM injection site.

The abdomen is used for subcutaneous injection, not for IM injection.

DIF: Cognitive Level: Application REF: Skill 22.5 OBJ: Discuss factors to consider when selecting injection sites.

TOP: Intramuscular Injection Sites in Children KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 3. The nurse is administering a parenteral medication to the patient. Which action by the nurse

demonstrates proper technique? a. Using strict aseptic technique b. Using work-arounds to administer medications in a timely manner c. Injecting the medication smoothly but rapidly d. Inserting the needle into the patient’s skin smoothly and slowly ANS: A

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Strict aseptic technique is used during all steps of preparation and administration of parenteral medications. Work-arounds bypass a procedure, policy, or protocol and should not be used.

Medication should be injected slowly and smoothly. The needle should be inserted smoothly and quickly.

DIF: Cognitive Level: Application REF: Procedural Guideline 22.1 OBJ: Identify advantages, disadvantages, and risks of administering medication by each parental route. TOP: Aseptic Technique in Injections KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The nurse is preparing a medication that comes in an ampoule. Which action by the nurse is

appropriate? a. Tapping the ampoule so fluid moves from the bottom of the ampoule to the neck b. Avoiding inversion of the ampoule after opening to prevent spillage of the medication c. Using a filter needle long enough to reach the bottom of the ampoule d. Guiding the needle against the rim of the ampoule to access the medication ANS: C

Filter needles filter out any fragments of glass, and reaching the bottom of the ampoule allows the medication to be completely withdrawn. The top of the ampoule is tapped to move the fluid from the neck into the bottom of the ampoule, where it is withdrawn. The ampoule is held upside down or is set on a flat surface for withdrawal of the medication. The medication will not spill from the ampoule after opening unless the needle tip or shaft touches the rim.

The rim is considered contaminated and should not be touched by the needle.

DIF: Cognitive Level: ApplicatiN onURSINRGETFB : .SC kiO llM 22.1 OBJ: Correctly prepare injectable medications from a vial and an ampoule.

TOP: Preparing Injections: Ampoules and Vials KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse is teaching a patient how to mix 5 units of regular insulin and 15 units of NPH

insulin in the same syringe. The nurse determines that further instruction is needed if the patient does which of the following? a. Injects 5 units of air into the regular insulin vial first and withdraws 5 units of regular insulin. b. Injects 15 units of air into the NPH insulin vial but does not withdraw the medication. c. Withdraws 5 units of regular insulin before withdrawing 15 units of NPH insulin. d. Calculates the combined total insulin dose as 20 units after withdrawing the regular insulin from the vial.

ANS: A

When rapid- or short-acting insulin is mixed with intermediate- or long-acting insulin, air should be injected into the intermediate- or long-acting insulin vial first without withdrawal of the medication. Regular insulin is withdrawn first, and then the combined total insulin dose is calculated before the NPH insulin is withdrawn from the vial.

DIF: Cognitive Level: Application

REF: Box 22.2: Recommendations for Mixing Insulins

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections.

TOP: Mixing Insulin KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 6. A patient has prescriptions for 10 units of glargine insulin and 5 units of regular insulin to be

given at the same time. Which action by the nurse is appropriate? a. Injecting 10 units of air into the glargine insulin vial first and not withdrawing the medication b. Injecting 5 units of air into the regular insulin vial first and then 10 units of air into the glargine insulin vial c. Giving two separate injections using different needles and syringes d. Withdrawing 5 units of regular insulin first and then calculating the total dose of regular and glargine insulin combined ANS: C

If long-acting insulin glargine is prescribed, it should not be mixed with other insulin preparations, so two separate injections are prepared. Air is injected into one vial, and this is followed by withdrawal of the medication. It does not matter which one is drawn up first because they are in separate syringes.

DIF: Cognitive Level: Application REF: Box 22.2: Recommendations for Mixing Insulins OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections.

TOP: Mixing Insulin KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. The nurse is preparing several medications that are administered parenterally. The patient

receiving which medication will have an intradermal injection? a. Opioid NURSINGTB.COM b. Medication for allergy testing c. Low-molecular-weight heparin d. Glargine insulin ANS: B

The nurse typically gives intradermal injections for skin testing, for example, in tuberculin screening and allergy tests. Opioid pain medications, low-molecular-weight heparin, and insulin are administered subcutaneously, not intradermally.

DIF: Cognitive Level: Application REF: Skill 22.2 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections.

TOP: Intradermal Injections KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The nurse is preparing to administer an intradermal injection to an adult patient. Which action

should be taken by the nurse? a. Use a tuberculin syringe with a 2.5 cm (1-inch) 25-gauge needle. b. Inject no more than 1 mL of solution at one site. c. Insert the needle at a 5- to 15-degree angle 3 finger widths below the antecubital space. d. Expect a bleb and a small amount of bleeding after injection.

ANS: C

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

The angle of insertion for an intradermal injection is 5 to 15 degrees. If possible, the site should be 3 to 4 finger widths below the antecubital space and one hand width above the wrist. To administer an injection intradermally, use a tuberculin or small syringe with a short 9.5 mm to 16 mm (3/8 to 5/8 inch), fine-gauge (25–27) needle. Inject only small amounts of medication (0.01–0.1 mL) intradermally. If a bleb does not appear, or if the site bleeds after needle withdrawal, the medication may have entered subcutaneous tissue. In this situation, skin test results will not be valid.

DIF: Cognitive Level: Application REF: Skill 22.2 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections.

TOP: Intradermal Injections KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The nurse administers a tuberculin screening test to a patient who has no known risk factors

for tuberculosis (TB). When the test site is read 48 hours later, which result is considered positive? a. Induration of 2 mm or more b. Induration of 5 mm or more c. Induration of 10 mm or more d. Induration of 15 mm or more ANS: D

A raised, reddened, or hard zone around the test site indicates a positive tuberculin skin test.

An induration of 15 mm or more indicates a positive reaction in patients with no known risk factors for TB. An induration that measures 5 mm or more in diameter indicates a positive TB reaction in patients who are human immunodeficiency virus (HIV) positive, have fibrotic changes on chest radiograph consistent with previous TB infection, have had organ NnGiTndBu.raCtiOonM of 10 mm or more indicates a positive transplants, or are immunosuppNreUsR seSdI .A TB reaction in patients who are recent immigrants; injection drug users; residents and employees in high-risk settings; patients with certain persistent illnesses; children younger than 4 years of age; and infants, children, and adolescents exposed to high-risk adults.

DIF: Cognitive Level: Application REF: Skill 22.2 OBJ: Evaluate the effectiveness and outcomes of administering medications by each injection route.

TOP: Positive TB Test Results KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 10. The nurse is teaching a family member of an obese patient how to administer a subcutaneous

U-100 insulin injection to the patient. Which instruction should be included in the teaching plan? a. Carefully massage the site after the injection to aid absorption. b. Draw the medication into a tuberculin syringe with a 27-gauge needle. c. Insert the needle quickly and firmly at a 90-degree angle. d. Rotate injection sites between the abdomen, thighs, and upper arms.

ANS: C

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

For an obese patient, the skin is pinched and the needle is inserted quickly and firmly at a 90-degree angle. Massage can damage underlying tissue. Subcutaneous U-100 insulin is given using an insulin syringe with a preattached needle of 28 to 31 gauge. Injection site rotation is no longer necessary because newer human insulins carry a lower risk for hypertrophy.

Patients choose one anatomical area (e.g., the abdomen) and systematically rotate sites within that region—a practice that maintains consistent insulin absorption from day to day.

DIF: Cognitive Level: Application REF: Skill 22.4 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections.

TOP: Insulin Injection KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 11. The nurse is teaching a patient how to inject low-molecular-weight heparin. What instruction

should be included in the teaching plan? a. The injection can be given in the abdomen or the upper thighs. b. Before injecting the medication, be sure to expel the air bubble in the syringe. c. After inserting the needle, pull back on the plunger of the syringe before injecting the medication. d. After injecting the medication, apply gentle pressure to the injection site for 30 to 60 seconds.

ANS: D

Gentle pressure for 30 to 60 seconds prevents bleeding at the site. To minimize the pain and bruising associated with low-molecular-weight heparin (LMWH), it is given subcutaneously on the right or left side of the abdomen, at least 5 cm (2 inches) away from the umbilicus; this area is commonly referred to as a patient’s “love handles.” LMWH comes in a prefilled syringe, and the air bubble should not be expelled before administration. Aspiration after a subcutaneous injection is not nN ecUesRsS arI y.NAGsT piBra.tiC onOM after an LMWH injection is not recommended.

DIF: Cognitive Level: Application REF: Skill 22.4 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections.

TOP: Low-Molecular-Weight Heparin Injections KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The nurse is preparing an intramuscular injection for a thin older patient. The nurse is aware

that the maximum volume most likely tolerated by this patient is which amount? a. 1 mL b. 2 mL c. 3 mL d. 5 mL ANS: B

Older people and thin patients often tolerate only 2 mL in a single injection. A normal, well-developed adult can safely tolerate 2 to 5 mL of medication in larger muscles such as the ventrogluteal. However, clinically it is unusual to administer more than 3 mL of medication in a single injection because the body does not absorb it well.

DIF: Cognitive Level: Application REF: Skill 22.5 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY TOP: Volume of Medication That Can Be Given Safely IM KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. The nurse is preparing to administer an intramuscular injection via the Z-track method. Which

action should be taken by the nurse? a. Pinch the skin between the thumb and the first finger. b. Insert the needle at a 90-degree angle. c. Immediately remove the needle after injecting the medication. d. Release the skin before removing the needle from the site.

ANS: B

For an intramuscular injection, the needle is inserted perpendicular to the patient’s body as close to 90 degrees as possible. In using the Z-track method, the overlying skin and subcutaneous tissues are pulled approximately 2.5 to 3.5 cm laterally to the side with the ulnar side of the nondominant hand. Keep the needle inserted for 10 seconds after injection to allow the medication to disperse evenly. Release the skin after withdrawing the needle.

DIF: Cognitive Level: Application REF: Skill 22.5 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections.

TOP: Z-Track Method KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. A student nurse is preparing to administer an intramuscular injection into the ventrogluteal

muscle. The nursing instructor should question which action by the student? a. Asking the patient to assume a sitting position b. Placing the heel of the hand over the patient’s greater trochanter c. Asking the patient to flex thNeUkR nS eeIaN ndGT hiB p .COM d. Using the right hand to locate the injection site on the patient’s left side ANS: A

The patient should lie in either the supine or the lateral position while the ventrogluteal muscle is located. To locate the ventrogluteal site, the heel of the hand is placed over the greater trochanter of the patient’s hip with the wrist almost perpendicular to the femur. The right hand is used for the left hip, and the left hand is used for the right hip. To relax the muscle, the patient lies on the side or back with the knee and hip flexed.

DIF: Cognitive Level: Application REF: Skill 22.5 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections.

TOP: Ventrogluteal Injection Site KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. The nurse is preparing to administer an immunization to a toddler. Which action by the nurse

is appropriate? a. Grasp the body of the muscle during injection. b. Place one hand above the knee and one below the knee to find the site. c. Have the patient’s knee flexed with the foot internally rotated. d. Ask the mother to hold the toddler on his or her side.

ANS: A

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

The vastus lateralis is the preferred injection site for administration of immunizations to infants, toddlers, and children. With young children, it helps to grasp the body of the muscle during injection to be sure the medication is deposited in muscle tissue. The muscle is located on the anterior lateral aspect of the thigh. In an adult, one hand is placed above the knee and one below the greater trochanter to locate the muscle. To relax the muscle, the patient lies flat with the knee slightly flexed and the foot externally rotated or assumes a sitting position. A side-lying position would not be appropriate for this immunization.

DIF: Cognitive Level: Application REF: Skill 22.5 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections.

TOP: Vastus Lateralis Injection Site KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. The nurse is preparing to give a medication by intravenous (IV) bolus. When assessing the

patient’s IV insertion site, the nurse notes that it is warm, reddened, and tender. What action should the nurse take first? a. Slow the infusion rate and slowly inject the medication. b. Discontinue the IV infusion. c. Inject a local anaesthetic to relieve the tenderness. d. Apply warm compresses over the insertion site.

ANS: B

Swelling, warmth, redness, and tenderness indicate infiltration or phlebitis. Stop the IV infusion, remove the IV catheter, treat the IV site as indicated by institutional policy, and insert a new IV catheter if therapy continues.

DIF: Cognitive Level: Application REF: Skill 22.6 OBJ: Correctly administer an intN raU veRnS ouIsN inGfuTsiB on.bCyOinMtravenous piggyback, intermittent infusion, or bolus.

TOP: Phlebitis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 17. A patient with a continuous intravenous (IV) infusion has a prescription for ciprofloxacin to

be given by IV piggyback. Which action by the nurse is appropriate for administering the medication? a. Hang the bag with ciprofloxacin higher than the continuous infusion bag. b. Stop the continuous infusion while running the ciprofloxacin. c. Connect the piggyback tubing into the Y-port on the tubing of the continuous infusion that is closest to the patient. d. Occlude the tubing of the continuous infusion just above the injection port while injecting the medication.

ANS: A

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

The set is called a piggyback because the small bag or bottle is set higher than the primary infusion bag or bottle. In the piggyback setup, the main line does not infuse when a compatible piggybacked medication is infusing. The port of the primary IV line contains a back-check valve that automatically stops the flow of the primary infusion once the piggyback infusion flows. After the piggyback solution infuses and the solution within the tubing falls below the level of the primary infusion drip chamber, the back-check valve opens, and the primary infusion starts to flow again. The piggyback is connected to a short tubing line that connects to the upper Y-port of a primary infusion line or to an intermittent venous access.

The tubing is occluded to check for blood return or to give an IV bolus, but not for a piggyback medication.

DIF: Cognitive Level: Application REF: Skill 22.7 OBJ: Correctly administer an intravenous infusion by intravenous piggyback, intermittent infusion, or bolus.

TOP: Piggyback Infusion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. The nurse is preparing to administer an intravenous (IV) antibiotic using a mini-infusion

pump. Which action should the nurse do first? a. Place the syringe into the mini-infusion pump. b. Hang the pump on an IV pole. c. Connect the end of the mini-infusion tubing to the main IV line. d. Apply pressure to the syringe plunger to fill the tubing with medication.

ANS: D

After connecting the prefilled syringe to the mini-tubing, the nurse carefully applies pressure to the syringe plunger to fill the tubing with fluid and to ensure that the tubing is free of air UfRteSr I bubbles to prevent air embolusN .A thN eG tuTbB in. gC isOfM illed with fluid, the syringe is placed into the mini-infusion pump and is hung on an IV pole. Then the mini-infusion tubing is connected to the main IV line.

DIF: Cognitive Level: Application REF: Skill 22.7 OBJ: Correctly administer an intravenous infusion by intravenous piggyback, intermittent infusion, or bolus.

TOP: Mini-infusion Pump KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. The nurse is preparing to administer a medication using a volume-controlled administration

set or Volutrol. Which action should the nurse do first? a. Open the clamp between the Volutrol and the main intravenous (IV) bag. b. Open the air vent on the Volutrol. c. Inject the medication into the Volutrol. d. Clean the injection port on top of the Volutrol.

ANS: A

The Volutrol is filled with the desired amount of IV fluid (50–100 mL) by opening the clamp between the Volutrol and the main IV bag. After the Volutrol is filled with the desired amount of fluid, the clamp is closed and the clamp on the air vent of the Volutrol is checked and opened if necessary. The injection port on the Volutrol is cleaned, and the medication is injected through the port.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY DIF: Cognitive Level: Application REF: Skill 22.7 OBJ: Correctly administer an intravenous infusion by intravenous piggyback, intermittent infusion, or bolus.

TOP: Volume-Control Administration Sets KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. The student nurse is preparing to administer an intravenous (IV) bolus medication through a

small-gauge IV catheter. The student notes that there is no blood return on aspiration. Which action by the student should the nursing instructor question? a. Checking the IV site for redness and swelling b. Immediately stopping the IV infusion and removing the IV catheter c. Checking to see if the IV is infusing without difficulty d. Injecting the IV medication if no signs of infiltration ANS: B

The student should stop the V, remove the catheter, and start a new one only if the line is not patent. In some cases, especially with a smaller-gauge IV catheter, blood return is not always aspirated, even if the IV is patent. Confirm patency. If the IV site does not show signs of infiltration and the IV fluid is infusing without difficulty, give the IV bolus medication.

DIF: Cognitive Level: Application REF: Skill 22.6 OBJ: Compare the risks of three different intravenous routes.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: IV Bolus

21. The nurse is teaching a patient about continuous subcutaneous infusion with an insulin pump.

What should the nurse include in the teaching plan? a. Rotate the site every 1 to 2 N daUyRs.SINGTB.COM b. Place a gauze dressing over the insertion site. c. Select an insertion site in the abdomen away from the waistline. d. Pull the skin laterally before inserting the needle.

ANS: C

Insulin is absorbed most consistently in the abdomen, so a site should be chosen in the abdomen away from the waistline. The site is changed every 2 to 7 days unless erythema or leaking occurs. An occlusive transparent dressing is used over the site. The skin should be gently pinched or lifted up to ensure that the needle will enter subcutaneous tissue.

DIF: Cognitive Level: Application REF: Skill 22.3 OBJ: Initiate, maintain, and discontinue a continuous subcutaneous infusion.

TOP: Continuous Subcutaneous Infusion (CSQI) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. A patient has medication prescribed to be given by intravenous (IV) bolus. The nurse

recognizes which advantage of this type of administration? a. There is a slower onset of medication effects. b. Medications are given over a longer time frame. c. Medications given by IV bolus are less irritating to the veins. d. Small volumes are used, so fluid overload can be avoided.

ANS: D

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

An intravenous (IV) bolus usually requires small volumes of fluid, which is an advantage for patients who are at risk for fluid overload. With IV bolus medications, rapid onset of medication effects occurs, which is useful for patients who are experiencing critical or emergent health problems. Medications can be prepared quickly and given over a shorter time frame rather than by IV piggyback. Medications given by IV bolus may cause direct irritation to the lining of the blood vessel.

DIF: Cognitive Level: Analysis REF: Skill 22.6 OBJ: Compare the risks of three different intravenous routes.

TOP: Intravenous Bolus Administration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. The health care provider prescribes 4 units of regular insulin and 10 units of NPH insulin

subcutaneously before breakfast. The nurse draws the regular insulin into the syringe and is preparing to draw the NPH insulin into the same syringe. When finished, the syringe should contain units. a. 10 b. 12 c. 14 d. 16 ANS: C

The combined units of insulin are determined by adding the number of units of both insulins together (4 units of regular + 10 units of NPH = 14 units).

DIF: Cognitive Level: Application REF: Skill 22.3 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections.

GETYB: .NCuO TOP: Subcutaneous Insulin InjecNtiU onRSINK rsM ing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. The nurse injects the medication into the loose connective tissue just under the dermis when

giving a a. subcutaneous b. intramuscular c. intradermal d. intravenous

injection.

ANS: A

A subcutaneous injection involves depositing medication into the loose connective tissue underlying the dermis.

DIF: Cognitive Level: Understanding REF: Skill 22.3 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections.

TOP: Subcutaneous Injection KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. The nurse informs the patient that the medication will be absorbed rapidly because it was

injected into tissue with a rich blood supply. The patient has just received a injection. a. subcutaneous b. intramuscular c. intradermal

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY d. intravenous ANS: B

The intramuscular (IM) injection route deposits medication into deep muscle tissue, which has a rich blood supply, allowing the medication to be absorbed faster than by the subcutaneous or intradermal route.

DIF: Cognitive Level: Application REF: Skill 22.5 OBJ: Identify advantages, disadvantages, and risks of administering medication by each injection route. TOP: Intramuscular (IM) Injection KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 26. The patient is receiving allergy testing. The nurse is using the inner forearm to inject the

allergen as a(n) a. subcutaneous b. intramuscular c. intradermal d. intravenous

injection.

ANS: C

Intradermal (ID) injections are used for allergy testing. They are injected into the dermis, usually in the inner forearm or upper back.

DIF: Cognitive Level: Application REF: Skill 22.2 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections.

TOP: Intradermal Injections KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

NURSINGTB.COM

27. A patient with multiple intravenous (IV) lines has blood infusing in the right antecubital

space, parenteral nutrition infusing through a right subclavian line, and normal saline with potassium infusing in the left forearm. An intravenous medication is prescribed stat. Which line should the nurse use to administer the IV medication? a. Right antecubital b. Right subclavian c. Left forearm d. Neither ANS: C

Never administer IV medications through tubing that is infusing blood, blood products, or parenteral nutrition solutions.

DIF: Cognitive Level: Application REF: Skill 22.6 OBJ: Correctly administer an intravenous infusion by intravenous piggyback, intermittent infusion, or bolus.

TOP: Intravenous (IV) Injection or Infusion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 28. The nurse is preparing to give an intramuscular injection to a toddler. To decrease pain, a

eutectic mixture of local anaesthetics (EMLA) cream is applied to the injection site at least hour(s) before administration of the injection. a. 0.5 b. 1

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY c. 2 d. 4 ANS: B

EMLA cream should be applied to the injection site at least 1 hour before IM injection to decrease pain.

DIF: Cognitive Level: Application REF: Skill 22.5 OBJ: Discuss ways to promote patient comfort while administering an injection.

TOP: Pediatric Considerations for Intramuscular Injections KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse follows practice guidelines when administering injections to a patient to avoid

which possible complications? (Select all that apply.) a. Medication response that is too rapid or too slow b. Nerve injury with possible pain or paralysis c. Death of tissue surrounding the injection site d. Death of the patient ANS: A, B, C, D

Failure to inject a medication correctly will result in complications such as an inappropriate medication response (e.g., too rapid and too slow), nerve injury with associated pain or paralysis, localized bleeding, tissue necrosis, and sterile abscess. Administration of an intravenous push medication too quickly can cause death.

DIF: Cognitive Level: UnderstaN ndUinRgSINRGETFB : .SC kiO llM 22.6 OBJ: Identify advantages, disadvantages, and risks of administering medication by each parental route. TOP: Choosing Correct Injection Method KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse is preparing to administer an intramuscular medication. In determining which size

needle and syringe to use to administer the medication, the nurse must consider which of the following? (Select all that apply.) a. The volume of medication b. The viscosity of the medication c. The size and weight of the patient d. Whether or not the syringe has a safety needle ANS: A, B, C

The nurse needs to determine the appropriate size of syringe and needle to be used. The smallest syringe possible for the volume of medication should be used to improve the accuracy of medication preparation. The needle length is chosen by the patient’s size and weight, the type of tissue to be injected, and the route of administration. The needle gauge is determined by the viscosity of the medication.

DIF: Cognitive Level: Application REF: Skill 22.5 OBJ: Explain the importance of selecting the proper-size syringe and needle for an injection.

TOP: Choosing Correct Syringe and Needle Size KEY: Nursing Process Step: Implementation

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY MSC: NCLEX: Physiological Integrity 3. The nurse is preparing a subcutaneous injection for a patient. The nurse is careful not to touch

which part of the syringe or needle? (Select all that apply.) a. Needle hub b. Needle shaft c. Syringe outer barrel d. Needle bevel ANS: A, B, D

The needle hub, shaft, and bevel must remain sterile at all times.

DIF: Cognitive Level: Application REF: Skill 22.1 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections.

TOP: Maintaining Needle Sterility KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The nurse is teaching a patient how to give a subcutaneous injection. The nurse includes

which sites as acceptable for this route of administration? (Select all that apply.) a. Ventrogluteal area between the greater trochanter and the iliac crest b. Outer aspect of the upper arms c. Abdomen from below the costal margins to the iliac crests d. Anterior thighs ANS: B, C, D

The best subcutaneous injection sites include the outer aspect of the upper arms, the abdomen from below the costal margins to the iliac crests, and the anterior aspects of the thighs. These areas are easily accessible and N arU eR laS rgIeNeG noTuB gh.tChO atMyou can rotate multiple injections within each anatomical location. The ventrogluteal area is used for intramuscular injections.

DIF: Cognitive Level: Application REF: Skill 22.4 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections.

TOP: Subcutaneous Injection Sites KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse administers an injection of iron to a patient using the Z-track method. The nurse

recognizes which of the following as advantages of this method? (Select all that apply.) a. Provides faster absorption of the medication b. Reduces discomfort from the needle c. Prevents leakage of the medication into subcutaneous tissue d. Prevents the medication from irritating sensitive tissue ANS: C, D

The Z-track method is recommended for intramuscular (IM) injections. The Z-track technique, which pulls the skin laterally before injection, prevents leakage of medication into subcutaneous tissue, seals medication in the muscle, and minimizes irritation.

DIF: Cognitive Level: Understanding REF: Skill 22.5 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections.

TOP: Z-Track Method KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 6. The nurse is preparing to administer an intravenous (IV) medication that must be diluted in 60

mL of fluid and then given over 45 minutes. Which of the following methods can the nurse use to give this medication? (Select all that apply.) a. Piggyback infusion b. Volume-control device c. Mini-infusion pump d. IV bolus injection ANS: A, B, C

Piggyback infusions contain 25 to 250 mL, volume-control devices contain 50 to 150 mL, and mini-infusion pumps contain 5 to 60 mL. All three can be set to deliver the medication over a specific time frame. IV bolus injections are smaller volumes that are delivered quickly, usually over a few minutes.

DIF: Cognitive Level: Application REF: Skill 22.7 OBJ: Correctly administer an intravenous infusion by intravenous piggyback, intermittent infusion, or bolus.

TOP: Administration of IV Medication KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

NURSINGTB.COM

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 23: Oxygen Therapy Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. A patient diagnosed with chronic obstructive pulmonary disease (COPD) is on oxygen

therapy at 3 L per nasal cannula. Which assessment finding should alert the nurse to a potential problem with this patient? a. Respiratory rate of 26 b. Low carbon dioxide levels c. Arterial oxygen saturation level of 99% d. Lower oxygen saturation levels at night than during the day ANS: C

In the patient with COPD, high levels of oxygen can extinguish the stimulus to breathe. In the individual with healthy lungs, the chemoreceptors are sensitive to small changes in carbon dioxide levels and effectively regulate ventilation. In patients with COPD who retain carbon dioxide, the chemoreceptors are not sensitive to small changes in carbon dioxide and regulate ventilation poorly. In these patients, it is the change in the oxygen level that stimulates changes in ventilation. Patients with COPD are at risk of retaining carbon dioxide and developing carbon dioxide narcosis induced by administration of high levels of oxygen.

Uncontrolled oxygen administration may cause acute hypoventilation and carbon dioxide retention with dire consequences. Arterial oxygen saturation levels should be at 88% to 92% and no higher. Some patients with COPD have normal oxygen levels during the day but oxygen desaturation during sleep.

NURSINGTB.COM DIF: Cognitive Level: Analysis REF: Principles for Practice OBJ: Discuss indications for oxygen therapy.

TOP: Carbon Dioxide Retention and Oxygen Drive KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 2. A patient with pneumonia is receiving supplemental oxygen. Which assessment finding(s) by

the nurse should be reported as an early indication of hypoxia? a. Cyanosis around the lips and oral mucosa b. Anxiety and restlessness c. Decrease in the level of consciousness d. Decreased blood pressure and respiratory rate ANS: B

Anxiety, confusion, and restlessness are early signs of hypoxia. Cyanosis around the lips and mouth is a sign of hypoxia, but it is a late sign. Decreased level of consciousness, decreased respiratory rate, and decreased blood pressure are also late signs of hypoxia. The respiratory rate will increase as the body attempts to compensate for the decreased level of oxygen. As hypoxia worsens, the respiratory rate may decline. During early stages of hypoxia, blood pressure is elevated unless the condition is caused by shock.

DIF: Cognitive Level: Application REF: Box 23.1: Signs and Symptoms Associated with Acute Hypoxia OBJ: Discuss indications for oxygen therapy.

TOP: Early Signs of Hypoxia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

3. A patient with chronic obstructive pulmonary disease (COPD) has carbon dioxide retention

and is prescribed oxygen therapy. The nurse anticipates the use of which oxygen-delivery system? a. Face tent b. Face mask c. Nasal cannula d. Nonrebreathing mask ANS: C

Oxygen can be delivered via the nasal cannula at flow rates of 1 to 2 L per minute, which deliver 24% to 28% FiO2 and are useful for patients with chronic lung disease. The face tent is used primarily for humidification and for oxygen only when the patient cannot or will not tolerate a tight-fitting mask. The FiO2 cannot be controlled, and there is no way to estimate how much oxygen is delivered. The simple face mask is used for short-term oxygen therapy.

It fits loosely and delivers oxygen concentrations from 40% to 60%. The mask is contraindicated for patients with carbon dioxide retention because it will make the retention worse. When used as a nonrebreather, the plastic face mask with a reservoir bag delivers 60% to 100% oxygen at appropriate flow rates. This oxygen mask maintains a high-concentration oxygen supply in the reservoir bag. If the bag deflates, the patient breathes in large amounts of exhaled carbon dioxide.

DIF: Cognitive Level: Analysis REF: Oxygen-Delivery Devices OBJ: Demonstrate applying an oxygen-delivery device.

TOP: Nasal Cannulas KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 4. The nurse is caring for several patients receiving oxygen by various delivery systems. Which

assessment finding by the nurseNiUnR diS caIteNsGpT roBp. erCuO seMof the oxygen device? a. No mist is noted in a face tent. b. The reservoir of the rebreathing mask collapses on inhalation. c. The flow rate is between 1 and 6 L per minute for a nasal cannula. d. The flow rate for an oxygen hood is set at 3 L per minute.

ANS: C

The nasal cannula is used with an oxygen flow rate of 1 to 6 L per minute. The face tent provides high humidity, and mist is expected. The reservoir of the rebreathing mask remains partially inflated when operating effectively to avoid rebreathing of carbon dioxide. The flow rate for an oxygen hood may be 5 L per minute or more to prevent carbon dioxide (CO2) narcosis.

DIF: Cognitive Level: Understanding REF: Oxygen-Delivery Devices OBJ: Demonstrate applying an oxygen-delivery device.

TOP: Nasal Cannulas KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. A patient in respiratory distress enters the emergency department. The patient denies a history

of chronic obstructive pulmonary disease (COPD). The nurse anticipates a prescription for oxygen delivered by which method to achieve the highest possible concentration of oxygen? a. Simple face mask at 15 L per minute b. Nonrebreathing face mask at 15 L per minute c. Venturi mask at 15 L per minute d. Oxygen tent at 15 L per minute

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

ANS: B

When used as a nonrebreather, the face mask with a reservoir bag delivers 60% to 90% oxygen at 15 L per minute. The simple face mask delivers oxygen concentrations from 40% to 60% when set at 5 to 8 L per minute. It is not used at 15 L per minute. A Venturi mask delivers oxygen concentrations from 24% to 60% when set at 4 to 12 L per minute. It is not used at 15 L per minute. An oxygen tent is usually for pediatric use and delivers up to 50% oxygen concentration at 10 to 15 L per minute.

DIF: Cognitive Level: Analysis REF: Oxygen-Delivery Devices OBJ: Discuss methods for administering oxygen therapy.

TOP: Oxygen Mask KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 6. A patient with a nasal cannula at 5 L per minute has skin irritation around the nares and

complains of a dry mouth and nose. Which action by the student nurse should be questioned by the nursing instructor? a. Using humidification b. Applying petroleum-based gel to the nares c. Providing frequent oral care d. Asking the physician for a prescription for sterile nasal saline ANS: B

Petroleum-based gel should not be used around oxygen because it is flammable. If the oxygen flow rate is greater than 4 L per minute, humidification should be used. Frequent oral care and sterile nasal saline will help when there is drying of the nasal and oral mucosa.

DIF: Cognitive Level: Application REF: Safety Guidelines OBJ: Discuss methods for adminNisUteR riS ngIoNxG ygTenBt. heCraOpM y.

TOP: Unexpected Outcomes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. A patient with a tracheostomy tube has a prescription for oxygen. Which action by the nurse is

appropriate? a. Apply sterile gloves to connect the oxygen to the tracheostomy tube. b. Check the oxygen tubing frequently to make sure water is present in the tubing. c. Attach the T tube to a humidified oxygen source. d. Monitor the response to oxygen with hourly arterial blood gas levels.

ANS: C

The T tube connects an oxygen source to an artificial airway such as a tracheostomy tube.

Humidification is necessary because the artificial airway bypasses the normal humidification process of the nose and mouth. Clean gloves, not sterile gloves, are used to connect oxygen to the artificial airway. Fluid should be drained from the tubing so that it does not provide a medium for bacterial growth. Hourly arterial blood gases (ABGs) are not the standard for monitoring patients with artificial airways and oxygen.

DIF: Cognitive Level: Application REF: Oxygen-Delivery Devices OBJ: Demonstrate administering oxygen therapy to a patient with an artificial airway.

TOP: Attaching a T Tube KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 8. The nurse is caring for several patients postoperatively after abdominal surgery. Which patient

will benefit the least from the use of incentive spirometry? a. Middle-aged man with a history of smoking since high school b. Older woman with type 2 diabetes c. Middle-aged woman with a history of chronic respiratory disease d. Adolescent girl with atelectasis ANS: B

Incentive spirometry (IS) assists the patient in deep breathing. It is used most often after abdominal or thoracic surgery to help reduce the incidence of postoperative pulmonary atelectasis. It is especially beneficial in patients with a history of smoking, pneumonia, chronic respiratory disease, or atelectasis.

DIF: Cognitive Level: Application REF: Skill 22.3 OBJ: Demonstrate proper use of incentive spirometry.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Incentive Spirometry

9. The nurse is teaching a patient how to use a flow-oriented incentive spirometer (IS) the night

before abdominal surgery. Which statement by the patient indicates an understanding of the procedure? a. “I need to get the balls to the top as quickly as possible.” b. “Rapid breaths are the most effective when the incentive spirometer is used.” c. “I need to keep the balls elevated as long as possible.” d. “The balls must be elevated to be effective.”

ANS: C

The goal is to keep the balls eleNvU atR edSfIoN r aGsTloBn.gCaO s pMossible to ensure maximal sustained inhalation, not to snap the balls to the top of the chamber quickly with a rapid, brief, low-volume breath. Even if very slow inspiration does not elevate the balls, this pattern helps to improve lung expansion.

DIF: Cognitive Level: Application REF: Skill 22.3 OBJ: Demonstrate proper use of incentive spirometry.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Incentive Spirometry

10. A patient is planning to perform incentive spirometry after abdominal surgery. The nurse

should encourage the patient to do which of the following? a. Get comfortable in a semireclined position. b. Inhale as deeply as possible and then exhale into the incentive spirometry device. c. Hold the breath for at least 3 seconds before exhaling. d. Exhale as quickly as possible.

ANS: C

The patient should hold his or her breath for at least 3 seconds after inhalation. The patient should be positioned in the most erect position (e.g., high-Fowler’s position) if tolerated. This promotes optimal lung expansion during respiratory manoeuvres. The patient should exhale completely through the mouth and place the lips around the mouthpiece, and then he or she should take a slow, deep breath, hold it for at least 3 seconds, and exhale normally.

DIF: Cognitive Level: Application

REF: Skill 22.3

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY OBJ: Demonstrate proper use of incentive spirometry.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Incentive Spirometry

11. A patient has been using continuous positive airway pressure (CPAP), and now the health care

provider is recommending bi-level positive airway pressure (BiPAP). The patient is asking the nurse to explain the difference again. Which response is appropriate? a. “CPAP maintains a set positive airway pressure during inspiration only.” b. “CPAP opens the airways during inspiration and allows them to close during expiration.” c. “BiPAP maintains a set pressure that is the same for inspiration and expiration.” d. “BiPAP delivers sufficient expiratory pressure to keep the airways open.”

ANS: D

BiPAP uses two modes of pressure: one for inspiration and one for expiration. During expiration, BiPAP delivers sufficient pressure to keep the airways open. CPAP maintains a set positive airway pressure during inspiration and expiration. It keeps the airways open and prevents upper airway collapse.

DIF: Cognitive Level: Application REF: Skill 23.4 OBJ: Demonstrate use of noninvasive positive-pressure ventilation (NPPV) using continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP).

TOP: CPAP/BiPAP KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. A patient is admitted to the emergency department after a motor vehicle accident. The patient

is unconscious and has a broken jaw, a broken nose, and facial lacerations. The patient’s breath sounds are diminished, aNnU dR thSeIhN eaGltT hB ca.reCpOrM ovider suspects atelectasis. Frequent suctioning is required to clear the airway. Oxygen saturation levels range from 70% to 75%.

The nurse recognizes that this patient most likely will have which type of ventilatory device prescribed? a. Continuous positive airway pressure (CPAP) b. Bi-level positive airway pressure (BiPAP) c. Nasal cannula d. Mechanical ventilation ANS: D

Noninvasive ventilation, including CPAP and BiPAP, is contraindicated in cardiac or respiratory arrest, nonrespiratory organ failure, facial surgery or trauma, inability to protect the airway and/or high risk for aspiration, and inability to clear secretions. A nasal cannula cannot be used with nasal obstruction from a broken nose.

DIF: Cognitive Level: Analysis REF: Skill 23.5 OBJ: Demonstrate use of noninvasive positive-pressure ventilation (NPPV) using continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP).

TOP: CPAP/BiPAP | Noninvasive Positive-Pressure Ventilation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. A patient is admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) and

the health care provider prescribes bi-level positive airway pressure (BiPAP). Which action by the nurse is appropriate? a. Set the initial bi-level positive airway pressure (BiPAP) settings at 4 to 8 cm H2O

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

for inspiration and expiration. b. Draw arterial blood gas (ABG) levels after the first hour. c. Make sure the mask does not have quick-release straps. d. Set the initial BiPAP settings at 4 to 10 cm H2O for inspiration and at 10 to 15 cm

H2O for expiration.

ANS: B

When BiPAP is initiated, especially in patients with COPD, it is important to obtain ABG levels after the first hour and then per employer policy (usually every 2–6 hours) during the first day because these patients may retain carbon dioxide. BiPAP initial settings are 10 to 15 cm H2O for inspiratory pressure and 4 to 10 cm H2O for expiratory pressure. It is imperative that the mask have quick-release straps. In the case of an emergency (e.g., vomiting and respiratory arrest), quick-release straps allow the mask to be removed quickly. This system also allows the patient to remove the mask quickly as needed.

DIF: Cognitive Level: Application REF: Skill 23.4 OBJ: Demonstrate use of noninvasive positive-pressure ventilation (NPPV) using continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP).

TOP: Initiation of Noninvasive Positive-Pressure Ventilation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. The nurse is caring for a patient on a mechanical ventilator and the low-pressure alarm

sounds. Which action by the nurse is most appropriate? a. Assess for secretions in the airway and suction the patient. b. Administer a sedative to the patient to prevent coughing. c. Assess the endotracheal tube cuff to make sure it is deflated. d. Check the ventilator tubingNaU ndRrSeI coNnG neTcB t i. fC diO scMonnected.

ANS: D

The low-pressure alarm sounds when the ventilator has no resistance to inflating the lung. The patient may be disconnected from the ventilator, or a leak may have developed in the ventilator circuit. The high-pressure alarm sounds when the ventilator has met resistance to delivery of the tidal volume. This may result from coughing, increased secretions, or biting on the endotracheal tube. The cuff of the endotracheal tube is inflated to create a seal for positive-pressure ventilation. A cuff that is leaking could cause the low-pressure alarm to sound.

DIF: Cognitive Level: Application REF: Skill 23.5 OBJ: Demonstrate care of a patient receiving mechanical ventilation.

TOP: Ventilator Alarms KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15. The nurse is caring for a patient on mechanical ventilation. The nurse determines that the

endotracheal tube is properly placed by which assessment? a. Auscultating both lungs and watching the rise and fall of both sides of the chest b. Monitoring and comparing the blood pressure in both arms c. Observing and measuring inspiratory and expiratory rates d. Checking the settings on the ventilator and the low-pressure and high-pressure alarm settings ANS: A

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Verify placement of the endotracheal tube by auscultating the lungs and assessing chest wall symmetry. This ensures that the tube has not migrated into the right main-stem bronchus.

Many factors can cause blood pressure fluctuations and fluctuations in respiratory rate.

Always assess the patient first. Once the patient is determined to be safe, the settings for the ventilator alarm can be checked as well.

DIF: Cognitive Level: Application REF: Skill 23.5 OBJ: Demonstrate care of a patient receiving mechanical ventilation.

TOP: Artificial Airway Placement KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 16. A patient on mechanical ventilation has an FiO2 setting of 38%. The nurse is reviewing

arterial blood gas results and pulse oximetry readings. The nurse is aware that the desired level of oxygen is which of the following? a. PaO2 greater than 90 mm Hg b. SpO2 greater than 60% c. PaO2 greater than 60 mm Hg d. SpO2 greater than 95% ANS: C

A patient on mechanical ventilation ideally has an FiO2 setting less than 40% to maintain PaO2 levels greater than 60 mm Hg and SpO2 levels greater than 90%.

DIF: Cognitive Level: Analysis REF: Skill 23.5 OBJ: Demonstrate care of a patient receiving mechanical ventilation.

TOP: Care of the Patient on a Ventilator KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

NURSINGTB.COM

17. A condition in which oxygen is insufficient to meet the metabolic demands of the tissues and

cells is known as a. hypoxia b. hypoxemia c. cyanosis d. anemia

.

ANS: A

Hypoxia is a condition in which oxygen is insufficient to meet the metabolic demands of the tissues and cells. Hypoxemia is decreased oxygen in the blood.

DIF: Cognitive Level: Understanding REF: Principles for Practice OBJ: Discuss indications for oxygen therapy.

TOP: Hypoxia KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 18. The amount of air inspired and expired with each breath while a patient is on mechanical

ventilation is known as the a. respiratory rate b. positive end-expiratory pressure c. exhaled minute ventilation d. tidal volume ANS: D

.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

The tidal volume, the amount of air per breath, is usually set by the patient’s ideal body weight (5–8 mL/kg).

DIF: Cognitive Level: Understanding REF: Table 23.3: Ventilator Parameters OBJ: Demonstrate care of a patient receiving mechanical ventilation.

TOP: Tidal Volume KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is reviewing laboratory results for a patient with hypoxemia. The nurse is aware

that which of the following results may worsen the patient’s hypoxemia? (Select all that apply.) a. Low sodium levels b. Low hemoglobin levels c. Increased blood pH d. Decreased blood pH ANS: B, C

Hypoxemia is a deficiency of arterial blood oxygen. Decreased hemoglobin levels reduce the amount of oxygen transported to the cells. Acidemia (decreased blood pH) increases the ability of hemoglobin to release oxygen to the tissues. Alkalemia (increased blood pH) decreases the ability of hemoglobin to release oxygen to the tissues.

DIF: Cognitive Level: Application REF: Skill 23.5 OBJ: Discuss indications for oxygen therapy.

TOP: Hemoglobin and Acid–Base Status KEY: Nursing Process Step: Assessment NURSINGTB.COM MSC: NCLEX: Physiological Integrity 2. The nurse is assessing a patient for hypoxia and observes a bluish discolouration in the

following areas. Which areas indicate hypoxia? (Select all that apply.) a. Oral mucosa b. Conjunctiva of the eye c. Around the lips d. On the nail beds ANS: A, B, C

Cyanosis caused by hypoxia is observed in the oral mucosa, in the conjunctiva of the eye, and around the lips, known as circumoral cyanosis. Nail bed cyanosis may be caused by peripheral vascular disease or cold temperatures.

DIF: Cognitive Level: Application REF: Box 23.1: Signs and Symptoms Associated with Acute Hypoxia OBJ: Discuss indications for oxygen therapy.

TOP: Cyanosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. A patient will be using a nasal cannula continuously to deliver oxygen at home, and the nurse

is instructing the patient and family about important safety guidelines. Which of the following should be included in the teaching plan? (Select all that apply.) a. Smoking is allowed if it is not done in the same room in which the oxygen device is placed.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY b. If you feel short of breath, increase your oxygen by 2 to 3 L per minute. c. Avoid using an electric razor. d. Keep the oxygen tank at least 5 feet away from the stove.

ANS: C, D

Items that create a spark such as an electric razor should not be used while a nasal cannula is in use. Oxygen delivery systems should be at least 1.5 metres (5 feet) from any heat source.

No smoking is allowed on the premises. Oxygen is a medication. Increasing the oxygen litre flow for shortness of breath is similar to doubling heart, asthma, or other medications.

DIF: Cognitive Level: Application REF: Box 23.3: Oxygen Safety Guidelines OBJ: Discuss indications for oxygen therapy.

TOP: Oxygen Therapy Safety Guidelines KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse is checking the oxygen flow rate on several patients. All flowmeters are set at 2 L

per minute. The nurse should question this flow rate for which delivery system(s)? (Select all that apply.) a. Nasal cannula b. Simple face mask c. Oxymizer d. Venturi mask ANS: B, D

Flow rates for a nasal cannula are 1 to 6 L per minute, and flow rates for an oxymizer are 1 to 15 L per minute, so 2 L per minute is appropriate for either device. Flow rates for a simple face mask are 5 to 8 L per minute to prevent rebreathing of CO2. Flow rates for a Venturi mask are 4 to 12 L per minute,NanUdRaSsIpN ecG ifT icBr. atC eO isMnecessary to deliver a specific FiO2.

DIF: Cognitive Level: Application REF: Oxygen-Delivery Devices OBJ: Describe methods for administering oxygen therapy.

TOP: Flow Rates for Oxygen Delivery Systems KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 5. The nurse is caring for several patients who require oxygen therapy. The nurse anticipates a

prescription for noninvasive positive-pressure ventilation (NPPV) for the patients with which diagnoses? (Select all that apply.) a. Pulmonary edema b. Obstructive sleep apnea c. Stroke with dysphagia d. Congestive heart failure ANS: A, B, D

In the cardiac patient, NPPV reduces pulmonary edema because the increased alveolar pressure forces interstitial fluid out of the lungs and back into the pulmonary circulation. In patients who retain carbon dioxide, such as with obstructive sleep apnea, NPPV keeps the airway open and prevents upper airway collapse. In selected patients, such as those with postpolio syndrome and other neuromuscular diseases, congestive heart failure, sleep disorders, and pulmonary diseases, NPPV is often the treatment of choice in supporting ventilation without the hazards associated with endotracheal intubation. NPPV is contraindicated in patients at high risk for aspiration, such as after a stroke with dysphagia.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY DIF: Cognitive Level: Application REF: Skill 23.4 OBJ: Demonstrate use of noninvasive positive-pressure ventilation (NPPV) using continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP).

TOP: Noninvasive Ventilation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. The nurse is teaching a patient with asthma how to measure peak expiratory flow rate (PEFR).

What should be included in the teaching plan? (Select all that apply.) a. Assume a recumbent position before measuring PEFR. b. Take a deep breath in, exhale, then place the mouthpiece in the mouth and form a firm seal with the lips. c. After placing the mouthpiece in the mouth, blow out as hard and as fast as possible through the mouth in only one single breath. d. Measure PEFR three times and record the highest number.

ANS: C, D

To measure PEFR, the patient should be standing. If the patient is unable to stand, high-Fowler’s position or any other position that promotes optimum lung expansion should be used. The patient should take in a deep breath, place the mouthpiece in the mouth, and form a tight seal. Then the patient should blow out as hard and as fast as possible through the mouth in only one single breath. Two additional measurements are taken, and the highest number is recorded.

DIF: Cognitive Level: Application REF: PG 23.1 OBJ: Demonstrate obtaining peak expiratory flow rate (PEFR) measurements.

TOP: Use of a Peak Flowmeter KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

NURSINGTB.COM

7. The patient is placed on mechanical ventilation. After the initial settings have been applied,

the nurse should watch for which of the following complications? (Select all that apply.) a. Signs of decreased cardiac output b. Tension pneumothorax c. Pneumonia d. Failure to wean ANS: A, B, C

Multiple complications are associated with positive-pressure ventilation: decreased cardiac output, aspiration, tension pneumothorax, bronchospasm, laryngeal trauma, sinusitis, and ventilator-associated pneumonia. Failure to wean is not a major factor in starting the use of a ventilator; however, as the length of time needed for mechanical ventilation increases, the risk for failure to wean from the ventilator is increased.

DIF: Cognitive Level: Analysis REF: Principles for Practice OBJ: Demonstrate care of a patient receiving mechanical ventilation.

TOP: Initiation of Mechanical Ventilation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. The patient is on mechanical ventilation. Which actions by the nurse are appropriate? (Select

all that apply.) a. Keep the patient in a supine position. b. Note and mark the level of the endotracheal (ET) tube at the lips or nares. c. Have suction equipment available for immediate use.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY d. Perform mouth care at least twice daily.

ANS: B, C

The patient should be positioned with the head of bed elevated 30 to 45 degrees to reduce gastric reflux, thereby decreasing the risk for aspiration and ventilator-associated pneumonia.

Note and mark the level of the ET tube at the lips or nares. This provides a baseline for depth of tube placement and ensures that the tube is not too close to the carina or in the right mainstem bronchus. Set up suction equipment, including oral suctioning, to provide airway care and suctioning as needed of the ET or tracheostomy tube, to prevent plugging of the airway, and to reduce the risk for infection. Perform mouth care at least four times per 24 hours. Use a toothbrush and a solution such as chlorhexidine, which is effective in reducing oral bacteria and the risk for ventilator-associated pneumonia.

DIF: Cognitive Level: Application REF: Skill 23.5 OBJ: Demonstrate care of a patient receiving mechanical ventilation.

TOP: Care of the Patient on a Ventilator KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

NURSINGTB.COM

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 24: Performing Chest Physiotherapy Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The nurse receives prescriptions on several patients for chest percussion, vibration, and

shaking. The nurse is aware that chest physiotherapy manoeuvres are indicated for which patient? a. 18-year-old who sustained thoracic trauma from a motor vehicle accident b. 75-year-old with osteoporosis who is underweight c. 15-year-old with cystic fibrosis d. 20-year-old with a fractured clavicle ANS: C

Chest physiotherapy (CPT) and coughing manoeuvres assist with airway clearance of mucus in patients with retained tracheobronchial secretions. Secretions accumulate in the airways of patients with bronchitis, asthma, cystic fibrosis (CF), pneumonia, and bronchiectasis. Thoracic trauma, osteoporosis, and fracture of rib cage structures such as the clavicle contraindicate percussion, vibration, and shaking.

DIF: Cognitive Level: Comprehension REF: Purpose OBJ: Determine the need to modify or discontinue CPT manoeuvres.

TOP: Indications for CPT KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse auscultates the patients’ lung fields and notes congestion in several patients. The

nurse anticipates that postural dNrU aiR naSgI eN mG ayTbBe.uCseOdMfor the patient with which condition? a. Congestive heart failure (CHF) with pulmonary edema b. History of cigarette smoking with recent hemoptysis c. Chronic bronchitis with frequent coughing d. Pulmonary embolism after a long international flight ANS: C

Secretions accumulate in patients with bronchitis, asthma, cystic fibrosis (CF), pneumonia, and bronchiectasis. Contraindications for postural drainage include pulmonary edema associated with congestive heart failure, active hemoptysis, and pulmonary embolism.

DIF: Cognitive Level: Analysis REF: Skill 24.1 OBJ: Determine the need to modify or discontinue CPT manoeuvres.

TOP: Contraindications and Indications for Postural Drainage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse is teaching a caregiver how to perform postural drainage at home for a patient with

chronic bronchitis. What instruction should the nurse provide? a. Plan to perform postural drainage three times a day about 1 hour after meals. b. Don’t give any pain medication within 2 hours of performing postural drainage. c. Perform postural drainage 20 minutes after the patient uses the inhaler. d. Encourage the patient to remain in each position for 30 minutes to adequately drain the area.

ANS: C

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Patients receiving inhaled bronchodilators, nebulizers, or aerosol treatments should have postural drainage performed 20 minutes after such therapy. If a patient’s pain is 4 or greater, analgesics should be administered 20 minutes before chest physiotherapy (CPT) manoeuvres.

Pain control is essential for the patient to actively participate and cough forcefully to clear the airways. Treatments should not overlap with meals. Avoid postural drainage 1 to 2 hours before and after meals. The patient should maintain each position for 10 to 15 minutes.

DIF: Cognitive Level: Application REF: Skill 24.1 OBJ: Explain how to prepare a patient and caregiver for the performance of each CPT manoeuvre.

TOP: Teaching Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The nurse receives a prescription for a high-frequency chest wall oscillation (HFCWO) vest

airway clearance system on several patients. The nurse should question the prescription on the patient with which condition? a. Chronic bronchitis b. Asthma c. Cystic fibrosis d. Pleural effusion ANS: D

The HFCWO vest airway clearance system is a respiratory rehabilitation device designed to aid sputum clearance. Patients with chronic conditions such as cystic fibrosis, chronic bronchitis, and asthma appear to receive the greatest benefit from this type of treatment. Chest physiotherapy (CPT) is contraindicated in patients with pleural effusion.

DIF: Cognitive Level: Application REF: High-Frequency Chest Wall Oscillation OBJ: Perform the outlined CPT N mU anRoS euI vrNesG, T inB cl. udCinOgMstandard and modified versions.

TOP: Acapella Device KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. The nurse is teaching a patient how to use a positive expiratory pressure (PEP) device. What

instruction should the nurse give to the patient? a. Take a full deep breath in and fill your lungs. b. Hold your breath for 5 to 10 seconds after placing the mouthpiece in your mouth. c. Cough forcefully to clear your lungs while maintaining a tight seal on the mouthpiece. d. Exhale slowly for 3 to 4 seconds through the device while it vibrates.

ANS: D

Instruct the patient to try not to cough and to exhale slowly for 3 to 4 seconds through the device while it vibrates. The patient should be instructed to take in a breath that is larger than normal, but not to fill the lungs completely—about 75% of inspiratory capacity. Hold the breath for 2 to 3 seconds, and try not to cough.

DIF: Cognitive Level: Application REF: Procedural Guideline 24.1 OBJ: Describe discharge teaching and planning related to the use of each CPT manoeuvre in the home setting.

TOP: Positive Expiratory Pressure (PEP) Device KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 6. A patient has received instructions on the use of a positive expiratory pressure (PEP) device.

Which action by the patient indicates an understanding of the teaching? a. Complains of not being able to use an aerosol medication with the device b. Turns the frequency adjustment dial to medium resistance c. After completing one cycle, repeats for 2 more breaths d. After removing the mouthpiece, performs 1 to 2 forceful exhalations and “huff” coughs ANS: D

When the cycles are completed, the mouthpiece is removed and 1 to 2 forceful exhalations and “huff” coughs are performed. If aerosol medication therapy is prescribed, a nebulizer is attached to the end of the Acapella device. For the initial setting, the frequency adjustment dial should be set at the lowest resistance setting. The cycle should be repeated for 5 to 10 breaths as tolerated.

DIF: Cognitive Level: Application REF: Procedural Guideline 24.1 OBJ: Describe discharge teaching and planning related to the use of each CPT manoeuvre in the home setting.

TOP: Acapella Device KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. The health care provider prescribes percussion on a patient to help clear airway secretions.

Which action by the nurse is appropriate? a. Performing percussion over the ribs, while avoiding the clavicles and sternum b. Administering pain medication before performing the percussion because the vibrations will be painful c. Performing percussion during exhalation only with the flat part of the palm NyUsRliS d. Creating a rocking motion b ghItlNyGleTaB ni. ngCoOnMthe patient’s chest ANS: A

Percussion is performed by clapping the chest wall with cupped hands over the ribs only. The clavicles, breast tissue, sternum, spine, waist, and abdomen should not be used. If done correctly, percussion painlessly sets up vibrations in the chest to dislodge retained secretions.

Vibration is done during exhalation only with the flat part of the palm. Shaking requires the caregiver to slightly lean on a patient’s chest and create a rocking motion.

DIF: Cognitive Level: Application REF: Procedural Guideline 24.2 OBJ: Perform the outlined CPT manoeuvres, including standard and modified versions.

TOP: Percussion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. A patient who is very frail and thin with osteoporosis has just undergone abdominal surgery.

The nurse anticipates that which technique will be used to control respiratory secretions in this patient? a. Forceful coughing b. Percussion c. Vibration d. Shaking ANS: A

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Thin, frail patients with osteoporosis are most susceptible to injury and are taught other secretion control measures (e.g., forceful coughing and humidification). Percussion, vibration, and shaking are contraindicated with rib fracture; fracture of other rib cage structures such as clavicle or sternum; pain; severe dyspnea; and severe osteoporosis.

DIF: Cognitive Level: Analysis REF: Procedural Guideline 24.2 OBJ: Describe expected and unexpected outcomes of each CPT manoeuvre.

TOP: Percussion, Shaking, and Vibration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. Percussion and vibration are prescribed on a patient with retained pulmonary secretions.

Which action by the student nurse should the nursing instructor question? a. Performs percussion for 3 to 5 minutes in each position as tolerated b. Uses the wrist and elbow to create movement when performing percussion c. While the patient inhales, gently pushes down and vibrates the chest wall with the flat part of the hand d. Repeats the vibration three times and then instructs the patient to take a deep breath and cough while exhaling ANS: C

Vibration is performed while the patient is exhaling, not inhaling. Percussion is performed for 3 to 5 minutes in each position. When clapping, most arm movement comes from the elbow and wrist joints. Vibration is repeated three times and then the patient cascade coughs by taking a deep breath and doing a series of small coughs until the end of the breath.

DIF: Cognitive Level: Application REF: Procedural Guideline 24.2 OBJ: Perform the outlined CPT manoeuvres, including standard and modified versions.

TOP: Percussion KEY: NursNinUgRPS roI ceNssGSTteBp. : IC mO plM ementation MSC: NCLEX: Physiological Integrity 10. A patient has retained secretions in the right and left lower lobe superior bronchi. A nurse is

demonstrating to the caregiver how to perform percussion and vibration. Which action by the nurse is appropriate? a. Positioning the patient in a chair leaning forward on a table b. Asking the patient to lie flat on the stomach with a pillow under the stomach c. Assisting the patient to the right side with the arm overhead and the feet elevated d. Asking the patient to lie on the left side with the head elevated ANS: B

Have the patient lie flat on the stomach with a pillow under the stomach. Percuss and vibrate below the scapula on either side of the spine. Sitting up and leaning forward is the position for drainage of the left and right upper lobe posterior apical branch. Having the patient lying on the right side in Trendelenburg’s position with the arm overhead facilitates drainage of the left upper lobe lingular bronchi. On the left side with the head elevated is not a correct position for any drainage procedure.

DIF: Cognitive Level: Application REF: Table 24.1: Positions and Procedures for Drainage, Percussion, and Vibration OBJ: Explain how to prepare a patient and caregiver for the performance of each CPT manoeuvre.

TOP: Patient Positioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 11. The nurse positions the patient flat on the back with a small pillow under the knees to drain

the right and left a. anterior upper lobe bronchi b. anterior lower lobe bronchi c. posterior upper lobe bronchi d. posterior lower lobe bronchi

.

ANS: A

The patient is positioned flat on the back with a small pillow under the knees for the right and left anterior upper lobe bronchi.

DIF: Cognitive Level: Application REF: Table 24.1: Positions and Procedures for Drainage, Percussion, and Vibration OBJ: Explain how to prepare a patient and caregiver for the performance of each CPT manoeuvre.

TOP: Positions for CPT KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The patient is complaining of feeling congested. After assessing the patient, the nurse places

the patient in the proper position and claps his or her cupped hands against the patient’s thorax. He or she does this because he or she is aware that assists in loosening retained secretions from the airway. a. warmth b. percussion c. massage d. therapeutic touch ANS: B

Percussion involves clapping thNeUcR heSsI tw thCcO upMped hands. It sets up vibrations in the NaGllTwBi. chest to dislodge retained secretions from the airway.

DIF: Cognitive Level: Comprehension REF: Procedural Guideline 24.2 OBJ: Assess for the need to perform chest physiotherapy (CPT) manoeuvres.

TOP: Percussion KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. The system that lines the internal lumen of the tracheobronchial tree and consists of a thin

layer of mucus that constantly is propelled toward the larynx by cilia is called the . a. normal flora b. peristaltic system c. mucociliary transport system d. humidification system ANS: C

In the normal lung, the mucociliary transport system clears the airways of excessive mucus and inhaled particles. This system lines the internal lumen of the entire tracheobronchial tree and consists of a thin layer of mucus that is constantly being propelled toward the larynx by cells that have hairlike projections called cilia.

DIF: Cognitive Level: Comprehension REF: Principles for Practice OBJ: Assess for the need to perform chest physiotherapy (CPT) manoeuvres.

TOP: Mucociliary Transport System KEY: Nursing Process Step: Assessment

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is teaching the family of a patient with cystic fibrosis how to use a high-frequency

chest wall oscillation (HFCWO) vest. The nurse informs the family that this device will do which of the following? (Select all that apply.) a. Allow patient to perform other tasks while receiving therapy. b. Improve patient adherence to chest physiotherapy. c. Assist in the removal of secretions from the lungs. d. Decrease the viscosity of mucus so coughing it up will be easier.

ANS: A, B, C, D

The use of HFCWO such as the Vest airway clearance system often improves patient attitude toward chest physiotherapy because the patient is able to perform other tasks while receiving therapy. The HFCWO therapy assists with the removal of secretions from the lungs and decreases the viscosity of mucus, making it easier to cough productively.

DIF: Cognitive Level: Application REF: High-Frequency Chest Wall Oscillation OBJ: Assess for the need to perform chest physiotherapy (CPT) manoeuvres.

TOP: Mechanical Devices KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse is planning to perform postural drainage on a patient who is receiving continuous

tube feedings. What should the nurse do before performing the treatment? (Select all that apply.) a. Stop the tube feedings for 1NtU oR 2 ShI ouNrsGbTeB fo.reCaOnM d after postural drainage. b. Check for residual feeding in the patient’s stomach and hold treatment if greater than 100 mL. c. Give the prescribed inhaled bronchodilator 20 minutes before the procedure. d. Auscultate all lung fields, assess vital signs, and draw arterial blood gas (ABG) levels.

ANS: B, C

Stop all continuous gastric tube feedings for 30 to 45 minutes before postural drainage. Check for residual feeding in the patient’s stomach; if greater than 100 mL, hold treatment. If the patient is receiving inhaled bronchodilator, nebulizer, or aerosol treatment, postural drainage is performed 20 minutes after such therapy is provided. Assessing lung sounds and vital signs, but not blood gas levels, is routinely done. Instead, pulse oximetry readings can be assessed.

DIF: Cognitive Level: Application REF: Procedural Guideline 24.1 OBJ: Determine the need to modify or discontinue CPT manoeuvres.

TOP: Preparation for CPT KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The nurse is reviewing medical records on several patients. Which findings reported in the

chart indicate the need for postural drainage? (Select all that apply.) a. Atelectasis reported on chest x-ray examination b. Thick, sticky, tenacious, green secretions noted in the nurse’s notes c. Multiple rib fractures noted on chest x-ray examination d. Chest x-ray report indicating pneumonia with collapse of right lower lobe

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

ANS: A, B, D

Chest x-ray film changes consistent with atelectasis, lobar collapse pneumonia, or bronchiectasis indicate a need for postural drainage. Other signs are ineffective coughing and thick, sticky, tenacious, discoloured secretions that are difficult to cough up.

Rib fractures are a contraindication for postural drainage.

DIF: Cognitive Level: Application REF: Procedural Guideline 24.1 OBJ: Assess for the need to perform chest physiotherapy (CPT) manoeuvres.

TOP: Indications for Postural Drainage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse receives a prescription for postural drainage using Trendelenburg’s position. On

which patients should the nurse question the prescription? (Select all that apply.) a. Patient with a history of gastroesophageal reflux disease (GERD) b. Postoperative patient with a distended abdomen c. Patient with blood pressure of 180/100 d. Patient with bronchiectasis on chest x-ray examination ANS: A, B, C

Trendelenburg’s position is contraindicated for uncontrolled hypertension, distended abdomen, esophageal surgery, recent gross hemoptysis, and uncontrolled airway at risk for aspiration. When patients have a risk for or history of GERD, the head-down position should not be used. Bronchiectasis is an indication for postural drainage.

DIF: Cognitive Level: Application REF: Box 24.1: Contraindications for Postural Drainage OBJ: Determine the need to modify or discontinue CPT manoeuvres.

TOP: Contraindications to Trendelenburg’s Position NURSINGTB.COM KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 25: Airway Management Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. A patient with a tracheostomy tube has thick, tenacious mucus that is difficult to remove. The

nurse should choose which technique to suction the airway? a. Normal saline instillation (NSI) before suctioning b. Dry suctioning one time followed by NSI with suctioning two more times c. Dry suctioning as long as the heart rate is greater than 60 beats per minute d. Dry suctioning ANS: D

Normal saline instillation (NSI) into artificial airways is no longer recommended as standard practice. Clinical studies show that suctioning with or without NSI produces similar amounts of secretions and significant decreases in oxygen saturation. Potential side effects include increases in heart rate for 4 to 5 minutes after suctioning using NSI as opposed to dry suctioning. NSI has the potential to increase ventilator-associated pneumonia because bacteria from the upper airway can be dislodged to the lower airway.

DIF: Cognitive Level: Application REF: Safety Guidelines OBJ: Correctly perform oropharyngeal, nasopharyngeal and nasotracheal, and tracheal suctioning; endotracheal care; and tracheostomy tube care.

TOP: Normal Saline Instillation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. A patient using a nasal cannulaNhU asRgSuI rgNliG ngTB on.iC nsOpM iration. The nurse notes a productive

cough but the inability to clear the secretions from the mouth. Which action should the nurse take first to prepare for oropharyngeal suctioning? a. Apply clean gloves and a mask. b. Insert the suction device to the back of the throat. c. Remove the patient’s nasal cannula. d. Connect the tubing to a standard suction catheter.

ANS: A

Perform hand hygiene and apply clean gloves. Apply a mask or face shield if splashing is likely. Insert the device into the mouth along the gum line to the pharynx. Remove the patient’s oxygen mask, if present. A nasal cannula may remain in place. Connect one end of the connecting tubing to the suction machine and the other to a Yankauer suction catheter.

DIF: Cognitive Level: Application REF: Skill 25.2 OBJ: Correctly perform oropharyngeal, nasopharyngeal and nasotracheal, and tracheal suctioning; endotracheal care; and tracheostomy tube care.

TOP: Oropharyngeal Suctioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. After oropharyngeal suctioning of a patient, the nurse notes bloody secretions in the suction

catheter and tubing. What should the nurse do next? a. Increase the suction pressure. b. Provide additional oxygen.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY c. Reduce the frequency of oral hygiene. d. Check the suction catheter for nicks.

ANS: D

Observe the catheter tip for nicks, which can cause mucosal trauma. The nurse should assess the oral cavity for trauma or lesions, reduce the amount of suction pressure used, provide supplemental oxygen only if respiratory distress occurs, and increase the frequency of oral hygiene.

DIF: Cognitive Level: Application REF: Skill 25.1 OBJ: Describe the nursing interventions for airway management.

TOP: Oropharyngeal Suctioning KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 4. The nurse is caring for an infant who has been vomiting and is having difficulty breathing.

What actions by the nurse are appropriate for suctioning the infant? a. Place the infant in a side-lying position. b. Suction only when a large amount of mucus is present. c. Suction for only 30 seconds. d. Compress the bulb syringe after it is placed in the nostril.

ANS: A

Position infants with breathing problems or excessive vomitus in a side-lying position.

Airways of infants and children are smaller than those of an adult; even small amounts of mucus can cause airway obstruction. Suction should be completed for only 5 seconds with 30 to 60 seconds in between for the patient to reoxygenate. Compress the bulb syringe before insertion to prevent forcing secretions into the infant’s bronchi.

NURSINGTB.COM DIF: Cognitive Level: Application REF: Skill 25.1 OBJ: Describe the nursing interventions for airway management.

TOP: Pediatric Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. A patient on mechanical ventilation with an endotracheal tube requires suctioning. A closed

in-line catheter is in place. Which action by the nurse is appropriate? a. Use manual ventilation to hyperoxygenate the patient with 100% oxygen via Ambu bag. b. Push the catheter and slide the plastic sleeve back when the patient exhales. c. Push the catheter in until resistance is felt or the patient coughs. d. Apply suction for no longer than 30 seconds as the catheter is removed.

ANS: C

The catheter is pushed in while the plastic sleeve is slid back between the thumb and forefinger until resistance is felt or the patient coughs. Hyperoxygenation is done by adjusting the FiO2 setting on the ventilator. Manual ventilation is not recommended. The catheter is pushed in when the patient inhales. Suction is applied for no longer than 15 seconds.

DIF: Cognitive Level: Application REF: Procedural Guideline 25.1 OBJ: Correctly perform oropharyngeal, nasopharyngeal and nasotracheal, and tracheal suctioning; endotracheal care; and tracheostomy tube care.

TOP: Closed (In-line) Suction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

6. The nurse is assessing several patients who have returned from surgery. Which finding most

likely indicates a need for suctioning? a. Complaint of pain when breathing b. Cough producing thick yellow mucus c. Oxygen saturation level of 88% d. Drowsiness and respiratory rate of 8 ANS: C

When a patient’s oxygen saturation falls to less than 90%, this is a good indicator of the need for suctioning. Pain with breathing is probably related to the surgery. If a cough is productive, suctioning is not necessary. Drowsiness and a decreased respiratory rate may be due to administration of pain medications such as opioids.

DIF: Cognitive Level: Application REF: Principles for Practice OBJ: Discuss the indications for airway suctioning.

TOP: Indications for Suctioning KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. A patient with head trauma after a motor vehicle accident is on mechanical ventilation with an

endotracheal tube. Which action by the nurse will reduce the risk for elevations in intracranial pressure during suctioning? a. Avoid hyperoxygenating the patient before suctioning. b. Insert the suction catheter just to the end of the endotracheal tube. c. Apply suction while inserting the catheter. d. Limit suctioning to two times with each suctioning procedure.

ANS: D

Suctioning can cause elevationN s iUnRinStrIaN crG anTiaBl .pC reO ssM ure in patients with head injury. To reduce the risk, the nurse should hyperoxygenate the patient before suctioning and should suction only twice with each suctioning procedure. The catheter is inserted past the end of the endotracheal tube until resistance is met to adequately remove secretions from the airway.

Suction should be applied while the catheter is removed.

DIF: Cognitive Level: Application REF: Skill 25.2 OBJ: Describe the nursing interventions for airway management.

TOP: Increased Intracranial Pressure With Suctioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The student nurse is preparing to perform nasotracheal suctioning on an adult patient wearing

a face mask. Which action by the student should the nursing instructor question? a. Increasing the oxygen flow rate for the face mask and asking the patient to deep breathe slowly before suctioning b. Inserting the catheter into the nares slanting slightly downward c. Asking the patient to swallow while the catheter is being inserted d. Inserting the catheter about 8 inches without applying suction ANS: C

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

The suction catheter should not be inserted during swallowing because it will most likely enter the esophagus. Insert during inhalation because the epiglottis is open. The patient should be hyperoxygenated before suctioning. The oxygen flow rate can be increased on the face mask, and the patient can deep breathe slowly to accomplish this. The catheter should be inserted along the natural course of the nares—slightly slanted downward. In adults the catheter is inserted about 20 cm (8 inches).

DIF: Cognitive Level: Application REF: Skill 25.2 OBJ: Correctly perform oropharyngeal, nasopharyngeal and nasotracheal, and tracheal suctioning; endotracheal care; and tracheostomy tube care.

TOP: Nasotracheal Suctioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The nurse is providing nasotracheal suctioning for a 13-year-old patient with secretions in the

throat and trachea. Which action by the nurse demonstrates proper technique? a. Applying sterile petroleum jelly to the distal tip of the suction catheter b. Applying clean gloves to both hands c. Inserting the suction catheter 16 to 20 cm (6–8 inches) during inspiration d. Suctioning the pharynx first and then the trachea ANS: C

In older children the suction catheter is inserted about 16 to 20 cm (6–8 inches). The catheter is always inserted during inspiration. The catheter should be lubricated with water-soluble lubricant to avoid lipid aspiration pneumonia from a petroleum-based gel. The procedure requires sterile gloves, at least on one hand. The trachea should be suctioned before the pharynx because the mouth and the pharynx contain more bacteria than the trachea.

DIF: Cognitive Level: ApplicatiN onURSINRGETFB : .SC kiO llM 25.2 OBJ: Correctly perform oropharyngeal, nasopharyngeal and nasotracheal, and tracheal suctioning; endotracheal care; and tracheostomy tube care.

TOP: Nasotracheal Suctioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. The nurse is performing nasotracheal suctioning for a patient. Which action by the nurse is

appropriate? a. Applying intermittent suctioning while slowly withdrawing the suction catheter b. Carefully pushing the suction catheter in and out while applying suction c. Applying suction for 15 seconds or less d. Asking the patient to deep breathe for 15 seconds before passing the catheter a second time ANS: C

Suction should be applied for 15 seconds or less to avoid cardiopulmonary compromise from hypoxemia or vagal overload. Continuous suction and back and forth rotation of the catheter are now recommended because studies show that tracheal damage from intermittent and continuous suctioning was similar. The catheter should be rotated back and forth, not pushed in and out. At least 1 minute should be allowed between suction passes for ventilation and oxygenation.

DIF: Cognitive Level: Application REF: Skill 25.2 OBJ: Correctly perform oropharyngeal, nasopharyngeal and nasotracheal, and tracheal suctioning; endotracheal care; and tracheostomy tube care.

TOP: Nasotracheal Suctioning

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. The nurse is performing nasotracheal suctioning on a patient. The nurse should discontinue

the suctioning if which of the following occurs? a. The patient coughs as the catheter is inserted. b. The heart rate decreases from 84 beats per minute to 60 beats per minute. c. An increase in pulse occurs from 74 beats per minute to 94 beats per minute. d. Oxygen saturation levels decrease from 97% to 94%.

ANS: B

If the patient’s pulse drops by more than 20 beats per minute, suctioning should be discontinued. The patient should cough, and this is expected. If the patient’s pulse increases by more than 40 beats per minute or pulse oximetry falls to less than 90% or 5% from baseline, suctioning should be discontinued.

DIF: Cognitive Level: Analysis REF: Skill 25.2 OBJ: Identify safety guidelines for managing a patient’s airway.

TOP: Discontinuation of Suction KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 12. The nurse is suctioning a patient with an endotracheal tube. Which action should the nurse

take when the patient develops respiratory distress? a. Quickly remove the catheter and carefully reinsert it. b. Continue to apply intermittent suction to remove thick secretions. c. Administer oxygen directly through the suction catheter. d. Withdraw the catheter and encourage the patient to cough and deep breathe.

NURSINGTB.COM

ANS: C

If the patient develops respiratory distress during suctioning, the catheter should be immediately withdrawn and supplemental oxygen and breaths supplied as needed. In an emergency, disconnect suction and attach oxygen at the prescribed flow rate through the catheter.

DIF: Cognitive Level: Application REF: Skill 25.2 OBJ: Describe the nursing interventions for airway management.

TOP: Respiratory Distress While Suctioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. The nurse has completed suctioning a patient’s airway. Which action should the nurse take

first? a. Reduce the suction level to medium. b. Remove the face shield and save for future suctioning. c. Reposition the patient and assist with oral hygiene using sterile gloves. d. Pull the gloves off over the rolled catheter and discard.

ANS: D

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

When suctioning is completed, disconnect the catheter from the connecting tubing. Roll the catheter around the fingers of the dominant hand. Pull the glove off inside out so that the catheter remains coiled in the glove. Pull off the other glove over the first glove in the same way. Discard in an appropriate receptacle. The suction device should be turned off when suctioning is complete. There is no further need for suction. Remove the face shield and discard into an appropriate receptacle. Apply clean gloves to give personal care.

DIF: Cognitive Level: Application REF: Skill 25.2 OBJ: Correctly perform oropharyngeal, nasopharyngeal and nasotracheal, and tracheal suctioning; endotracheal care; and tracheostomy tube care.

TOP: Completing Airway Suctioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. The nurse is preparing to suction an infant with a tracheostomy tube. Which action by the

nurse follows appropriate procedure? a. Using a suction catheter that is half the diameter of the tracheostomy tube b. Suctioning 0.5 cm to 1.25 cm (0.2–0.5 inches) beyond the tip of the tracheostomy tube c. Hyperoxygenating with 90% oxygen to avoid oxygen toxicity d. Using less than 150 mm Hg negative pressure ANS: A

Suction catheters for pediatrics should be half the diameter of the child’s tracheostomy tube.

The distance suctioned should be no greater than 0.5 cm (0.2 inches) beyond the tip of the artificial airway. To determine distance, the catheter is placed near a sample artificial airway.

Hyperoxygenate with 100% oxygen in pediatric patients. Negative pressure for suctioning should not exceed 100 mm Hg.

NURSINGTB.COM

DIF: Cognitive Level: Application REF: Endotracheal or Tracheostomy Suctioning OBJ: Correctly perform oropharyngeal, nasopharyngeal and nasotracheal, and tracheal suctioning; endotracheal care; and tracheostomy tube care.

TOP: Pediatric Considerations for Suctioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. A patient has been on mechanical ventilation with an endotracheal tube for 1 week. Which

intervention by the nurse will help prevent ventilator-associated pneumonia (VAP)? a. Providing oral care with a toothbrush at least twice daily b. Changing the ventilator circuits at least every 72 hours c. Removing subglottal secretions before every position change d. Maintaining endotracheal cuff pressures at 10 cm H2O ANS: C

Subglottal secretions should be removed every 4 to 6 hours or before position changes. Oral care should be provided with a chlorhexidine swab or toothbrush (if chlorhexidine is contraindicated) every 8 hours. The ventilator circuits should be changed every 48 hours because of potential bacteria within the tubing condensation. The endotracheal cuff pressures should be maintained at 20 cm H2O to decrease movement of secretions into the lower airways.

DIF: Cognitive Level: Application REF: Evidence-Informed Practice OBJ: Describe the nursing interventions for airway management.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY TOP: Ventilator-Associated Pneumonia (VAP) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 16. The nurse is caring for a patient with an oral endotracheal tube in place. Which intervention

by the nurse demonstrates proper procedure when providing endotracheal tube care? a. Determining proper endotracheal tube depth by noting the length of tube beyond the gum line b. Instructing the assistant to hold the tube away from the lips while changing the tape c. Removing the oral airway if the patient is actively biting down after the tape is removed from the endotracheal tube d. Repositioning the tube on the opposite side or at the centre of the mouth at least every 24 to 48 hours ANS: D

The endotracheal tube should be repositioned to the opposite side or at the centre of the mouth every 24 to 48 hours to prevent formation of pressure sores at the sides of the mouth. The proper depth of the endotracheal tube is determined by noting the centimetre mark at the lip or gum line. This line is marked on the tube and is recorded in the patient’s record at the time of intubation. The tube should not be held away from the lips because this allows too much “play” in the tube and increases the risk for tube movement and accidental extubation. The oral airway should not be removed if the patient is actively biting down until tape partially or completely secures the tube.

DIF: Cognitive Level: Application REF: Skill 25.3 OBJ: Correctly perform oropharyngeal, nasopharyngeal and nasotracheal, and tracheal suctioning; endotracheal care; and tracheostomy tube care.

TOP: Endotracheal Tube Care N U R S I N GTB.COM KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. The nurse is assessing a patient who is intubated and on a ventilator. When listening above the

sternal notch with a stethoscope, the nurse notes a minimal amount of air leak at the end of inspiration. Which action by the nurse is appropriate? a. Remove all air from the cuff and reinflate the cuff until no air leak is present. b. Note that the cuff is properly inflated. c. Notify the health care provider. d. Suction the patient.

ANS: B

The cuff should be inflated to minimal leak. If the air leak is audible with the ear, it is too large. A properly inflated cuff should have a minimal air leak that is heard only with a stethoscope. The air should not be removed, the health care provider does not need to be notified, and the patient does not need to be suctioned because the cuff is properly inflated.

DIF: Cognitive Level: Application REF: Skill 25.3 OBJ: Correctly inflate a cuff on an endotracheal or tracheostomy tube.

TOP: Checking Air Leak KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 18. The student nurse is providing tracheostomy care to a patient who has intratracheal secretions

and a damp tracheostomy dressing and ties. Which action by the student should the nursing instructor question? a. Suctioning the tracheostomy tube before removing the soiled tracheostomy dressing b. Assisting the patient to semi-Fowler’s position c. Placing new tracheostomy ties before cutting the old ties d. Cutting gauze pads to place around the tracheostomy tube ANS: D

Do not use scissors to cut gauze pads because they may shed fibres that could be inhaled by the patient. Use a manufactured pad with a slit. Suctioning the tube removes secretions to avoid occluding the outer cannula while the inner cannula is removed. Usually a supine or semi-Fowler’s position is used to promote patient comfort and prevent muscle strain for the nurse. If changing ties without an assistant, the old ties are not cut until the new ties are securely in place.

DIF: Cognitive Level: Application REF: Skill 25.4 OBJ: Correctly perform oropharyngeal, nasopharyngeal and nasotracheal, and tracheal suctioning; endotracheal care; and tracheostomy tube care.

TOP: Tracheostomy Tube Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. The nurse is providing care to a patient with a tracheostomy tube that has an inner cannula.

Which intervention by the nurse follows proper procedure for tracheostomy tube care? a. Carefully removes the inner cannula and places it in a basin of 1:10 bleach solution b. Scrubs the inner cannula on the inside and outside with a 1:10 bleach solution c. After scrubbing the inner caNnU nR ulS a,IriNnG seT sB it.wCitO hM normal saline d. Uses a wet 4  4 gauze and cleans the inside of the outer cannula ANS: C

After the inner cannula is thoroughly cleaned, it is rinsed with normal saline. The inner cannula is removed and is placed in a basin of normal saline to loosen secretions. It is scrubbed and then rinsed with normal saline. The outer cannula is not cleaned on the inside.

The exposed outer cannula surfaces at the stoma are dried with a 4  4 gauze to prevent a moist environment and prohibit microorganism growth and skin excoriation.

DIF: Cognitive Level: Application REF: Skill 25.4 OBJ: Change a tracheostomy tube or inner cannula.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Tracheostomy Tube Care

20. A patient with a tracheostomy tube is accidentally extubated. What should the nurse do

immediately? a. Call the health care provider. b. Mechanically ventilate the patient. c. Insert a new tracheostomy tube. d. Hold the stoma open with the fingertips.

ANS: C

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Replace the old tracheostomy tube with a new tube. Some experienced nurses or respiratory therapists may be able to quickly reinsert the tracheostomy tube. A spare tracheostomy tube of the same size and kind should be kept at the bedside in the event of emergency replacement.

Notify the health care provider after re-establishing the airway. Be prepared to manually ventilate the patient with an Ambu bag if respiratory distress develops until the tracheostomy is replaced. An endotracheal tube of the same size can be inserted in the stoma in an emergency.

DIF: Cognitive Level: Application REF: Skill 25.4 OBJ: Correctly perform oropharyngeal, nasopharyngeal and nasotracheal, and tracheal suctioning; endotracheal care; and tracheostomy tube care.

TOP: Accidental Decannulation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. When assessing a patient’s tracheostomy site, the nurse notes redness and inflammation

around the stoma. Which intervention can the nurse provide to address this problem? a. Decrease the frequency of tracheostomy care. b. Apply a dry gauze dressing just under the stoma. c. Remove the ties at frequent intervals. d. Apply a topical antibacterial solution and allow it to dry.

ANS: D

Apply a topical antibacterial solution and allow it to dry. Increase the frequency of tracheostomy care. Apply a hydrocolloid or transparent dressing just under the stoma to protect the skin from breakdown. Consult with a skin-care specialist. Adjust the ties or apply new ones when the ties are loose or tight. Never remove the ties.

DIF: Cognitive Level: ApplicatiN onURSINRGETFB : .SC kiO llM 25.4 OBJ: Describe the nursing interventions for airway management.

TOP: Stomal Inflammation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. The nurse is assessing a patient with an endotracheal tube on mechanical ventilation. Which

assessment finding indicates a partially deflated cuff? a. Increased exhaled tidal volume b. Spasmodic coughing c. Tense test balloon on the endotracheal tube d. Vocalizations by the patient ANS: D

A partially deflated cuff allows secretions to enter the trachea and permits vocalization. Other signs of an underinflated cuff are decreased exhaled tidal volume, a flaccid test balloon on the tube, and gurgling on expiration. An overinflated cuff can cause spasmodic coughing and a tense test balloon on the tube.

DIF: Cognitive Level: Analysis REF: Skill 25.3 OBJ: Correctly inflate a cuff on an endotracheal or tracheostomy tube.

TOP: Underinflated Cuff KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 23. The nurse is assessing a patient with an endotracheal tube and notes an audible air leak when

standing by the patient. Which intervention should the nurse perform first to address this problem? a. Deflating the cuff of the endotracheal tube b. Repositioning the patient or tube c. Inserting a new endotracheal tube d. Notifying the health care provider ANS: B

If an air leak is audible with the ear, it is too large. Repositioning the patient or the tube may correct the problem. Reinflation of the cuff may be necessary. Prepare for insertion of a new tube by the health care provider or trained personnel if the cuff ruptures. Repositioning and reinflating the cuff are performed before the health care provider is notified.

DIF: Cognitive Level: Analysis REF: Skill 25.4 OBJ: Correctly inflate a cuff on an endotracheal or tracheostomy tube.

TOP: Air Leak KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. Too much oxygen reduces the drive to breathe in patients with chronic a. hypocapnia b. hypercapnia c. hyponatremia d. hypernatremia

.

ANS: B

Too much oxygen reduces the drive to breathe in patients with chronic hypercapnia (elevated arterial carbon dioxide tension)N. URSINGTB.COM DIF: Cognitive Level: Understanding REF: Skill 25.2 OBJ: Identify safety guidelines for managing a patient’s airway.

TOP: Hypercapnia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 25. An adult patient has extremely copious and thick oral secretions. The nurse provides

oropharyngeal suctioning using a a. Yankauer b. bulb c. nasal aspirator d. inflated cuff

suction device.

ANS: A

A Yankauer, or tonsillar tip, suction device is used for oropharyngeal suctioning. This catheter is used instead of a standard suction catheter when oral secretions are extremely copious and thick, because it can handle large volumes of secretions better than a standard suction catheter can. The Yankauer suction catheter is angled to facilitate removal of secretions through a patient’s mouth.

DIF: Cognitive Level: Application REF: Skill 25.2 OBJ: Correctly perform oropharyngeal, nasopharyngeal and nasotracheal, and tracheal suctioning; endotracheal care; and tracheostomy tube care.

TOP: Yankauer Suction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

26. A plastic or rubber tube that is inserted through the nares or mouth past the epiglottis and

vocal cords to maintain an airway is known as an a. nasogastric tube b. nasoduodenal tube c. endotracheal tube d. tracheostomy tube

.

ANS: C

An endotracheal (ET) tube is inserted through the nares (nasal ET tube) or the mouth (oral ET tube) past the epiglottis and vocal cords, into the trachea. ET tubes usually are made of plastic or rubber.

DIF: Cognitive Level: Understanding REF: Endotracheal Tubes OBJ: Correctly perform oropharyngeal, nasopharyngeal and nasotracheal, and tracheal suctioning; endotracheal care; and tracheostomy tube care.

TOP: Endotracheal (ET) Tubes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 27. A

is inserted directly into the trachea through a small incision made in the patient’s neck. a. nasogastric tube b. nasoduodenal tube c. endotracheal tube d. tracheostomy tube ANS: D

A tracheostomy tube is inserted directly into the trachea through a small incision made in the patient’s neck.

NURSINGTB.COM DIF: Cognitive Level: Understanding REF: Tracheostomy Tubes OBJ: Correctly perform oropharyngeal, nasopharyngeal and nasotracheal, and tracheal suctioning; endotracheal care; and tracheostomy tube care.

TOP: Tracheostomy Tube KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is assessing the risk for aspiration of gastric contents into the lungs resulting in

airway obstruction. The nurse identifies patients with which conditions as creating increased risk? (Select all that apply.) a. Presence of a gastrostomy feeding tube b. History of smoking two packs per day for 30 years c. Head injury with a decreased level of consciousness d. Stroke with dysphagia ANS: A, C, D

Conditions that increase the patient’s risk for aspiration include enteral feeding tubes or other nasal or oral gastric tubes, a decreased level of consciousness, and a decreased swallowing ability.

DIF: Cognitive Level: Application REF: Safety Guidelines OBJ: Identify safety guidelines for managing a patient’s airway.

TOP: Risk for Aspiration KEY: Nursing Process Step: Assessment

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY MSC: NCLEX: Physiological Integrity 2. A patient with increased secretions may develop airway obstruction. The nurse can promote a

patent airway by using which of the following techniques? (Select all that apply.) a. Limiting fluid intake b. Positioning c. Deep breathing d. Humidity ANS: B, C, D

Hydration, positioning, deep breathing, and humidity are techniques that are helpful in maintaining a patent airway.

DIF: Cognitive Level: Application REF: Safety Guidelines OBJ: Describe the nursing interventions for airway management.

TOP: Airway Management KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The nurse performing nasotracheal suctioning should be assessing the patient for which

possible unexpected outcomes? (Select all that apply.) a. Severe reduction in heart rate b. Wheezing and inability to breathe c. Reduction in oxygen saturation d. Nasal bleeding ANS: A, B, C, D

Nasotracheal suctioning has many risks associated with it. The most serious relate to hypoxemia, which often resultsNiU nR caSrdIiN acGaTrrB hy.tC hm OiMas, laryngeal spasm, and bradycardia (as a result of stimulation of the vagus nerve). Nasal trauma and bleeding can develop as the result of trauma from the suction catheter.

DIF: Cognitive Level: Application REF: Skill 25.2 OBJ: Describe the nursing interventions for airway management.

TOP: Risks of Nasotracheal Suctioning KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse is providing care to a patient on mechanical ventilation with an endotracheal tube.

The nurse carefully inflates the cuff of the endotracheal tube using the minimal leak method, knowing that a properly inflated cuff provides which benefits to the patient? (Select all that apply.) a. Prevents aspiration of gastric contents b. Promotes accumulation of secretions below the epiglottis c. Prevents air from escaping between the tube and the tracheal wall d. Promotes lung inflation for mechanical ventilation ANS: A, C, D

A cuff on an endotracheal tube prevents the escape of air between the tube and the walls of the trachea and reduces aspiration when a patient is receiving mechanical ventilation. The goals of correctly inflating the cuff on an artificial airway are to promote lung inflation for mechanical ventilation, prevent aspiration of gastric contents, and at the same time allow drainage of secretions that accumulate between the epiglottis and the cuff.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY DIF: Cognitive Level: Understanding REF: Skill 25.3 OBJ: Correctly inflate a cuff on an endotracheal or tracheostomy tube.

TOP: Endotracheal (ET) Tube Cuffs KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse is caring for a patient who has a tracheostomy. To prevent the patient from

developing an airway obstruction, the nurse assesses which of the following? (Select all that apply.) a. Patient’s nutritional status b. Environmental humidity c. Existing respiratory infection d. Patient’s ability to cough ANS: A, B, C, D

The patient’s hydration and nutritional status, humidity delivered to the tracheostomy tube, the status of an existing infection, and the ability to cough are all factors that affect the amount and consistency of secretions in the tracheostomy tube and the patient’s ability to clear the airway.

DIF: Cognitive Level: Understanding REF: Skill 25.4 OBJ: Discuss the indications for tracheostomy care.

TOP: Preventing Airway Obstruction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. A nurse is preparing to suction a patient via the nasotracheal route. Which conditions should

the nurse recognize as contraindications to nasotracheal suctioning? (Select all that apply.) a. Motor vehicle accident with acute head injuries b. History of hemophilia NURSINGTB.COM c. Epiglottitis or croup d. Environmental allergies with sinus drainage ANS: A, B, C

Contraindications to nasotracheal suctioning include facial or neck trauma/surgery, acute head injuries, bleeding disorders, nasal bleeding, epiglottitis or croup, laryngospasm, irritable airway, and gastric surgery. These conditions are contraindications because the passage of a catheter through the nasal route causes additional trauma, increases nasal bleeding, or causes severe bleeding in the presence of bleeding disorders. In the presence of epiglottitis, croup, laryngospasm, or irritable airway, the entrance of a suction catheter via the nasal route causes intractable coughing, hypoxemia, and severe bronchospasm; this may necessitate emergency intubation or tracheostomy. Patients with allergies leading to sinus drainage will have increased volume of secretions in the pharynx and may require suctioning.

DIF: Cognitive Level: Application REF: Skill 25.2 OBJ: Correctly perform oropharyngeal, nasopharyngeal and nasotracheal, and tracheal suctioning; endotracheal care; and tracheostomy tube care.

TOP: Contraindications to Nasotracheal Suctioning KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The nurse is caring for a patient on mechanical ventilation with an endotracheal tube. Which

nursing interventions will help prevent ventilator-associated pneumonia (VAP)? (Select all that apply.) a. Changing the patient’s position every 2 hours

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY b. Keeping the head of the bed elevated 30 to 45 degrees c. Providing oral care with a toothette every 8 hours d. Keeping the head flat during and for 30 minutes after enteral feedings ANS: A, B

Best-practice guidelines indicate that the following interventions are advantageous in preventing VAP: elevating the head of the bed at 30 to 45 degrees to prevent aspiration, changing patient position every 2 hours to decrease risk for atelectasis and pulmonary infection, providing oral care with a toothbrush every 8 hours to remove dental plaque organisms (toothettes are not adequate to clean dental plaque, but they may be used between brushings for comfort), maintaining the endotracheal cuff pressures at 20 cm H2O to decrease movement of secretions to the lower airways, and carefully monitoring the patient for aspiration when enteral feedings are infusing.

DIF: Cognitive Level: Application REF: Safety Guidelines OBJ: Describe the nursing interventions for airway management.

TOP: Ventilator-Associated Pneumonia (VAP) Prevention KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The nurse is evaluating a patient to determine whether the endotracheal tube cuff is properly

inflated. Which findings indicate proper inflation? (Select all that apply.) a. Exhaled tidal volume is 50 mL less than the tidal volume set on the ventilator. b. Air leak is heard with a stethoscope only at the end of inspiration. c. The patient is able to vocalize. d. Gastric contents are noted in airway secretions.

ANS: A, B

NURSINGTB.COM

The exhaled tidal volume from mechanical ventilation should not be less than 50 mL of the delivered tidal volume to ensure appropriate ventilation of the lungs. The air leak should be audible only with a stethoscope at the end of inspiration. Excessive phonation and gastric secretions in the airway indicate a partially deflated cuff.

DIF: Cognitive Level: Application REF: Skill 25.3 OBJ: Correctly inflate a cuff on an endotracheal or tracheostomy tube.

TOP: Inflating the Cuff on an Artificial Airway KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 26: Cardiac Care Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. Proper placement of the electrocardiogram (ECG) electrodes is essential for which reason? a. To ensure real-time detection of arrhythmias b. To prevent painful removal of the electrodes c. To facilitate capture of all leads d. To reduce ventricular arrhythmias ANS: A

Proper placement of the ECG electrodes is essential to ensure real-time detection of arrhythmias. Proper placement is not related to a less painful removal procedure. One primary lead is chosen to view the electrical activity of the heart and this determines where the electrodes are placed. Ventricular arrhythmias are not reduced by ECG electrode placement.

DIF: Cognitive Level: Application REF: Purpose OBJ: Determine correct electrode placement to obtain an accurate ECG tracing.

TOP: ECG Electrode Placement KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. When applying electrocardiogram (ECG) electrodes to a woman, it is important to give

special consideration to which of the following objectives? a. Place the electrode as close to the chest wall as possible, close to the breast tissue. b. Place the electrode away from the chest wall, close to the breast tissue.

UR c. Place the electrode as closeNto thS eI chNeG stTwBa. ll C asOpMossible, avoiding the breast tissue. d. Place the electrode away from the chest way, avoiding the breast tissue.

ANS: C

When applying ECG electrodes to a woman, take special consideration to place the electrode as close to the chest wall as possible, avoiding the breast tissue.

DIF: Cognitive Level: Application REF: Person-Centred Care OBJ: Determine correct electrode placement to obtain an accurate ECG tracing.

TOP: ECG Electrode Placement KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. Identify the first step toward establishing appropriate alarms and response expectations. a. Instructing the patient and immediate family members about the necessity of the

alarms b. Obtaining a physician’s prescription for electrocardiogram (ECG) monitoring c. Adjusting the volume of the alarms so the primary nurse can hear them d. Determining which patients require ECG monitoring ANS: D

The first step toward establishing appropriate alarms and response expectations is appropriate patient selection. Ensuring appropriate patient selection supersedes a physician’s prescription and adjustment of alarm volume. Instruction of the patient and family members is addressed after the patient is identified for ECG monitoring.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY DIF: Cognitive Level: Application REF: Evidence-Informed Practice OBJ: Describe measures to reduce false alarms.

TOP: Evidence-Based Practice KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse has explained to the patient that a 12-lead electrocardiogram (ECG) is indicated.

The patient refused to have the procedure done citing that she fears that the electrodes will cause harm to her heart. The nurse recognizes that which of the following patient rationales are contraindications for a 12-lead ECG? a. The patient refuses the test. b. The patient is receiving chemotherapy. c. The patient is ordered to have nothing by mouth (NPO). d. The patient has just been medicated for a pain level of 8 on a scale of 1 to 10.

ANS: A

No absolute contraindications to performing an ECG exist other than patient refusal.

DIF: Cognitive Level: Application REF: Contraindications OBJ: Identify the indications to perform a 12-lead ECG and cardiac monitor application.

TOP: Evidence-Based Practice Contraindications KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. The nurse understands that it is a priority to obtain the 12-lead electrocardiogram (ECG) on

the patient newly admitted with chest pain because the ECG must be obtained within how many minutes of the onset of pain? a. 3 minutes b. 5 minutes c. 8 minutes d. 10 minutes NURSINGTB.COM ANS: D

Patients suffering from chest pain need to have their 12-lead ECG within 10 minutes of the assessment and onset of pain.

DIF: Cognitive Level: Comprehension REF: Safety Guidelines OBJ: Identify the indications to perform a 12-lead ECG and cardiac monitor application.

TOP: Safety Guidelines KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. The nurse is assessing several patients who have returned from surgery when a 12-lead

electrocardiogram (ECG) is ordered for a newly admitted patient. Prioritizing patient needs, the nurse determines that obtaining the 12-lead ECG can be most appropriately delegated to which member of the health care team? a. Administrative secretary b. Another registered nurse c. Unregulated care provider d. Admitting physician ANS: B

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

The skill of obtaining a 12-lead ECG cannot be delegated to unregulated care providers or administrative secretaries. As long as the other registered nurse (RN) has been properly trained in obtaining 12-lead ECGs, he or she would be the best choice for this skill. The admitting physician would also be able to obtain the 12-lead ECG, but the RN would be the best choice.

DIF: Cognitive Level: Application REF: Skill 26.1: Delegation and Collaboration OBJ: Identify the indications to perform a 12-lead ECG and cardiac monitor application.

TOP: Delegation and Collaboration KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 7. Which of the following is true about alarm fatigue? a. There is no way to reduce alarm fatigue. b. Alarm fatigue develops when a person is exposed to an excessive number of

alarms. c. People become more sensitized with the increased exposure to alarms. d. Alarm fatigue does not influence response time.

ANS: B

This situation can result in sensory overload, which may cause the person to become desensitized to the alarms. Consequently the response to alarms may be delayed, or alarms may be missed altogether. There are strategies to reduce alarm fatigue, provided by the American Association of Critical-Care Nurses (AACN).

DIF: Cognitive Level: Understanding REF: Skill 26.2 OBJ: Describe measures to reduce false alarms.

TOP: Applying a Cardiac Monitor KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

NURSINGTB.COM

8. The student nurse is preparing to perform a 12-lead electrocardiogram (ECG) on an adult

patient. Which action by the student should the nursing instructor question? a. Cleansing and preparing the isolated electrode area with soap and water b. Wiping the area with a rough cloth or gauze to gently scrape the area c. Clipping the excessive hair from the electrode area d. Using alcohol to cleanse the electrode area ANS: D

Cleanse and prepare the isolated electrode area with soap and water. Wipe the area with a rough washcloth or gauze or use the edge of the electrode to gently scrape the area. Clip excessive hair from the electrode area. Never use alcohol to cleanse the area because it will dry out the skin.

DIF: Cognitive Level: Understanding REF: Skill 26.1 OBJ: Identify the indications to perform a 12-lead ECG and cardiac monitor application.

TOP: 12-Lead ECG Implementation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The nurse is observing a nursing student perform a 12-lead electrocardiogram (ECG) tracing

on a newly admitted patient. The nurse recognizes that the student requires additional training on this skill when he or she observes which of the following erroneous lead placements? a. V1—Fourth intercostal space at the right sternal angle b. V2—Fourth intercostal space at the right sternal border

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY c. V4—Fifth intercostal space at the midclavicular line d. V6—Left midaxillary line at the level of V4 horizontally ANS: B

The V2 electrode is placed at the fourth intercostal space at the left sternal border.

DIF: Cognitive Level: Application REF: Skill 26.1 OBJ: Determine correct electrode placement to obtain an accurate ECG tracing.

TOP: ECG Tracing Implementation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. While the nurse is performing a 12-lead electrocardiogram (ECG) tracing, the patient

complains of crushing chest pain. The nurse recognizes that the timing of the chest pain is important to note for which of the following reasons? a. The 12-lead ECG must be held until the pain is relieved and continued as soon as it passes. b. The physician will order a follow-up ECG exactly 5 minutes post the last episode of chest pain. c. It helps correlate the ECG changes to symptoms of chest pain. d. The ECG tracing must be stopped immediately.

ANS: C

The nurse should note and document if the patient experiences any chest discomfort during the procedure because this helps correlate ECG changes to symptoms of chest pain.

DIF: Cognitive Level: Application REF: Skill 26.1 OBJ: Determine correct electrode placement to obtain an accurate ECG tracing.

TOP: 12-Lead ECG Implementation KEY: Nursing Process Step: Implementation NURSINGTB.COM MSC: NCLEX: Physiological Integrity 11. To determine the patient’s and caregiver’s levels of understanding of the rationale for

obtaining the 12-lead ECG, the nurse most effectively uses which of the following statements? a. “Can you tell me why you need this test?” b. “Did you experience pain during the test?” c. “Can you tell me when the test results will be shared with you?” d. “Can you give me your name and date of birth?”

ANS: A

Use a teach-back statement: “I want to be sure that I explained why you need this ECG. Can you tell me about why you need the test?” This determines the patient’s and caregiver’s levels of understanding of the topic. Pain is assessed during the test and helps correlate changes in the ECG tracing. The timing of the results does not assess rationale for the test. Patient identifiers are required to ensure patient safety.

DIF: Cognitive Level: Application REF: Skill 26.1 OBJ: Determine the correct electrode placement to obtain an accurate ECG tracing.

TOP: 12-Lead ECG Implementation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 12. The nurse is obtaining a 12-lead ECG on a patient with chest discomfort and interprets the

results as a very thick-lined waveform tracing. The nurse troubleshoots this tracing by performing which appropriate intervention? a. Unplugs the battery-operated equipment in the room one item at a time. b. Reapplies the electrodes to ensure proper connection with the skin. c. Adjusts the extremity electrodes on the wrists and ankles. d. Asks the patient to hold his or her breath to see if the tracing improves.

ANS: A

Artifact that looks like a very thick-lined waveform is 60-cycle interference. The nurse should unplug battery-operated equipment in the room one item at a time to see if the interference disappears. Sixty-cycle interference is rare. The tracing needs to be repeated. The electrode placement and the patient’s breathing pattern do not cause 60-cycle interference.

DIF: Cognitive Level: Analysis REF: Skill 26.1 OBJ: Determine correct electrode placement to obtain an accurate ECG tracing.

TOP: 12-Lead ECG Unexpected Outcomes KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 13. The nurse changes the electrocardiogram (ECG) electrodes on a patient who is on a

continuous cardiac monitor. The patient tells the nurse that the electrodes were just changed the previous day. Which of the following rationales is the correct explanation for the nurse to share with the patient? a. Changing the electrodes more often than every 24 hours can result in skin breakdown. b. It is not necessary to change the electrodes daily. c. It was not documented that the electrodes were changed.

RiSllIdNecGreTaBse.tCheOnMumber of false alarms. d. Changing the electrodes daN ilyUw ANS: D

The nurse recognizes that the ECG electrodes should be changed daily or more often if electrode contact to the skin is loose. Changing the ECG electrodes will decrease the number of false alarms. If there is poor skin contact, it may be necessary to change the electrodes more frequently; this will not cause skin breakdown.

DIF: Cognitive Level: Application REF: Skill 26.2 OBJ: Describe measures to reduce false alarms.

TOP: Continuous Cardiac Monitoring KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. The nurse is preparing to apply electrodes for continuous cardiac monitoring to a newly

admitted adult with syncope. Which action by the nurse follows appropriate procedure? a. Cleanse and prepare the chest area for electrode placement with chlorhexidine. b. Use a blanket to cover the patient’s abdomen while the limb electrodes are being placed. c. Scrape the area to roughen the dermis layer of skin to allow electrical signals to travel more easily. d. Place the patient in a supine position.

ANS: D

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

The chest area is prepared for electrode placement with soap and water. There are no limb electrodes for continuous cardiac monitoring. Ensure the patient’s abdomen and thighs are covered. Roughening the skin helps remove the epidermis outer layer to allow electrical signals to travel. Do not roughen the dermis layer of skin. Electrodes should be applied when the patient is in the supine position.

DIF: Cognitive Level: Application REF: Skill 26.2 OBJ: Determine correct electrode placement to obtain an accurate ECG tracing.

TOP: Continuous Cardiac Monitoring Implementation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. The nurse is supervising a nursing student while applying electrodes for continuous cardiac

monitoring to an elderly patient. The nurse recognizes the need for further education when the student makes which comment about polarity while attaching the monitor leads to the electrode? a. White is negative. b. Black is neutral. c. Red is the ground lead. d. Brown is positive.

ANS: B

Colours of the leads represent their polarity. The black lead is positive, not neutral. The other leads are correctly identified here.

DIF: Cognitive Level: Application REF: Skill 26.2 OBJ: Determine correct electrode placement to obtain an accurate ECG tracing.

IpNleGmTenBta.tiConOM TOP: Continuous Cardiac MonitN orU inR gS Im KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. The nurse is caring for a patient on continuous cardiac monitoring. The nurse assesses the

rhythm as regular with a normal PQRST complex and a rate of 62 beats per minute. Which analysis is the correct interpretation of this cardiac rhythm? a. Sinus bradycardia b. Sinus tachycardia c. Premature bradycardia d. Normal sinus rhythm ANS: D

Characteristics of normal sinus rhythm include regular rhythm, rate 60 to 99 beats per minute, and a normal PQRST complex. Sinus bradycardia is a heart rate less than 60 beats per minute.

Sinus tachycardia is a heart rate 100 to 180 beats per minute. There is no rhythm known as premature bradycardia.

DIF: Cognitive Level: Application REF: Table 26.1: Common Basic Cardiac Rhythms OBJ: Determine correct electrode placement to obtain an accurate ECG tracing.

TOP: Common Basic Cardiac Rhythms KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 17. The nurse is caring for a 6-year-old child after open-heart surgery. When assessing the patient,

the nurse notes that the position of the leads may be different in the pediatric population.

Which lead placement explains this special consideration? a. The position of the green lead can be changed to mirror one of the precordial lead positions. b. The standard placement for V1 is at the fifth intercostal space, right sternal border. c. The standard placement for V1 is at the fourth intercostal space, left sternal border. d. In general, mechanisms of dysrhythmias are the same in children as they are in adults.

ANS: D

The position of the brown lead can be changed to mirror one of the precordial (chest) lead positions, V1 to V6. The standard placement is for V1 at the fourth intercostal space, right sternal border. In general, the mechanisms of dysrhythmias are the same in children as they are in adults; however, the appearance of the arrhythmias on the ECG may differ because of developmental issues such as heart size, baseline heart rate, sinus and atrioventricular (AV) node function, and autonomic innervation.

DIF: Cognitive Level: Application REF: Pediatric (Skill 26.2) OBJ: Determine correct electrode placement to obtain an accurate ECG tracing.

TOP: Continuous Cardiac Monitoring Special Considerations Pediatrics KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. Reduction of alarm fatigue is an important nursing practice. The nurse addresses this concern

when which of the following actions is implemented? a. Changes the electrodes once per shift b. Provides initial and ongoinN gU edRuS caItiN onGT abBo. utCthOeMintravenous pumps c. Monitors all patients diagnosed with cancer on continuous cardiac monitoring d. Uses preset parameters for the pulse oximetry machine ANS: B

Electrodes should be changed daily. Monitor only those patients with clinical indications for monitoring. A patient with cancer is not an indication for continuous cardiac monitoring.

Provide initial and ongoing education about devices with alarms (intravenous pumps).

Customize delay and threshold settings on oxygen saturation via pulse oximetry monitors.

DIF: Cognitive Level: Application REF: Skill 26.2 OBJ: Determine measures to reduce false alarms.

TOP: Expected Practice and Nursing Actions for the Reductions of Alarm Fatigue KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. The nurse analyzes the patient’s cardiac rhythm as follows: regular rhythm, rate 108 beats per

minute, normal PQRST complex. The nurse interprets that the clinical significance of this cardiac rhythm is most likely related to which indication? a. Decreased cardiac output b. Dizziness c. Pain d. Syncope ANS: C

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

The rhythm is identified as sinus tachycardia: regular rhythm, rate 100 to 180 beats per minute, normal PQRST complex. This rhythm is common as a normal response to exercise, pain, fever, hyperthyroidism, and certain medications. Decreased cardiac output, dizziness, and syncope are indicators of sinus bradycardia.

DIF: Cognitive Level: Analysis REF: Table 26.1: Common Basic Cardiac Rhythms OBJ: Identify the indications to perform a 12-lead ECG and cardiac monitor application.

TOP: Common Basic Rhythms KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 20. The nurse is reviewing the patient’s do-not-resuscitate orders when the cardiac alarm sounds.

The rhythm is chaotic with no identifiable waves and the rate cannot be determined. Based on these clinical findings, the nurse determines that the patient is in which of the following cardiac rhythms? a. Asystole b. Ventricular fibrillation c. Ventricular tachycardia d. Sinus bradycardia ANS: B

Ventricular fibrillation is a chaotic rhythm with no identifiable waves and therefore a rate cannot be identified. Asystole is a flat line with no waves. Ventricular tachycardia is a rate of 100 to 200 beats per minute. Sinus bradycardia is a rate of less than 60 beats per minute.

DIF: Cognitive Level: Analysis REF: Table 26.1: Common Basic Cardiac Rhythms OBJ: Identify the indications to perform a 12-lead ECG and cardiac monitor application.

TOP: Common Basic Dysrhythmias KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological IntN egUriR tySINGTB.COM 21. When describing the rationale for connecting electrodes to each limb and around the heart, the

nurse shares with the patient which appropriate explanation? a. The leads view a specific portion of the heart’s surface to help determine which part has sustained damage. b. Multiple leads are necessary to provide a three-dimensional view of the heart. c. The electrodes are necessary to provide a shock to the heart if needed during cardiac conversion. d. The limb electrodes are required to provide a backup study in the event of artifact.

ANS: A

A 12-lead ECG does not construct a three-dimensional view of the heart. A 12-lead ECG does not cardiovert the heart. Limb electrodes do not eliminate artifact. The leads view a specific portion of the heart’s surface to help determine which part has sustained damage, origin, and flow of the impulse.

DIF: Cognitive Level: Analysis REF: Skill 26.1 OBJ: Determine correct electrode placement to obtain an accurate ECG tracing.

TOP: Obtaining a 12-Lead Electrocardiogram KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 22. The nurse is obtaining a 12-lead electrocardiogram (ECG) on a patient with syncope. Which

of the following actions, if taken by the nurse, are effective at reducing the presence of artifact in the ECG tracing? a. Instruct the patient to stop talking. b. Turn the ECG machine on after all the electrodes are applied. c. Position the patient in semi-Fowler’s position. d. Maintain the gown on the patient to provide privacy.

ANS: A

Talking produces artifact that may necessitate repeating the 12-lead ECG. The ECG machine should be turned on first to help identification of electrodes and lead issues on application.

Position the patient in the supine position. Remove the patient’s gown to expose the patient’s chest and arms.

DIF: Cognitive Level: Application REF: Skill 26.1 OBJ: Determine correct electrode placement to obtain an accurate ECG tracing.

TOP: Obtaining a 12-Lead ECG Implementation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. After obtaining a 12-lead electrocardiogram (ECG), the nurse records the date and time the

ECG was obtained, the reason for obtaining the ECG, and who the ECG was given to for interpretation in the patient’s chart. After this documentation, what is the appropriate action of the nurse? a. Immediately report any unexpected outcomes. b. Reposition the patient to a position of comfort. c. Report to the unregulated care provider that the 12-lead ECG is completed. d. Invite the caregivers to visiN t aUt R thSeIbN edGsiTdB e..COM ANS: A

After documentation of the details related to the 12-lead ECG, the nurse should report any unexpected outcomes immediately. Repositioning the patient and inviting caregivers to the bedside are not related to the completion of the 12-lead ECG. Although it assists with communication between team members, the unregulated care provider does not need to immediately know that the test was completed.

DIF: Cognitive Level: Application REF: Communication and Documentation (Skill 26.1) OBJ: Determine correct electrode placement to obtain an accurate ECG tracing.

TOP: Air Leak KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is assessing if the patient needs a 12-lead electrocardiogram (ECG). Which of the

following indications, if identified, indicates that a 12-lead ECG should be obtained? (Select all that apply.) a. Suspected acute coronary syndromes including myocardial infarction b. History of smoking two packs per day for 30 years c. Evaluation of syncope d. Disorders of the cardiac rhythm

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY ANS: A, C, D

Indications for 12-lead ECG include suspected acute cardiac syndromes including myocardial infarction, evaluation of implanted defibrillators and pacemakers, disorders of the cardiac rhythm, evaluation of syncope, evaluation of metabolic disorders, effects and side effects of pharmacotherapy, and evaluation of primary and secondary cardiomyopathic processes.

DIF: Cognitive Level: Application REF: Skill 26.1 OBJ: Identify indications to perform a 12-lead ECG and cardiac monitor application.

TOP: Evidence-Based Practice Indications KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse is reviewing the patient’s medications and recognizes that which of the following

medications can cause arrhythmias? (Select all that apply.) a. Digoxin b. Amlodipine c. Amiodarone d. Lasix ANS: A, B, C

Some medications, particularly beta blockers, some calcium channel blockers, and other antiarrhythmics, can cause arrhythmias. Lasix is a diuretic.

DIF: Cognitive Level: Application REF: Safety Guidelines OBJ: Identify the indications to perform a 12-lead ECG and cardiac monitor application.

TOP: Safety Guidelines KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse identifies the appropN riU atR eS eqIuN ipG mTeB nt.nC ecOeM ssary to obtain a 12-lead

electrocardiogram (ECG) and gathers the following supplies: (Select all that apply.) a. 12-lead ECG machine b. Clean, dry towel c. Hair clippers d. Betadine cleanser ANS: A, B, C

Equipment necessary to obtain a 12-lead ECG includes 12-lead ECG machine; 10 ECG leads; 10 ECG electrodes; clean, dry towel or sponge wipes; and hair clippers. Betadine cleanser is not necessary.

DIF: Cognitive Level: Understanding REF: Skill 26.1 OBJ: Determine correct electrode placement to obtain an accurate ECG tracing.

TOP: Equipment KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 4. The nurse is obtaining a 12-lead electrocardiogram (ECG) on a patient and notices that the

ECG cannot be interpreted. Which of the following interventions are appropriate for the nurse to take? (Select all that apply.) a. Inspect the electrodes for secure placement. b. Reposition any wires that move as a result of patient breathing or movement. c. Reposition electrodes that are in the correct position. d. Remind the patient to remain still to obtain a good tracing.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY ANS: A, B, D

When the ECG cannot be interpreted, the nurse should inspect electrodes for secure placement, reposition any wires that move as a result of patient breathing or movement, and remind the patient to lie still. Do not reposition electrodes if in the correct position.

DIF: Cognitive Level: Analysis REF: Skill 26.1 OBJ: Describe measure to reduce false alarms.

TOP: 12-Lead ECG Evaluation KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 5. The nurse is caring for a patient who has chest discomfort. While the nurse obtains the 12-lead

electrocardiogram (ECG), the patient complains of feeling very anxious. Which of the following interventions should the nurse take in caring for the patient’s anxiety? (Select all that apply.) a. Continue to monitor the patient. b. Reassess factors contributing to anxiety or distress. c. Ask the caregiver to leave the room. d. Notify the health care provider.

ANS: A, B, D

If the patient experiences chest pain or anxiety during the obtainment of a 12-lead ECG, the nurse should continue to monitor the patient, reassess factors contributing the anxiety or distress, notify the health care provider, and follow specific prescriptions related to findings.

Asking the caregiver to leave the room may increase the patient’s anxiety.

DIF: Cognitive Level: Application REF: Skill 26.1 OBJ: Describe measures to reduce false alarms.

TOP: 12-Lead ECG Unexpected Outcomes GSTCB: .NCCOLM KEY: Nursing Process Step: EvaN luU atR ioS n INM EX: Physiological Integrity 6. A patient is being monitored on a continuous cardiac monitor. The nurse directs the

unregulated care provider (UCP) to immediately report which of the following patient findings? (Select all that apply.) a. Patient complaints of pain b. Shortness of breath c. Hypotension d. Patient’s request to use the bedside commode ANS: A, B, C

The nurse directs the UCP to immediately report to the nurse alarms or patient complaints of pain, shortness of breath, or hypotension. The UCP also ensures that the parameters for alarms are set as per the health care provider’s prescriptions.

DIF: Cognitive Level: Application REF: Delegation and Collaboration (Skill 26.1) OBJ: Describe measures to reduce false alarms.

TOP: Applying a Cardiac Monitor Delegation and Collaboration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The nurse is caring for a patient on continuous cardiac monitoring who is experiencing

occasional premature ventricular contractions. Which of the following actions demonstrate appropriate protocol? (Select all that apply.) a. Review alarm trends and waveforms at least once per shift. b. Review alarm trends and waveforms on report of an alarm.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY c. Record at least one rhythm strip per shift to the patient’s medical record. d. Report any unexpected outcomes to the health care provider at the end of the shift.

ANS: A, B, C

Review alarm trends and waveforms at least once per shift and on report of an alarm. Record at least one rhythm strip per shift per employer policy, either on paper or save to the electronic health record. Report any unexpected outcomes immediately to the health care provider; do not wait until the end of the shift.

DIF: Cognitive Level: Application REF: Skill 26.2 OBJ: Describe measures to reduce false alarms.

TOP: Continuous Cardiac Monitoring Recording and Reporting KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The nurse recognizes the following indications as appropriate for continuous cardiac

monitoring: (Select all that apply.) a. Postresuscitation patients b. Patients with heart failure c. Patients older than age 75 years d. Diagnosis of arrhythmias in children ANS: A, B, D

Patients’ age 75 years or older is not an indication for continuous cardiac monitoring.

Indications include postresuscitation status, heart failure, and a diagnosis of arrhythmia in a child.

DIF: Cognitive Level: ApplicatiN onURSINRGETFB : .SC kiO llM 26.2 OBJ: Identify indications to perform a 12-lead ECG and cardiac monitor application.

TOP: Class 1 Indications for Continuous Cardiac Monitoring KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 27: Closed Chest Drainage Systems Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The nurse is caring for a patient who is comatose and on a ventilator. When s/he enters the

room, s/he notices that the patient’s trachea has shifted toward the left side of the patient’s neck, and s/he has become tachycardic. S/he assesses the patient’s blood pressure and notes that it is 84/38. The nurse calls for help, having recognized that the patient has developed which of the following conditions? a. Hemothorax b. Pneumothorax on the left side c. Pneumothorax on the right side d. Myocardial infarction ANS: C

A tension pneumothorax occurs from rupture in the pleura when air accumulates in the pleural space more rapidly than it is removed. If left untreated, the lung on the affected side collapses, and the mediastinum and the trachea shift to the opposite (unaffected) side. The patient has sudden chest pain, a fall in blood pressure, and tachycardia, and cardiopulmonary arrest can occur. Patients with chest trauma, fractured ribs, and invasive thoracic bedside procedures (such as insertion of central lines) and those on high-pressure mechanical ventilation are at risk for tension pneumothorax. A hemothorax is a collapse of the lung caused by an accumulation of blood and fluid in the pleural cavity between the chest wall and the lung, usually as a result of trauma. Nothing in this scenario would suggest myocardial infarction.

NURSINGTB.COM DIF: Cognitive Level: Synthesis REF: Principles for Practice OBJ: List three conditions requiring chest tube insertion.

TOP: Pneumothorax KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. For a patient with a pneumothorax, where does the nurse anticipate that the chest tube will be

located? a. Second to third intercostal space (apical), anterior b. Fifth to sixth intercostal space, posterior c. Fifth to sixth intercostal space, lateral d. Mediastinal area ANS: A

Apical (second or third intercostal space) and anterior chest tube placement promotes removal of air, which is necessary in the case of a pneumothorax. Chest tubes are placed low (usually in the fifth or sixth intercostal space) and posterior or lateral to drain fluid. A mediastinal chest tube is placed in the mediastinum, just below the sternum. This tube drains blood or fluid, preventing its accumulation around the heart. A mediastinal tube commonly is used after open-heart surgery.

DIF: Cognitive Level: Analysis REF: Principles for Practice OBJ: List three common sites for chest tube placement.

TOP: Chest Tube Position KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 3. The patient’s chest tube is attached to a one-way flutter valve that allows air to escape the

chest cavity and prevents air from re-entering. How does the nurse document this finding? a. Heimlich chest drain valve b. Pneumovax c. Water seal d. Pleurovac ANS: A

The device described is a Heimlich chest drain valve. Pneumovax is a pneumococcal vaccine that is effective against 23 common strains of Pneumococcus. A Pleurovac is the brand name of a water-seal set.

DIF: Cognitive Level: Understanding REF: Principles for Practice OBJ: Describe principles and mechanisms of chest tube suction.

TOP: Type of Chest Tube KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse is caring for a patient who has a chest tube connected to a water seal. The patient is

not on a ventilator. Which of the following would the nurse consider normal? a. The fluid level in the water seal rises with inspiration. b. The fluid level in the water seal falls with inspiration. c. Constant bubbling occurs in the water seal. d. The fluid level in the water seal falls with expiration 3 days after insertion.

ANS: A

Observe the water seal for intermittent bubbling from its U tube or for a rise and fall of fluid that is synchronous with respirations. (For example, in a nonmechanically ventilated patient, the fluid rises during inspiratioN n,UaR ndStIhN e fGluTidB. leC veOl M falls during expiration. When a patient is on a mechanical ventilator, the opposite occurs.) In a nonmechanically ventilated patient, the fluid rises during inspiration, and the fluid level falls during expiration. Constant bubbling in the water seal or a sudden, unexpected stoppage of water-seal activity is considered abnormal and requires immediate attention. After 2 to 3 days, tidalling or bubbling on expiration is expected to stop, indicating that the lung has re-expanded.

DIF: Cognitive Level: Analysis REF: Principles for Practice OBJ: Describe principles and mechanisms of chest tube suction.

TOP: Water-Seal Tidalling KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 5. The nurse is caring for a patient with a chest tube that was inserted 4 days earlier. She notices

that the drainage contains a large amount of pus. What does the presence of the pus indicate? a. Malignancy b. Pulmonary infarction c. Empyema d. Hemothorax ANS: C

Pus indicates an empyema, which is a collection of pus in the pleural cavity, and the drainage is pus coloured. Blood-tinged fluid usually indicates malignancy, pulmonary infarction, or severe inflammation. Frank blood indicates a hemothorax.

DIF: Cognitive Level: Understanding

REF: Safety Guidelines

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY OBJ: Describe principles and mechanisms of chest tube suction.

TOP: Pleural Drainage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. What is indicated by continuous bubbling in the water-seal chamber with no bubbles noted in

the suction-control chamber of the drainage system? a. A leak in the system b. Normal functioning c. A drainage obstruction d. Insufficient suction pressure ANS: A

Continuous bubbling in the water-seal chamber with an absence of bubbles in the suction-control chamber indicates that there is a leak in the system. Normal functioning is indicated by gentle, continuous bubbling in the suction chamber and occasional bubbling in the water seal, with fluctuations on inspiration and expiration. Constant bubbling in the water seal or a sudden, unexpected stoppage of water-seal activity is considered abnormal and requires immediate attention. Insufficient suction pressure has little to no bubbling in the suction chamber.

DIF: Cognitive Level: Analysis REF: Safety Guidelines OBJ: Describe methods of troubleshooting chest tube systems.

TOP: Bubbling in Suction-control Chamber KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. What condition is indicated when a patient with a chest tube experiences sharp, stabbing chest

pain without a change in pulse or blood pressure? a. Pneumonitis NURSINGTB.COM b. Tube displacement c. Myocardial infarction d. Tension pneumothorax ANS: D

Sharp, stabbing chest pain with or without decreased blood pressure and increased heart rate may indicate a tension pneumothorax. A chest tube is not an expected treatment for pneumonitis. Tube displacement is an unexpected outcome and can lead to increased pneumothorax. Immediately apply pressure over the chest tube insertion site. Myocardial infarction pain is expressed as “crushing” or “pressure” over the sternal area.

DIF: Cognitive Level: Analysis REF: Safety Guidelines OBJ: Describe methods of troubleshooting chest tube systems. TOP: Tension Pneumothorax KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 8. Which of the following is an expected outcome of chest tube insertion? a. Mild chest pain is maintained. b. Breath sounds are auscultated in all lobes. c. Drainage from the pleural cavity increases over time. d. Lung expansion is increased beyond the unaffected side.

ANS: B

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

When breath sounds are auscultated in all lobes, lung expansion is symmetrical, oxygen saturation (SaO2) is stable or improved, and respirations are nonlaboured. Chest pain is not an expected outcome. Treatment is effective when the patient reports no chest pain. Drainage from the pleural cavity decreases over time with re-expansion of the lung. Lung expansion would be equal to preinjury status.

DIF: Cognitive Level: Understanding REF: Skill 27.1 OBJ: Describe methods of troubleshooting chest tube systems.

TOP: Expected Outcomes of Chest Tube Insertion KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. What should the nurse do to establish a two-chamber waterless chest tube system? a. Add sterile water to the suction chamber. b. Add sterile solution to the water seal. c. Set the float ball to the correct drainage pressure. d. Connect directly to the chest tube and add nothing.

ANS: D

The waterless two-chamber system is ready for connecting to the patient’s chest tube after the wrappers have been opened. The waterless system’s principles are similar to those of the water-seal system, except that fluid is not required for setup. Because water is not used, accidentally tipping over the system does not compromise the patient’s condition. The suction chamber does not depend on water. Instead, it contains a float ball, which is set by a suction control dial after the suction source is turned on.

DIF: Cognitive Level: Application REF: Table 27.1: Comparison of Chest Tube Drainage Systems OBJ: Describe closed chest drainNaU geRsS ysIteN mG s:TwBa. teC r-sOeM al and waterless systems.

TOP: Two-Chamber Waterless Chest Tube System KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. Which of the following represents appropriate technique when providing care for a patient

with chest tubes? a. Applying an occlusive dressing over the site b. “Stripping” the tube on a regular basis c. Assessing the patient hourly after insertion d. Keeping excess loops of tubing from hanging over the side of the bed ANS: D

Lay excess tubing horizontally on the mattress next to the patient. Secure with a rubber band and safety pin or with the system’s clamp. This prevents excess tubing from hanging over the edge of the mattress in a dependent loop. Drainage could collect in the loop and occlude the drainage system. Physician responsibility in chest tube placement includes covering the insertion site with sterile petroleum gauze, 4  4-inch gauze, and a large dressing to form an occlusive dressing supported with an elastic bandage. Strip or milk the chest tube only if indicated (this means compressing the tube to encourage clots to press through the tube).

Stripping may cause complications because it creates excessive negative intrapleural pressure.

Check employer policy. Monitor vital signs, SaO2, and the insertion site every 15 minutes for the first 2 hours.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY DIF: Cognitive Level: Application REF: Skill 27.1 OBJ: Discuss the nursing principles in caring for patients with chest tubes.

TOP: Providing Care to the Patient Who Has a Chest Tube KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. Which of the following is the correct positioning for a patient after a chest tube has been

inserted for a pneumothorax? a. Supine b. Side-lying c. Semi-Fowler’s d. High-Fowler’s ANS: D

After the tube is placed, assist the patient to a comfortable position. Supine does not facilitate drainage or removal of air or fluid, and side-lying does not facilitate lung expansion. The high-Fowler’s position is used to evacuate air (pneumothorax).

DIF: Cognitive Level: Application REF: Skill 27.1 OBJ: Discuss the nursing principles in caring for patients with chest tubes.

TOP: Positioning the Patient Who Has a Chest Tube KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. What is the expected amount of drainage for an adult patient with a mediastinal chest tube? a. Less than 100 mL per hour during the immediate postoperative period b. Less than 10 mL per hour during the immediate postoperative period c. 1000 mL per hour during thNeUfiRrsSt I 24N-G hoTuB r. peCriO odM d. 200 mL per hour during the first 24-hour period ANS: A

In the adult, less than 50 to 200 mL per hour is drained immediately after surgery in a mediastinal chest tube. No standard is known for 10 mL per hour in the immediate postoperative period. Expected drainage in the adult with a mediastinal chest tube is approximately 500 mL in the first 24 hours.

DIF: Cognitive Level: Comprehension REF: Skill 27.2 OBJ: Discuss the nursing principles in caring for patients with chest tubes.

TOP: Postoperative Drainage From a Mediastinal Chest Tube KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. What is the expected amount of drainage for an adult patient with a posterior chest tube? a. 100 to 300 mL during the first 3 hours b. 10 to 50 mL during the first 2 hours c. 200 mL during the first 24 hours d. 400 to 500 mL during the first 24 hours ANS: A

In the adult, between 100 and 300 mL of fluid may drain from a posterior tube during the first 3 hours after insertion. The 24-hour rate is 500 to 1000 mL. DIF: Cognitive Level: Comprehension

REF: Skill 27.1

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY OBJ: Discuss the nursing principles in caring for patients with chest tubes.

TOP: Drainage From a Pleural Chest Tube KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. A nurse determines that there may be a leak in the chest tube system. Clamps are applied near

the patient’s chest, and the nurse finds that the bubbling stops. What should the nurse do next? a. Change the tubing. b. Change the drainage container. c. Move the clamps farther down the chest tube. d. Reinforce the dressing and notify the physician.

ANS: D

Assess for the location of the air leak by clamping the chest tube close to the chest wall with two shodded hemostats. If the bubbling stops, the leak is inside the thorax or insertion site.

Unclamp the tube, reinforce the dressing, and notify the physician immediately. If bubbling continues with the clamps near the chest wall, gradually move one clamp at a time down the tubing toward the patient. If bubbling stops, replace the tubing or secure the connections. If bubbling continues, replace the drainage system.

DIF: Cognitive Level: Application REF: Table 27.3: Problem Solving with Chest Tubes OBJ: Discuss the nursing principles in caring for patients with chest tubes.

TOP: Detecting Air Leak in a Chest Tube System KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. During assessment of a patient, the chest tube becomes dislodged. What should the nurse do

first? a. Have an assistant apply an N ocUcR luS siI veNgGaT uzBe.dC reOssMing and tape on all four sides. b. Clamp the chest tube. c. Attempt to gently reinsert the tube. d. Apply pressure over the insertion site.

ANS: D

If the chest tube becomes dislodged, immediately apply pressure over the chest tube insertion site. The nurse should first stabilize the patient to the best of his or her ability before calling the physician. Applying gauze to all four sides of an occlusive dressing would not allow for the escape of any air from the pleural space and could lead to a tension pneumothorax.

Because the chest tube has become dislodged, it is outside of the body. Clamping the tube at this point would be useless. Nurses are not allowed to reinsert chest tubes. Immediately apply pressure over chest tube insertion site. Have an assistant apply gauze dressing and tape three sides. Notify the health care provider.

DIF: Cognitive Level: Application REF: Skill 27.1 OBJ: Discuss the nursing principles in caring for patients with chest tubes.

TOP: Dislodged Chest Tube KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. What does the expected role of the nurse include during chest tube removal? a. Prepares an occlusive dressing b. Performs clipping of the sutures c. Provides support and assessment of the patient

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY d. Removes the chest tube firmly and quickly ANS: C

The nurse supports the patient physically and emotionally while the physician or an advanced practice nurse (APN) removes the dressing and clips the sutures. A physician or an APN prepares an occlusive dressing of petroleum gauze on a pressure dressing, sets it aside on a sterile field, and applies sterile gloves; removes the dressing and clips the sutures; and pulls out the chest tube.

DIF: Cognitive Level: Application REF: Skill 27.2 OBJ: Discuss the nursing principles in caring for patients with chest tubes.

TOP: Chest Tube Removal KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. Appropriate intervention for the patient who is having a reinfusion of chest tube drainage is

noted when the nurse a. hangs the reinfusion lower than the usual intravenous (IV) bag. b. uses a microaggregate filter on the reinfusion bag. c. maintains 500 mm Hg pressure in the gravity blood cuff. d. keeps the clamps open on the drainage tubing during bag transfer.

ANS: B

Use a new microaggregate filter to reinfuse each autotransfusion bag. Hang the bag on an IV pole and continue to prime the tubing until all air is gone. Clamp the tubing, attach it to the patient’s IV access, and adjust the clamp to deliver the reinfusion at the appropriate rate.

Reinfusion is delivered by gravity or by application of a blood cuff (not to exceed 150 mm Hg pressure) or a blood-compatible IV pump. Connect the red and blue connectors on top of the initial collection bag, and remoN veUiRt S byIlN ifG tinTgBi. t fCroOmMthe side hook and then from the foot hook. This maintains a closed system within the bag and removes it for use in autotransfusion.

DIF: Cognitive Level: Application TOP: Autotransfusion MSC: NCLEX: Physiological Integrity

REF: Skill 27.3 OBJ: Describe autotransfusion.

KEY: Nursing Process Step: Implementation

18. Of the following nursing assessments, which should be reported to the primary care provider

immediately by the nurse? a. A patient with a hemothorax has bloody drainage. b. Subcutaneous emphysema is noted on assessment. c. Bubbling in the water seal stops on a patient with a pneumothorax. d. More than 300 mL of drainage has been collected in the system in the past hour.

ANS: D

Drainage exceeding 100 mL/hr should be reported immediately because this would be considered abnormal. Drainage would be expected to be bloody if the patient has a hemothorax. Cessation of bubbling in the water seal indicates that the air has been evacuated in the patient with a pneumothorax. Although the finding of subcutaneous emphysema should be reported, documented, and monitored, it is not an emergency.

DIF: Cognitive Level: Analysis REF: Skill 27.1 OBJ: Discuss the nursing principles in caring for patients with chest tubes.

TOP: Chest Tube Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

19. The nurse is providing care for a patient with a pneumothorax. He or she anticipated removal

of the chest tube because of the absence of an air leak for the past a. 6 to 8 b. 12 to 16 c. 18 to 24 d. 48 to 72

hours.

ANS: C

One of the signs that indicate that the chest tube may be removed is lack of an air leak for 24 to 48 hours. Lack of an air leak for less than 24 hours is usually not long enough, and there is no need to wait 4 days. Other findings that indicate that the chest tube may be removed include a chest x-ray examination showing lung re-expansion, minimal tube drainage, and lack of water-seal tidalling.

DIF: Cognitive Level: Analysis REF: Skill 27.2 OBJ: Discuss the nursing principles in caring for patients with chest tubes.

TOP: Chest Tube Removal KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 20. The nurse is caring for a patient with blood collecting in the pleural space. The nurse

documents this as a. pleural effusion. b. hemothorax. c. pulmonary hemorrhage. d. pneumothorax.

ANS: B

NURSINGTB.COM

A hemothorax is a collection of blood in the pleural space. A pneumothorax is the collection of air in the pleural space. A pulmonary hemorrhage is bleeding inside the lung. A pleural effusion is the collection of fluid within the pleura.

DIF: Cognitive Level: Understanding REF: Principles for Practice OBJ: Discuss the nursing principles in caring for patients with chest tubes.

TOP: Chest Tubes DrainageKEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

is the proper term to describe that the patient’s water seal is fluctuating up and down with each breath. a. bubbling b. tidalling c. fluttering d. alternating

21. The nurse knows that

ANS: B

The term for the fluctuation of the water-seal chamber when the patient breathes is tidalling.

Bubbling is different from tidalling, because bubbling is the presence of gas moving through the chamber, whereas tidalling is an up and down movement that correlates with the patient’s breathing. Fluttering and alternating reflect incorrect terminology.

DIF: Cognitive Level: Understanding REF: Safety Guidelines OBJ: Discuss the nursing principles in caring for patients with chest tubes.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY TOP: Chest Tube Functioning MSC: NCLEX: Physiological Integrity

KEY: Nursing Process Step: Assessment

22. The nurse is caring for a patient with a chest tube connected to water-seal drainage. The nurse

may delegate which of the following tasks to an unregulated care provider (UCP)? a. Changing the chest tube drainage system b. Milking the chest tube c. Measuring chest tube output d. Turning and positioning the patient ANS: D

The UCP may turn and position the patient as long as the nurse ensures that the UCP understands how to manipulate the tubing safely and knows what signs and symptoms should be reported immediately. Care of the chest tube, including milking the tube if ordered, measuring chest tube output, and changing the chest tube drainage system, should never be delegated to UCPs. DIF: Cognitive Level: Application REF: Delegation and Collaboration (Skill 27.2) OBJ: Discuss measures to maintain patient safety during chest tube insertion, maintenance, and removal.

TOP: Chest Tube Assessment KEY: Nursing Process Step: Planning MSC: NCLEX: Safe and Effective Care Environment 23. The patient has a chest tube for a pneumothorax. Assessment revealed continuous bubbling in

the water-seal chamber. The nurse finds no loose connections. After the chest tube near the patient is clamped, the bubbling stops. The nurse’s first action should be to a. apply pressure to the dressing around the chest tube insertion site. b. move the clamp farther down the tube and note whether bubbling resumes. c. replace the entire collectionNtU ubRinSgIaNnG dT syBs. teC mO .M d. increase suction control until bubbling does not resume when the clamp is removed.

ANS: A

If bubbling stops when the chest tube is clamped between the collecting system and the body, the leak is at the insertion site or inside the patient. Applying pressure to the dressing will determine which of the sites is leaking. If bubbling continues after the chest tube is clamped, the leak is below the clamp, and the next step would be to move the clamp farther away from the patient and reassess. Only if the bubbling never stops after the clamp is moved all the way down the tubing should the collection system be replaced. Turning the suction device higher will increase bubbling in the suction chamber and will not affect bubbling in the water-seal chamber.

DIF: Cognitive Level: Application REF: Table 27.3: Problem Solving with Chest Tubes OBJ: Discuss the nursing principles in caring for patients with chest tubes.

TOP: Chest Tube Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. A pneumothorax can be caused by which of the following? (Select all that apply.) a. Trauma b. Rupture of a small bleb

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY c. Emphysema d. Dyspnea ANS: A, B, C

A variety of mechanisms can cause a pneumothorax. A traumatic pneumothorax develops as a result of penetrating chest trauma, such as a stabbing or a case of the chest striking the steering wheel in an automobile accident. A spontaneous or primary pneumothorax sometimes occurs from the rupture of a small bleb (blister) on the surface of the lung or from an invasive procedure, such as insertion of a subclavian intravenous (IV) line. Secondary pneumothorax occurs because of underlying disease, such as emphysema. A patient with a pneumothorax usually feels pain as atmospheric air irritates the parietal pleura. Dyspnea is a symptom of pneumothorax, not a cause.

DIF: Cognitive Level: Comprehension REF: Principles for Practice OBJ: List three conditions requiring chest tube insertion.

TOP: Pneumothorax KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse is caring for a patient with a chest tube connected to wall suction. To keep the tube

patent, the nurse should implement which of the following? (Select all that apply.) a. Routinely “milk” the drainage tubing. b. Avoid dependent loops of the drainage tubing. c. Lift and clear the tube every 15 to 30 minutes. d. Coil the drainage tubing to prevent dependent loops.

ANS: B, C

Chest tube milking or stripping usually is contraindicated because it does not improve catheter patency. Careful management of chest tube drainage prevents the need to milk the chest tube.

Institute nursing interventions tNoUmRaS inI taNinGtT ubBe.pCatOenMcy. These interventions include avoiding dependent loops of the drainage tube, or, when these loops cannot be avoided, such as when the patient is sitting, lifting and clearing the tube every 15 minutes. If the tubing is coiled, looped, or clotted, drainage is impeded, and this can result in a tension pneumothorax.

DIF: Cognitive Level: Application REF: Skill 27.1 OBJ: Discuss the nursing principles in caring for patients with chest tubes.

TOP: Chest Tube Patency KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The nurse is caring for a patient with a chest tube that was inserted 4 days earlier. She notices

that the drainage is blood tinged. What might this indicate to the nurse? (Select all that apply.) a. Malignancy b. Pulmonary infarction c. Empyema d. Hemothorax ANS: A, B

Blood-tinged fluid usually indicates malignancy, pulmonary infarction, or severe inflammation. Pus indicates an empyema, which is a collection of pus in the pleural cavity, and the drainage is pus coloured. Frank blood indicates a hemothorax.

DIF: Cognitive Level: Analysis REF: Principles for Practice OBJ: Discuss the nursing principles in caring for patients with chest tubes.

TOP: Pleural Drainage KEY: Nursing Process Step: Assessment

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY MSC: NCLEX: Physiological Integrity 4. The nurse is preparing to assist the physician in removal of a chest tube. What should the

nurse do to prepare the patient? (Select all that apply.) a. Assess the patient’s need for pain medication. b. Instruct the patient about the process. c. Teach the patient to take a deep breath and hold it. d. Clamp the chest tubes.

ANS: A, B, C

The nurse should prepare the patient for chest tube removal by (1) assessing the need for pre-removal analgesia and obtaining the required medication prescriptions and (2) instructing the patient about the process and what will be requested of the patient. During removal of the chest tube, it is important to instruct the patient to take a deep breath and hold it until the tube is removed. This manoeuvre prevents air from being sucked into the chest as the tube is pulled out and an occlusive dressing is applied. Although clamping of the chest tubes is done to determine whether the chest tube can be eliminated, this is not part of the immediate chest tube removal procedure.

DIF: Cognitive Level: Application REF: Table 27.2: Process for Insertion of Chest Tubes OBJ: Discuss the nursing principles in caring for patients with chest tubes.

TOP: Chest Tube Removal KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse is caring for a patient who has a chest tube. Attached to the top of the patient’s bed

are two shodded hemostats. In which situations would these be used? (Select all that apply.) a. To assess an air leak b. To quickly empty or changN eU diR spSoI saNbG leTsyBs. teC mOs M c. To quickly seal off the lungs if the system becomes disconnected d. To assess whether the patient is ready to have the chest tube removed ANS: A, B, D

Chest tubes are clamped only under the following specific circumstances, per health care provider prescription or nursing policy and procedure: to assess air leak, to quickly empty or change disposable systems, or to assess whether the patient is ready to have the chest tube removed (which is done by a health care provider’s prescription). Clamping an open system could lead to a tension pneumothorax.

DIF: Cognitive Level: Application REF: Skill 25.2 OBJ: Describe methods of troubleshooting chest tube systems.

TOP: Two-Chamber Waterless Chest Tube System KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. The nurse is performing an initial assessment of a patient with a chest tube placed in the

eighth intercostal space. Which of the following findings would the nurse need to assess further? (Select all that apply.) a. Respiratory rate of 18 breaths per minute b. Continuous bubbling in the water-seal chamber c. The presence of subcutaneous emphysema d. Complaints of pain at the insertion site

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY e. Serous drainage on the chest tube dressing the size of a bean ANS: B, C, D

Continuous bubbling in the water-seal chamber could indicate a leak in the system and should be assessed further. The presence of subcutaneous emphysema must be assessed further because it can be caused by a poor seal at the chest tube insertion site. Complaints of pain at the insertion site can be expected but should be fully assessed before analgesics are administered. A respiratory rate of 18 breaths per minute falls within the normal range and does not, by itself, indicate a need for further assessment. A small amount of drainage on the chest tube dressing can be expected, and serous drainage would be normal; however, it should be monitored for any change in appearance.

DIF: Cognitive Level: Analysis REF: Skill 27.1 OBJ: Discuss the nursing principles in caring for patients with chest tubes.

TOP: Chest Tube Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The nurse is caring for a patient who has had a chest tube in place for 2 days. As the nurse

begins his or her shift assessment, he or she should ensure that what equipment is at the bedside? (Select all that apply.) a. Two rubber-tipped clamps b. Plain 4  4 gauze c. Sterile petroleum gauze d. Extra drainage system e. A sterile chest tube of the same size as the one inserted in the patient ANS: A, B, C, D

The nurse should ensure that twNoUrR ubSbIerN-tGipTpB ed.cClaOmMps are at the bedside to clamp the tubing in case of emergency, as well as a plain 4  4 gauze and sterile petroleum gauze to make an occlusive dressing, should the chest tube become dislodged, and an extra drainage system, should the current system become full. There is no need to keep a spare chest tube in most instances because it could be obtained while waiting for the primary care provider to arrive and reinsert.

DIF: Cognitive Level: Application REF: Skill 27.1 OBJ: Demonstrate appropriate documentation and reporting of chest tube care.

TOP: Chest Tube Assessment KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 28: Emergency Measure for Life Support Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The nurse is providing cardiopulmonary resuscitation (CPR) to an unresponsive patient

according to the 2015 American Heart Association (AHA) resuscitation guidelines. The nurse is performing chest compressions correctly when he or she performs them at which rate? a. 40 to 60 per minute b. 60 to 80 per minute c. 80 to 100 per minute d. 100 to 120 per minute ANS: D

The 2015 AHA resuscitation guidelines recommend performing chest compressions at a rate of 100 to 120 per minute.

DIF: Cognitive Level: Application REF: Table 28.2: Common Cardiac Dysrhythmias OBJ: Discuss the process of code management.

TOP: Chest Compressions KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse is working in the emergency department when an 8-year-old patient is brought in

with respiratory distress. The nurse is preparing to insert an oral airway. Which of the following is the appropriate size for this patient? a. Size 1 b. Size 2 NURSINGTB.COM c. Size 3 d. Size 7 ANS: C

Oral airways vary in length and width. Pediatric sizes are 000, 00, 0, 1, 2, and 3 cm.

School-age children are usually size 3 or 4. Adult sizes are 4 through 10 or small, medium, and large. The nurse chooses the size of an oral airway on the basis of the patient’s age and the width and length of the patient’s mouth.

DIF: Cognitive Level: Application REF: Table 28.1: Oral Airway Guidelines for Size by Age OBJ: Discuss indications for basic airway adjunct insertion.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Oral Airway

3. While measuring an oral airway for proper fit, the nurse places the airway so that the flange is

held parallel to the front teeth with the airway against the patient’s cheek. Where is the end of the curve? a. At the angle of the jaw b. Above the ear c. To the level of the nose d. Upside down ANS: A

NURSINGTB.COM

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Size is correct if, when the flange is held parallel to the front teeth with the airway against the patient’s cheek, the end of the curve reaches the angle of the jaw.

DIF: Cognitive Level: Application REF: Table 28.1: Oral Airway Guidelines for Size by Age OBJ: Discuss indications for basic airway adjunct insertion.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Oral Airway

4. Which sign or symptom of airway compromise may require insertion of an oral airway? a. Ability of the patient to speak b. Ability of the patient to cough forcefully c. Presence of wheezing between coughs d. Presence of gurgling with the respiratory cycle ANS: D

Identify the need to insert an oral airway. Signs and symptoms include upper airway gurgling with breathing, absence of a gag reflex, increased oral secretions, excessive drooling, grinding of teeth, clenched teeth, biting of the orotracheal or gastric tube, laboured respirations, and increased respiratory rate. These conditions place the patient at risk for obstruction of the upper airway. Normal response shows no evidence of airway obstruction or compromise.

Wheezing may be present as a symptom of allergy but not necessarily of airway obstruction.

DIF: Cognitive Level: Application REF: Skill 28.1 OBJ: Discuss indications for basic airway adjunct insertion.

TOP: Oral Airway KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

nRoS raI l aNirGwTaB y. inCaOpMatient who is exhibiting signs of potential 5. The nurse is preparing to insertNaU respiratory distress. The nurse knows that candidates for oral airway placement are those a. with oral trauma. b. with loose teeth. c. who are unconscious. d. who have had recent oral surgery.

ANS: C

Never insert an oral airway in a conscious patient or a patient with recent oral trauma, oral surgery, or loose teeth. Use oral airways only in unconscious patients. Oral airways may stimulate vomiting or laryngospasm if inserted in the semiconscious or conscious patient.

DIF: Cognitive Level: Application REF: Skill 28.1 OBJ: Discuss indications for basic airway adjunct insertion.

TOP: Oral Airway KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. Which of the following is the appropriate technique for a nurse to implement when inserting

an oral airway? a. Insert the airway with the curved end up, then rotate it 180 degrees at the back of the throat. b. Insert the airway with the curved end down along the curve of the tongue. c. Use a tongue blade to insert and push the airway into position. d. Insert the airway sideways, then rotate it with the curved end up.

ANS: A

NURSINGTB.COM

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Hold the oral airway with the curved end up, insert the distal end until the airway reaches the back of the throat, then turn the airway more than 180 degrees and follow the natural curve of the tongue. Never push the airway into position. The nurse may also hold the airway sideways, insert it halfway, and then rotate it 90 degrees while gliding it over the natural curvature of the tongue (curved end down).

DIF: Cognitive Level: Application REF: Skill 28.1 OBJ: Discuss indications for basic airway adjunct insertion.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Oral Airway Insertion

7. The nurse is providing an educational seminar to a group of nursing students on the

advantages of using an automated external defibrillator (AED). She knows that her teaching has been effective when the students reply: a. “Health care providers do not need to learn CPR to use the AED.” b. “The health care provider is given a printout of the rhythm change.” c. “The health care provider can safely use both CPR skills and AED skills.” d. “The health care provider can adjust the level of shock administered.”

ANS: C

The advantage of the AED is that laypeople or health care providers trained in basic life support, who have less training than advanced cardiac life support (ACLS) personnel, can defibrillate. AEDs eliminate the need for training in rhythm interpretation and make early defibrillation practical and achievable. The AED is an automated external defibrillator that incorporates a rhythm analysis system. On rhythm identification, some AEDs will automatically provide the electrical shock after a verbal warning (fully automated). Other AEDs will recommend a shock, if needed, and then will prompt the responder to press the shock button. The provider doeNs U noRtSnI eeNdGtoTaBd. juCstOaMnything.

DIF: Cognitive Level: Application REF: Skill 28.3 OBJ: Identify indications for use of an external defibrillator (automated or manual).

TOP: Advantages of an Automated External Defibrillator (AED) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The nurse finds a patient lying on the bathroom floor. The patient is unresponsive and has a

pulse but is not breathing. What is the nurse’s first action? a. Give two breaths using mouth-to-mouth without a barrier device. b. Give two breaths using mouth-to-mouth without a barrier device and watch for chest movement. c. Give two breaths using a bag-mask device. d. Start chest compressions until an automated external defibrillator (AED) is available.

ANS: C

Give two breaths using mouth-to-mouth with a barrier device, a mouth-to-mask device, or a bag-mask device. Watch for chest rise and fall. In a hospital setting where protected methods of artificial ventilation are available, mouth-to-mouth without a barrier device is not recommended because of the risk for microbial contamination. Watch for chest rise and fall.

Motion, by itself, could be caused by fasciculation and is not indicative of air moving into and out of the chest.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

DIF: Cognitive Level: Application REF: Skill 28.3 OBJ: State indications for cardiopulmonary resuscitation (CPR).

TOP: Mouth-to-Mouth With a Barrier Device KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The patient is brought to the emergency department after a motor vehicle accident. The patient

has head and neck trauma and has stopped breathing. What should the nurse do? a. Open the airway using the head tilt–chin lift method. b. Open the airway using the jaw-thrust method. c. Give two breaths using mouth-to-mouth and a barrier device. d. Give two breaths using a bag-mask device.

ANS: B

First determine whether the patient has spontaneous respirations by opening the airway.

Consider spinal cord injury in patients with trauma. In these situations a rescuer must use the jaw-thrust manoeuvre. Prevention of head extension and neck movement is very important to prevent paralysis or spinal cord injury. Apply a rigid cervical collar as soon as possible to reduce cervical spine motion.

DIF: Cognitive Level: Analysis REF: Table 28.3: Common Cardiac Dysrhythmias OBJ: State indications for cardiopulmonary resuscitation (CPR).

TOP: Jaw-Thrust Manoeuvre KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. During the secondary survey of the code event, the nurse realizes that the patient is not

breathing on his own. What shoNuUldRtS heInNuGrsTeBd. oC neOxM t? a. Immediately intubate the patient. b. Prepare supplies for the code team to intubate the patient. c. Begin cardiopulmonary resuscitation (CPR). d. Obtain automated external defibrillator (AED).

ANS: B

If, during the secondary survey, respirations are absent, the nurse should help the code team with endotracheal (ET) intubation. Ensure that the light source on the laryngoscope is functional. Light is necessary on the laryngoscope to visualize the vocal cords and intubate the trachea. Batteries may have to be changed. If respirations are absent, assist the code team with endotracheal intubation. Have available a laryngoscope handle, curved and straight blades, ET tubes, a stylet, suction, and tape or an ET tube holder.

DIF: Cognitive Level: Application REF: Skill 28.3 OBJ: Discuss the process of code management.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Intubation

11. The nurse is performing cardiopulmonary resuscitation (CPR) on an adult patient who has an

endotracheal tube in place. At what rate does the nurse, who is alone, administer breaths? a. 8 per minute b. 12 per minute c. 20 per minute d. 24 per minute

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

ANS: A

Rescue breaths for CPR with an advanced airway (endotracheal tube/tracheotomy) are given at 8 to 10 breaths per minute.

DIF: Cognitive Level: Application REF: Table 28.3: Adult, Child, and Infant Cardiopulmonary Resuscitation Techniques OBJ: Discuss the process of code management.

TOP: Rescue Breathing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The nurse enters her patient’s room to find him unresponsive. She begins cardiopulmonary

resuscitation (CPR) according to protocol. How deep should the nurse do chest compressions in this pulseless adult? a. 2 to 3 cm in depth b. 3 to 4 cm in depth c. 5 to 6 cm in depth d. 7 to 8 cm in depth ANS: C

Chest compressions for an adult are done on the lower half of the sternum between the nipples, with the heel of one hand and with the other hand on top compressing 5 to 6 cm (2–2.4 inches).

DIF: Cognitive Level: Application REF: Table 28.3: Adult, Child, and Infant Cardiopulmonary Resuscitation Techniques OBJ: Discuss the process of code management.

TOP: Chest Compressions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological IntN egUriR tySINGTB.COM 13. The nurse observes a person collapse and stop breathing. The nurse would establish an airway

by a. b. c. d.

inserting an endotracheal tube. inserting a finger to pull the tongue forward. using the head tilt–chin lift manoeuvre. using a modified jaw-thrust manoeuvre.

ANS: C

The nurse would establish an airway by tilting the head back and lifting the chin. An endotracheal tube should not be inserted by the nurse. It is not necessary to put tension on the tongue because proper head tilt with chin thrust will remove the tongue from obstructing the airway. A modified jaw thrust would be used if a neck injury was suspected, but because this patient collapsed in front of the nurse, that would not be a concern in this scenario.

DIF: Cognitive Level: Application REF: Table 28.3: Adult, Child, and Infant Cardiopulmonary Resuscitation Techniques OBJ: Discuss the process of code management.

TOP: Steps Used in Performing Rescue Breathing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 14. The nurse is performing cardiac compressions on a 4-year-old child with the assistance of

another nurse. The nurses would deliver breaths and compressions at a ratio of compressions for breaths. a. 30; 2 b. 5; 1 c. 15; 2 d. 5; 2 ANS: C

The correct ratio of compressions to breaths is 15 chest compressions followed by 2 breaths if there are two rescuers for a child. A ratio of 30:2 would be used in adult CPR; if there are two rescuers, 1 breath is interspersed after 15 compressions, but the ratio remains 30:2. Ratios of 5:1 and 5:2 are always incorrect when cardiopulmonary resuscitation (CPR) is performed on a child.

DIF: Cognitive Level: Application REF: Table 28.3: Adult, Child, and Infant Cardiopulmonary Resuscitation Techniques OBJ: Discuss the process of code management.

TOP: Steps Used in Administering External Cardiac Compressions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. When applying an automated external defibrillator, the nurse would a. connect the cable to the machine, apply the pads, and turn on the power. b. turn on the power, apply the pads, and connect the cable. c. turn on the power, connect the cable, and apply the pads. d. connect the cable, turn on the power, and apply the pads.

NURSINGTB.COM

ANS: B

As soon as the cable is connected, the machine begins to attempt to analyze the rhythm, so the power should be turned on and the pads should be applied to the chest wall before the cable is connected to the machine. Connecting the cable, applying the pads, and then turning on the power would cause the machine to malfunction or would delay analysis while it cycles on.

Connecting the cable before applying the pads could result in the rescuer being shocked.

DIF: Cognitive Level: Application REF: Skill 28.3 OBJ: Discuss the process of code management.

TOP: Steps Used in Administering Automated External Defibrillation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. When using an automated external defibrillator (AED), it is important for the nurse to ensure

that no one is touching the patient a. after connecting the cable to the machine. b. when the machine is plugged in. c. while the pads are applied. d. while the machine analyzes the rhythm.

ANS: A

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

The nurse needs to ensure that no one is touching the patient while the machine is analyzing because this may interfere with correct interpretation of the patient’s rhythm and could put anyone touching the patient at risk of being shocked. Cardiopulmonary resuscitation (CPR) may be continued up until the machine is ready to analyze, although CPR may need to be momentarily stopped for placement of the chest pad, and when the AED instructs the user to resume CPR. There is no risk in touching the patient while the machine is plugged in, and it is not possible to apply the pads without touching the patient. CPR should be performed until an AED is brought to the patient and the cable is ready to be inserted into the machine with the pads already in place.

DIF: Cognitive Level: Application REF: Skill 28.3 OBJ: Identify indications for use of an external defibrillator (automated or manual).

TOP: Steps Used in Administering Automated External Defibrillation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. The nurse sees on the cardiorespiratory monitor that the patient’s cardiac rhythm has changed

from normal sinus rhythm to ventricular fibrillation. The nurse knows that the most effective means of converting this rhythm is a. cardiopulmonary resuscitation (CPR). b. defibrillation. c. oxygen. d. precordial thump.

ANS: B

CPR should be performed until the defibrillator patches are applied, but it is not the most effective means of converting the electrical rhythm; rather it supports life until defibrillation can be performed. Oxygen shoN ulU dR beSaIdN mGinTisBte.reCdOdMuring CPR, but it is not the means of converting the rhythm. Precordial thumps are controversial at best and would not be the most effective means of converting the rhythm.

DIF: Cognitive Level: Application REF: Table 28.3: Adult, Child, and Infant Cardiopulmonary Resuscitation Techniques OBJ: Identify indications for use of an external defibrillator (automated or manual).

TOP: Key Terms Used in the Skills of Hospital Emergency Measures and Cardiopulmonary Resuscitation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. The nurse would call the code team for which of the following patients? a. A patient with blood pressure of 60/28 mm Hg b. A patient experiencing severe dyspnea secondary to asthma c. A patient in atrial fibrillation d. An unconscious patient in ventricular tachycardia ANS: D

A patient who becomes unconscious while in ventricular tachycardia requires the rapid intervention of the cardiac/respiratory arrest team. A hypotensive patient or a patient experiencing dyspnea requires the intervention of the rapid response team. A patient in atrial fibrillation requires notification of the primary care provider.

DIF: Cognitive Level: Application REF: Table 28.2: Common Cardiac Dysrhythmias OBJ: State indications for cardiopulmonary resuscitation (CPR).

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY TOP: Oral Airway KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 19. The nurse enters the patient’s room and finds that the patient is not breathing and has no

pulse. The patient does not have a do-not-resuscitate order. What would the nurse’s most immediate action be? a. Call the cardiac/respiratory arrest team. b. Begin cardiopulmonary resuscitation (CPR). c. Call a coworker for help. d. Get the crash cart.

ANS: A

The nurse’s first action should be to summon the cardiac/respiratory arrest team because it will take them a few minutes to arrive, and the patient’s best outcome depends on their rapid arrival. As soon as the team has been called, the nurse should begin CPR. If the arrest is not called over the public address system, the nurse should call a coworker for help while performing CPR or after initiating CPR. If the code is called over the public address system, coworkers will hear the call and will come to the room without being summoned. Once coworkers have been alerted, they can obtain the crash cart and summon additional support.

DIF: Cognitive Level: Application REF: Skill 28.3 OBJ: Discuss the process of code management.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Oral Airway

20. For which of the following patients would the nurse request the rapid response team’s

immediate intervention? a. A patient complaining of seNvU erR eS poIsN toGpT erB at. ivCeOinMcisional pain b. A patient with no pulse who is not breathing c. A patient complaining of chest pain, hypotension, and shortness of breath d. A patient with blood pressure of 164/96 mm Hg ANS: C

The nurse would request the rapid response team’s immediate intervention for the patient with chest pain, hypotension, and shortness of breath to prevent a potentially life-threatening situation. A patient with postoperative pain can be successfully treated by the nurse on the unit and does not require the rapid response team. If the patient has no pulse and no respirations, the nurse should call the arrest team, not the rapid response team. The nurse should call the primary care provider for the patient who is hypertensive.

DIF: Cognitive Level: Application REF: Table 28.3: Adult, Child, and Infant Cardiopulmonary Resuscitation Techniques OBJ: Discuss the process of code management.

TOP: Oral Airway KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 21. A patient has been found with no pulse or respirations. The cardiopulmonary arrest team has

been called. What should the nurse do while awaiting the team’s arrival? a. Gather the patient’s medical record and medication administration record. b. Obtain the crash cart. c. Notify the patient’s primary care provider. d. Perform cardiopulmonary resuscitation (CPR).

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY ANS: D

The nurse’s responsibility while awaiting the arrest team is to perform CPR, with or without assistance as available. Other team members can collect the patient’s records, obtain the crash cart, and notify the primary care provider. The nurse assigned to the patient should stay with the patient to provide the history when the team arrives.

DIF: Cognitive Level: Application REF: Skill 28.3 OBJ: Discuss the process of code management.

TOP: The Nurse’s Role in Initiating and Participating in a Cardiopulmonary Arrest Situation in a Hospital KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. The most common cause of airway obstruction in an unresponsive patient is the a. food b. tongue c. teeth d. secretions

.

ANS: B

The tongue is the most common cause of blocked airway in an unresponsive patient.

DIF: Cognitive Level: Understanding REF: Skill 28.1 OBJ: Discuss indications for basic airway adjunct insertion.

TOP: Airway Obstruction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse in the critical care unNitU(R CS CI UN ) iGs T caBri.nC gO foMr a newly admitted patient with chest

pain. She is aware that arrhythmia may be caused by which of the following? (Select all that apply.) a. Electrolyte disturbances b. Heart damage c. Medications d. Respiratory arrest ANS: A, B, C, D

Causes of arrhythmia may include electrolyte disturbances (potassium, magnesium, calcium), heart damage, and certain prescribed or recreational medications. Early intervention for a respiratory arrest usually prevents a cardiac arrest.

DIF: Cognitive Level: Understanding REF: Skill 28.3 OBJ: State indications for cardiopulmonary resuscitation (CPR).

TOP: Cardiac Arrest KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse walks into his or her patient’s room to find him unresponsive. He or she begins

cardiopulmonary resuscitation (CPR), knowing that during a “code” situation, chest compressions should be interrupted for which of the following? (Select all that apply.) a. Ventilation b. Pulse checks c. Intubation

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY d. Defibrillation ANS: A, B, C, D

The 2010 American Heart Association (AHA) resuscitation guidelines recommend performing chest compressions at a rate of 100 per minute with few and very brief interruptions for ventilation, pulse checks, intubation, and defibrillation.

DIF: Cognitive Level: Application REF: Skill 28.3 OBJ: Discuss the process of code management.

TOP: Chest Compressions KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse is caring for an unconscious patient who has an oral airway in place and who has

copious amounts of oral secretions. What may the nurse have to do while caring for this patient? (Select all that apply.) a. Cleanse the mouth frequently using lemon glycerine swabs. b. Replace or clean the oral airway. c. Suction the oral cavity frequently. d. Keep the airway in place for extended periods.

ANS: B, C

Do not use lemon glycerine swabs for oral care because they are drying to mucosal tissues and promote bacterial growth. The oral airway will have to be removed, cleaned or discarded, and replaced in patients with excessive oral secretions. Frequent suctioning of the oral cavity may be required. Oral airways are not a long-term solution. They can cause significant lip and tongue erosion.

DIF: Cognitive Level: Application REF: Skill 28.1 OBJ: Discuss indications for basN icUaR irw djT unBct.iC nsO erM tion.

SaIyNaG KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Oral Airway Maintenance

4. What is the nurse’s responsibility for the patient after he has been intubated during a code

event? (Select all that apply.) a. Ventilate using a bag-mask device at a rate of 22 breaths per minute. b. Monitor the carbon dioxide detector. c. Auscultate both lungs. d. Call for a chest radiograph.

ANS: B, C

Assist in confirmation of endotracheal tube placement by auscultating the lungs for bilateral breath sounds. Monitor the carbon dioxide detector to confirm correct airway placement.

Intubation personnel usually perform secondary confirmation by using a carbon dioxide detector. Ventilate using a bag-mask device on intubation at a rate of 8 to 10 breaths per minute. Avoid hyperventilation. Increased intrathoracic pressure caused by incomplete exhalation results in reduced cardiac output. A chest radiograph usually is obtained after the patient has been stabilized to confirm placement of the endotracheal tube and central venous catheters.

DIF: Cognitive Level: Application REF: Skill 28.3 OBJ: Discuss the process of code management.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Intubation

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 29: Vascular Access and Infusion Therapy Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The nurse is caring for a patient receiving antineoplastic medications intravenously. The nurse

discovers that the intravenous site is red, edematous, and painful. The nurse knows that antineoplastic medications are vesicant medications and documents that the patient has experienced which of the following events? a. Occlusion b. Extravasation c. Phlebitis d. Thrombophlebitis ANS: B

When a vesicant medication infiltrates the tissue, this is called an extravasation. Occlusion refers to a thrombus or fibrin sheath that impedes the flow of intravenous (IV) fluids. Phlebitis occurs with redness surrounding the vein, and extravasation leads to trauma within the vein.

Thrombophlebitis occurs when trauma occurs within a vein as a result of a thrombus.

DIF: Cognitive Level: Application REF: Skill 29.2 OBJ: Discuss complications of infusion therapy.

TOP: Assessment of IV Site KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 2. Established standards for routine replacement of peripheral intravenous (IV) catheters and IV

administration sets have recommended a maximum of NURSINGTB.COM contamination and prevent catheter site complications. a. 24 b. 48 c. 72 d. 96

hours to reduce IV fluid

ANS: D

Established standards for routine replacement of peripheral IV catheters and IV administration sets have recommended a maximum of 96 hours to reduce IV fluid contamination and prevent catheter site complications.

DIF: Cognitive Level: Comprehension REF: Table 29.5: Intravenous Administration Set Changes OBJ: Discuss complications of infusion therapy.

TOP: Replacement of IV Catheters and Administration Sets KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. While assessing the patient, the nurse recognizes that special caution should be taken with the

intravenous (IV) infusion because of fluid volume excess when the nurse notes the presence of which condition? a. Poor skin turgor b. Crackles in the lungs c. Decreased blood pressure

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY d. Dry skin and mucous membranes ANS: B

Auscultation of crackles or rhonchi in the lungs may signal fluid buildup in the lungs caused by fluid volume excess. Poor skin turgor is common with fluid volume deficit. The pinched skin stays elevated for several seconds (tenting). This may be an indication of the need for IV therapy. Decreased blood pressure may indicate fluid volume deficit caused by a decrease in stroke volume. This may indicate the need for IV therapy. Dry skin and mucous membranes may indicate dehydration.

DIF: Cognitive Level: Comprehension REF: Skill 29.2 OBJ: Discuss complications of infusion therapy.

TOP: Fluid Volume Excess KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse needs to specifically prevent air emboli that may result from intravenous (IV)

therapy. What should the nurse make sure to do to prevent air emboli? a. Use a needleless system. b. Prime the tubing completely. c. Check for medication compatibility. d. Select a larger-gauge needle or catheter.

ANS: B

Prime the infusion tubing by filling it with IV solution. Be certain that the tubing is clear of air and air bubbles. Large air bubbles can act as emboli. A needleless system does not specifically prevent the introduction of air emboli. Medication incompatibility may lead to crystallization of the medication and may cause emboli to form from precipitate. It will not lead, however, to air embolism. Catheter size does not contribute to emboli formation.

NURSINGTB.COM

DIF: Cognitive Level: Application REF: Skill 29.2 OBJ: Discuss complications of infusion therapy.

TOP: Air Embolism KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. Which of the following steps is necessary when a patient is prepared for intravenous (IV)

catheter insertion? a. Shaving the hair from the site b. Selecting a proximal site in an extremity c. Applying a tourniquet 10 to 15 cm above the selected site d. Vigorously taping and massaging the selected vein ANS: C

Apply a flat tourniquet around the arm, above the antecubital fossa or 10 to 15 cm (4–6 inches) above the proposed insertion site. Do not shave the area. Shaving may cause microabrasions and may predispose to infection. Use the most distal site in the nondominant arm, if possible. Vigorous friction and multiple taping of the veins, especially in older persons, may cause hematoma or venous constriction.

DIF: Cognitive Level: Application REF: Skill 29.1 OBJ: Explain how to prepare the patient and caregiver for infusion therapy.

TOP: Applying a Tourniquet KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 6. What should be the next action by the nurse once an over-the-needle catheter (ONC) has been

inserted through the skin and into the vein? a. Loosen the stylet for removal. b. Check for blood return in the flashback chamber. c. Stabilize the catheter and release the tourniquet. d. Advance the catheter until the hub rests at the insertion site.

ANS: B

Observe for blood return through the flashback chamber of the catheter or the tubing of the winged cannula, indicating that the bevel of the needle has entered the vein. Lower the needle until almost flush with the skin. Advance the catheter another 3 to 6 mm (1/8 to 1/4 inch) into the vein, and then loosen the stylet site on the ONC. Only after the catheter is advanced and is in its final position is the catheter stabilized with one hand while the tourniquet is released.

Only after the blood and the needle are observed to advance another 3 to 6 mm (1/8 to 1/4 inch) into the vein is the stylet loosened. At that point, continue to hold the skin taut, and advance the catheter into the vein until the hub rests at the venipuncture site.

DIF: Cognitive Level: Application REF: Skill 29.1 OBJ: Demonstrate initiating infusion therapy, regulating IV flow rate, changing IV solutions, changing IV administration sets, changing peripheral vascular access device (PVAD) dressings, and discontinuing a PVAD. TOP: Inserting the Over-the-Needle Catheter KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. What should the nurse do once he or she recognizes that the patient has phlebitis at his

intravenous (IV) catheter site? a. Reduce the IV flow rate. b. Elevate the affected extremN itU y.RSINGTB.COM c. Place a moist warm compress over the site. d. Adjust the additive in the current IV. ANS: C

Phlebitis is indicated by pain, increased skin temperature, and erythema along the path of the vein. Stop the infusion and discontinue the IV catheter. Start a new IV if continued therapy is necessary. Place a moist warm compress over the area of phlebitis. Document the degree of phlebitis and nursing interventions per employer policy and procedure. The extremity is elevated for an infiltration to reduce edema.

DIF: Cognitive Level: Application REF: Skill 29.2 OBJ: Discuss complications of infusion therapy.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Phlebitis

8. What should the nurse do on noting bleeding around a dressing at an intravenous (IV) catheter

insertion site? a. Discontinue the IV. b. Assess the insertion site. c. Leave the dressing intact but reinforce it. d. Elevate and apply warm compresses to the extremity.

ANS: B

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

When blood appears on the dressing, verify that the system is intact, and change the dressing.

The IV catheter should be discontinued in the event of infiltration or phlebitis. If bleeding occurs around the venipuncture site and the catheter is within the vein, gauze dressing may be applied over the site. Be aware that if gauze dressing is used, it must be removed to accurately assess the insertion site. Elevation is used in cases of infiltration to reduce edema. Warm compresses are used in cases of phlebitis.

DIF: Cognitive Level: Application REF: Skill 29.2 OBJ: Discuss complications of infusion therapy.

TOP: Bleeding at Venipuncture Site KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. Which patient would a nurse anticipate would be a candidate for a peripherally inserted

central catheter (PICC)? a. An older person who is having cataracts removed b. A perinatal patient who is having prolonged labour c. A neonate requiring blood therapy d. An adolescent who is having surgery for reduction of a fracture ANS: C

When a child is critically ill or when long-term intravenous (IV) access is anticipated, a PICC catheter, a Broviac catheter, or an implanted port may be used to access a larger vein. PICCs can be used to infuse IV fluids, parenteral nutrition, blood and blood products, and medications such as antibiotics. Gerontological veins are very fragile, with less subcutaneous support tissue and with thinning of the skin. In older patients, use the smallest gauge possible.

For example, a 22-gauge needle is adequate for fluid and medication therapy. PICC lines are not inserted routinely. PICCs are used when long-term IV therapy is needed.

NURSINGTB.COM

DIF: Cognitive Level: Comprehension REF: Table 29.6: Central Vascular Access Devices OBJ: Explain how to prepare the patient and caregiver for infusion therapy.

TOP: Pediatric Considerations KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 10. The nurse is caring for a patient receiving intravenous (IV) therapy. The nurse should report

which of the following to the primary care provider? a. Completion of each liter of fluid b. Initiation of IV fluids c. Small infiltration d. Extravasation ANS: D

If a patient suffers an extravasation, the primary care provider should be notified as soon as possible because complications of some vesicants can be reduced by injection of specific medications, whereas others require rapid medical intervention. It is not necessary to report when you routinely initiate or complete IV therapy. Primary care providers do not need to be notified of a small infiltrate, but it should be documented in the patient’s medical record, and your employer may require completion of an event reporting form.

DIF: Cognitive Level: Application REF: Communication and Documentation (Skill 29.1) OBJ: Identify safety guidelines for IV fluid administration.

TOP: Assessment of IV Therapy Access Devices

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

11. The patient has intravenous (IV) therapy prescribed to infuse at 1000 mL over 10 hours. The

infusion set has a calibration of 15 gtt/mL. At which rate does the nurse regulate the infusion? a. 20 gtt per minute b. 25 gtt per minute c. 30 gtt per minute d. 32 gtt per minute ANS: B

Select one of the following formulas to calculate drop rate based on drops per minute: mL/hr/60 min = mL/min followed by drop factor  mL/min = drops/min, or mL/hr  drop factor/60 min = drops/min.

DIF: Cognitive Level: Analysis REF: Skill 29.2 OBJ: Demonstrate initiating infusion therapy, regulating IV flow rate, changing IV solutions, changing IV administration sets, changing peripheral vascular access device (PVAD) dressings, and discontinuing a PVAD. TOP: IV Rate Calculation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The prescription is for the patient to receive 500 mL over 4 hours. The nurse has an electronic

infusion device (EID) in place that provides for the regulation of hourly infusion. The intravenous (IV) tubing available is 10 gtt/mL. What is the setting for the infusion device? a. 125 mL per hour b. 500 mL per hour c. 21 gtt per minute NURSINGTB.COM d. 32 gtt per minute ANS: A

For use of EID for infusion, turn on the power button, select the required drops per minute or volume per hour, close the door to the control chamber, and press the start button. In this case, 500 mL/4 hr = 125 mL/hr.

DIF: Cognitive Level: Analysis REF: Skill 29.2 OBJ: Demonstrate initiating infusion therapy, regulating IV flow rate, changing IV solutions, changing IV administration sets, changing peripheral vascular access device (PVAD) dressings, and discontinuing a PVAD. TOP: IV Rate Regulation via EID KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. A pediatric patient has an intravenous (IV) catheter with microdrip tubing. The prescription is

for 40 mL per hour to infuse. At what rate does the nurse set the microdrip? a. 10 gtt per minute b. 20 gtt per minute c. 40 gtt per minute d. 80 gtt per minute ANS: C

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Select one of the following formulas to calculate drop rate based on drops per minute: mL/hr/60 min = mL/min followed by drop factor  mL/min = drops/min, or mL/hr  drop factor/60 min = drops/min. In this case, 40 mL/hr  60 gtt/mL = 240 gtt/hr  1 hr/60 min = 40 gtt/min. When microdrip is used, mL per hour always equals gtt per minute.

DIF: Cognitive Level: Analysis REF: Skill 29.2 OBJ: Demonstrate initiating infusion therapy, regulating IV flow rate, changing IV solutions, changing IV administration sets, changing peripheral vascular access device (PVAD) dressings, and discontinuing a PVAD. TOP: IV Rate Regulation via Microdrip KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. While assessing the patient’s intravenous (IV) infusion, the nurse notes that it is infusing more

slowly than it should be. What should the nurse do first? a. Discontinue the IV. b. Increase the rate of infusion. c. Observe for fluid overload. d. Check the position of the IV fluid and extremity.

ANS: D

Check the patient for positional changes that might affect infusion rate, height of the IV container, and tubing obstruction. Check the condition of the site. The most likely cause of a slow-running IV is positioning. An infiltrated or clotted IV line probably will not be running at all. Discontinue the IV if it is determined that it is infiltrated or clotted off. Position will affect flow even if rate is increased. Fluid overload is not associated with slowing of the infusion rate. Often it occurs when an IV is running too quickly.

DIF: Cognitive Level: ApplicatiN onURSINRGETFB : .SC kiO llM 29.2 OBJ: Demonstrate initiating infusion therapy, regulating IV flow rate, changing IV solutions, changing IV administration sets, changing peripheral vascular access device (PVAD) dressings, and discontinuing a PVAD. TOP: Slow-Running IV KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. The nurse caring for a patient receiving intravenous (IV) fluids knows that the current

recommendation for changing the tubing on a continuously running IV is a. at least every 48 hours. b. every 24 hours. c. no more often than every 96 hours. d. with each IV solution bag change.

ANS: C

IV tubing administration sets remain sterile for 96 hours. Current recommendations state that tubing should be changed no more frequently than every 96 hours. When possible, schedule tubing changes when it is time to hang a new IV container.

DIF: Cognitive Level: Application REF: Skill 29.4 OBJ: Demonstrate initiating infusion therapy, regulating IV flow rate, changing IV solutions, changing IV administration sets, changing peripheral vascular access device (PVAD) dressings, and discontinuing a PVAD. TOP: IV Tubing Change for Continuous Infusions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

16. The nurse is caring for a patient diagnosed with pneumonia who receives intravenous (IV)

antibiotics every 8 hours. How often should the nurse change the primary intermittent IV sets? a. No more often than every 72 hours b. At least every 72 hours c. With each IV bag change d. Every 24 hours ANS: D

The nurse should change primary intermittent sets every 24 hours because the IV system becomes interrupted, which increases the risk for contamination.

DIF: Cognitive Level: Application REF: Skill 29.4 OBJ: Demonstrate initiating infusion therapy, regulating IV flow rate, changing IV solutions, changing IV administration sets, changing peripheral vascular access device (PVAD) dressings, and discontinuing a PVAD. TOP: IV Tubing Change for Intermittent Infusions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. What is an appropriate technique for the nurse to implement when changing the dressing at a

peripheral intravenous (IV) catheter site? a. Wear sterile gloves to remove the old dressing. b. Keep one finger over the IV catheter until the tape is replaced. c. Cleanse with an antiseptic solution in a circular manner toward the site. d. Tape the connection between the IV catheter port and the tubing.

ANS: B

Keep one finger over the cathete r aRt S alI lN tim NU GeTsBu.ntCilOthMe tape or dressing secures placement. If the patient is restless or uncooperative, it is helpful to have another staff member assist with the procedure. Perform hand hygiene. Apply disposable gloves. Apply the final swab in a circular pattern, moving outward from the insertion site. Do not tape over the connection of the access tubing or port to the IV catheter.

DIF: Cognitive Level: Application REF: Skill 29.5 OBJ: Demonstrate initiating infusion therapy, regulating IV flow rate, changing IV solutions, changing IV administration sets, changing peripheral vascular access device (PVAD) dressings, and discontinuing a PVAD. TOP: IV Dressing Change KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. What should the nurse do when discontinuing a peripheral intravenous (IV) catheter? a. Withdraw the catheter quickly. b. Keep the hub perpendicular to the skin. c. Apply pressure to the site for 1 minute. d. Inspect the catheter for intactness after removal.

ANS: D

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Inspect the catheter for intactness after removal, noting tip integrity and length. Place clean sterile gauze above the site, and withdraw the catheter using a slow, steady motion. Keep the hub parallel to the skin. Do not raise or lift the catheter before it is completely out of the vein, to avoid trauma or hematoma formation. Apply pressure to the site for 2 to 3 minutes using a dry, sterile gauze pad. Secure with tape. Note: Apply pressure for 5 to 10 minutes if the patient is taking anticoagulants.

DIF: Cognitive Level: Application REF: Procedural Guideline 2.1 OBJ: Demonstrate initiating infusion therapy, regulating IV flow rate, changing IV solutions, changing IV administration sets, changing peripheral vascular access device (PVAD) dressings, and discontinuing a PVAD. TOP: Discontinuing a Peripheral IV KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. The patient is expected to require intravenous (IV) therapy for several years as treatment for a

chronic disease process. Which of the following would be the best choice for venous access in this patient? a. Peripherally inserted central catheter (PICC) b. Nontunnelled percutaneous central venous catheter c. Subcutaneous implanted port d. Peripheral IV line ANS: C

Implanted infusion ports are used for long-term and complex IV infusion therapy. When not in use, no external catheter is present, and port manufacturers recommend that the port be heparinized every 4 weeks to maintain patency. No other care is required for an unused port.

PICCs provide alternative IV access when the patient requires intermediate-length venous IN access (greater than 7 days to sN evUeR raS lm onGthTsB )..TC heOsM e catheters are used for shorter placements (e.g., 5–10 days). Use of peripheral IV therapy increases the risk for patients to develop infection, vein sclerosis, phlebitis, and infiltration.

DIF: Cognitive Level: Synthesis REF: Table 29.6: Central Vascular Access Devices OBJ: Identify common types of central vascular access devices (CVADs).

TOP: Subcutaneous Implanted Ports KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 20. The nurse is assisting the physician during the insertion of a central line into the subclavian

vein. How should the nurse cleanse the area? a. With chlorhexidine in a back and forth scrubbing motion b. With chlorhexidine followed by alcohol in a back and forth scrubbing motion c. With alcohol in a circular motion for 5 minutes d. With antimicrobial solution that must be dabbed dry with a sterile towel ANS: A

Antiseptics such as chlorhexidine remove resident and transient bacteria. Alcohol should not be applied after the application of iodophor solution. Chlorhexidine is scrubbed in a back and forth motion for 30 seconds. Allow the antimicrobial solution to air dry completely. This ensures maximum antimicrobial effect.

DIF: Cognitive Level: Application REF: Skill 29.6 OBJ: Identify common types of central vascular access devices (CVADs).

TOP: Inserting a Central Venous Access Device

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. The nurse is preparing to draw blood from a central venous access device for blood cultures.

Which of the following steps is part of that process? a. Apply sterile gloves. b. Flush the port with 5 to 10 mL of 0.9% sodium chloride. c. Slowly aspirate 5 mL of blood and discard the syringe. d. Use the distal lumen to draw blood.

ANS: D

Use the distal (red or brown) lumen to draw blood if the device has more than one lumen. The distal (red or brown) lumen typically is the largest-gauge lumen. Apply clean gloves to prevent transfer of body fluids. Do not flush before drawing blood for blood cultures. If blood cultures have been ordered, do not discard any blood. Use the initial specimen for blood cultures.

DIF: Cognitive Level: Application REF: Skill 29.6 OBJ: Identify common types of central vascular access devices (CVADs).

TOP: Blood Sampling KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. What should the nurse do to decrease the potential for infection related to intravenous (IV)

infusion therapy? a. Use the clean technique for dressing changes. b. Change the IV tubing every 12 hours. c. Palpate the insertion site daily through the intact dressing.

NiGthTaBs.teCriO d. After cleansing the skin, daN bUitRdS ryIw leMgauze pad.

ANS: C

Palpate the catheter insertion site for tenderness daily through the intact dressing. Perform hand hygiene before and after palpating, inserting, replacing, or dressing any intravascular device. Maintain use of sterile dressings. Replace IV tubing no more frequently than at 72-hour intervals unless clinically indicated. Allow the site to air dry before proceeding with the procedure.

DIF: Cognitive Level: Application REF: Skill 29.2 OBJ: Explain techniques for preventing transmission of infection for a patient receiving infusion therapy.

TOP: Standards to Decrease Intravascular Infection Related to IV Therapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. The nurse is caring for a patient with a continuous intravenous infusion of 0.9% normal saline

with 40 mmol of potassium chloride added to each liter. During a routine hourly check of the infusion, the nurse discovers that 4 hours of fluid has infused in the past 1 hour. The nurse’s first action should be to a. notify the primary care provider. b. assess the patient. c. reduce the infusion rate. d. notify the charge nurse.

ANS: C

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

If the intravenous fluid is infusing four times faster than prescribed, the first intervention should be to reduce the infusion rate. Notification of the primary care provider and the charge nurse would occur after the flow rate is reduced and an assessment of the patient is performed.

Although assessing the patient is vitally important, you do not want to allow the fluid to continue infusing at a rapid rate while you are performing the assessment.

DIF: Cognitive Level: Analysis REF: Skill 29.2 OBJ: Demonstrate initiating infusion therapy, regulating IV flow rate, changing IV solutions, changing IV administration sets, changing peripheral vascular access device (PVAD) dressings, and discontinuing a PVAD. TOP: IV Administration Rates KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. The nurse is caring for a patient who has experienced hypovolemia secondary to acute

vomiting and diarrhea. The nurse anticipates what type of intravenous fluid to be prescribed by the health care provider? a. Hypotonic or isotonic solutions b. Hypertonic or isotonic solutions c. Hypertonic solutions only d. Whole blood ANS: A

Hypotonic solutions are administered for cellular dehydration, whereas isotonic solutions replace intravascular fluid, so both of these might be appropriate for this patient. Hypertonic solutions pull fluid from extravascular spaces and would not be appropriate for this patient.

Whole blood is not indicated because there is no evidence of blood loss.

DIF: Cognitive Level: AnalysisNURSINRGETFB : .InCtrOaM venous Solutions OBJ: Identify common indications for intravenous (IV) therapy.

TOP: Different IV Fluids KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 25. Which of the following patients would the nurse anticipate requiring the placement of a

central venous catheter? a. A patient in same-day surgery who might require blood transfusions b. A patient in the intensive care unit requiring multiple simultaneous intravenous medications c. A patient in the cardiac care unit diagnosed with possible myocardial infarction d. A patient on the surgical unit recovering from hernia repair ANS: B

The most likely candidate for a central venous catheter is the patient in intensive care requiring the administration of multiple medications. The central venous catheter will simplify the administration of multiple medications to this critically ill patient. Because same-day surgery patients are expected to go home at the end of the day, it would be unlikely this patient would need a central catheter. A patient diagnosed with myocardial infarction would be unlikely to need a central line unless his condition deteriorated. A patient post–hernia repair would be unlikely to require a central venous line unless complications arose, which is not indicated in this scenario.

DIF: Cognitive Level: Application

REF: Skill 29.6

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY OBJ: Identify common types of central vascular access devices (CVADs).

TOP: Tunnelled Central Venous Catheters KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 26. The nurse assigns an unregulated care provider (UCP) to care for several patients with

continuous intravenous (IV) infusions. Which of the following can a UCP assist with? a. Changing empty IV solution containers b. Confirming the correct IV drip rate c. Assessing the patient for response to IV therapy d. Informing the nurse if anything abnormal is noticed ANS: D

If UCP notices anything considered abnormal, the UCP should notify the nurse. It is the nurse’s responsibility to inform the UCP of specific things to look for. Changing empty IV solution containers cannot be delegated to UCP because the procedure requires knowledge of sterile technique. Confirming the correct IV drip rate is the nurse’s responsibility. Assessment is not the responsibility of UCP; it is the responsibility of the nurse.

DIF: Cognitive Level: Application REF: Delegation and Collaboration (Skill 29.1) OBJ: Demonstrate initiating infusion therapy, regulating IV flow rate, changing IV solutions, changing IV administration sets, changing peripheral vascular access device (PVAD) dressings, and discontinuing a PVAD. TOP: Intravenous Devices KEY: Nursing Process Step: Planning MSC: NCLEX: Safe and Effective Care Environment 27. Fluids that have the same osmolality as body fluids are used most often to replace

extracellular volume and are known as a. hypotonic b. hypertonic NURSINGTB.COM c. isotonic d. osmotonic

fluids.

ANS: C

Isotonic fluids have the same osmolality as body fluids and are used most often to replace extracellular volume (e.g., prolonged vomiting). Isotonic fluids effectively mimic the body’s fluid loss in the absence of an electrolyte imbalance.

DIF: Cognitive Level: Understanding REF: Intravenous Solutions OBJ: Discuss patient conditions requiring intravenous (IV) therapy.

TOP: Isotonic Fluids KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 28.

solutions pull fluid into the vascular space by osmosis, resulting in an increased vascular volume that could result in pulmonary edema. a. Hypotonic b. Hypertonic c. Isotonic d. Osmotonic ANS: B

Hypertonic solutions pull fluid into the vascular space by osmosis, resulting in an increased vascular volume that possibly will result in pulmonary edema.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY DIF: Cognitive Level: Understanding REF: Intravenous Solutions OBJ: Discuss complications of infusion therapy.

TOP: Hypertonic Fluids KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 29. The nurse is caring for a patient who will be on long-term antibiotic therapy for 6 weeks. The

patient has had numerous intravenous (IV) catheters in the past, but because the upcoming therapy will be given on a long-term basis, the nurse suggests that a be inserted. a. subcutaneous port b. peripherally inserted central catheter (PICC) line c. saline lock d. peripheral vascular access device (PVAD) ANS: B

The PICC line would be the best option for a patient requiring long-term antibiotic therapy because it is a short-term central vascular access device (CVAD) that can be used for several days to weeks. The subcutaneous port is used for longer-term infusion therapy, and the insertion is more invasive than the PICC insertion. A saline lock and PVAD are both short-term solutions.

DIF: Cognitive Level: Comprehension REF: Table 29.6: Central Vascular Access Devices OBJ: Identify common types of central vascular access devices (CVADs).

TOP: Central Venous Access Devices (CVADs) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 30. The nurse is caring for a patient who has a peripheral intravenous (IV) catheter. While

performing her routine assessment, he or she notes that the insertion site is pale, cool, and edematous. The patient indicateNsUthRaS tI thN eG siT teBis.aClsOoMpainful to the touch. The nurse recognizes these symptoms as revealing a possible . a. catheter occlusion b. infiltration c. phlebitis d. medical adhesive–related skin injury (MARSI) ANS: B

Infiltration is indicated by swelling and possible pitting edema, pallor, coolness, pain at the insertion site, and a possible decrease in flow rate.

DIF: Cognitive Level: Analysis REF: Skill 29.2 OBJ: Discuss complications of infusion therapy.

TOP: Infiltration KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 31. Which of the following is manifested by decreased urine output, dry mucous membranes,

decreased capillary refill, a disparity in central and peripheral pulses, tachycardia, hypotension, and shock? a. Fluid volume excess b. Fluid volume deficit c. Infection d. Phlebitis ANS: B

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Fluid volume deficit is manifested by decreased urine output, dry mucous membranes, decreased capillary refill, a disparity in central and peripheral pulses, tachycardia, hypotension, and shock.

DIF: Cognitive Level: Understanding REF: Skill 29.2 OBJ: Discuss complications of infusion therapy.

TOP: Fluid Volume Deficit KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 32. The nurse is caring for a patient who is receiving intravenous (IV) fluids at a rate of 150 mL

per hour. During her assessment, the nurse notes that the patient is having more laboured respirations, and that crackles have developed in the patient’s lungs. The nurse reduces the IV rate and notifies the physician. She does this while recognizing that the patient is experiencing signs of . a. fluid volume excess b. fluid volume deficit c. infection d. phlebitis ANS: A

Fluid volume excess is manifested by crackles in the lungs, shortness of breath, and edema.

DIF: Cognitive Level: Analysis REF: Skill 29.2 OBJ: Discuss complications of infusion therapy.

TOP: Fluid Volume Excess KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 33. While assessing the patient’s intravenous (IV) catheter site, the nurse notes that the site is

reddened and warm. The patient states that it is “sore.” The nurse recognizes these as signs of .

NURSINGTB.COM a. fluid volume excess b. fluid volume deficit c. infiltration d. phlebitis ANS: D

Phlebitis is indicated by pain, increased skin temperature, and erythema along the path of the vein.

DIF: Cognitive Level: Application REF: Skill 29.2 OBJ: Discuss complications of infusion therapy.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Phlebitis

34. An intravenous catheter that is inserted through a large arm vein and is advanced until the tip

enters the central venous system is known as a(n) a. implanted venous port b. peripherally inserted central catheter (PICC) c. external tunnelled catheter d. nontunnelled percutaneous venous access device

.

ANS: B

A PICC is inserted through a large arm vein (e.g., cephalic or basilic vein) and is advanced until the tip enters the central venous system in the lower third of the superior vena cava.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

DIF: Cognitive Level: Understanding REF: Table 29.6: Central Vascular Access Devices OBJ: Identify common types of central vascular access devices (CVADs).

TOP: Peripherally Inserted Central Catheter (PICC) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 35. Intravenous catheters that are inserted directly through the skin and into the internal or

external jugular, subclavian, or femoral vein for up to several weeks are known as . a. implanted venous ports b. peripherally inserted central catheters (PICCs) c. external tunnelled catheters d. nontunnelled percutaneous venous access devices ANS: D

Nontunnelled percutaneous venous access devices are inserted directly through the skin and into the internal or external jugular, subclavian, or femoral vein. The tip of the catheter rests in the superior vena cava. These catheters may be left for anywhere from several days up to several weeks.

DIF: Cognitive Level: Understanding REF: Table 29.6: Central Vascular Access Devices OBJ: Identify common types of central vascular access devices (CVADs).

TOP: Nontunnelled Percutaneous Central Venous Catheters KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 36.3 rgN icG alT lyBi. nsCeO rteMd through a tunnel into subcutaneous NaUreRsSuI 6 tissue, usually between the clavicle and the nipple, into the internal jugular or subclavian vein, . with the catheter tip resting in the distal end of the superior vena cava. The subcutaneous

tunnel allows the catheter to remain in place for months to years.

Implanted venous ports Peripherally inserted central catheters (PICCs) External tunnelled catheters Nontunnelled percutaneous venous access devices

a. b. c. d.

ANS: C

Tunnelled central venous catheters are surgically inserted through a tunnel into subcutaneous tissue, usually between the clavicle and the nipple, into the internal jugular or subclavian vein, with the catheter tip resting in the distal end of the superior vena cava. The subcutaneous tunnel allows the catheter to remain in place for months to years.

DIF: Cognitive Level: Understanding REF: Table 29.6: Central Vascular Access Devices OBJ: Identify common types of central vascular access devices (CVADs).

TOP: Tunnelled Central Venous Catheters KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 1. The patient is on daily weights and is receiving intravenous therapy. The nurse notices that the

patient has gained 2 kg since the previous morning. What else would the nurse expect to observe? (Select all that apply.) a. Dry skin and mucous membranes b. Distended neck veins c. Tenting of the skin d. Crackles or rhonchi in the lungs ANS: B, D

A change in body weight of 1 kg corresponds to 1 L of fluid retention or loss. Dry skin and mucous membranes suggest fluid volume deficit (FVD). Distended neck veins suggest fluid volume excess (FVE). Poor skin turgor is seen when the skin fails to return to normal position within 3 seconds after pinching. With FVD, the pinched skin stays elevated for several seconds. This is called tenting. Auscultation of crackles or rhonchi in the lungs may signal fluid buildup in the lungs caused by FVE. DIF: Cognitive Level: Analysis REF: Skill 29.2 OBJ: Discuss complications of infusion therapy.

TOP: Fluid Volume Excess KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. What should the nurse do upon noting that the patient’s intravenous (IV) catheter site is pale,

cool, and edematous? (Select all that apply.) a. Stop the infusion. b. Elevate the extremity. c. Start a new IV. d. Flush the IV site.

ANS: A, B, C

NURSINGTB.COM

Infiltration is indicated by swelling and possible pitting edema, pallor, coolness, pain at the insertion site, and a possible decrease in flow rate. The nurse should stop the infusion and should discontinue the IV catheter, elevate the affected extremity, start a new IV if continued therapy is necessary, and document the degree of infiltration and nursing intervention.

Flushing the IV site is not recommended.

DIF: Cognitive Level: Application REF: Skill 29.2 OBJ: Discuss complications of infusion therapy.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Infiltration

3. The nurse is preparing to start an intravenous (IV) infusion on a 92-year-old patient. The

nurse realizes that he or she may need to take which of the following actions? (Select all that apply.) a. Avoid using veins in the hand. b. Avoid using veins in the dominant arm. c. Use the largest-gauge catheter possible for maximum flow. d. Avoid using a tourniquet.

ANS: A, B, D

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

In older patients, use the smallest gauge possible. For example, a 22-gauge needle is adequate for fluid and medication therapy; use a 24-gauge in frail, older persons. Smaller-gauge catheters are less traumatizing to the vein but still allow blood flow to provide increased hemodilution of IV fluids or medications. If possible, avoid the back of the older person’s hand or the dominant arm for venipuncture because they interfere with the older person’s independence. Minimize pressure from tourniquets or avoid them if possible. Apply a blood pressure cuff in place of a tourniquet.

DIF: Cognitive Level: Application REF: Gerontological (Skill 29.6) OBJ: Explain how to prepare the patient and caregiver for infusion therapy.

TOP: Starting IVs in Older Patients KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. For which patients are electronic infusion devices (EIDs) used? (Select all that apply.) a. Those who require low hourly rates b. Those who are at risk for volume overload c. Those who have impaired renal clearance d. Those who are receiving fluids that require a specific hourly volume ANS: A, B, C, D

Infusion pumps are necessary for patients requiring low hourly rates, at risk for volume overload, with impaired renal clearance, or receiving medications or fluids that require a specific hourly volume.

DIF: Cognitive Level: Understanding REF: Skill 29.2 OBJ: Demonstrate initiating infusion therapy, regulating IV flow rate, changing IV solutions, changing IV administration sets, changing peripheral vascular access device (PVAD) dressings, and NURSINTGOTPB: .ECleOctMronic Infusion Device (EID) discontinuing a PVAD. KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. Central venous access devices (CVADs) can be used in the home, in the hospital, and in

long-term care facilities for patients who require which of the following? (Select all that apply.) a. Supplemental nutrition b. Blood and blood products c. Hemodynamic monitoring d. Blood sampling ANS: A, B, C, D

CVADs can be used in the home, in the hospital, and in long-term care facilities for patients who require supplemental nutrition, blood and blood products, continuous fluids, medications, hemodynamic monitoring, and blood sampling.

DIF: Cognitive Level: Comprehension REF: Skill 29.6 OBJ: Identify common types of central vascular access devices (CVADs).

TOP: Central Venous Access Devices (CVADs) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. Which of the following are central venous access devices (CVADs)? (Select all that apply.) a. Implanted subcutaneous ports

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY b. Peripherally inserted central catheter (PICC) lines c. Saline locks d. Heparin locks ANS: A, B

Four types of CVADs are available: nontunnelled percutaneous central venous catheters, tunnelled central venous catheters, PICCs, and implanted subcutaneous ports.

DIF: Cognitive Level: Comprehension REF: Table 29.6: Central Vascular Access Devices OBJ: Identify common types of central vascular access devices (CVADs).

TOP: Central Venous Access Devices (CVADs) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

NURSINGTB.COM

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 30: Blood Therapy Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. A transfusion in which the donor is the patient is known as a(n) a. allogenic b. autologous c. leukocyte d. antibody

transfusion.

ANS: B

In autologous transfusion, or autotransfusion, the donor is the patient.

DIF: Cognitive Level: Understanding REF: Principles for Practice OBJ: Discuss indications for blood therapy.

TOP: Autologous Transfusion KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse is caring for a patient who needs a blood transfusion. The patient has been tested

and was found to have blood type O. The nurse knows this means that which antigen is present on the surface of the red blood cells? a. The type A antigen is present. b. The type B antigen is present. c. Neither type A nor type B antigens are present. d. Both type A and type B antigens are present.

ANS: C

NURSINGTB.COM

When neither A nor B antigens are present, the blood group is type O. When the type A antigen is present, the blood group is type A. When the type B antigen is present, the blood group is type B. When both A and B antigens are present, the blood group is type AB. DIF: Cognitive Level: Application REF: ABO System OBJ: Describe various transfusion reactions.

TOP: Blood Type KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. A nurse is concerned about the type of blood that a patient is to receive. A patient with an O

blood type may safely receive which type of blood? a. Type A blood b. Type B blood c. Type AB blood d. Type O blood ANS: D

People with type O blood have both A and B antibodies and therefore can receive only type O blood. People with type A blood have anti-B antibodies and therefore can receive only type A blood. People with type B blood have anti-A antibodies and therefore can receive only type B blood. People with type AB blood have neither antibodies and therefore can receive all blood types.

DIF: Cognitive Level: Comprehension REF: ABO System OBJ: Demonstrate the following skills on selected patients: initiating blood therapy and monitoring

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY for adverse transfusion reactions.

KEY: Nursing Process Step: Assessment

TOP: Type O Blood MSC: NCLEX: Physiological Integrity

4. The patient is brought to the emergency department after a motor vehicle accident and has lost

a large volume of blood. The patient’s blood type is AB. Which blood type may this patient safely receive in transfusion? a. Only type AB blood b. Only type O blood c. All blood types d. Only type A blood ANS: C

People with type AB blood have neither antibodies and therefore can receive all blood types.

DIF: Cognitive Level: Application REF: ABO System OBJ: Demonstrate the following skills on selected patients: initiating blood therapy and monitoring for adverse transfusion reactions.

TOP: Type AB Blood KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. The patient is scheduled to receive a blood transfusion. Preadministration laboratory tests are

run to assess the level of which component in the patient’s blood? a. Sodium (Na) b. Calcium (Ca) c. Potassium (K) d. Iron (Fe) ANS: C

When blood is stored, there is cNoU ntRinSuI alNdG esTtrB u. ctC ioO nM of red blood cells (RBCs), which releases potassium from the cells into the plasma. If blood is transfused rapidly, transient elevated potassium levels may occur before the potassium is reabsorbed and put the patient at risk.

DIF: Cognitive Level: Application REF: Principles for Practice OBJ: Describe various transfusion reactions.

TOP: Hypocalcemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. The patient has received a total of 7 units of blood over the past 8 hours. The nurse assesses

the patient’s laboratory test results. Which of the following would be an expected complication? a. Hypokalemia b. Hyperkalemia c. Hypercalcemia d. Iron deficiency ANS: B

When blood is stored, there is continual destruction of red blood cells (RBCs), which releases potassium from the cells into the plasma. If blood is transfused rapidly, transient hyperkalemia may occur before the potassium is reabsorbed. Blood that is preserved with citrate phosphate dextrose (CPD) contains a high concentration of citrate ions. The excess citrate may combine with the ionized calcium in the recipient’s blood, resulting in transient low ionized calcium levels. Patients receiving multiple transfusions should be assessed for iron overload.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY DIF: Cognitive Level: Application REF: Principles for Practice OBJ: Describe various transfusion reactions.

TOP: Hyperkalemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. The patient is to receive 2 units of packed red blood cells (RBCs). The units are cold, and the

nurse is concerned that this could lead to arrhythmias and/or a reduction in core temperature.

What action may the nurse take to prevent this? a. Warm the blood in a microwave. b. Warm the blood using hot water. c. Warm the blood using a blood warmer. d. Allow the blood to warm to room temperature before administering.

ANS: C

In emergency situations, rapid transfusion of cold blood may lead to arrhythmias and a reduction in core temperature. Sometimes a blood warmer machine is used for large transfusions of greater than 50 mL/kg per hour or in patients with cold agglutinins. Heating blood products in a microwave or with hot water is dangerous and may destroy blood cells.

Blood must be given within a prescribed time frame. Allowing the blood to come to room temperature before administration would decrease the time available for administration.

DIF: Cognitive Level: Application REF: Optional Equipment OBJ: Describe various transfusion reactions.

TOP: Blood Warmer KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The patient is scheduled to receive 1 unit of packed red blood cells (RBCs). She has small,

fragile veins, and a 22-gauge inNtrUavReSnI ouNsG(ITVB) . paCteOnM t catheter is in place. What should the nurse do? a. Cancel the blood transfusion. b. Insert a 16-gauge IV catheter into the antecubital fossa. c. Use the IV catheter that is in place. d. Transfuse the blood over 6 hours.

ANS: C

In emergency situations that require rapid transfusions, a large-gauge cannula is preferred; however, transfusions for therapeutic indications may be infused with cannulas ranging from 20 to 24 gauge. Large-gauge cannulas (18 or 20 gauge) promote rapid flow of blood components. 16-Gauge catheters are used often in surgery, but not usually on acute care units.

Blood must be transfused within 4 hours. Use of smaller-gauge cannulas, such as 24 gauge, often requires the blood bank to divide the unit so that each half can be infused within the allotted time or requires the use of pressure-assisted devices.

DIF: Cognitive Level: Application REF: Skill 30.1 OBJ: Describe various transfusion reactions.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: IV Catheter Size

9. What primary intervention should a nurse who is preparing a blood transfusion perform? a. Set up the Y tubing. b. Obtain 0.9% saline.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY c. Verify the blood product and the patient. d. Have the patient void or empty the urine drainage container.

ANS: C

Correctly verify the product and identify the patient with a person considered qualified by your employer. Strict adherence to verification procedures before administration of blood or blood components reduces the risk of administering the wrong blood to the patient. Clerical errors are the cause of most hemolytic transfusion reactions. Y tubing is used to facilitate maintenance of intravenous (IV) access in case a patient will need more than 1 unit of blood.

However, the focus here is on prevention of possible blood reactions. Use of Y tubing will not prevent a blood reaction. Normal saline is compatible with blood products, unlike solutions that contain dextrose, which causes coagulation of donor blood. However, strict adherence to verification procedures before administration of blood or blood components reduces the risk of administering the wrong blood to the patient. Empty the urine drainage collection container or have the patient void. If a transfusion reaction occurs, a urine specimen containing urine produced after initiation of the transfusion will be sent to the laboratory.

DIF: Cognitive Level: Application REF: Skill 30.1 OBJ: Demonstrate the following skills on selected patients: initiating blood therapy and monitoring for adverse transfusion reactions.

TOP: Pretransfusion Procedure KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. The patient is to receive 1 unit of packed red blood cells (RBCs). The nurse obtains the blood

from the blood bank and returns to the unit to find that the patient has been taken to radiology for a computed tomography (CT) scan and is expected to return in about an hour. What should the nurse do?

NURSINGTB.COM a. Go to radiology and administer the blood. b. Keep the blood refrigerated until the patient returns. c. Return the blood to the blood bank. d. Hang the blood in the patient’s room and start it when the patient returns.

ANS: C

Initiate the blood transfusion within 30 minutes of the time of release from the blood bank. If the blood cannot be started because the patient is in the bathroom or the physician has to be notified of an elevated temperature, immediately return the blood to the blood bank and retrieve it when it can be administered.

DIF: Cognitive Level: Application REF: Skill 30.1 OBJ: Demonstrate the following skills on selected patients: initiating blood therapy and monitoring for adverse transfusion reactions.

TOP: Delayed Start of Transfusion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. The nurse is preparing to administer a unit of blood to a patient using blood tubing. On the

blood product side of the Y tubing, the nurse will hang blood. What will be hung on the other side of the Y tubing? a. Dextrose 5% b. Normal saline c. Dextrose 10% d. Dextrose 5%/normal saline

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY ANS: B

Normal saline is compatible with blood products, unlike solutions that contain dextrose, which causes coagulation of donor blood.

DIF: Cognitive Level: Application REF: Skill 30.1 OBJ: Demonstrate the following skills on selected patients: initiating blood therapy and monitoring for adverse transfusion reactions.

TOP: Normal Saline and Blood Products KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The nurse is administering blood. What should the nurse do to detect a blood reaction as

quickly as possible? a. Remain with the patient during the first 15 minutes. b. Transfuse the blood at 10 mL per minute. c. Monitor vital signs q 1 hour. d. Transfuse blood at 50 gtt per minute.

ANS: A

Remain with the patient during the first 15 minutes of a transfusion. Most transfusion reactions occur within the first 15 minutes of a transfusion. The initial flow rate during this time should be 2 mL per minute, or 20 gtt per minute. Initially infusing a small amount of blood component minimizes the volume of blood to which the patient is exposed, thereby minimizing the severity of a reaction. Monitor the patient’s vital signs at 5 minutes, at 15 minutes, and every 30 minutes until 1 hour after transfusion or per employer policy. Frequent monitoring of vital signs will help quickly alert the nurse to a transfusion reaction.

DIF: Cognitive Level: Application REF: Skill 30.1 OBJ: Demonstrate the followingNsU kiR llsSoI nN seGleT ctB ed.pCaO tieMnts: initiating blood therapy and monitoring for adverse transfusion reactions.

TOP: Early Detection of Blood Reaction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. An appropriate technique for the nurse to implement for a blood transfusion is to a. provide medication through the intravenous (IV) tubing with the blood. b. regulate the flow of blood so that it infuses over 8 hours. c. clear the IV tubing with normal saline after the blood infuses. d. administer a blood product with clots through a filter line.

ANS: C

After the blood has infused, clear the IV line with 0.9% normal saline and discard the blood bag according to employer policy. Medication should never be injected into the same IV line as a blood component because of the risk of contaminating the blood product with pathogens and the possibility of incompatibility. A separate IV line must be maintained if the patient requires IV infusion (total parenteral nutrition, pain control) during the transfusion. A unit of blood should not hang for longer than 4 hours because of the danger of bacterial growth.

Check the appearance of blood product for leaks, bubbles, clots, or a purplish colour. Do not transfuse blood if its integrity is compromised. Blood serves as a medium for bacteria.

DIF: Cognitive Level: Application REF: Skill 30.1 OBJ: Demonstrate the following skills on selected patients: initiating blood therapy and monitoring for adverse transfusion reactions.

TOP: Blood Product Administration KEY: Nursing Process Step: Implementation

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY MSC: NCLEX: Physiological Integrity 14. When a patient’s adverse reaction to a blood transfusion is differentiated, which of the

following signs and symptoms indicates the presence of an anaphylactic response? a. Wheezing and chest pain b. Headache and muscle pain c. Hypotension and tingling of the extremities d. Crackles in the lungs and increased central venous pressure ANS: A

Observe the patient for wheezing, chest pain, and possible cardiac arrest. All of these are indications of an anaphylactic reaction. Be alert to patient complaints of headache or muscle pain in the presence of a fever. Both may be indicative of a febrile nonhemolytic reaction.

Observe patients receiving massive transfusions for mild hypothermia, cardiac arrhythmias, hypotension, and hypocalcemia. Cold blood products can affect the cardiac conduction system, resulting in ventricular arrhythmias. Other cardiac dysrhythmias, hypotension, and tingling may indicate hypocalcemia, which occurs when citrate (used as a preservative for some blood products) combines with the patient’s calcium. Crackles in the bases of lungs and rising central venous pressure (CVP) are indications of circulatory overload.

DIF: Cognitive Level: Analysis REF: Table 30.2: Transfusion Reaction Chart OBJ: Describe various transfusion reactions.

TOP: Anaphylactic Response KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 15. The patient is receiving a unit of packed red blood cells (RBCs). Fifteen minutes into the

procedure, he complains of severe kidney pain, and his temperature increases by 1.6°C (3°F).

The nurse stops the transfusion immediately, suspecting that which of the following reactions NURSINGTB.COM is occurring? a. Delayed hemolytic transfusion reaction b. Nonhemolytic febrile reaction c. Acute hemolytic transfusion reaction d. Severe allergic reaction ANS: C

Symptoms of an acute hemolytic reaction usually begin within 15 minutes of transfusion initiation and include severe pain in the kidney area and chest, increased temperature (up to 40.5°C [105°F]), increased heart rate, and a sensation of heat and pain along the vein receiving blood, as well as chills, low back pain, headache, nausea, chest or back pain, chest tightness, dyspnea, bronchospasm, anxiety, hypotension, vascular collapse, disseminated intravascular coagulation, and possibly death. Symptoms of a delayed hemolytic reaction usually begin 2 to 14 days after the transfusion and include unexplained fever, an unexplained decrease in hemoglobin/hematocrit (Hgb/Hct), increased bilirubin levels, and jaundice.

Symptoms of a nonhemolytic febrile reaction begin between 30 minutes after initiation and 6 hours after completion of transfusion and include fever greater than 1°C above baseline, flushing, chills, headache, and muscle pain; they occur most often in immunosuppressed patients. Symptoms of an acute severe allergic reaction usually begin within 5 to 15 minutes of initiation of transfusion and include coughing, nausea, vomiting, respiratory distress, wheezing, hypotension, loss of consciousness, and possible cardiac arrest.

DIF: Cognitive Level: Analysis REF: Table 30.2: Transfusion Reaction Chart OBJ: Describe various transfusion reactions.

TOP: Acute Hemolytic Reaction

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

16. The patient has been home from the hospital for 10 days. On the last day of his

hospitalization, he received 2 units of packed red blood cells (RBCs). This morning, he noticed that his skin had a yellow tint to it and his temperature was elevated. Which reaction might this patient be experiencing? a. Delayed hemolytic transfusion reaction b. Acute hemolytic transfusion reaction c. Nonhemolytic febrile reaction d. Severe allergic transfusion reaction ANS: A

Symptoms of a delayed hemolytic reaction usually begin 2 to 14 days after the transfusion and include unexplained fever, unexplained decrease hemoglobin/hematocrit (Hgb/Hct), increased bilirubin levels, and jaundice. Symptoms of an acute hemolytic reaction usually begin within 15 minutes of transfusion initiation and include severe pain in the kidney area and chest, increased temperature (up to 40.5°C [105°F]), increased heart rate, and increased sensation of heat and pain along the vein receiving blood, as well as chills, low back pain, headache, nausea, chest or back pain, chest tightness, dyspnea, bronchospasm, anxiety, hypotension, vascular collapse, disseminated intravascular coagulation, and possibly death. Symptoms of a nonhemolytic febrile reaction begin between 30 minutes after initiation and 6 hours after completion of transfusion and include fever greater than 1°C above baseline, flushing, chills, headache, and muscle pain; they occur most often in immunosuppressed patients. Symptoms of an acute severe allergic reaction usually begin within 5 to 15 minutes of initiation of transfusion and include coughing, nausea, vomiting, respiratory distress, wheezing, hypotension, loss of consciousness, and possible cardiac arrest.

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DIF: Cognitive Level: Analysis REF: Care in the Community (Skill 30.1) OBJ: Describe various transfusion reactions.

TOP: Delayed Hemolytic Reaction KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 17. The specific blood product used for replacement of clotting factors and fibrinogen is a. whole blood. b. packed red blood cells (RBCs). c. cryoprecipitate. d. albumin, 25% pooled.

ANS: C

Cryoprecipitate replaces factors VIII and XIII, von Willebrand’s factor, and fibrinogen. It also replaces red cell mass and plasma volume and is expected to raise hemoglobin by 1 g/100 mL and hematocrit by 3% in a nonhemorrhaging adult. Using cryoprecipitate is the preferred method of replacing red blood cell mass.

DIF: Cognitive Level: Understanding REF: Table 30.3: Blood and Blood Component Products OBJ: Discuss indications for blood therapy.

TOP: Cryoprecipitate KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 18. The nurse is administering 1 unit of packed red blood cells as ordered by the primary care

provider. While the nurse is measuring vital signs 15 minutes after starting the transfusion, the patient complains of chills and back pain. What is the nurse’s first action? a. Stop the blood transfusion and keep the vein patent by administering saline to

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

infuse from the other side of the Y tubing. b. Slow the blood transfusion and notify the charge nurse. c. Disconnect the blood tubing from the catheter and replace it with an infusion of

normal saline. d. Stop the blood transfusion and notify the primary care provider.

ANS: C

The nurse’s first priority is to stop the blood transfusion. To keep the intravenous site patent, normal saline can be infused at a keep-open rate, but the tubing must be changed to avoid administering more blood as the saline flushes the blood from the tubing. If the tubing is not changed, additional blood will be administered, and the possible transfusion reaction will increase. The charge nurse or the primary care provider should be notified only after the patient has been assessed.

DIF: Cognitive Level: Application REF: Skill 30.1 OBJ: Explain techniques for managing symptoms of adverse transfusion reactions.

TOP: Transfusion Reaction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. The patient has received blood within the past 6 hours. The patient begins to feel short of

breath and calls for the nurse. The nurse finds that the patient is dusky in colour with crackles throughout his lungs and is coughing up pink frothy sputum. The nurse calls the physician immediately, knowing that the patient is showing signs of . a. delayed hemolytic transfusion reaction b. transfusion-related acute lung injury (TRALI) c. nonhemolytic febrile reaction d. severe allergic transfusion reaction

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ANS: B

Possible adverse outcomes that result from transfusion therapy include transmission of diseases, circulatory overload, and TRALI characterized by noncardiogenic pulmonary edema with onset within 6 hours of transfusion.

DIF: Cognitive Level: Analysis REF: Table 30.2: Transfusion Reaction Chart OBJ: Describe various transfusion reactions.

TOP: Transfusion-Related Acute Lung Injury (TRALI) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 20. Under the ABO system, the blood type

can be given to any individual and is

known as the “universal donor.” a. O positive b. O negative c. AB positive d. AB negative ANS: B

O negative can be given to people of any blood type and is known as the “universal donor.”

DIF: Cognitive Level: Understanding REF: ABO System OBJ: Demonstrate the following skills on selected patients: initiating blood therapy and monitoring for adverse transfusion reactions.

TOP: Universal Donor KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

MULTIPLE RESPONSE 1. Transfusion therapy is the intravenous (IV) administration of which of the following? (Select

all that apply.) a. Whole blood b. Plasma products c. Red blood cells (RBCs) d. Platelets ANS: A, B, C, D

Transfusion therapy or blood replacement is the IV administration of whole blood, its components, or plasma-derived product for therapeutic purposes.

DIF: Cognitive Level: Comprehension REF: Principles for Practice OBJ: Discuss indications for blood therapy.

TOP: Transfusion Therapy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. What is the purpose of administering a transfusion? (Select all that apply.) a. Restore intravascular volume. b. Restore the oxygen-carrying capacity of blood. c. Provide clotting factors. d. Improve blood pressure.

ANS: A, B, C

Transfusions are used to restore intravascular volume with whole blood or albumin, to restore the oxygen-carrying capacity of blood with red blood cells (RBCs), and to provide clotting Me may increase blood pressure, factors or platelets. Although inNcU reRasSinIgNbGloToB d. voClO um increasing blood pressure is not a primary objective of transfusion.

DIF: Cognitive Level: Comprehension REF: Principles for Practice OBJ: Discuss indications for blood therapy.

TOP: Transfusion Therapy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 3. The patient is to receive 2 units of packed red blood cells (RBCs). Before administering the

blood, what does the nurse need to do? (Select all that apply.) a. Insert an 18-gauge intravenous (IV) cannula. b. Have the patient complete a consent form. c. Obtain pretransfusion vital signs. d. Notify the physician for a temperature of 37°C. ANS: B, C

In emergency situations that require rapid transfusions, a large-gauge cannula is preferred; however, transfusions for therapeutic indications may be infused with cannulas ranging from 20 to 24 gauge. Check that the patient has properly completed and signed transfusion consent before retrieving blood. Most agencies require patients to sign consent forms before receiving blood component therapy because of the inherent risks. Obtain and record pretransfusion vital signs, including temperature, immediately before initiation of the transfusion. If the patient is febrile (temperature greater than 37.8°C [100°F]), notify the physician or the health care provider before initiating the transfusion. Change from baseline vital signs during infusion will alert the nurse to a potential transfusion reaction or adverse effect of therapy.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

DIF: Cognitive Level: Application REF: Skill 30.1 OBJ: Demonstrate the following skills on selected patients: initiating blood therapy and monitoring for adverse transfusion reactions.

TOP: Pretransfusion Procedure KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The patient is receiving blood when he suddenly complains of low back pain and develops

diaphoresis and chills. The nurse should (Select all that apply.) a. stop the transfusion. b. start normal saline connected to the Y tubing. c. notify the physician. d. start normal saline using new intravenous (IV) tubing.

ANS: A, C, D

If signs of a transfusion reaction occur, stop the transfusion, start normal saline with new primed tubing directly to the ventricular assist device (VAD) at the keep-vein-open rate (KVO), and notify the physician immediately.

DIF: Cognitive Level: Application REF: Skill 30.2 OBJ: Explain techniques for managing symptoms of adverse transfusion reactions.

TOP: Blood Reaction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. Symptoms that indicate an adverse reaction to blood products include which of the following?

(Select all that apply.) a. Fever b. Skin rash c. Hypotension d. Cardiac arrest

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ANS: A, B, C, D

Symptoms that indicate an adverse reaction range from fever, chills, and skin rash to hypotension and cardiac arrest.

DIF: Cognitive Level: Understanding REF: Table 30.2: Transfusion Reaction Chart OBJ: Describe various transfusion reactions.

TOP: Symptoms of a Blood Product Reaction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 31: Oral Nutrition Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The nurse is admitting a person to the unit and is assessing the patient’s nutritional status. In

assessing the patient’s nutritional status, the nurse realizes that a. body mass index (BMI) is the main indicator of obesity. b. ideal body is the standard gauge for nutritional status. c. clinical judgement is required, along with other indicators. d. the amount of weight change is the main nutritional indicator.

ANS: C

Use clinical judgement when evaluating muscular patients or patients with large amounts of edema or ascites, because these physiological states will lead to false overestimation of the degree of fatness. BMI alone is not a perfect predictor of overweight or obesity. You gather weight information in several ways, including usual body weight (UBW), ideal body weight (IBW), actual body weight (ABW), and BMI. A thorough nutritional assessment usually requires the collection of all these weight measures. The magnitude and direction of weight change are more meaningful than standardized weight references when one is dealing with sick or debilitated patients.

DIF: Cognitive Level: Application REF: Skill 31.1 OBJ: Perform accurate nutritional screening.

TOP: Anthropometrics/Body Weight KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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2.

are measures of height; weight; head, arm, and muscle circumferences; and skinfold thickness. a. Anthropometrics b. Body mass index readings c. Growth curves d. Obesity scales ANS: A

Anthropometrics are measures of height; weight; head, arm, and muscle circumferences; and skinfold thickness.

DIF: Cognitive Level: Understanding REF: Pediatric (Skill 31.1) OBJ: Perform accurate nutritional screening.

TOP: Anthropometrics KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse recognizes that the patient is exhibiting signs of

when he or she notices that the patient has difficulty holding food and fluid in his mouth and experiences difficulty moving it to his esophagus. a. stroke b. dysphagia c. getting older d. oral cancer ANS: B

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Classic signs of dysphagia include inability to hold food and fluid in the mouth or difficulty moving food into the esophagus. Any condition that produces muscle weakness may result in impairment of the swallowing mechanism, which could include stroke, getting older, or oral cancer. Early recognition of the patient’s difficulty will allow the nurse to implement aspiration precautions to protect the patient from complications of dysphagia.

DIF: Cognitive Level: Understanding REF: Skill 31.3 OBJ: Assess a patient’s ability to swallow.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Aspiration

4. The nurse is caring for a patient who requires assistance with eating. The patient repeatedly

apologizes to the nurse, saying, “I’m so sorry. I’m like a baby. I’m such a burden since I can’t even feed myself.” What is the most appropriate strategy for the nurse to use? a. Feed all of the solid foods first, and then offer liquids. b. Feed the patient quickly so as not to make the patient feel like it is taking a great deal of time out of the nurse’s day. c. Minimize conversation so that the patient can eat faster. d. Appear unhurried, sit at the bedside, and encourage the patient to feed himself as much as possible.

ANS: D

Meals should be a pleasant event for the patient. Conversation promotes socialization. Adults who need help to eat need compassion and understanding. Given the importance of nutrition in the healing process, the nurse should use common sense to provide a socially meaningful mealtime. Feeding the patient quickly is likely to accentuate his belief that he is a burden. It is best to offer fluids after every three or four bites of solid food or whenever the patient requests NURSINGTB.COM a drink.

DIF: Cognitive Level: Application REF: Skill 31.2 OBJ: Demonstrate how to properly feed a patient who cannot self-feed.

TOP: Assisting the Patient With Oral Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 5. What must the nurse do before assisting the patient with feeding? a. Assess the patient’s gag reflex. b. Make sure that the consistency of the food is thin. c. Remove the patient’s dentures to prevent gagging. d. Prepare the patient to be fed by a staff member.

ANS: A

Assess the patient’s ability to swallow and the patient’s gag reflex. Some patients (those who have neurological diseases or who are handicapped) have a reduced gag reflex and/or dysphagia, increasing the risk for aspiration. Changes in the consistency of the diet (thickened liquids, pureed, soft), swallow training, or alternative means of nutrition are often necessary and require a speech therapist or a registered dietitian. If the patient wears dentures, check to ensure that they fit well and are clean. This ensures that the patient is able to chew food and swallow more normally. Patients with any level of independence should not be totally fed by hospital staff. A thorough understanding of the patient’s physical and cognitive limitations alerts the nurse to the type of assistance the patient needs.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

DIF: Cognitive Level: Application REF: Skill 31.2 OBJ: Demonstrate how to properly feed a patient who cannot self-feed.

TOP: Assisting the Patient With Oral Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. The nurse is caring for an infant who is 3 months old and is being bottle-fed human milk. Will

the nurse need to provide the infant with any additional sources of nutrition or fluids? a. The infant will need extra water in between feedings. b. The infant will need juice in between feedings. c. No additional fluids will be needed between meals. d. The child will need to start on infant cereal.

ANS: C

Human breast milk is the most desirable complete diet for infants during the first 6 months.

Infants who are breast- or bottle-fed human milk do not require additional fluids, especially water or juice, during the first 4 months of life. Excessive intake of water causes water intoxication, failure to thrive, and hyponatremia. Typically, infants do not consume solid foods until age 4 to 6 months. Iron-fortified infant cereal is usually the first solid food to be offered.

DIF: Cognitive Level: Application REF: Pediatric (Skill 31.2) OBJ: Perform accurate nutritional screening.

TOP: Pediatric Considerations With Oral Feedings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

NURSINGTB.COM 7. What is an appropriate technique for the nurse to use to prevent aspiration when assisting a

patient with meals? a. Keep the patient’s head back and straight. b. Offer thin-consistency foods. c. Provide large amounts of fluids. d. Have the patient sit up for 30 minutes after eating.

ANS: D

Ask the patient to remain sitting upright for at least 30 minutes after the meal to reduce the risk for gastroesophageal reflux, which can cause aspiration. The patient must be sitting upright for passage of food through the pharynx and esophagus. Observe the patient’s ability to ingest foods of various textures and thicknesses to indicate whether aspiration risk is increased with thin liquids. Observe the patient with various consistencies of liquids.

Difficulty managing certain foods may indicate dysphagia, and referral to a dietitian is appropriate if a patient has difficulty with a particular consistency.

DIF: Cognitive Level: Application OBJ: Identify risk factors for aspiration.

KEY: Nursing Process Step: Assessment

REF: Skill 31.3 TOP: Preventing Aspiration MSC: NCLEX: Physiological Integrity

8. The patient is admitted with a diagnosis of stroke. The nurse attempts to feed the patient, but

the patient coughs and gags when food is placed in his mouth. What should the nurse do to assist this patient? a. Feed the patient more slowly.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY b. Feed the patient more quickly. c. Contact the speech pathology department. d. Ignore the cough and try again later.

ANS: C

If the patient coughs, gags, complains of food “stuck in the throat,” or has pockets of food in the mouth, the patient may require a swallowing evaluation by a licensed speech-language pathologist or by videofluoroscopy. Consider consultation with a speech therapist for swallowing exercises and techniques to improve swallowing and reduce risk for aspiration.

Notify the physician of any symptoms that occurred during the meal and which foods caused the symptoms.

DIF: Cognitive Level: Application OBJ: Identify risk factors for aspiration.

KEY: Nursing Process Step: Assessment

REF: Skill 31.3 TOP: Suspected Dysphagia MSC: NCLEX: Physiological Integrity

9. The nurse is caring for a patient who is 6 feet 2 inches tall and weighs 250 pounds. What is

the patient’s body mass index (BMI)? a. 18.5 kg/m2 b. 30.2 kg/m2 c. 32.13 kg/m2 d. 40.11 kg/m2 ANS: C

BMI = Weight (pounds) / Height (inches)  Height (inches) = 703. In this case, 250 / (74  74)  703  250 / 5476  703  0.0457  703 = 32.13 kg/m2.

DIF: Cognitive Level: AnalysisNURSINRGETFB : .SC kiO llM 31.1 OBJ: Perform accurate nutritional screening.

TOP: BMI KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 10. The nurse is caring for a patient who is believed to be suffering from malnutrition. The nurse

calculates that the patient’s body mass index (BMI) is 16.4 kg/m2. What does this indicate about the patient’s weight? a. The patient is underweight. b. The patient’s weight is normal. c. The patient is overweight. d. The patient is obese (class 1).

ANS: A

Underweight is defined as a BMI less than 18.5 kg/m2. Normal weight is classified as a BMI between 18.5 and 24.9 kg/m2. Overweight is defined as a BMI between 25 and 29.9 kg/m2.

Obesity (class 1) is defined as a BMI between 30 and 34.9 kg/m2.

DIF: Cognitive Level: Analysis REF: Skill 31.1 OBJ: Perform accurate nutritional screening.

TOP: Underweight KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11. A patient is admitted to the hospital for evaluation for sleep apnea. The nurse calculates his

body mass index (BMI) at 42 kg/m2. What does this indicate about the patient’s weight? a. The patient is overweight. b. The patient falls into the class 1 range of obesity.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY c. The patient falls into the class 2 range of obesity. d. The patient falls into the class 3 range of extreme obesity.

ANS: D

Extreme obesity (class 3) is defined as a BMI equal to or greater than 40 kg/m2. Overweight is defined as a BMI between 25 and 29.9 kg/m2. Class 1 obesity is defined as a BMI between 30 and 34.9 kg/m2. Class 2 obesity is defined as a BMI between 35 and 39.9 kg/m2.

DIF: Cognitive Level: Analysis REF: Skill 31.1 OBJ: Perform accurate nutritional screening.

TOP: Extreme Obesity KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. The nurse is caring for a patient 2 days after surgery. The prescribed diet is a mechanical soft

diet. Which of the following foods may the patient choose to eat? a. Salad b. Baked potato without skin c. Cooked cereal d. Soft peeled apples ANS: C

Mechanically altered diets consist of chopped, ground, mashed, or pureed foods for patients who have problems with chewing or swallowing. Consistency can be varied according to the patient’s own ability to chew or swallow. Small amounts of liquids added to foods contribute to an appropriate consistency. Liquids that are added should complement the food and should not conceal the food’s original flavour. Butter, margarine, and honey can be added to increase caloric density. A regular diet with no restrictions could include a salad. A baked potato without the skin or soft peeled apples would be allowed on a dysphagia advanced diet that uses regular food, with the exceNpUtiR onSoIfNvG erT yBh. arC d,OsM ticky, or crunchy foods.

DIF: Cognitive Level: Application REF: Table 31.4: Progressive and Therapeutic Diets OBJ: Perform accurate nutritional screening.

TOP: Types of Therapeutic Diets KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. The patient is placed on a clear liquid diet after surgery. Which of the following foods may

the patient select? a. Coffee with milk and sugar b. Gelatin, popsicles, apple juice c. Water, orange juice, Jell-O d. Black coffee, popsicles, ice cream ANS: B

A clear liquid diet consists of foods that are clear and liquid at room or body temperature (e.g., water, clear fruit juice, gelatin, popsicles). Caution should be exercised with regard to the amount of caffeine received by patients on clear liquids. Coffee with milk, orange juice, and ice cream are not clear liquids.

DIF: Cognitive Level: Application REF: Table 31.4: Progressive and Therapeutic Diets OBJ: Perform accurate nutritional screening.

TOP: Clear Liquid Diet KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. Which of the following is a sign of vitamin C deficiency? a. Cheilosis (redness/swelling of the lips)

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY b. Glossitis c. Spongy, bleeding, abnormal redness of the gingiva d. Spoon-shaped, brittle, ridged fingernails ANS: C

Spongy, bleeding gingiva is indicative of inadequate vitamin C intake. Cheilosis, glossitis, and spoon-shaped, brittle, ridged nails are symptoms of iron deficiency.

DIF: Cognitive Level: Understanding REF: Table 31.1: Physical Signs of Nutritional Status Alteration OBJ: Perform accurate nutritional screening.

TOP: Vitamin C Deficiency KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15. The patient is on the puree/extremely thick stage (stage 4) of the international dysphagia diet.

Which of the following foods may the patient select? a. Mashed potatoes b. Toast and peanut butter c. Well-cooked noodles in gravy d. Milkshake ANS: A

The puree/extremely thick stage (stage 4) of the international dysphagia diet includes foods that do not require chewing and cannot be drunk from a cup or sucked through a straw.

Examples include mashed potatoes, pureed meat, pureed pasta, yogurt, and cooked cereals.

DIF: Cognitive Level: Analysis REF: Table 31.4: Progressive and Therapeutic Diets OBJ: Perform accurate nutritional screening.

TOP: National Dysphagia Diet KEY: Nursing Process Step: AssN esU sm e nt M S C : N C L EX: Physiological Integrity RSINGTB.COM 16. The nurse is preparing to assess the nutritional status of an 80-year-old patient in a long-term

care facility. What screening tool would best suit this purpose? a. The Malnutrition Universal Screening Tool (MUST) b. Mini Nutritional Assessment (MNA) c. Anthropometric measurements d. A daily nutrition intake log ANS: B

The MNA is specifically designed to meet the needs of geriatric patients in long-term care facilities. The MUST is particularly designed for assessing older persons in clinical settings, including acute care. Including anthropomorphic measurements might be part of an assessment, as might information from the nutrition intake log, but neither would provide a complete picture in this case.

DIF: Cognitive Level: Application REF: Box 31.3: Nutritional Screening Tools OBJ: Perform accurate nutritional screening.

TOP: Nutritional Screening Tools KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 17. The nurse will collaborate with a

identified as being at nutritional risk. a. physician b. registered dietitian c. nutritionist

to develop a nutritional plan for a patient

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY d. respiratory therapist ANS: B

A registered dietitian (RD) is a vital member of the health care team. An RD will assess the patient’s nutritional status and recommend the intervention that will best address the patient’s unique nutrition diagnosis.

DIF: Cognitive Level: Understanding REF: Skill 31.1 OBJ: Identify the need and collaborate with dietitian when needed for a patient’s nutritional assessment.

TOP: Registered Dietitian KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is admitting a patient to the medical unit. Which of the following are reasons the

nurse may perform a nutritional screening on this patient? (Select all that apply.) a. To assess risk for malnutrition b. To assist with feeding c. To identify risk for aspiration d. To determine body weight ANS: A, B, C

A nurse’s role includes performing nutritional screening to assess a patient’s risk status for malnutrition, assessing and assisting an adult patient with feeding, and identifying patients at risk for aspiration during oral feeding. Although determining body weight is one aspect of assessing nutritional status, it is not the focus of a nutritional screening.

DIF: Cognitive Level: ApplicatiN onURSINRGETFB : .SC kiO llM 31.1 OBJ: Perform accurate nutritional screening.

TOP: Nutritional Screening KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The Nutrition Care Process (NCP) provides structure for the provision of nutritional care to all

patients and provides a framework for the registered dietitian (RD) to make decisions regarding medical nutrition therapy. The steps involved in this process include which of the following? (Select all that apply.) a. Nutrition assessment b. Nutrition diagnosis c. Nutrition intervention d. Nutrition evaluation ANS: A, B, C, D

In 2003 the American Dietetic Association published the Nutrition Care Process (NCP) and model. This process provides structure for the provision of nutritional care to all patients and provides a framework for the RD to think critically and make decisions regarding medical nutrition therapy. This process consists of four steps: nutrition assessment, nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluation.

DIF: Cognitive Level: Understanding REF: Skill 31.1 OBJ: Perform accurate nutritional screening.

TOP: Nutrition Care Process KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 3. A patient has residual dysphagia after stroke. The nurse notes that the prescribed diet is the

international dysphagia diet. He or she knows this diet comprises which of the following levels? (Select all that apply.) a. Slightly thick b. Mildly thick c. Minced and moist d. Regular ANS: A, B, C, D

In January 2018 Dietitians of Canada supported the International Dysphagia Diet Initiative (IDDI) to standardize terminology and descriptors for texture of foods and liquids that would meet the needs of individuals with dysphagia across all ages and care settings. The diet comprises eight levels: thin, slightly thick, mildly thick, liquidized/moderately thick, pureed/extremely thick, minced and moist, soft and bite-sized, and regular.

DIF: Cognitive Level: Understanding REF: Table 31.5: International Dysphagia Diet Levels OBJ: Identify risk factors for aspiration related to dysphagia.

TOP: National Dysphagia Diet KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. Which of the following are signs of nutritional status alteration? (Select all that apply.) a. Pale eye membranes b. Cheilosis (redness/swelling) of the lips c. Yellow-tinged skin d. Glossitis ANS: A, B, D

Pale eye membranes, cheilosis, and glossitis are all signs of iron deficiency. Yellow-tinged skin, or jaundice, is not one a sN igU nR ofSnIuN trG itiToB na.l C stO atM us alteration.

DIF: Cognitive Level: Understanding REF: Table 31.1: Physical Signs of Nutritional Status Alteration OBJ: Perform accurate nutritional screening.

TOP: Physical Signs of Nutritional Status Alteration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. A nurse’s role includes performing a nutritional screening, which includes (Select all that

apply.) a. assessing a patient’s risk status for malnutrition. b. collecting patient history. c. reviewing laboratory results. d. a focused physical assessment.

ANS: A, B, C, D

Part of nutritional screening is application of physical examination findings (including height and weight). A nurse conducts a complete or focused physical examination at the time of a patient's admission to a health care facility. During an examination, learn to recognize the physical signs that indicate a nutritional alteration and review laboratory results that further support a patient's nutritional status. A nurse also collects a patient history at the time of admission.

DIF: Cognitive Level: Understanding REF: Table 31.1: Physical Signs of Nutritional Status Alteration

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY OBJ: Identify the need and collaborate with dietitian when needed for a patient’s nutritional assessment.

TOP: Nutritional Screening KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. Which of the following patients is at elevated nutritional risk? (Select all that apply.) a. A person with a cancer diagnosis b. A person with infected or draining wounds c. A person with burns on 60% of their body d. A person who has had a fever for more than 2 days ANS: A, B, C, D

Risk factors for potential nutritional problems include cancer diagnoses, infected or draining wounds, burns, and elevated body temperature for more than 2 days. Patients exhibiting these conditions should be assessed for their nutritional status.

DIF: Cognitive Level: Understanding REF: Box 31.1: Risk Factors for Potential Nutritional Problems OBJ: Identify the need and collaborate with dietitian when needed for a patient’s nutritional assessment.

TOP: Nutritional Risk KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 32: Enteral Nutrition Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. Of the patients listed, which would be a candidate for nasoenteric feeding tube placement? a. Post–motor vehicle accident victim with a broken nose and jaw b. Patient with a bleeding ulcer and possible esophageal varices c. Elderly patient with a diagnosis of failure to thrive and an inability to chew d. Patient with an esophageal tumour ANS: C

Enteral nutrition, commonly called tube feeding, is the administration of nutrients through the gastrointestinal tract when a patient cannot ingest, chew, or swallow but can digest and absorb nutrients. Nasoenteric tubes are contraindicated in patients with facial trauma, prolonged bleeding, and upper gastrointestinal (GI) blockage (as is seen in cases of solid cancer).

DIF: Cognitive Level: Analysis REF: Skill 32.1 OBJ: Assess patients who are to receive enteral tube feedings.

TOP: Indications/Contraindications for Nasoenteric Tube Insertion KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse has just inserted a nasogastric (NG) feeding tube into a patient. What should the

nurse do to definitively ascertain that the tube is in the stomach or in the intestine? a. Test the pH of the contents. b. Use a carbon dioxide sensor. c. Lower the head of the bed tN oU1R 5S deIgN reGesT. B.COM d. Obtain an order for a chest radiograph.

ANS: D

The most reliable method of feeding tube verification is a chest radiograph (chest x-ray).

Gastric and intestinal pH measurements have been shown to differentiate tube placement, with the stomach having a lower pH than the intestines. This helps ensure that the tube is beyond the pylorus, theoretically reducing the risk for aspiration. This method is helpful before and after radiological confirmation. Carbon dioxide sensors are helpful in determining tube placement between the stomach and the lung. A small plastic piece with an embedded yellow sensor is attached to the end of the feeding tube; the sensor changes colour when carbon dioxide is present. Investigators have shown that this reduces the incidence of inadvertent pulmonary placement. This method is helpful before and after radiological confirmation.

Elevation of the head of the bed to a minimum of 30 degrees is a simple method used to keep the risk for aspiration at a minimum. The nurse is instrumental in achieving this goal. This method does not ascertain placement but may be useful in preventing aspiration.

DIF: Cognitive Level: Application REF: Principles for Practice OBJ: Demonstrate the ability to insert a small-bore feeding tube correctly.

TOP: Determining Position of NG Tubes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 3. The nurse is checking gastric residual on a patient who has a continuously running tube

feeding and finds that the patient has a 600-mL gastric residual volume (GRV). How should the nurse respond? a. Stop the tube feeding. b. Slow the tube feeding. c. Continue the tube feeding at the same rate. d. Increase the rate of the tube feeding.

ANS: A

Tube feedings are stopped if the patient has a GRV greater than 500 mL. DIF: Cognitive Level: Application REF: Evidence-Informed Practice OBJ: Assess patient who are to receive enteral tube feedings.

TOP: Residual Volume KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. Before insertion of a nasogastric (NG) tube, of which finding should the physician be

notified? a. Patent nares b. Absent bowel sounds c. Evident gag reflex d. Impaired swallowing ANS: B

Absent bowel sounds may indicate decreased or absent peristalsis and increased risk for aspiration. A finding of patent nares rules out obstruction or irritated nares, septal defect, or facial fracture and does not need to be reported to the physician because it is a “normal” finding. The nurse should assesNsUthReSpI atN ieG ntTfB or.aCgOaM g reflex to determine the patient’s ability to swallow and to discern whether a greater risk for aspiration exists. An evident gag reflex is a normal finding and does not need to be reported to the physician. Impaired swallowing is the probable reason for insertion of the NG tube.

DIF: Cognitive Level: Application REF: Skill 32.1 OBJ: Demonstrate the ability to insert a small-bore feeding tube correctly.

TOP: Absent Bowel SoundsKEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. An appropriate technique for nasogastric (NG) tube insertion is for the nurse to a. position the patient supine. b. apply oil-based lubricant to the plastic tube. c. advance the tube while the patient swallows. d. measure the tube length from the nose to the sternum.

ANS: C

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Encourage the patient to swallow by giving small sips of water or ice chips. Advance the tube as the patient swallows. Rotate the tube 180 degrees while inserting. Swallowing facilitates passage of the tube past the oropharynx. Position the patient sitting with the head of the bed elevated at least 30 degrees. If the patient is comatose, place him in semi-Fowler’s position with the head propped forward using a pillow. If the patient is forced to lie supine, place him in reverse Trendelenburg’s position. This reduces the risk for pulmonary aspiration in the event that the patient should vomit. Apply water-soluble lubricant. The tip of the tube must reach the stomach. Measure the distance from the tip of the nose to the earlobe to the xiphoid process of the sternum. Add 20 to 30 cm (8–12 inches) for a nasoenteric tube.

DIF: Cognitive Level: Application REF: Skill 32.1 OBJ: Demonstrate the ability to insert a small-bore feeding tube correctly.

TOP: NG Tube Insertion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. Which technique is appropriate for the nurse to implement during nasogastric (NG) tube

insertion? a. Use sterile gloves. b. Have the patient mouth breathe. c. Advance the tube quickly when the patient coughs. d. Bend the patient’s head backward after the tube is through the nasopharynx.

ANS: B

Emphasize the need to breathe through the mouth and swallow during the procedure. This facilitates passage of the tube and alleviates the patient’s fears during the procedure. Put on clean gloves. Do not force the tube. If resistance is met, or if the patient starts to cough or choke or becomes cyanotic, stop advancing the tube, pull the tube back, and start over. Have the patient flex his head towardNhUisRcShI esNt G afT teB r. thC eO tuM be has passed through the nasopharynx.

This closes off the glottis and reduces the risk that the tube may enter the trachea.

DIF: Cognitive Level: Application REF: Skill 32.1 OBJ: Demonstrate ability to insert a small-bore feeding tube correctly.

TOP: NG Tube Insertion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. The nurse has inserted a nasogastric (NG) feeding tube. The feeding tube has a stylet in place

to aid insertion. What should the nurse do once the tube is in place? a. Remove the stylet immediately. b. Reinsert the stylet if the radiograph determines incorrect placement. c. Fasten the end of the NG tube to the patient’s gown using tape and a safety pin. d. Leave the stylet in place and obtain a chest/abdomen radiograph.

ANS: D

Leave the stylet in place (if used) until correct position has been verified by x-ray film. Never attempt to reinsert a partially or fully removed stylet while the feeding tube is in place. This can cause perforation of the tube and can injure the patient. Do not use safety pins to pin the tube to the patient’s gown. Safety pins become unfastened and can cause injury to the patient.

DIF: Cognitive Level: Application REF: Skill 32.1 OBJ: Demonstrate ability to insert a small-bore feeding tube correctly.

TOP: NG Tube Insertion KEY: Nursing Process Step: Implementation

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY MSC: NCLEX: Physiological Integrity 8. The nurse is caring for a patient who is receiving continuous tube feedings. What must the

nurse do to care for this patient? a. Verify tube position every 4 to 6 hours. b. Obtain a radiograph every 4 to 12 hours. c. Instill air into the stomach via the tube and listen for bubbles. d. Do not worry about tube placement because the tube has already been determined to be in the right place.

ANS: A

After initial radiographic verification that a tube is positioned in the desired site (either the stomach or the small intestine), the nurse is responsible for ensuring that the tube has remained in the intended position before administering formula or medications through the tube. Therefore the nurse must verify tube position every 4 to 6 hours and as needed. Because it is not practical to do radiographic checks at this frequency, other methods of determining placement have been investigated. Insufflation of air into the tube while the abdomen is auscultated is not a reliable means of determining the position of the feeding tube tip. It is possible for the tip of a feeding tube to move into a different location (from the stomach to the intestine or from the intestine into the stomach) without any external evidence that the tube has moved. The risk for aspiration of regurgitated gastric contents into the respiratory tract increases when the tip of the tube accidentally dislocates upward into the esophagus.

DIF: Cognitive Level: Application REF: Skill 32.2 OBJ: Discuss the rationale for methods to determine nasogastric or nasoenteric feeding tube placement.

TOP: NG Tube Placement KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological IntN egUriR tySINGTB.COM 9. The home health nurse evaluates the provision of intermittent tube feedings by the patient’s

caregiver. The nurse notes that additional teaching is required when she notices that the caregiver a. keeps the formula refrigerated between feedings. b. keeps the feeding tube capped between feedings. c. begins the feeding before checking tube placement. d. irrigates the tube with 30 to 60 mL of water before and after feedings.

ANS: C

For intermittent tube-fed patients, test placement immediately before each feeding and before each administration of medication. Each administration of feeding/medication can lead to aspiration if the tube is displaced. For intermittent feeding, have a syringe ready and be sure that the formula is at room temperature. When tube feedings are not being administered, cap or clamp the proximal end of the feeding tube. Draw up in the syringe 30 mL of normal saline or tap water. This amount of solution will flush the length of the tube.

DIF: Cognitive Level: Application REF: Skill 32.2 OBJ: Demonstrate three appropriate techniques for administering enteral formulas.

TOP: Beginning Tube Feedings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. Which evaluation indicates that placement of a nasogastric or enteric tube is correct?

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. b. c. d.

Nasointestinal aspirate with a pH of less than 6 Pleural fluid pH of less than 6 Gastric aspirate with a pH of 5 or less after patient fasting Gastric aspirate with a pH of 4 and continuous tube feedings

ANS: C

Gastric fluid from a patient who has fasted for at least 4 hours usually has a pH of 5 or less.

Fluid from an enteric tube of a fasting patient usually has a pH greater than 6. The pH of pleural fluid from the tracheobronchial tree is generally greater than 6. Patients with continuous tube feeding may have a pH of 5 or greater.

DIF: Cognitive Level: Analysis REF: Skill 32.2 OBJ: Discuss the rationale for methods to determine nasogastric or nasoenteric feeding tube placement.

TOP: NG Tube Placement KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 11. The nurse is checking the residual volume on a patient who is getting intermittent tube

feedings via his NG tube. Which of the following may indicate that the patient has started to bleed again? a. The nurse obtains brown aspirate. b. The nurse notices that the abdomen is distended. c. The nurse obtains red aspirate. d. The nurse notices severe respiratory distress.

ANS: C

Red or brown colouring (coffee-grounds appearance) of fluid aspirated from a feeding tube indicates new blood or old blood, respectively, in the gastrointestinal tract. If the colour is not related to medications recentlyNadUm d,Bn. otC ifO yM the physician. Abdominal distension RiSniIstNerGeT usually indicates that the tube feeding is not progressing through the gastrointestinal tract.

This could be a sign of paralytic ileus. Stop the tube feeding and notify the physician. If the patient develops severe respiratory distress (e.g., dyspnea, decreased oxygen saturation, increased pulse rate), this may be a result of aspiration or tube displacement into the lung.

Stop any enteral feedings. Notify the physician. Obtain chest radiographs as ordered.

DIF: Cognitive Level: Analysis REF: Skill 32.2 OBJ: Discuss the reasons for risks of pulmonary complications during the insertion and maintenance of a feeding tube.

TOP: NG Tube Placement KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The nurse determines that a nasogastric (NG) tube needs irrigation when she a. obtains more than 200 mL of residual volume. b. obtains a small amount of thin watery residual. c. does not encounter resistance when aspirating the residual. d. obtains unusually thick secretions.

ANS: D

Thick secretions indicate the need to irrigate the tube. Note the ease with which tube feeding infuses through the tubing. Excess volume of secretions (more than 200 mL) indicates delayed gastric emptying. Irrigating the NG tube will not help. Failure of the formula to infuse as desired may indicate a developing obstruction.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY DIF: Cognitive Level: Analysis REF: Skill 32.3 OBJ: Demonstrate the appropriate technique for irrigating a feeding tube.

TOP: NG Tube Irrigation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. What is an appropriate amount of nasogastric irrigant for an adult patient? a. 1 to 2 mL b. 30 mL c. 5 to 15 mL d. 250 mL ANS: B

Draw up 30 mL of normal saline or tap water in a syringe. This amount of solution will flush the length of the tube. Irrigation of a tube requires a smaller volume of solution in children: 1 to 2 mL for small tubes to 5 to 15 mL or more for large ones.

DIF: Cognitive Level: Understanding REF: Skill 32.3 OBJ: Demonstrate the appropriate technique for irrigating a feeding tube.

TOP: NG Tube Irrigation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. Which technique is appropriate for providing intermittent tube feeding once placement of the

tube has been checked? a. Cooling the formula b. Lowering the head of the bed c. Allowing the bag to empty gradually over 30 to 45 minutes d. Adding food colouring to detect aspiration ANS: C

NURSINGTB.COM

Allow the bag to empty gradually over 30 to 45 minutes. Gradual emptying of tube feeding by gravity from the feeding bag reduces the risk for abdominal discomfort, vomiting, or diarrhea induced by bolus or too-rapid infusion of tube feedings. Cold formula causes gastric cramping. Place the patient in high-Fowler’s position or elevate the head of the bed at least 30 degrees to prevent aspiration. Do not add food colouring or dye to formula to assist in detecting aspiration, presumably by staining tracheobronchial secretions. This is associated with increased risk for contamination and may cause patient deaths.

DIF: Cognitive Level: Application REF: Skill 32.4 OBJ: Demonstrate three appropriate techniques for administering enteral formulas.

TOP: Administering Tube Feedings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. The nurse is preparing to administer an enteral feeding for the patient. The patient has been on

enteral feedings for 2 days. The nurse knows that the most appropriate technique for implementing enteral feeding is a. weighing the patient weekly. b. measuring the gastric residual every hour. c. changing the formula every 12 hours in an open system. d. leaving the formula in place in an open system for up to 24 hours.

ANS: C

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Maximum hang time for formula is 12 hours in an open system and 24 to 48 hours in a closed, ready-to-hang system (if it remains closed). Weigh the patient daily until the maximum administration rate is reached and maintained for 24 hours, and then weigh the patient three times per week. Check the gastric residual volume. Residual volume should be assessed before each feeding for intermittent feedings.

DIF: Cognitive Level: Comprehension REF: Skill 32.4 OBJ: Demonstrate three appropriate techniques for administering enteral formulas.

TOP: Administering Tube Feedings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. The nurse is initiating a continuous tube feeding for a patient who has a gastrostomy tube.

Which of the following procedures indicates proper practice? a. Allow the container to empty gradually over 60 minutes. b. Change the bag every 24 hours. c. Do not use water to flush the tube. d. Quickly increase the rate of administration.

ANS: B

Rinse the bag and tubing with warm water whenever feedings are interrupted. Use a new administration set every 24 hours. Allowing the container to empty over 30 to 45 minutes is the method used for intermittent administration of tube feedings. Administer water via a feeding tube as ordered or between feedings. This provides the patient with a source of water to help maintain fluid and electrolyte balance and clears the tubing of formula. Gradually advancing the rate of concentration of the tube feeding helps to prevent diarrhea and gastric intolerance to formula.

DIF: Cognitive Level: ComprehN enUsiRoS n INRGETFB : .SC kiO llM 32.4 OBJ: Demonstrate three appropriate techniques for administering enteral formulas.

TOP: Gastrostomy Tube Feedings KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 17. The nurse would anticipate the need for an enteral access device in which of the following

patients? a. Patient whose bowel sounds have not yet returned after abdominal surgery b. Patient recently diagnosed with a cerebrovascular accident (CVA) c. Patient who dislikes the taste of the health care institution’s meals d. Patient who suffers from severe acute dysphagia ANS: D

A patient who is unable to swallow because of severe acute dysphagia will require an enteral access device to provide adequate nutrition. The patient recently diagnosed with a CVA may require an enteral access device if the ability to swallow is affected, but more information would be needed before this option is chosen. A patient whose bowel sounds have not yet returned will remain on nothing by mouth (NPO) status and may have no need for an enteral access device. Less invasive strategies can be used for the patient who does not like the taste of food provided by the health care institution.

DIF: Cognitive Level: Evaluation REF: Skill 32.4 OBJ: Assess patients who are to have enteral tubes inserted.

TOP: Enteral Access Devices KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

18. A tube passed through the nose with the end terminating in the stomach, used in feeding the

patient for short periods, is known as which type of tube? a. Nasogastric b. Orogastric c. Nasoduodenal d. Jejunostomy ANS: A

A nurse passes a nasogastric (NG) tube through the nose with the end terminating in the stomach for use in delivering supplemental nutrition or facilitating gastric decompression.

DIF: Cognitive Level: Understanding REF: Skill 32.1 OBJ: Assess patients who are to receive tube feedings.

TOP: Nasogastric Feeding Tube KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19. The nurse is caring for a patient in a chronic vegetative state with inadequate gastric

emptying. The nurse would anticipate finding a patient’s nutritional needs. a. nasogastric b. orogastric c. gastrostomy d. jejunostomy

tube placed to assist with this

ANS: D

A jejunostomy tube would be appropriate for this patient. A nasally inserted tube would be inappropriate for long-term use; this fact rules out nasogastric and nasoenteric tubes. A tube placed into the stomach would N beUiRnS apIpN roGpT riaBte.fCoO r aMpatient with inadequate gastric emptying; this fact rules out gastrostomy and nasogastric tubes.

DIF: Cognitive Level: Analysis REF: Procedural Guideline 32.1 OBJ: Assess patients who are to have enteral tubes inserted.

TOP: Types of Access Devices KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is caring for a patient with an enteral feeding tube in place. The nurse assesses for

pulmonary aspiration as the main complication related to feeding tubes. Other complications include which of the following? (Select all that apply.) a. Infection b. Diarrhea c. Tube clogging d. Tube dislodgement ANS: A, B, C, D

The main complication related to feeding tubes is pulmonary aspiration with possible lung compromise. Other complications include misplaced tubes, infection, diarrhea, tube clogging, and tube dislodgement.

DIF: Cognitive Level: Comprehension REF: Safety Guidelines OBJ: Discuss the rationale for methods to determine nasogastric or nasoenteric feeding tube

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY placement.

TOP: Complications Related to Feeding Tubes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse, physician, and dietitian collaborate to select an enteral feeding formula for the

patient. Their decision should be based on which of the following? (Select all that apply.) a. Protein requirements of the patient b. Digestive ability of the patient c. Amount of lactose required d. The patient’s disease process ANS: A, B

The nurse, dietitian, and physician collaborate to select an enteral feeding formula based on the patient’s protein and calorie requirements and digestive ability.

DIF: Cognitive Level: Comprehension REF: Skill 32.4 OBJ: Assess patients who are to receive enteral tube feedings. TOP: Enteral Feeding Formulas KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. Conditions that increase the risk for spontaneous tube dislocation include which of the

following? (Select all that apply.) a. Retching/vomiting b. Nasotracheal suction c. Coughing d. Cyanosis ANS: A, B, C

Conditions that increase the risk for spontaneous tube dislocation include retching/vomiting, nasotracheal suction, and severN eU boRuStsIoNf G coTuB gh.iC ngO. M Cyanosis may be an indicator of displacement but is not a cause.

DIF: Cognitive Level: Comprehension REF: Skill 32.2 OBJ: Discuss the rationale for methods to determine nasogastric or nasoenteric feeding tube placement.

TOP: Dislocation of NG Tube KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The nurse is caring for a patient with a nasogastric tube in place. What interventions would

the nurse perform to reduce the risk of clogging the feeding tube? (Select all that apply.) a. Use the smallest barrel syringe possible to reduce the pressure in the tube. b. Mix medication with feedings to thoroughly dilute the medication. c. Flush the tube liberally with water before, between, and after each medication instillation. d. Use the largest barrel syringe possible to reduce the pressure in the tube. e. Crush solid medications thoroughly and mix them in water before administration.

ANS: C, D, E

Flushing the tube liberally with water before, between, and after each medication instillation will reduce the risk of clogging, as will crushing solid medications thoroughly and mixing them in water before administration. The largest barrel, not the smallest barrel, syringe exerts less pressure and reduces the risk of clogging. Mixing medications with formula is contraindicated because it increases the risk of clogging.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY DIF: Cognitive Level: Application REF: Skill 32.3 OBJ: Evaluate a patient’s tolerance of enteral feeding.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: NG Tube Clogging

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 33: Parenteral Nutrition Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. A 72-year-old patient is admitted to the hospital with a medical diagnosis of intestinal failure.

Which intervention should the nurse include in the plan of care to deliver nutritional needs? a. Enteral nutrition (EN) b. Parenteral nutrition (PN) c. A combination of enteral and parenteral nutrition d. Oral nutrition ANS: B

In situations where partial or complete intestinal failure has occurred and oral nutrition or enteral tube feeding is not possible, parenteral nutrition (PN) is the therapy of choice. When a patient’s gastrointestinal (GI) tract is functional, clinicians assess the patient and choose the best method of delivering nutritional needs, which may include enteral feeding, parenteral feeding, or a combination of both.

DIF: Cognitive Level: Analysis REF: Purpose OBJ: Identify patients who are candidates for PN. TOP: Parenteral Nutrition KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The patient has been prescribed parenteral nutrition (PN) but will require the nutritional

therapy to continue for several months. Which route is most important for the nurse to consider? a. Second intravenous line NURSINGTB.COM b. Enteral feeding tube c. Central venous access device (CVAD) d. Parenteral feeding tube ANS: C

The ideal method to administer parenteral nutrition (PN) over an extended period is through a central venous catheter, which allows for higher concentration of nutrients.

DIF: Cognitive Level: Analysis REF: Principles for Practice OBJ: Identify patients who are candidates for PN. TOP: Central Lines KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 3. The nurse is caring for a patient who is receiving PN. As part of therapy, the patient

undergoes routine bedside glucose monitoring that reveals which expected outcome? a. Lower than normal blood glucose to determine adequate tolerance for PN b. Slightly higher than normal blood glucose to meet increased cellular needs c. Slightly higher than normal blood glucose to prevent infection or systemic sepsis d. Normal blood glucose to prevent associated complications ANS: D

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

For PN to be used safely, its administration must be closely monitored. Special care is necessary to maintain blood glucose levels in the normal range. Higher glucose levels are often associated with cardiovascular events, general infection, systemic sepsis, acute renal failure, and death.

DIF: Cognitive Level: Analysis OBJ: Discuss risks associated with PN. KEY: Nursing Process Step: Evaluation

REF: Skill 33.1 TOP: Blood Sugar Control MSC: NCLEX: Physiological Integrity

4. A patient had surgery 1 week ago, has not been eating his meals, and states that he has no

appetite. The nurse assesses that the patient has been progressively losing weight. Which intervention has the highest priority? a. Encourage the patient to eat. b. Force-feed the patient. c. Consult with the nutritional support team. d. Be aware that the patient will come around when hungry.

ANS: C

Often the nurse will be the first to identify risk factors, such as progressive weight loss, restricted or limited fluid intake, intolerance to enteral feedings, increased energy need (burns, sepsis, and trauma), and being NPO (nothing by mouth) for 3 or more days. The first sign of a developing problem is a pattern of a decline in oral food intake and reduced appetite.

Assessment provides information for consulting with the nutritional support team and the physician in an effort to initiate appropriate PN. Force-feeding the patient may only lead to worse issues, especially if the patient has a nonfunctioning intestinal system.

DIF: Cognitive Level: Analysis REF: Delegation and Collaboration (Skill 33.1) N U R S I N OBJ: Identify patients who are candidates foGrT PB N..COM TOP: Nutritional Support Team KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 5. During intravenous (IV) administration of fat (lipid) emulsions, the patient voices complaints.

Which complaint indicates to the nurse that the patient is experiencing a complication associated with the administration? a. Fever, chills, and malaise b. Low temperature, chills, and headache c. Fever, flushing, and muscle relaxation d. Low temperature, muscle aches, and dyspnea ANS: A

Fever, chills, and malaise are symptoms of catheter-related sepsis.

DIF: Cognitive Level: Analysis REF: Table 33.1: Complications of Parenteral Nutrition OBJ: Discuss risks associated with PN. TOP: Lipid Infusion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. Which assessment should a nurse expect to see for a patient receiving parenteral nutrition

(PN)? a. Weight gain of 0.5 kg per week b. Crackles in the lungs c. Serum potassium level of 2.8 mmol/L

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY d. Serum glucose level of more than 8.3 mmol/L ANS: A

The patient’s ideal weight gain is usually between 0.5 to 1.5 kg per week. Crackles in the lungs are an indication of fluid overload. A serum potassium of 2.8 mmol/L is not in the normal range. A serum glucose level of more than 8.3 mmol/L is not in the normal range.

DIF: Cognitive Level: Analysis REF: Skill 33.1 OBJ: List the monitoring procedures used for patients receiving PN. TOP: Weight Gain KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 7. A patient receiving parenteral nutrition (PN) has gained 2 kg over a 24-hour period. Given

this weight gain, which interpretation by the nurse is most accurate? a. Increased nutrition from the patient’s parenteral infusions b. Decreased linoleic acid intake c. Increased fluid loss d. Fluid retention ANS: D

Weight gain greater than 0.5 kg per day indicates fluid retention. The patient’s ideal weight gain is usually between 0.5 and 1.5 kg per week. Weight is an indicator of the patient’s nutritional status and determines fluid volume. A nutritional regimen without adequate fatty acids leads to essential fatty acid deficiency (EFAD), characterized by dry, scaly skin; sparse hair growth; impaired wound healing; decreased resistance to stress; increased susceptibility to respiratory tract infection; anemia; thrombocytopenia; and liver function abnormalities.

DIF: Cognitive Level: AnalysisNURSINRGETFB : .SC kiO llM 33.1 OBJ: Demonstrate appropriate nursing care and the use of safe precautions when caring for a patient receiving PN. TOP: Fluid Retention KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 8. To detect a common but unwanted effect of interrupting a parenteral nutrition (PN) infusion,

the nurse should assess the patient for development of which symptom? a. Fever b. Chest pain c. Erythema and induration d. Shaking and dizziness ANS: D

Do not interrupt a parenteral nutrition (PN) infusion. This infusion maintains a continuous supply of nutrients and prevents a hypoglycemic reaction. Fever could be caused by systemic infection. Chest pain could be caused by air embolism. Localized infection can occur at the exit site or tunnel.

DIF: Cognitive Level: Application REF: Table 33.1: Complications of Parenteral Nutrition OBJ: Demonstrate appropriate nursing care and the use of safe precautions when caring for a patient receiving PN. TOP: Complications of Parenteral Nutrition KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 9. The nurse is managing the care of a patient receiving parenteral nutrition (PN). Which

assessment finding indicates potential septicemia?

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. b. c. d.

Shakiness and dizziness Chest pain/hypotension Increased thirst Increased temperature

ANS: D

Know the patient’s recent temperature range. Patients with peripheral or central intravenous (IV) lines are susceptible to septicemia; elevated temperature can be an early indicator of a bacterial process. Hypoglycemia causes the patient to be shaky, dizzy, nervous, and anxious; the patient senses hunger and has a blood sugar level less than 80 mg/100 mL. Air embolism results in sudden respiratory distress, shortness of breath, coughing, chest pain, and decreased blood pressure. Hyperglycemia leads to excessive thirst.

DIF: Cognitive Level: Analysis REF: Table 33.1: Complications of Parenteral Nutrition OBJ: Demonstrate appropriate nursing care and the use of safe precautions when caring for a patient receiving PN. TOP: Complications of Parenteral Nutrition KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 10. The nurse has been caring for a patient who has had a central venous access device (CVAD)

in place. The patient complains of sudden chest pain and difficulty breathing. These assessment findings are symptoms of which severe complication? a. Exit site infection b. Catheter-related sepsis c. Pneumothorax d. Hyperglycemia ANS: C

Symptoms of pneumothorax inN clU udReSsI udNdGenTB ch.esCt OpM ain, difficulty breathing, decreased breath sounds, cessation of normal chest movement on the affected side, and tachycardia. Symptoms of exit site infection include erythema, tenderness, induration, or purulence within 2 cm of the skin at the exit site. Symptoms of catheter-related sepsis include isolation of the same microorganism from a blood culture and catheter segment, with the patient having fever, chills, malaise, and elevated white blood cell count. Symptoms of hyperglycemia include excessive thirst, urination, and confusion.

DIF: Cognitive Level: Application REF: Table 33.1: Complications of Parenteral Nutrition OBJ: Demonstrate appropriate nursing care and the use of safe precautions when caring for a patient receiving PN. TOP: Complications of Central Parenteral Nutrition KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11. The nurse is caring for a patient receiving parenteral nutrition (PN). In planning the patient’s

care for the day, which nursing assessment is most essential? a. Electrolyte levels b. Weight c. Temperature d. Condition of catheter insertion site ANS: A

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Because the need for parenteral nutrition (PN) is usually associated with conditions that result in electrolyte instability, maintaining electrolyte balance during therapy is crucial. Monitor the patient’s electrolyte levels (potassium, magnesium, and phosphorus) for low serum levels, which may indicate a risk for arrhythmias and muscle weakness. Patients at risk may require having electrolyte panels done several times a day. Although it is necessary to monitor the patient’s weight and temperature and be alert for signs of infection at the insertion site, the biggest risk to the patient is electrolyte instability.

DIF: Cognitive Level: Application REF: Skill 33.1 OBJ: Demonstrate appropriate nursing care and the use of safe precautions when caring for a patient receiving PN. TOP: Assessment/Planning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. If parenteral nutrition (PN) must be discontinued suddenly, hang

at the same

infusion rate to prevent hypoglycemia. a. normal saline b. 10% dextrose in water c. enteral formula d. sterile water ANS: B

The 10% dextrose solution (D10W) will maintain the fluid and electrolyte balance of the patient until the PN therapy may be either restarted or gradually withdrawn.

DIF: Cognitive Level: Understanding REF: Table 33.1: Complications of Parenteral Nutrition OBJ: Identify measures used to prevent complications of PN. TOP: Lipids ReSntINM GSTCB: .NCCOLM KEY: Nursing Process Step: AssN esU sm EX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is caring for a patient who is receiving parenteral nutrition (PN). The nurse realizes

that PN is associated with which of the following risks? (Select all that apply.) a. Decreased mortality b. Bloodstream infection c. Pneumothorax d. Decreased length of stay e. Liver disease ANS: B, C, E

Use of parenteral nutrition (PN) in the perioperative patient is controversial, and although benefits are more likely in the severely malnourished, evidence has shown little effect of PN in preventing mortality. PN creates risks. It has been associated with catheter-related bloodstream infection, noninfective complications such as pneumothorax, increased hospital length of stay, and liver disease.

DIF: Cognitive Level: Comprehension OBJ: Discuss risks associated with PN. KEY: Nursing Process Step: Assessment

REF: Table 33.1: Complications of Parenteral Nutrition TOP: Parenteral Nutrition Complications MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 2. The patient will be discharged to home on parenteral nutrition (PN). The patient and his

caregiver will need to perform which of the following care steps? (Select all that apply.) a. Monitor the patient’s weight. b. Monitor the patient’s serum glucose levels. c. Measure the patient’s intake and output. d. Perform catheter care. e. Limit the patient’s activity.

ANS: A, B, C, D

The patient and caregiver will need to learn to monitor the patient’s weight, blood glucose levels, and intake and output. They will also need to know how to perform catheter care and dressing changes. Home-based parenteral nutrition (PN) can be managed to allow the patient a reasonable amount of mobility, and limiting activity should not be required.

DIF: Cognitive Level: Comprehension OBJ: Discuss risks associated with PN. KEY: Nursing Process Step: Assessment

REF: Care in the Community (Skill 33.1) TOP: Quality of Life MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 34: Urinary Elimination and Catheterization Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The nurse is assessing a patient whose 24-hour output is 2400 mL. Which finding reflects the

nurse’s understanding of urine output? a. Increased output b. Decreased output c. Normal output d. Balanced output ANS: C

The average output range for adult urinary output averages between 2200 and 2700 mL in 24 hours.

DIF: Cognitive Level: Comprehension REF: Principles for Practice OBJ: Discuss the relationship between fluid balance and urinary elimination.

TOP: Normal Urinary Output KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 2. On the basis of the nurse’s assessment of kidney function for an adult patient, which finding is

normal? a. 10 mL per hour b. 20 mL per hour c. 30 mL per hour d. 100 mL per hour

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ANS: C

The minimum average hourly output is 30 mL. DIF: Cognitive Level: Understanding REF: Principles for Practice OBJ: Discuss the relationship between fluid balance and urinary elimination.

TOP: Normal Urinary Output KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 3. Which activities related to urinary elimination may be delegated to an unregulated care

provider (UCP)? a. Catheterization b. Positioning the patient c. Evaluating alternatives to catheter use d. Assessing urinary drainage ANS: B

UCPs may position the patient, focus lighting for the procedure, and enhance the patient’s comfort during the procedure through measures such as holding the patient’s hand or keeping the patient warm. The nurse uses sterile asepsis when inserting an indwelling or straight catheter to reduce the risk for bladder infection. The nurse evaluates possible alternatives to catheter use, and assessment is the responsibility of the nurse.

DIF: Cognitive Level: Application

REF: Delegation and Collaboration (Skill 34.2)

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY OBJ: Describe ways to provide for patient safety when managing urinary elimination needs.

TOP: Delegation Considerations for Inserting a Urinary Catheter KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 4. The nurse is planning care for a 12-year-old female patient who needs a Foley catheter

inserted. It is most important for the nurse to use a catheter of which size French (Fr)? a. 5 to 6 Fr b. 8 to 10 Fr c. 12 Fr d. 14 to 16 Fr ANS: C

Gender and age determine catheter size. A 12-Fr catheter may be considered for use in young girls. The prescriber may order a larger size. For infants, 5 to 6 Fr is generally used; for children, 8 to 10 Fr with a 3-mL balloon is used; and 14 to 16 Fr is indicated for adult women.

DIF: Cognitive Level: Analysis REF: Skill 34.1 OBJ: Perform the following skills: place and remove urinal, insert urinary catheter, care for an indwelling urinary catheter, measure postvoid residual (PVR) with catheterization and bladder scan, irrigate a catheter, remove an indwelling catheter, apply a condom catheter, and care for a suprapubic catheter.

TOP: Size of Urinary Catheter KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 5. The nurse notes that urine does not flow after a female patient is catheterized. The nurse

believes that the catheter has been placed into the vagina. Which action should the nurse take? a. Remove the catheter and reinsert it. b. Irrigate the catheter with saline. c. Leave the catheter in place N anUdRiS nsIerNt G anToB th.erCoOnM e. d. Insert the catheter 17 to 22.5 cm (9–10 inches) farther into the patient to verify that it is in the vagina.

ANS: C

If no urine appears, check whether the catheter is in the vagina. If misplaced, leave the catheter in the vagina as a landmark indicating where not to insert it, and insert another catheter into the meatus. Reinserting a catheter that has already been contaminated by vaginal exposure could lead to urinary tract infection.

DIF: Cognitive Level: Application REF: Skill 34.1 OBJ: Perform the following skills: place and remove urinal, insert urinary catheter, care for an indwelling urinary catheter, measure postvoid residual (PVR) with catheterization and bladder scan, irrigate a catheter, remove an indwelling catheter, apply a condom catheter, and care for a suprapubic catheter.

TOP: Inserting Catheter Into a Female Patient KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 6. When the balloon on an indwelling urinary catheter is inflated and the patient expresses

discomfort, it is essential for the nurse to take which action? a. Remove the catheter. b. Continue to blow up the balloon because discomfort is expected. c. Aspirate the fluid from the balloon and advance the catheter. d. Pull back on the catheter slightly to determine tension.

ANS: C

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

If resistance to inflation is noted, or if the patient complains of pain, the balloon may not be entirely within the bladder. Stop inflation, aspirate any fluid injected into the balloon, and advance the catheter a little farther before attempting again to inflate.

DIF: Cognitive Level: Application REF: Skill 34.1 OBJ: Perform the following skills: place and remove urinal, insert urinary catheter, care for an indwelling urinary catheter, measure postvoid residual (PVR) with catheterization and bladder scan, irrigate a catheter, remove an indwelling catheter, apply a condom catheter, and care for a suprapubic catheter.

TOP: Inflating the Balloon KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 7. The nurse is caring for a patient who has an indwelling urinary catheter. Which intervention is

most important to include in this patient’s plan of care? a. Maintaining tension on the tubing b. Emptying the urinary collection bag every 24 hours c. Cleaning in a circular motion from the meatus down the catheter d. Keeping the drainage bag on the bed or attached to the side rails ANS: C

Using a clean washcloth, wipe in a circular motion along the length of the catheter for about 10 cm (4 inches). Allow slack in the catheter so movement does not create tension on it.

Empty the drainage bag, and record amounts at least every 3 to 6 hours. The drainage bag must be below the level of the bladder; do not place the bag on the side rails of the bed.

DIF: Cognitive Level: Application REF: Skill 34.2 OBJ: Perform the following skills: place and remove urinal, insert urinary catheter, care for an indwelling urinary catheter, measure postvoid residual (PVR) with catheterization and bladder scan, irrigate a catheter, remove an indw inS gI caN thG etT erB , a.pC plO yM a condom catheter, and care for a suprapubic NeUllR catheter.

TOP: Catheter Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The nurse has been ordered to perform closed intermittent irrigation of a patient’s indwelling

urinary catheter. Which intervention is indicative of safe practice? a. Applies sterile gloves. b. Instills 100 mL of irrigant. c. Leaves the drainage tubing unclamped irrigation. d. Determines the amount of urinary drainage by subtracting the amount of irrigant from the total output.

ANS: D

Calculate the fluid used to irrigate the bladder and catheter and subtract from the volume drained to determine accurate urinary output. Closed intermittent irrigation does not require the use of sterile gloves. The typical amount of irrigant used is 30 to 50 mL, and the tubing is clamped during the process.

DIF: Cognitive Level: Application REF: Skill 34.3 OBJ: Perform the following skills: place and remove urinal, insert urinary catheter, care for an indwelling urinary catheter, measure postvoid residual (PVR) with catheterization and bladder scan, irrigate a catheter, remove an indwelling catheter, apply a condom catheter, and care for a suprapubic catheter.

TOP: Catheter Irrigation KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

9. When evaluating the health care team member’s ability to apply a condom catheter, it is most

important for the nurse to provide further instruction for which intervention? a. Clipping of hair at the base of the penis b. Applying skin preparation to the penis before catheter placement c. Using regular adhesive tape to hold the catheter in place d. Leaving 2.5 to 5 cm (1–2 inches) of space between the tip of the penis and the end of the catheter ANS: C

Use of an adhesive strip not designed for sheath application may be inflexible and may impede circulation to the penis. Clip hair at the base of the penis. Hair adheres to the condom and is pulled during condom removal or may get caught in rubber as the condom catheter is applied. Apply skin preparation to the penis and allow it to dry. Leave 2.5 to 5 cm (1–2 inches) of space between the tip of the glans penis and the end of the condom.

DIF: Cognitive Level: Application REF: Skill 34.4 OBJ: Perform the following skills: place and remove urinal, insert urinary catheter, care for an indwelling urinary catheter, measure postvoid residual (PVR) with catheterization and bladder scan, irrigate a catheter, remove an indwelling catheter, apply a condom catheter, and care for a suprapubic catheter.

TOP: Condom Catheter KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 10. When providing care for a patient with a suprapubic catheter who has acquired a urinary tract

infection (UTI), which intervention is most important for the nurse to implement? a. Using clean technique b. Securing the tube to the inner thigh c. Cleansing the insertion siteNinUaRdSiI reN ctG ioT nBto.wCaO rdMthe drain d. Promoting intake of 2200 mL of fluid per day ANS: D

Encourage the patient with a UTI to drink at least 2200 mL of fluid per day. The insertion site is cleansed in a circular swabbing pattern so as not to disturb the tubing. Standard care requires the use of clean gloves and securing the catheter to the abdomen.

DIF: Cognitive Level: Application REF: Skill 34.5 OBJ: Perform the following skills: place and remove urinal, insert urinary catheter, care for an indwelling urinary catheter, measure postvoid residual (PVR) with catheterization and bladder scan, irrigate a catheter, remove an indwelling catheter, apply a condom catheter, and care for a suprapubic catheter.

TOP: Suprapubic Catheterization KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. Which symptom is the patient with fluid overload likely to exhibit? a. Oliguria b. Distended neck veins c. Increased skin temperature d. Increased urine specific gravity ANS: B

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Cardiovascular signs of fluid volume excess include bounding pulse rate, normal blood pressure with or without orthostatic changes, third heart sound (S3), and distended neck veins.

Oliguria is a renal sign of fluid volume deficit. Increased skin temperature is a sign of fluid volume deficit. Increased urine specific gravity is a renal sign of fluid volume deficit.

DIF: Cognitive Level: Application REF: Table 34.1: Signs of Fluid Volume Deficit and Fluid Volume Excess OBJ: Discuss the relationship between fluid balance and urinary elimination.

TOP: Fluid Volume Excess KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. When observing a patient for symptoms of dehydration, the nurse should observe which

assessment? a. Increased salivation b. Diuresis c. Periorbital edema d. Decreased capillary filling ANS: D

Cardiovascular signs of fluid volume deficit include increased pulse rate, weak pulse, hypotension, decreased pulse volume/pressure, decreased capillary filling, and increased hematocrit. Increased salivation and periorbital edema are signs of fluid volume excess.

Diuresis is a renal sign of fluid volume excess.

DIF: Cognitive Level: Application REF: Skill 34.1 OBJ: Discuss the relationship between fluid balance and urinary elimination.

TOP: Fluid Volume Deficit KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological IntN egUriR tySINGTB.COM 13. When providing care for a patient in need of an indwelling catheter, the nurse understands that

which of the following is an indication for this need? a. Presence of a bladder outlet obstruction b. Presence of a yeast infection c. Presence of a urinary tract infection d. Overactive bladder (OAB) ANS: A

Indications for long-term catheterization include those who have a bladder outlet obstruction that is not medically or surgically correctable, and some patients with neurogenic bladder and retention. Indications for short-term indwelling catheter include acute urinary retention, urological and contiguous surgery, and the need for accurate measurement of urinary output in critically ill patients. The presence of yeast infections, urinary tract infections, and OAB are not indications for catheterization.

DIF: Cognitive Level: Comprehension REF: Skill 34.1 OBJ: Describe devices used to promote urinary elimination.

TOP: Foley Catheter KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. The nurse receives a prescription to insert a Foley catheter. In obtaining a catheter of the right

size, the nurse is aware that large catheters can lead to which complication? a. Urethral damage b. Bladder relaxation

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY c. Obstruction of urinary flow d. Decreased risk for infection ANS: A

Large catheters (larger than 16 Fr) can distend the urethra and permanently damage the urethra and bladder neck, as well as cause bladder spasms and leaking around the catheter.

Use a catheter of the smallest size possible to minimize trauma and promote adequate drainage of the periurethral glands. This will decrease the risk for infection.

DIF: Cognitive Level: Analysis REF: Skill 34.1 OBJ: Perform the following skills: place and remove urinal, insert urinary catheter, care for an indwelling urinary catheter, measure postvoid residual (PVR) with catheterization and bladder scan, irrigate a catheter, remove an indwelling catheter, apply a condom catheter, and care for a suprapubic catheter.

TOP: Size of Urinary Catheter KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 15. The nurse is caring for a patient who has an indwelling catheter attached to a drainage bag. To

achieve the desired outcome of this procedure, which nursing action should be taken? a. Make sure the tubing has dependent loops to gather urine. b. Make sure the tubing is coiled and secured to the bed. c. Make sure the tubing is kinked. d. Make sure the collection bag is higher than the bladder.

ANS: B

Check the drainage tubing and the bag to make sure that the tubing does not have dependent loops and the bag is not positioned above the level of the bladder. Check to make sure that the tubing is coiled and is secured to the bed linen, is free of kinks, and is not clamped and that the patient is not lying on it. NURSINGTB.COM DIF: Cognitive Level: Application REF: Skill 34.2 OBJ: Perform the following skills: place and remove urinal, insert urinary catheter, care for an indwelling urinary catheter, measure postvoid residual (PVR) with catheterization and bladder scan, irrigate a catheter, remove an indwelling catheter, apply a condom catheter, and care for a suprapubic catheter.

TOP: Catheter Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. The nurse is caring for a patient who is experiencing inadequate bladder emptying. To

determine postvoid residual, which technique is most important for the nurse to implement? a. Bladder scanner b. Indwelling catheterization c. Straight/intermittent catheterization d. Foley catheterization ANS: A

The bladder scan is most commonly used to measure postvoid residual (PVR); it is the least invasive method of making this determination.

DIF: Cognitive Level: Analysis REF: Procedural Guideline 34.2 OBJ: Perform the following skills: place and remove urinal, insert urinary catheter, care for an indwelling urinary catheter, measure postvoid residual (PVR) with catheterization and bladder scan, irrigate a catheter, remove an indwelling catheter, apply a condom catheter, and care for a suprapubic

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY catheter.

TOP: Residual Urine KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. The nurse is preparing the patient for a bladder scan to determine postvoid residual (PVR).

Which of the following is part of the preparation? a. Limit food intake for 2 hours before the scan. b. Begin scan 10 minutes after the patient has voided. c. Limit liquid intake for 30 minutes before the scan. d. Administer an analgesic 30 minutes before the scan.

ANS: B

The nurse will assist the patient to void, then wait 10 minutes before administering the bladder scan. There is no need to limit either food or fluids before the test. Because the test is completely noninvasive, there is no need to administer an analgesic beforehand.

DIF: Cognitive Level: Understanding REF: Procedural Guideline 34.2 OBJ: Perform the following skills: place and remove urinal, insert urinary catheter, care for an indwelling urinary catheter, measure postvoid residual (PVR) with catheterization and bladder scan, irrigate a catheter, remove an indwelling catheter, apply a condom catheter, and care for a suprapubic catheter.

TOP: Residual Urine KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. Antimicrobial catheters coated with silver or antibiotics have been shown to reduce the

incidence of a. bleeding b. bladder spasm c. infection d. trauma

.

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ANS: C

Silver-coated antimicrobial catheters have been effective in reducing incidences of infection (e.g., catheter-associated urinary tract infection [CAUTI]) in short-term catheter use.

DIF: Cognitive Level: Understanding REF: Skill 34.1 OBJ: Identify factors that increase risk for catheter-associated urinary tract infection (CAUTI).

TOP: Urinary Tract Infection KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19. The risk for catheter-associated urinary tract infection can be reduced by using

when inserting a catheter in the hospital setting. a. personal protective equipment (PPE) b. aseptic technique c. clean technique d. triple-lumen catheters ANS: B

Numerous studies have confirmed the effect of the use of aseptic technique in the insertion of urinary catheters in reducing the rate of catheter-associated infections. Clean technique should not be used for catheter insertion in the hospital setting.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY DIF: Cognitive Level: Understanding REF: Evidence-Informed Practice OBJ: Identify factors that increase risk for catheter-associated urinary tract infection (CAUTI).

TOP: Aseptic Technique During Catheter Insertion KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 20. A single-lumen catheter that is inserted into the bladder through the urethra only to empty the

bladder and then is removed is known as a(n) a. straight b. indwelling c. continuous closed irrigation d. intermittent open irrigation

catheter.

ANS: A

A straight or intermittent catheter is a single-lumen catheter that is inserted into the bladder through the urethra only to empty the bladder, and then is removed. Use this type of catheter on a one-time basis, for example, to determine the amount of residual urine in the bladder, or intermittently, when the patient cannot urinate because of a urinary obstruction or a neurological disorder such as spinal cord injury.

DIF: Cognitive Level: Understanding REF: Skill 34.1 OBJ: Describe ways to provide for patient safety when managing urinary elimination needs.

TOP: Straight or Intermittent Catheters KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. A(n)

catheter has a separate lumen that is used to inflate a balloon so the catheter remains in the bladder for short- or long-term use. a. straight b. indwelling NURSINGTB.COM c. continuous closed irrigation d. intermittent open irrigation ANS: B

An indwelling catheter has a separate lumen that is used to inflate a balloon so the catheter remains in the bladder for short- or long-term use.

DIF: Cognitive Level: Understanding REF: Skill 34.1 OBJ: Describe ways to provide for patient safety when managing urinary elimination needs.

TOP: Indwelling Catheter KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 22. a. b. c. d.

is the volume of urine in the bladder after a normal voiding.

Suprapubic volume Postvoid residual Tidal volume Incontinence

ANS: B

Residual urine, also referred to as postvoid residual (PVR), is the volume of urine in the bladder after a normal voiding.

DIF: Cognitive Level: Understanding REF: Procedural Guideline 34.2 OBJ: Perform the following skills: place and remove urinal, insert urinary catheter, care for an

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY indwelling urinary catheter, measure postvoid residual (PVR) with catheterization and bladder scan, irrigate a catheter, remove an indwelling catheter, apply a condom catheter, and care for a suprapubic catheter.

TOP: Residual Urine KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 23. A noninvasive device that is used to provide accurate determination of a patient’s bladder

volume by first creating an ultrasound image of the patient’s bladder and then calculating the urine volume in the bladder is known as a . a. suprapubic catheter b. bladder scanner c. tidal volume measurement d. condom catheter ANS: B

The bladder scanner is noninvasive, so there is no risk for health care–associated urinary tract infection (UTI) and possible trauma associated with urinary catheterization. It provides accurate determination of a patient’s bladder volume by first creating an ultrasound image of the patient’s bladder and then calculating the urine volume in the bladder.

DIF: Cognitive Level: Understanding REF: Procedural Guideline 34.2 OBJ: Perform the following skills: place and remove urinal, insert urinary catheter, care for an indwelling urinary catheter, measure postvoid residual (PVR) with catheterization and bladder scan, irrigate a catheter, remove an indwelling catheter, apply a condom catheter, and care for a suprapubic catheter.

TOP: Bladder Scanner KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

is a N noUnR inSvI asN ivGeTalBte.rnCaO tivMe for management of male urinary incontinence. Because it is noninvasive, the risk for urinary tract infection (UTI) is decreased.

The device fits over the penis and connects to a small collection bag that attaches to the leg with a strap, or to a standard urinary collection bag that hangs on the bedframe below the level of the bladder. a. suprapubic catheter b. bladder scanner c. tidal volume measurement d. condom catheter

24. A

ANS: D

A condom catheter, also referred to as an external catheter or a penile sheath, is a noninvasive alternative for management of male urinary incontinence. Because it is noninvasive, the risk for UTI is decreased. The device is a soft, flexible, condom-like sheath that fits over the penis and connects to a small collection bag that attaches to the leg with a strap, or to a standard urinary collection bag that hangs on the bedframe below the level of the bladder.

DIF: Cognitive Level: Understanding REF: Skill 34.4 OBJ: Perform the following skills: place and remove urinal, insert urinary catheter, care for an indwelling urinary catheter, measure postvoid residual (PVR) with catheterization and bladder scan, irrigate a catheter, remove an indwelling catheter, apply a condom catheter, and care for a suprapubic catheter.

TOP: Condom Catheter KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 25.

involves the insertion of a urinary catheter directly into the bladder through the lower abdominal wall. Urine drains from the catheter into a urinary drainage bag. a. Suprapubic catheterization b. Bladder scanning c. Tidal volume measurement d. Condom catheterization ANS: A

Suprapubic catheterization involves the insertion of a urinary catheter directly into the bladder through the lower abdominal wall. Urine drains from the catheter into a urinary drainage bag.

Suprapubic catheters are inserted with local or general anaesthetic for short- or long-term use.

DIF: Cognitive Level: Understanding REF: Skill 34.5 OBJ: Perform the following skills: place and remove urinal, insert urinary catheter, care for an indwelling urinary catheter, measure postvoid residual (PVR) with catheterization and bladder scan, irrigate a catheter, remove an indwelling catheter, apply a condom catheter, and care for a suprapubic catheter.

TOP: Suprapubic Catheterization KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. In assisting a male patient in using a urinal, which of the following actions should the nurse

take? (Select all that apply.) a. Assess for orthostatic hypotension. b. Assess the patient’s normal elimination habits. c. Assess for periods of incontinence. d. Prop the urinal in place if thNeUpR atSieInN t iG sT unBa. blCeOtoMhold it. e. Always stay with the patient during urinal use.

ANS: A, B, C

To assist the patient in using a urinal, the nurse should assess the patient’s normal urinary elimination habits and look for periods of incontinence. Always determine mobility status before having a patient stand to void, and assess for orthostatic hypotension if the patient has been on prolonged bed rest. If the patient is able to handle the urinal himself, allow him privacy. If the patient is unable to handle the urinal, the nurse will assist by holding it.

DIF: Cognitive Level: Understanding REF: Procedural Guideline 34.1 OBJ: Perform the following skills: place and remove urinal, insert urinary catheter, care for an indwelling urinary catheter, measure postvoid residual (PVR) with catheterization and bladder scan, irrigate a catheter, remove an indwelling catheter, apply a condom catheter, and care for a suprapubic catheter.

TOP: Assisting the Male Patient in Using a Urinal KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse has inserted an indwelling catheter and secured the catheter to the patient’s thigh,

making sure that there is enough slack that movement will not create tension on the catheter.

The nurse understands that the chief purpose of properly securing Foley catheters is to obtain which outcome? (Select all that apply.) a. Minimized risk for bleeding b. Reduced risk for bladder spasm c. Reduced risk for meatal necrosis

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY d. Reduced risk for trauma e. Increased bladder relaxation ANS: A, B, C, D

Securing the catheter will minimize accidental dislodgment. It also will minimize risks for bleeding, trauma, meatal necrosis, and bladder spasms from pressure and traction.

DIF: Cognitive Level: Analysis REF: Skill 34.2 OBJ: Perform the following skills: place and remove urinal, insert urinary catheter, care for an indwelling urinary catheter, measure postvoid residual (PVR) with catheterization and bladder scan, irrigate a catheter, remove an indwelling catheter, apply a condom catheter, and care for a suprapubic catheter.

TOP: Securing the Catheter KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 35: Bowel Elimination and Gastric Intubation Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The nurse is caring for a patient who has been on bed rest for several weeks. The nurse notes

that the patient is continually seeping liquid stool rectally. The nurse should take which action? a. Hold the patient’s antibiotics. b. Put the patient on a bran diet. c. Perform a digital rectal examination. d. Increase the dosage of the patient’s antibiotics.

ANS: C

Continual seepage of diarrhea may occur with an impaction, and a digital rectal examination can verify its presence. Diarrhea is often a result of diet or antibiotic use, which alters the normal flora in the gastrointestinal tract. However, a health care provider’s prescription is required to change these, and continual seepage of stool is more likely the result of impaction; this should be ruled out first.

DIF: Cognitive Level: Application REF: Procedural Steps OBJ: Discuss methods to relieve constipation or impaction.

TOP: Digital Rectal Examination KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The patient is a 74-year-old man who has been in the hospital for 4 days after an orthopaedic

surgical procedure. He is concerned because he has not moved his bowels every day as he did NURSINGTB.COM before surgery, but every other day. Which response made by the nurse is appropriate? a. Advise the patient to put himself on over-the-counter laxatives. b. Instruct the patient that daily bowel movements are not always necessary. c. Educate the patient that with increasing age, his bowel movements should increase in frequency. d. Inform the patient that he will call to get a laxative to get him back on track.

ANS: B

Reinforce with older patients that as long as the consistency of the stool remains normal, bowel movements occur with regularity. As long as he is able to move his bowels at least three times a week, he should not worry about not having a daily movement. Because there is no indication of constipation, the patient should not place himself on laxatives. However, because the patient is most likely less mobile and receiving strong pain medication after his orthopaedic surgery (both likely to cause constipation), the nurse should monitor the situation.

DIF: Cognitive Level: Application REF: Gerontological (Skill 35.1) OBJ: Discuss methods to relieve constipation or impaction.

TOP: Gerontological Considerations KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 3. The nurse assesses that a patient has a severe fecal impaction. Which action taken by the nurse

addresses this problem? a. Administering laxatives b. Providing a high-fibre diet

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY c. Performing a digital removal d. Administering an enema ANS: C

Prevention is the key to fecal impaction. However, once it occurs, digital removal of stool is the only alternative. Once the impaction is cleared, a high-fibre diet, increased activity, and adequate hydration may all reduce the likelihood of recurrence.

DIF: Cognitive Level: Application REF: Skill 35.2 OBJ: Describe factors that promote and impede normal bowel elimination.

TOP: Digital Removal of Fecal Impaction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse prepares to exercise a digital removal of feces. To detect an untoward effect of this

procedure, the nurse should assess the patient history for which condition? a. Heart disease b. Abdominal pain c. Urinary infection d. Diabetes mellitus ANS: A

Because of the potential to stimulate the vagus nerve, patients with a history of arrhythmia or heart disease are at greater risk for changes in heart rhythm. Be sure to monitor the patient’s pulse before and during the procedure. This procedure may be contraindicated in cardiac patients; if in doubt, verify with the physician. Symptoms of fecal impaction include constipation, rectal discomfort, anorexia, nausea, vomiting, abdominal pain, diarrhea (around the impacted stool), and urinary frequency. Abdominal pain by itself is not indicative of the need for extra caution. SymptoN mU sR ofSfI ecNaG l iT mB p. acC tiO onMinclude urinary frequency, not infection.

There is no correlation between the two.

DIF: Cognitive Level: Analysis REF: Skill 35.2 OBJ: Describe factors that promote and impede normal bowel elimination.

TOP: Digital Removal of Fecal Impaction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. When evaluating a student nurse’s ability to digitally remove feces, the nurse preceptor

determined that further teaching is required if the student nurse does which of the following interventions? a. Provides perianal skin care. b. Continues the procedure if bleeding starts. c. Follows the procedure by offering the patient the bedpan. d. Discontinues the procedure in the presence of bradycardia.

ANS: B

If the patient experiences bleeding from the rectum, the anal and perianal regions should be assessed to locate the source of the bleeding. Observe for the presence of perianal skin irritation. The presence of such indicates the need for postprocedure skin care to the perianal region to reduce pain during subsequent bowel elimination. After the procedure, assist the patient to the toilet or onto a clean bedpan. Removal of impaction stimulates the defecation reflex. The sacral branch of the vagus nerve is stimulated during digital stimulation; this may result in reflex slowing of the heart rate. Stop the procedure and retake vital signs.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY DIF: Cognitive Level: Analysis REF: Skill 35.2 OBJ: Perform the following skills: helping a patient use a bedpan, digitally removing stool, administering an enema, and inserting and removing a nasogastric tube.

TOP: Digital Removal of Fecal Impaction KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 6. The nurse is preparing to administer an enema to a patient. Which type of enema is most

likely to lead to circulatory overload? a. Hypertonic solution b. Soapsuds c. Tap water d. Harris flush ANS: C

A tap-water (hypotonic) enema should not be repeated after first instillation because water toxicity or circulatory overload can develop. Hypertonic solution is useful for patients who cannot tolerate large volumes of fluid. Only 120 to 180 mL (4–6 ounces) is usually effective (e.g., commercially prepared Fleet enema). A soapsuds enema (SSE) consists of pure castile soap added to tap water or normal saline, depending on the patient’s condition and the frequency of administration. Use only castile pure soap. The recommended ratio of pure soap to solution is 5 mL (1 teaspoon) to 1000 mL (1 quart) warm water or saline. Add soap to the enema bag after water is in place to reduce excessive suds. The Harris flush enema is a return-flow enema that helps expel intestinal gas. Fluid alternately flows into and out of the large intestine. This stimulates peristalsis in the large intestine and assists in expelling gas.

DIF: Cognitive Level: Analysis REF: Skill 35.3 OBJ: Perform the following skills: helping a patient use a bedpan, digitally removing stool, GT administering an enema, and inserNtiU ngRaS ndIrNem ovB in. gC aO naMsogastric tube.

TOP: Tap-Water Enema KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 7. When preparing an infant for an enema, the nurse understands that which solution is the

safest? a. Tap-water enema solution b. Hypertonic enema solution c. Oil retention d. Physiological normal saline ANS: D

Physiological normal saline is the safest solution. Infants and children can only tolerate this type of solution because of their predisposition to fluid imbalance. If solution is prepared at home, mix 500 mL of tap water with 1 teaspoon of table salt. Tap water, hypertonic, and oil retention enemas are not safe to use for infants and children.

DIF: Cognitive Level: Analysis REF: Table 35.1: Types of Enemas OBJ: Perform the following skills: helping a patient use a bedpan, digitally removing stool, administering an enema, and inserting and removing a nasogastric tube.

TOP: Saline Enema KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 8. The patient is being prepped for surgery and has a prescription for “enemas until clear.” The

nurse realizes that he or she will be giving a maximum of how many enemas?

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. b. c. d.

One Two Three Four

ANS: C

The “enemas until clear” prescription means that you repeat enemas until the patient passes fluid that is clear of fecal matter. Check employer policy, but usually a patient should receive a maximum of three consecutive enemas to avoid disruption of fluid and electrolyte balance.

If more are required, notify the physician before administering.

DIF: Cognitive Level: Application REF: Skill 35.3 OBJ: Perform the following skills: helping a patient use a bedpan, digitally removing stool, administering an enema, and inserting and removing a nasogastric tube.

TOP: Enemas Until Clear KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The nurse is preparing to administer an enema to an adult patient who has normal sphincter

control. For administration of the enema, the patient is placed in which position? a. Right side-lying b. Dorsal recumbent c. Sims’ d. Prone ANS: C

Assist the patient into left side-lying (Sims’) position with the right knee flexed. Additionally, place a child in dorsal recumbent position. This allows enema solution to flow downward by gravity along the natural curveNoU f tR heSsIigNm GoTidBc.oCloOnMand rectum, thus improving retention of solution.

DIF: Cognitive Level: Application REF: Skill 35.3 OBJ: Perform the following skills: helping a patient use a bedpan, digitally removing stool, administering an enema, and inserting and removing a nasogastric tube.

TOP: Enema Process: Positioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. The nurse has been directed to provide an enema for an elderly female patient who has very

poor rectal sphincter control. Which position is most appropriate for this patient? a. Sims’ position b. Dorsal recumbent position on the bedpan c. Sitting on the toilet d. Right lateral position ANS: B

If the patient has poor sphincter control, position the patient on the bedpan in a comfortable dorsal recumbent position. Patients with poor sphincter control cannot retain all of the enema solution. Administering an enema with the patient sitting on the toilet is unsafe because curved rectal tubing can abrade the rectal wall.

DIF: Cognitive Level: Application REF: Gerontological (Skill 35.3) OBJ: Perform the following skills: helping a patient use a bedpan, digitally removing stool, administering an enema, and inserting and removing a nasogastric tube.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY TOP: Dorsal Recumbent Position on the Bedpan KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. When preparing an adult patient for an enema, the nurse understands that the tube or nozzle

should be inserted how far? a. 2.5 to 3.75 cm b. 5 to 7.5 cm c. 7.5 to 10 cm d. 10 to 12.5cm ANS: C

Insert the nozzle of the container gently into the anal canal—for adults, 7.5 to 10 cm (3–4 inches). If administering to an infant, insert the tip of the tube 2.5 to 3.75 cm (1–1.5 inches). If administering to a child, insert the tip of the tube 5 to 7.5 cm (2–3 inches). However, children and infants usually do not receive prepackaged hypertonic enemas because hypertonic solutions cause rapid fluid shift. Inserting the tip of the tube more than 10 cm is not appropriate at any age.

DIF: Cognitive Level: Application REF: Skill 35.3 OBJ: Perform the following skills: helping a patient use a bedpan, digitally removing stool, administering an enema, and inserting and removing a nasogastric tube.

TOP: Insertion of Tubing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. While the nurse is administering an enema with a standard enema bag, which intervention is

important to implement? a. Keeping the solution at rooN SpIeN mUtR em raG tuTreB.COM b. Positioning the patient on the right side c. Raising the enema bag to 30 cm (12 inches) above the patient d. Instructing the patient to release the enema solution as soon as possible ANS: A

Maintaining a correct temperature for the solution is a critical safety precaution. If the solution is too hot it will burn the intestinal mucosa. Cold water can cause abdominal cramping.

Solution dripped on inner wrist should be comfortable. Unless patient condition requires a different position, the patient will lay on the left side with the top leg flexed (left lateral Sims’) and the bag of solution will be hung 45 cm (18 inches) above the rectum. The patient will be instructed to retain the solution as long as possible for maximum therapeutic effect.

DIF: Cognitive Level: Application REF: Skill 35.3 OBJ: Perform the following skills: helping a patient use a bedpan, digitally removing stool, administering an enema, and inserting and removing a nasogastric tube.

TOP: Temperature of Solution KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. While the nurse is administering an enema, the patient complains of some cramping. Which

action should the nurse take next? a. Discontinue the procedure completely. b. Increase the height of the solution. c. Slow the rate of infusion. d. Have the patient roll into a supine position.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

ANS: C

If abdominal cramping develops, decrease the height of the enema bag and slow the rate of instillation. Changing the patient position will not be helpful. Sometimes, temporarily stopping the solution (taking a break) minimizes cramping.

DIF: Cognitive Level: Application REF: Skill 35.3 OBJ: Perform the following skills: helping a patient use a bedpan, digitally removing stool, administering an enema, and inserting and removing a nasogastric tube.

TOP: Abdominal Cramping KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. When providing care for a patient who is disoriented during a nasogastric (NG) tube

placement, which intervention is important for the nurse to implement? a. Halt the procedure. b. Request assistance with insertion. c. Administer a hypnotic medication. d. Continue the procedure as with any other patient.

ANS: B

If the patient is confused, disoriented, or unable to follow commands, obtain assistance from another staff member to insert the tube.

DIF: Cognitive Level: Application REF: Skill 35.4 OBJ: Perform the following skills: helping a patient use a bedpan, digitally removing stool, administering an enema, and inserting and removing a nasogastric tube.

TOP: Disoriented Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

NURSINGTB.COM

15. When developing a plan of care for a patient requiring a nasogastric (NG) tube, the nurse

recognizes that it is essential to implement which technique in measuring the length of the tube? a. Measure from the nose to the earlobe to the patient’s navel. b. Measure from the nose to the earlobe to the patient’s xiphoid process of sternum. c. Measure and mark a point 76 cm (30 inches) from the end. d. Measure from the nose to the patient’s navel.

ANS: B

Measure from the nose to the earlobe to the patient’s xiphoid process of sternum, which approximates the distance from nose to stomach.

DIF: Cognitive Level: Application REF: Skill 35.4 OBJ: Perform the following skills: helping a patient use a bedpan, digitally removing stool, administering an enema, and inserting and removing a nasogastric tube.

TOP: Measuring Tube for Placement KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. In advancing the nasogastric (NG) tube, which technique provides the safest outcome? a. Rotate the tube if resistance is felt. b. Advance the tube in between swallows. c. Start with the patient’s head flexed. d. Check the tube placement by instilling air and auscultating over the stomach.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY ANS: A

If resistance is met, try to rotate the tube and see whether it advances. If there is still resistance, withdraw the tube, allow the patient to rest, relubricate the tube, and insert it into the other naris. Advance the tube 2.5 to 5 cm (1–2 inches) with each swallow of water. If the patient is not allowed fluids, instruct him to dry swallow or suck air through a straw. Initially, instruct the patient to extend his neck back against the pillow; insert the tube slowly through the naris with the curved end pointing downward. Verify tube placement. Check employer policy for preferred methods.

DIF: Cognitive Level: Application REF: Skill 35.4 OBJ: Perform the following skills: helping a patient use a bedpan, digitally removing stool, administering an enema, and inserting and removing a nasogastric tube.

TOP: Insertion of NG Tube KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. When care is provided for a patient with a nasogastric (NG) tube in place, which intervention

is safest for the nurse to implement? a. Tape the tube up and around the ear on the side of insertion. b. Secure the tubing to the bed by the patient’s head. c. Mark the tube where it exits the nose. d. Change the tubing daily.

ANS: C

Once placement is confirmed, a red mark should be made or place tape on the tube to indicate where the tube exits the nose. The mark or the tube length is to be used as a guide to indicate whether displacement may have occurred. The tube should be taped to the nose, not to the ear.

The tubing should be secured to the patient’s gown, not to the bed, and should not be changed daily, but it may be irrigated daNilU y.RSINGTB.COM DIF: Cognitive Level: Application REF: Skill 35.4 OBJ: Perform the following skills: helping a patient use a bedpan, digitally removing stool, administering an enema, and inserting and removing a nasogastric tube.

TOP: Marking NG Tube Placement KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. At what time of day is peristalsis the strongest? a. During the hour after the first meal of the day b. While sleeping c. One hour before bedtime d. During the hour after the last meal of the day ANS: A

Peristalsis is strongest during the hour after the first meal of the day. Anticipate when to offer the patient the bedpan.

DIF: Cognitive Level: Understanding REF: Skill 35.1 OBJ: Describe factors that promote and impede normal bowel elimination.

TOP: Peristalsis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19. A bedpan that is designed for patients with body or leg casts or for patients restricted from

raising their hips (e.g., after total joint replacement) is known as a

.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. b. c. d.

regular pan fracture pan Simons pan tapered pan

ANS: B

A fracture pan, designed for patients with body or leg casts or for those restricted from raising their hips (e.g., after total joint replacement), has a shallow end approximately 1.3 cm (0.5 inch) deep that slips easily under a patient. The open end of the regular pan fits just under the upper thighs, and the back of the pan fits under the patient’s buttocks toward the sacrum. For the fracture pan, the handle is just under the thighs, and the smaller portion is toward the buttocks.

DIF: Cognitive Level: Understanding REF: Skill 35.1 OBJ: Perform the following skills: helping a patient use a bedpan, digitally removing stool, administering an enema, and inserting and removing a nasogastric tube.

TOP: Fracture Pan KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 20. A(n)

is the instillation of a solution into the rectum and sigmoid colon to promote defecation by stimulating peristalsis. a. fecal impaction b. intubation c. enema d. suppository ANS: C

An enema is the instillation of N aU soRluStiI onNG inT toBth.eCrO ecMtum and sigmoid colon. Enemas promote defecation by stimulating peristalsis.

DIF: Cognitive Level: Understanding REF: Skill 35.3 OBJ: Perform the following skills: helping a patient use a bedpan, digitally removing stool, administering an enema, and inserting and removing a nasogastric tube.

TOP: Enema KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. A patient is admitted for constipation. When planning care for this patient, the nurse

recognizes that which interventions would help control constipation? (Select all that apply.) a. Increases in activity level b. Elimination of laxative use c. Decreased dietary fibre d. Increased fluids e. Timely response to urge to move bowels ANS: A, B, D, E

Changes in lifestyle that will be helpful to eliminate constipation cycles include increased dietary fibre, increased fluids, moderate exercise, and elimination of laxative use. It is also important to encourage patients to respond to the urge to move bowels when the urge first occurs because delay may promote constipation.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

DIF: Cognitive Level: Analysis REF: Box 35.1: Common Causes of Constipation OBJ: Describe factors that promote and impede normal bowel elimination.

TOP: Interventions to Control Constipation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The patient is receiving a soapsuds enema but is having a difficult time retaining the fluid.

What action should the nurse take? (Select all that apply.) a. Give the enema slowly. b. Place the patient in the dorsal recumbent position on a bedpan. c. Give the enema with the patient on the toilet. d. Give the enema in the right lateral position. e. Give the enema faster.

ANS: A, B

Give the enema slowly to aid absorption. If the patient is full of stool, retention is difficult. As stool is evacuated, there is more room in the colon for additional fluid. If the patient has poor sphincter control, position the patient on the bedpan in a comfortable dorsal recumbent position. Patients with poor sphincter control cannot retain all of the enema solution.

Administering an enema with the patient sitting on a toilet is unsafe because curved rectal tubing can abrade the rectal wall. Enemas are not given to patients in the right lateral position.

DIF: Cognitive Level: Application REF: Skill 35.3 OBJ: Perform the following skills: helping a patient use a bedpan, digitally removing stool, administering an enema, and inserting and removing a nasogastric tube.

TOP: Inability to Retain Enema Fluid KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological IntN egUriR tySINGTB.COM 3. The Levin tube and the Salem sump tube are used most commonly for stomach

decompression. Which of the following statements about these tubes is true? (Select all that apply.) a. Levin tubes have a blue “pigtail” that functions as an air vent. b. These tubes are inserted as a sterile procedure. c. The blue air vent should not be used for irrigation. d. The Salem sump tube has a blue “pigtail” that functions as an air vent. e. The Salem sump is preferred for stomach decompression.

ANS: C, D, E

The Levin tube is a single-lumen tube with holes near the tip. You connect the tube to a drainage bag or to an intermittent suction device to drain stomach secretions. The Salem sump tube has two lumina: one for removal of gastric contents and one to provide an air vent, which prevents suctioning of gastric mucosa into eyelets at the distal tip of the tube. A blue “pigtail” is the air vent that connects with the second lumen. Never clamp off the air vent, connect it to suction, or use it for irrigation. Nasogastric (NG) tube insertion does not require sterile technique. Clean technique is adequate. The Salem sump is preferred for gastric decompression.

DIF: Cognitive Level: Comprehension REF: Skill 35.4 OBJ: Perform the following skills: helping a patient use a bedpan, digitally removing stool, administering an enema, and inserting and removing a nasogastric tube.

TOP: Nasogastric (NG) Tube KEY: Nursing Process Step: Implementation

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY MSC: NCLEX: Physiological Integrity 4. What should the nurse do to verify nasogastric (NG) tube placement? (Select all that apply.) a. Ask the patient to speak. b. Inspect the posterior pharynx. c. Aspirate back on the syringe. d. Obtain an x-ray examination of the placement. e. Auscultate the lung fields.

ANS: A, B, C, D

Although a radiographic examination is the gold standard to verify NG tube placement, there are several steps the nurse can take to gauge correct placement. Ask the patient to speak. If the patient is unable to speak, the NG tube may have passed through the vocal cords. Inspect the posterior pharynx for the presence of a coiled tube. The tube is pliable and will coil up behind the pharynx instead of advancing into the esophagus. Aspirate gently back on the syringe to obtain gastric contents, observing colour. Gastric contents are usually cloudy and green but sometimes are off-white, tan, bloody, or brown. Aspiration of contents provides the means to measure fluid pH and thus determine tube tip placement in the gastrointestinal tract.

DIF: Cognitive Level: Application REF: Skill 35.4 OBJ: Perform the following skills: helping a patient use a bedpan, digitally removing stool, administering an enema, and inserting and removing a nasogastric tube.

TOP: Verifying Position of NG Tube KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 36: Ostomy Care Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The nurse is caring for a patient with an ostomy. The nurse notes that the ostomy is putting

out watery effluent. The nurse recognizes that this is indicative of which location? a. Descending colon b. Sigmoid colon c. Ileal portion of the small intestine d. Transverse colon ANS: C

An opening in the ileal portion of the small intestine is an ileostomy, and the fecal effluent will be watery to thick liquid that will contain some digestive enzymes. A colostomy in the descending or sigmoid colon generally results in a stool similar to that normally passed through the rectum. If the opening is in the transverse or ascending colon, the effluent will vary from thick liquid to semiformed stool.

DIF: Cognitive Level: Analysis REF: Principles for Practice OBJ: Explain the differences in consistency of effluent based on the type of ostomy.

TOP: Position of the Ostomy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse is caring for a patient who has an ostomy. The nurse notices that the effluent ranges

from a thick liquid to a semiformed stool. The nurse recognizes that this is indicative of which NURSINGTB.COM location? a. Descending colon b. Ileal portion of the small intestine c. Sigmoid colon d. Transverse or ascending colon ANS: D

If the opening is in the transverse or ascending colon, the effluent will vary from thick liquid to semiformed stool. A colostomy in the descending or sigmoid colon generally results in a stool similar to that normally passed through the rectum. An opening in the ileal portion of the small intestine is an ileostomy, and the fecal effluent will be watery to thick liquid that will contain some digestive enzymes.

DIF: Cognitive Level: Analysis REF: Principles for Practice OBJ: Explain the differences in consistency of effluent based on the type of ostomy.

TOP: Position of the Ostomy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse is caring for a patient who had a colostomy placed 5 days earlier. The nurse notes

that the stoma is red and moist. Which action should the nurse take? a. Notify the physician immediately. b. Apply pressure. c. Document the condition of the stoma. d. Change the appliance pouch.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY ANS: C

The stoma should be red or pink and moist. After assessment the nurse will note the appearance of the stoma in the patient electronic health record. If it is grey, purple, or black, report this to the charge nurse or physician immediately. Pressure is applied to control active bleeding. The information given in the question does not indicate that there is a need to change the appliance at this time.

DIF: Cognitive Level: Application REF: Skill 36.1 OBJ: Describe methods used to maintain integrity of the peristomal skin.

TOP: Condition of Ostomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. In caring for a patient who had a fecal surgical diversion, which nursing intervention is

essential? a. Place a pouch over the newly created stoma. b. Place a dressing over the stoma. c. Wait several days before placing a pouch. d. Prepare several pouches in advance.

ANS: A

Immediately after a fecal surgical diversion, it is necessary to place a pouch over the newly created stoma to contain effluent when the stoma begins to function. The pouch will keep the patient clean and dry, will protect the skin from drainage, and will provide a barrier against odour. Dressings would obstruct the opening and would become saturated with fecal material.

Preparing multiple pouches in advance would be counterproductive; in the immediate postoperative period, the stoma may be edematous and the abdomen distended. These symptoms eventually resolve, but during this time, it will be necessary to revise the pouching TB system to meet the changing siN zeUoRf S thIe N stG om a. anCdOthMe changes in body contours.

DIF: Cognitive Level: Application REF: Skill 36.1 OBJ: Describe methods used to maintain integrity of the peristomal skin.

TOP: Immediate Postsurgical Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. When planning care for a patient who has a colostomy, which intervention is important for the

nurse to perform when pouching the colostomy? a. Leave an intact skin barrier in place for 3 to 7 days. b. Use soap and water to cleanse the peristomal skin. c. Empty the pouch when it is two-thirds full. d. Use tape to secure pouches that have minor leaks.

ANS: A

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Observe the existing skin barrier and pouch for leakage and length of time in place. The pouch should be changed every 3 to 7 days, not daily. To minimize skin irritation, avoid unnecessary changing of the entire pouching system, but if the effluent is leaking under the wafer, change it, because skin damage from the effluent will cause more skin trauma than will be caused by early removal of the wafer. Cleanse the peristomal skin gently with warm tap water using a washcloth; do not scrub the skin. Pat the skin dry. Avoid soap; it leaves residue on the skin, which interferes with pouch adhesion. Pouches must be emptied when they are one-third to one-half full, because the weight of the pouch may disrupt the seal of the adhesive on the skin.

If the ostomy pouch is leaking, change it. Taping or patching it to contain effluent leaves the skin exposed to chemical or enzymatic irritation.

DIF: Cognitive Level: Application REF: Skill 36.1 OBJ: Pouch a fecal or a urinary diversion.

TOP: Pouching a Colostomy or Ileostomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. When providing care for a patient with a colostomy or an ileostomy, the nurse recognizes that

which is an expected assessment finding? a. A moist, reddish-pink stoma b. A dry, purplish stoma c. Erythema on the skin around the stoma d. No drainage noted from the stoma when washed ANS: A

Normal findings in a patient with a postoperative ostomy that is healing include a stoma that is moist and reddish-pink, skin that is intact and free of irritation, and sutures that are intact.

The stoma is edematous initiallNyUaR ndSsIhN rinGkTs B o. veCr O thM e next 4 to 6 weeks. A necrotic stoma is manifested by a purple or black colour and a dry instead of moist texture. The stoma is functioning normally when the stoma drains a moderate amount of liquid or soft stool and flatus in the pouch. Flatus indicates the return of peristalsis after surgery. Flatus is noted by bulging of the pouch. (Flatus may not be observable if the pouch has a gas filter.)

DIF: Cognitive Level: Application REF: Skill 36.1 OBJ: Pouch a fecal or a urinary diversion.

TOP: Pouching a Colostomy or Ileostomy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The nurse is caring for a preterm infant in the neonatal intensive care unit who has multiple

stomas. Given the uniqueness of infants, which action is essential for the nurse to take? a. Apply an ostomy pouch using standard sealants. b. Use a pouch that can accommodate increased amounts of flatus. c. Use multiple pouches (one for each stoma). d. Be aware that the stoma size will remain the same as the baby grows.

ANS: B

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Because babies swallow large amounts of air while sucking, it is normal to expect flatus.

Make sure that the pouch can accommodate increased amounts of flatus after feeding or be prepared to release flatus frequently. The skin of a preterm infant is not fully developed and is more absorbent than the skin of a full-term infant. Do not use skin sealants and adhesive removers unless they are approved for preterm infant use. Neonates may have multiple stomas on their tiny abdomens that are the result of corrective bowel surgeries. Select a cut-to-fit pouch that allows multiple stoma openings in the skin barrier yet still fits on the neonate’s abdomen. Usually a baby triples its birth weight in the first year. As a baby grows in size, so does the stoma.

DIF: Cognitive Level: Application REF: Pediatric (Skill 36.1) OBJ: Pouch a fecal or a urinary diversion.

TOP: Pediatric Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. In caring for a patient who has a pouch for a noncontinent urinary diversion, which nursing

intervention is essential? a. Empty the pouch when it is one-third to one-half full. b. Remove the ureteral stents after 2 days. c. Pouch the stoma with the patient sitting up. d. Dispose of used pouches in the toilet.

ANS: A

Empty pouches when they are one-third to one-half full so that the weight of the pouch does not disrupt the seal. A surgeon places the stents; these will be removed during the hospital stay or at the first postoperative visit with the surgeon. Place the patient in a semireclining position. If possible, provide the patient a mirror for observation. Properly dispose of used pouches and soiled equipment N acUcoRrS diI ngNG toTeB m. plCoO yeMr policy.

DIF: Cognitive Level: Application REF: Skill 36.2 OBJ: Pouch a fecal or a urinary diversion.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Pouching a Urostomy

9. When assessing the patient with a noncontinent urinary diversion, the nurse finds that the

urine has mucus shreds. Which action should the nurse take? a. Culture any drainage. b. Instruct the patient to consume less water. c. Document the characteristics of the urine. d. Cleanse the stoma with soap and water.

ANS: C

Mucus shreds are normal when urine flows through an intestinal segment. Obtain a urine specimen for culture and sensitivity to test for possible infection when ordered by the physician if urine output is less than 30 mL per hour or if the urine has a foul odour. Teach patients the significance and importance of drinking 1.5 to 2 quarts of fluid daily to prevent urinary tract infection. Avoid soap; it leaves residue on the skin, which interferes with pouch adhesion.

DIF: Cognitive Level: Analysis REF: Skill 36.2 OBJ: Pouch a fecal or a urinary diversion.

TOP: Mucous Shreds

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. The nurse has removed the patient’s old urostomy pouch and is attempting to measure the

stoma opening for placement of a new pouch. Which action should the nurse take next? a. Place the patient in a prone position. b. Cleanse the peristomal skin with warm soap and water. c. Remove any stents that are in place. d. Place rolled gauze at the stoma opening.

ANS: D

Wick the stoma continuously during pouch measurement and change. Place a rolled gauze wick at the stomal opening. Using a wick at the stoma opening prevents the peristomal skin from becoming wet with urine during a pouching-change procedure. Position the patient in a semireclining position. Avoid soap when cleansing the area. In the immediate postoperative period, urinary stents extend out from the stoma. A surgeon places the stents to prevent stenosis of the ureters at the site where the ureters are attached to the conduit. The stents will be removed during the hospital stay or at the first postoperative visit with the surgeon.

DIF: Cognitive Level: Application REF: Skill 36.2 OBJ: Pouch a fecal or a urinary diversion.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Wicking the Stoma

11. A patient who has a urostomy is being discharged to home. Which instruction will the nurse to

provide to the patient? a. Restrict fluid intake to reduce urine output. b. Report any mucus in his urN inU e.RSINGTB.COM c. Keep unused pouches in the refrigerator. d. Shower without covering the pouch.

ANS: D

The patient may shower without covering the pouch. Teach patients the significance and importance of drinking 1.5 to 2 quarts of fluid daily to prevent urinary tract infection. Patients should avoid storing pouches in extremely hot or cold locations like the refrigerator. Teach patients that some mucus in the urine is expected but that they should report to their physician any blood in the urine, excessively cloudy urine, chills, fever (38.3°C [101°F] or higher), or back (flank) pain.

DIF: Cognitive Level: Application REF: Skill 36.2 OBJ: Describe methods used to maintain integrity of the peristomal skin.

TOP: Patient Education KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The nurse is caring for a patient who has a urinary diversion. The nurse notices that the patient

has a temperature of 38.8°C (102°F) and foul-smelling urine. What action should the nurse take? a. Obtain a urine culture from the patient’s pouch. b. Catheterize the patient to obtain a sterile urine specimen. c. Notify the physician. d. Realize that these are normal findings.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY ANS: C

Common symptoms of a urinary tract infection (UTI) include fever and foul-smelling odour.

The nurse will need to contact the physician immediately. The health care provider will prescribe a catheterization so that a urine sample may be obtained. Although the nurse realizes the need for catheterization, it is an invasive procedure, and an invasive procedure requires a health care provider’s prescription. Obtaining a specimen of urine in a pouch does not result in an accurate finding because of the likely risk of contamination by microorganisms. Some mucus in the urine is expected.

DIF: Cognitive Level: Analysis OBJ: Catheterize a urinary diversion.

KEY: Nursing Process Step: Assessment

REF: Skill 36.2 TOP: Urinary Infection MSC: NCLEX: Physiological Integrity

13. The nurse is preparing to catheterize a patient who has a urostomy and uses a two-piece pouch

system. The nurse should take which action? a. Place the patient in a semirecumbent position. b. Remove both pieces of the pouch system. c. Remove the pouch and leave the barrier attached. d. Use sterile gloves to remove the system.

ANS: C

Remove the pouch. If the patient uses a two-piece system, remove the pouch but leave the barrier attached to the skin. Position the patient sitting, if possible; gravity facilitates the flow of urine. Sterile gloves are used for the actual catheterization. Clean gloves are donned when removing the pouch.

DIF: Cognitive Level: Application REF: Skill 36.3 OM OBJ: Catheterize a urinary diverN siU onR. SINTGOTPB : .RCem oving the Pouch KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. The output from a urinary or fecal stoma is called the a. bolus b. effluent c. influent d. conduit

.

ANS: B

The output from the stoma is called the effluent.

DIF: Cognitive Level: Understanding REF: Principles for Practice OBJ: Identify the types of fecal and urinary diversions.

TOP: Effluent KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15. A(n)

material. a. colostomy b. ileostomy c. urostomy d. ileal pouch ANS: A

is an opening in the large intestine or colon for elimination of fecal

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

An opening in the large intestine or colon is a colostomy, and the fecal effluent will vary in consistency depending on where the opening in the colon is surgically created.

DIF: Cognitive Level: Understanding REF: Principles for Practice OBJ: Identify the types of fecal and urinary diversions.

TOP: Colostomy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 16. An opening that is in the ileal portion of the small intestine is a(n) a. colostomy b. ileostomy c. urostomy d. ileal pouch

.

ANS: B

An opening in the ileal portion of the small intestine is an ileostomy, and the fecal effluent will be watery to thick liquid that will contain some digestive enzymes.

DIF: Cognitive Level: Understanding REF: Principles for Practice OBJ: Identify the types of fecal and urinary diversions.

TOP: Ileostomy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 17. An ostomy that is created from a portion of the ileum to form a stoma through which urine

can exit the body is called a(n) a. colostomy b. ileostomy c. urostomy d. ileal pouch

.

ANS: C

A urostomy or ileal conduit is created from a 15- to 20-cm (6- to 8-inch) portion of the intestine that is resected from the ileum. One end of the conduit is sutured closed, and the ureters are implanted through the mucosa. The other end is brought out of the abdominal wall, and a stoma is formed through which urine can exit the body.

DIF: Cognitive Level: Understanding REF: Principles for Practice OBJ: Identify the types of fecal and urinary diversions.

TOP: Urostomy or Ileal Conduit KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is caring for a patient who will have surgery in the morning to have a colostomy

placed. The nurse is aware of the physical and emotional stresses that the patient will experience. These include which of the following? (Select all that apply.) a. Body image changes b. Fear of social rejection c. Sexual function and intimacy issues d. Loss of independence e. Heightened immunity ANS: A, B, C, D

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

In addition to the stresses of illness and surgical recovery, patients with ostomies face body image changes, fear of social rejection, concern about sexual function and intimacy, and the need for help with personal care. It is very important to provide an effective pouching system to facilitate the emotional adjustment to the ostomy. A supportive nurse makes the initial period of adjustment easier.

DIF: Cognitive Level: Analysis REF: Person-Centred Care OBJ: Identify the types of fecal and urinary diversions.

TOP: Physical and Emotional Stressors Related to Ostomy Placement KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

NURSINGTB.COM

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 37: Preoperative and Postoperative Care Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. Health care–associated infections (HAIs) are the most prevalent hospital-associated infection.

Which of the following evidence-informed practice guidelines is effective at reducing surgical site infections? a. Remove all hair at the surgical site so it does not interfere with the surgical incision. b. Maintain the patient’s core temperature slightly hypothermic to reduce the risk of fever postoperatively. c. Insert urinary catheter devices only when necessary and leave in only as long as necessary. d. Administer prophylactic antibiotics 24 to 48 hours before the time of the incision.

ANS: C

Administer prophylactic antibiotics as close to incision time as possible (within 60 minutes preferred), but never more than 24 hours before surgery. Hair should not be clipped unless absolutely necessary, and if it must be clipped, an electric razor should be used. Patient’s temperature should be kept normothermic at 36°C to 38°C. To prevent HAIs, urinary catheter devices should be inserted only when necessary and left in only as long as necessary.

DIF: Cognitive Level: Application REF: Evidence-Informed Practice OBJ: Identify risk factors that have a potential for affecting a patient’s clinical outcomes postoperatively.

TOP: Hospital-Acquired Infections NURSINGTB.COM KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The goal of prophylactic antibiotic therapy is to protect the patient from infection with as little

risk as possible. To achieve this goal, the nurse recognizes that antibiotics should be administered when they will be most beneficial. When would that be? a. Twenty-four hours before surgery b. For 2 weeks after surgery c. For no longer than 24 hours after surgery d. When signs of infection first appear ANS: C

Overall, it is recommended that prophylactic antibiotics be given as close to the time of incision as possible (within 30–60 minutes) and not be given for longer than 24 hours postoperatively. However, vancomycin and fluoroquinolones may be given up to 2 hours before incision because of their longer infusion times. The goal of prophylactic antibiotic therapy is to protect the patient from infection with as little risk as possible. To achieve this goal, antibiotics must be administered when they will be most beneficial.

DIF: Cognitive Level: Application REF: Evidence-Informed Practice OBJ: Identify risk factors that have a potential for affecting a patient’s clinical outcomes postoperatively.

TOP: Hospital-Acquired Infections KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 3. The nurse is to obtain an informed consent for a patient before surgery is performed. The

nurse recognizes that which of the following statements is true? a. Informed consent is required by law to protect the surgeon in case of an adverse outcome. b. Only the patient can sign a surgical consent. c. The nurse’s legal responsibility is to ensure that the patient understands the information presented. d. The surgeon should give the patient information about the surgery.

ANS: D

The surgeon should give the patient information about the extent and type of surgery, alternative therapies, usual risks and benefits, and consequences of not having surgery in a nonthreatening manner. Informed consent is required by law to help protect patients’ rights, their autonomy, and their privacy. The patient or the patient’s legal guardian must sign a surgical consent form that includes this information. To provide culturally competent care to a surgical patient, the nurse should begin by assessing the family to determine not only who should be involved but also who legally is responsible for making decisions and giving consent for surgery. It is the nurse’s ethical (not legal) responsibility, acting as the patient’s advocate, to ensure that the patient understands the information. See institutional policy regarding consent.

DIF: Cognitive Level: Application REF: Safety Guidelines OBJ: Describe the benefits of structured preoperative teaching.

TOP: Informed Consent KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The nurse is planning care for a preoperative patient. Which intervention is implemented to

NURSINGTB.COM ensure safe nursing care? a. Allowing the patient to have ice chips b. Always keeping the patient nothing by mouth (NPO) for 12 to 14 hours before c. Allowing the patient to brush teeth and swallow water d. Allowing the patient to take specifically prescribed oral medications with small amounts of water ANS: D

Patients may take oral medications with sips of water (30 mL) if they are specially prescribed to be taken preoperatively (e.g., antiarrhythmic or seizure medications). All other oral medications are withheld. The nurse must later check postoperative prescriptions to ensure that scheduled medications unrelated to surgery are not forgotten. In general, food and fluids are withheld for 4 to 8 hours before surgery requiring general anaesthesia to minimize the risk for aspiration. Patients may brush their teeth but should not swallow water.

DIF: Cognitive Level: Application REF: Skill 37.1 OBJ: Describe the physical preparations needed for a patient facing surgery.

TOP: Preoperative Medication Administration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse is providing the patient with preoperative education. When the nurse informs the

patient that she will not be able to wear makeup, the patient states, “But I never go anywhere without my makeup.” The nurse’s response is based on what rationale?

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. b. c. d.

She will speak with the surgeon to see if he will make an exception.

The patient may wear makeup if she insists.

Makeup makes it difficult for the surgeon to assess the patient.

Makeup impedes circulation.

ANS: C

Instruct the patient to remove hairpins; clips; wigs; hairpieces; jewellery, including rings used in body piercings; and makeup (including nail polish and acrylic nails). Makeup, nail polish, and false nails impede the assessment of skin and oxygenation. In addition, acrylic nails harbour pathogenic organisms. Makeup does not impede circulation.

DIF: Cognitive Level: Application REF: Skill 37.2 OBJ: Describe the physical preparations needed for a patient facing surgery.

TOP: Makeup KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. The patient is in the hospital awaiting surgery. When asked to remove her jewellery, the

patient asks why she needs to remove her navel ring. What explanation should the nurse provide? a. The navel ring may impede assessment of the skin. b. The navel ring may decrease circulation. c. She may leave it in place if she chooses. d. The navel ring may cause injury.

ANS: D

Hair appliances and jewellery anywhere on the body may become dislodged and cause injury during positioning and intubation. Navel rings probably would not impede assessment or decrease circulation. Because oNf U thRe S riI skNoGfTinBju.rC yO ifMleft in place, allowing the patient to leave the ring in place is not an option.

DIF: Cognitive Level: Analysis REF: Skill 37.2 OBJ: Describe the physical preparations needed for a patient facing surgery.

TOP: Jewellery KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. The nurse is helping the patient prepare for surgery. The patient has removed her jewellery

and glasses. Which action should the nurse take to keep the jewellery safe? a. Put these items in the patient’s bedside stand. b. Inventory the items and give them to the family or caregiver. c. Place the items in a plastic bag and send them to the operating room with the patient. d. Keep these items with her until the patient returns.

ANS: B

Inventory the items and give them to family members or the patient’s caregiver or have security lock them up. Document a list of items and their locations in a preoperative checklist or in the nurses’ notes per employer policy. Valuables left in the patient’s room may be lost or stolen. Items not secured could be misplaced or lost. Keeping the items with the nurse creates a liability for the nurse.

DIF: Cognitive Level: Application REF: Skill 37.3 OBJ: Describe the physical preparations needed for a patient facing surgery.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY TOP: Jewellery KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The STOP-Bang assessment tool is often used to assess for risk of obstructive sleep apnea

(OSA). The B stands for a. bradycardia (heart rate less than 60 beats per minute). b. body mass index more than 35 kg/m2. c. bradypnea (respiratory rate less than 12 breaths per minute). d. bronchitis.

ANS: B

The B in STOP-Bang stands for body mass index more than 35 kg/m2. Bradycardia, bradypnea, and bronchitis are not part of the STOP-Bang assessment for obstructive sleep apnea.

DIF: Cognitive Level: Application REF: Skill 37.1 OBJ: Describe the physical preparations needed for a patient facing surgery.

TOP: Hearing Aids KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. In planning surgical care for an older patient, the nurse recognizes which of the following as

causing the greatest risk for surgery? a. Increased tactile sense b. Decreased glomerular filtration rate c. Increased numbers of red blood cells d. Decreased rigidity of arterial walls ANS: B

NURSINGTB.COM

Reduced glomerular filtration rate and excretory times limit the ability to remove drugs or toxic substances. Assess for adverse effects of medications. Older persons usually will have sensory losses, reduced numbers of red blood cells, and increased rigidity of the arterial walls.

DIF: Cognitive Level: Application REF: Table 37.2: Physiological Factors That Place Older Persons at Risk for Surgery OBJ: Describe the physical preparations needed for a patient facing surgery.

TOP: Gerontological Considerations KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 10. When providing care for an ambulatory surgical patient, the nurse recognizes that which

assessment indicates that the patient meets discharge criteria? a. The patient is able to drive home alone. b. Some respiratory depression is evident. c. The oxygen saturation level is at 85%. d. No intravenous (IV) narcotics have been given in the past 30 minutes.

ANS: D

An ambulatory surgical patient meets discharge criteria when no IV narcotics have been administered for the past 30 minutes, a responsible adult is present to accompany the patient home, respiratory depression is not present, and oxygen saturation is greater than 90%.

DIF: Cognitive Level: Application REF: Skill 37.5 OBJ: Discuss the differences in nursing assessment during the immediate postoperative period and

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY the convalescent phase of recovery.

KEY: Nursing Process Step: Assessment

TOP: Discharge From Ambulatory Care Surgery MSC: NCLEX: Physiological Integrity

11. The patient has been taught how to use diaphragmatic breathing. When the patient returns

from surgery, however, he cannot be placed upright and must remain flat. What does the nurse tell the patient about performing the diaphragmatic exercises? a. Diaphragmatic breathing cannot be done in this position. b. Alternative breathing exercises need to be found. c. Diaphragmatic breathing exercises still can be performed. d. Diaphragmatic breathing exercises may be postponed.

ANS: C

Although performing the diaphragmatic exercises in the upright position is ideal, the patient can still benefit from performing the exercises while lying flat. The upright position is preferred because it facilitates diaphragmatic excursion by using gravity to keep abdominal contents away from the diaphragm. It prevents tension on the abdominal muscles, which allows for greater diaphragmatic excursion.

DIF: Cognitive Level: Application REF: Skill 37.5 OBJ: Successfully teach a patient to perform postoperative exercises.

TOP: Diaphragmatic Breathing Exercises KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 12. When teaching the patient about positive expiratory pressure therapy (PEP) and “huff”

coughing, the nurse incorporates which of the following in the plan of care? a. Instruct the patient to remain flat in bed. b. Place a nose clip on the patient’s nose.

NeUtR c. Instruct the patient to breath hrS ouIgNhGhT isBn. osCeO .M d. Instruct the patient to exhale with long slow breaths.

ANS: B

Instruct the patient to assume semi-Fowler’s or high-Fowler’s position, and place a nose clip on the patient’s nose. Have the patient place his lips around the mouthpiece. Instruct the patient to exhale in quick, short, forced “huffs.” “Huff” coughing, or forced expiratory technique, promotes bronchial hygiene by increasing expectoration of secretions.

DIF: Cognitive Level: Application REF: Skill 37.2 OBJ: Successfully teach a patient to perform postoperative exercises.

TOP: Teaching Positive Expiratory Pressure Therapy (PEP) and “Huff” Coughing KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 13. When providing teaching to a patient, which action is important to help the patient in

performing controlled coughing? a. Repeat the breathing exercises twice. b. Cough two to three times and inhale between coughs. c. Place a pillow over the incisional site for splinting. d. Use the chest and shoulder muscles while inhaling during diaphragmatic breathing.

ANS: C

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

If the surgical incision is to be thoracic or abdominal, teach the patient to place a pillow over the incisional area and to place his hands over the pillow to splint the incision. The patient should begin by taking two or three slow, deep breaths inhaling through the nose and exhaling through the mouth. On the third inhale he should hold the breath to a count of three. The patient will then cough fully for two to three consecutive coughs without inhaling between coughs. Teach the patient to avoid using chest and shoulder muscles while inhaling. The patient will do this two to three times every hour he is awake.

DIF: Cognitive Level: Application REF: Skill 37.2 OBJ: Successfully teach a patient to perform postoperative exercises.

TOP: Teaching Controlled Coughing and Splinting KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 14. When providing care for a postoperative patient, it is important for the nurse to include which

postoperative exercise? a. Turning every 4 hours b. Completing leg exercises once daily c. Repeating individual leg exercises 20 times d. Performing exercises with the unaffected extremities ANS: D

A leg unaffected by surgery can be exercised safely unless the patient has pre-existing phlebothrombosis (blood clot formation) or thrombophlebitis (inflammation of the vein wall).

Instruct the patient to turn every 2 hours from side to back to the other side while awake. Have the patient continue to practice exercises at least every 2 hours while awake and repeat exercises five times. Instruct the patient to coordinate turning and leg exercises with diaphragmatic breathing, incentive spirometry, and coughing exercises.

NURSINGTB.COM

DIF: Cognitive Level: Application REF: Skill 37.5 OBJ: Successfully teach a patient to perform postoperative exercises.

TOP: Teaching Postoperative Exercises KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 15. When planning care for a postanaesthesia care unit (PACU) or recovery room patient, how

often should the nurse plan to assess the patient? a. Every 5 minutes b. Every 15 minutes c. Every 30 minutes d. Hourly ANS: B

Conduct complete assessment of all vital signs. Compare findings with the patient’s normal baseline. Continue assessing vital signs at least every 15 minutes until the patient’s condition stabilizes.

DIF: Cognitive Level: Application REF: Skill 37.4 OBJ: Discuss the differences in nursing assessment during the immediate postoperative period and the convalescent phase of recovery.

TOP: Assessment of Patient in PACU KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 16. When providing care for a patient who has received spinal anaesthesia, the nurse recognizes

that which position prevents spinal headaches? a. Prone b. Lying on the side c. Supine, with the head flat d. Trendelenburg’s position ANS: C

Position patients with spinal anaesthetic supine, without elevation of the head, for up to 24 hours to prevent spinal headache from loss of cerebrospinal fluid. Increased intravenous or oral fluids aid the body in replacing cerebrospinal fluid.

DIF: Cognitive Level: Application REF: Skill 37.4 OBJ: Discuss the differences in nursing assessment during the immediate postoperative period and the convalescent phase of recovery.

TOP: Positioning of Patient in PACU KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. While providing care for a postsurgical patient who has not received spinal anaesthesia, the

nurse recognizes that which position is required to maintain a patent airway in the recovery phase? a. On his or her side with head facing down and neck slightly extended b. On his or her side with head facing down and neck slightly flexed c. On his or her back with hands over the chest d. On his or her side with head facing up and neck slightly extended ANS: A

Position the patient on his or heNrUsiRdS eI wN ithGhTeB ad.fCaO ciM ng down and neck slightly extended.

Extension prevents occlusion of the airway at the pharynx. A downward position of the head moves the tongue forward, and mucus or vomitus can drain out of the mouth, preventing aspiration. Never position the patient with hands over the chest (reduces chest expansion).

DIF: Cognitive Level: Application REF: Skill 37.4 OBJ: Discuss the differences in nursing assessment during the immediate postoperative period and the convalescent phase of recovery.

TOP: Positioning of Patient in PACU KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. The nurse is providing care for a patient who is recovering in the postanaesthesia care unit

(PACU). Given that the patient is restricted to the supine position, which intervention provides the patient with adequate chest expansion? a. Keeping the bed flat during recovery b. Positioning the patient’s hands over the chest c. Flexing the neck and turning the head to the side d. Extending the neck and turning the head to the side ANS: D

If the patient is restricted to a supine position, elevate the head of the bed approximately 10 to 15 degrees, extend the neck, and turn the head to the side. Never position the patient with hands over the chest (reduces chest expansion).

DIF: Cognitive Level: Application

REF: Skill 37.4

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY OBJ: Discuss the differences in nursing assessment during the immediate postoperative period and the convalescent phase of recovery.

TOP: Positioning of Patient in PACU KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. A patient is being transferred to a room from the postanaesthesia care unit (PACU). What

should the nurse do on transfer? a. Remove the indwelling urinary catheter. b. Turn off the nasogastric tube suction. c. Use a black pen to note drainage on the dressing. d. Change the dressing immediately when the patient reaches the room.

ANS: C

Mark the dressing with a circle around the drainage using a black pen. Never use a felt-tip marker to mark the dressing because ink can bleed into the gauze, contaminating the incision site. Once the patient is transferred to the bed, immediately attach any existing oxygen tubing, hang intravenous (IV) fluids, check the IV flow rate, attach a nasogastric (NG) tube to suction, and place an indwelling catheter in drainage position. Reinforce the pressure dressing, or change a simple dressing as prescribed and needed. First dressing changes most often occur 24 hours postoperatively and usually are done by the physician.

DIF: Cognitive Level: Application REF: Skill 37.5 OBJ: Conduct an assessment of a postoperative patient.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Assessing Dressing

20. The nurse explains to the patient that the incentive spirometer is used to promote which of the

following outcomes?

NURSINGTB.COM a. Lung expansion b. Reduced likelihood of vascular complications c. Incisional healing d. Expectoration of mucus ANS: A

The use of the incentive spirometer promotes lung expansion. The visual incentive provided by the device encourages the patient to breathe as deeply as possible. Huff coughing is used to promote expectoration of mucus. Repositioning the patient regularly reduces the risk for vascular complications. While adequate oxygenation is needed for wound healing, the use of the incentive spirometer is not recommended for that outcome.

DIF: Cognitive Level: Application REF: Skill 37.5 OBJ: Conduct an assessment of a postoperative patient.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Incentive Spirometry

21. When assessing a postoperative patient, the nurse notes tenderness, redness, and swelling in

the left calf. What should the nurse do next? a. Massage the lower leg. b. Contact the surgeon and prepare for heparin therapy. c. Keep the leg in a dependent position. d. Have the patient exercise that extremity.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY ANS: B

Calf tenderness, redness, and edema in the lower extremity are signs and symptoms of venous thrombosis or thrombophlebitis. Notify the surgeon and anticipate prescriptions for bed rest, leg elevation, and initiation of anticoagulation (e.g., heparin intravenous drip). Do not massage the affected leg. Continue to have the patient do leg exercises with the unaffected leg, not the affected leg.

DIF: Cognitive Level: Analysis REF: Skill 37.5 OBJ: Conduct an assessment of a postoperative patient.

TOP: DVT KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 22. The nurse understands that ileus is a possible postoperative complication. Which assessment

provides the nurse with information about this postoperative complication? a. Auscultating for bowel sounds every 4 hours b. Checking blood pressure while sitting and standing c. Observing the patient’s performance of leg exercises d. Palpating the suprapubic region for distension ANS: A

Postoperative ileus can develop as a common complication after bowel or abdominal surgery.

Intestinal motility may return slowly, depending on anaesthetic effects. Assess for bowel sounds and flatus every 4 hours. A blood pressure check has little to do with postoperative ileus and is an assessment done before ambulation. Leg exercises may help prevent venous stasis and thrombosis, but observing them will not help you detect a postoperative ileus.

Palpation of the suprapubic region is part of the assessment for bladder distension.

DIF: Cognitive Level: Application REF: Skill 37.5 TOP: Paralytic Ileus OBJ: Conduct an assessment of N aU poR stS opIeN raG tivTeBp. atiCenOt.M KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Which of the following have been identified as evidence-informed guidelines to reduce health

care–associated infections (HAIs)? (Select all that apply.) a. Prepping the surgical site with a razor followed by an antiseptic scrub b. Giving antibiotics immediately after the procedure c. Maintaining blood glucose levels d. Maintaining normal body temperatures e. Maintaining proper positioning ANS: C, D

Four evidence-informed guidelines have been identified to reduce HAIs: Do not remove hair unless it will interfere with the operation, and remove it with electrical clippers if possible; give the correct antibiotic preoperatively and at the appropriate time; maintain blood glucose postoperatively, especially for patients undergoing cardiac surgery; and maintain normothermia.

DIF: Cognitive Level: Comprehension REF: Evidence-Informed Practice OBJ: Describe the physical preparations needed for a patient facing surgery.

TOP: Hospital-Acquired Infections KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

2. Therapies and regimens designed to prevent venous thromboembolism (VTE) include which

of the following? (Select all that apply.) a. Pneumatic compression stockings b. Venous foot pump c. Low-molecular-weight heparin d. Fondaparinux e. Elspar ANS: A, B, C, D

Mechanical therapies include the use of graduated compression stockings along with sequential compression devices (SCDs) or a venous foot pump (VFP). The VFP is limited primarily to when intermittent pneumatic compression (IPC) cannot be used, such as when surgery or injury occurs to the affected lower extremity. Pharmacological regimens that include the administration of low-dose unfractionated heparin, low-molecular-weight heparin, factor Xa inhibitor (fondaparinux), or warfarin are recommended. Elspar is a chemotherapeutic medication used to treat cancer, which can increase the risk for clot formation.

DIF: Cognitive Level: Analysis REF: Skill 37.3 OBJ: Describe the physical preparations needed for a patient facing surgery.

TOP: Venous Thromboembolism (VTE) Therapies KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. Being overweight or obese increases the risk for many diseases and health conditions,

including which of the following? (Select all that apply.) a. Hypertension NURSINGTB.COM b. Coronary heart disease c. Sleep apnea d. Respiratory problems e. Hypotension ANS: A, B, C, D

Being overweight or obese increases the risk for many diseases and health conditions, including hypertension, dyslipidemia, type 2 diabetes, coronary heart disease, stroke, sleep apnea, and respiratory problems. These conditions increase risks for postoperative complications. Hypotension is not a complication of obesity.

DIF: Cognitive Level: Analysis REF: Skill 37.1 OBJ: Describe the physical preparations needed for a patient facing surgery.

TOP: Obesity KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 38: Intraoperative Care Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The charge nurse is assigning duties in the surgical arena. Which member of the surgical team

should be assigned to the role of circulating nurse? a. Registered nurse (RN) b. Licensed practical nurse (LPN) c. Certified surgical technologist (CST) d. Certified registered nurse anaesthetist (CRNA) ANS: A

The circulating nurse is always an RN, who is the charge nurse in the operating room.

DIF: Cognitive Level: Application REF: Principles for Practice OBJ: Describe the roles of a registered nurse in the operating room.

TOP: The Circulating Nurse KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. Which of the following is true about the circulating nurse’s primary responsibility? a. The nurse is a “sterile” member of the surgical team. b. The nurse provides the surgeon with instruments. c. The nurse is a “nonsterile” member of the surgical team. d. The nurse performs delegated medical functions or skills.

ANS: C

NURSINGTB.COM

The circulating nurse is a “nonsterile” member of the surgical team who assumes responsibility and accountability for maintaining patient safety and continuity of quality care.

This includes supervising the conduct of the scrub technician and delegating tasks to licensed and unlicensed care providers as appropriate. The circulating nurse is also an assistant to the first assistant, the scrub nurse/technician, and the surgeon. The scrub nurse/technician provides the surgeon with instruments and supplies. The registered nurse first assistant (RNFA) performs a combination of nursing and delegated medical functions and skills.

DIF: Cognitive Level: Application REF: Box 38.3: Role of the Circulating Nurse OBJ: Describe the roles of a registered nurse in the operating room.

TOP: The Circulating Nurse KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 3. When planning care for a surgical patient, the nurse implements which technique to maintain

sterility in the operating room? a. Keeps the hands below the waist. b. Tucks the hands under the axilla. c. Uses sterile gloved hands to move a sterile drape under a table. d. Has anyone who is unscrubbed stay at least 30 cm (1 foot) away from the sterile field.

ANS: D

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Unscrubbed persons should always stay at least 30 cm (1 foot) away from the sterile field while keeping it in constant view and should contact only unsterile areas. Sterile persons must keep their hands in view, above waist level and below the neckline, to avoid contamination.

When wearing a sterile gown, do not fold the arms with hands tucked in the axillary region.

This area is not considered sterile once operating room personnel have donned gowns.

Sterile-draped tables are sterile only at table level. The sides of the drape extending below table level are unsterile.

DIF: Cognitive Level: Application REF: Safety Guidelines OBJ: Identify guidelines for use of sterile technique in the operating room.

TOP: Principles of Sterile Technique KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 4. When one prepares to enter the operating room, which technique demonstrates the safest

outcome? a. Keeping the hands below the elbows b. Applying surgical gloves before the scrub c. Scrubbing for at least 3 to 5 minutes with an antimicrobial agent d. Drying the hands and arms, starting at the elbow and moving toward the fingers ANS: C

A 3- to 5-minute hand and arm scrub with an approved antimicrobial agent for all surgical procedures is recommended. Rinse hands and arms thoroughly under running water. Grasp one end of the sterile towel to dry one hand thoroughly, moving from fingers to elbow in a rotating motion. Use the opposite end of the towel to dry the other hand.

DIF: Cognitive Level: Application REF: Skill 38.1 OBJ: Perform surgical hand antiN seU psRisScI orN reG ctT lyB . .COM KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: The Surgical Hand Scrub

5. When evaluating a health care team member’s ability to put on a sterile gown and perform

closed gloving, it is most important for the nurse to assess for which outcome? a. Opening the sterile gown pack on a sterile surface b. Holding the gown close to the body before applying c. Having the circulating nurse tie the gown at the hip d. Keeping the hands inside the sleeves of the gown until the gloves are applied ANS: D

Apply gloves using the closed-glove method, with hands covered by gown cuffs and sleeves.

Open the sterile gown and glove package on a clean, dry, flat surface. This can be done by the scrub nurse (before scrubbing hands) or the circulating nurse. While keeping it at arm’s length away from the body, allow the gown to unfold with the inside of the gown toward the body.

Do not touch the outside of the gown, and do not allow it to touch the floor. Have the circulating nurse tie the gown at the neck and waist. If the gown is wraparound style, the sterile front flap is not touched until the scrub nurse has gloved.

DIF: Cognitive Level: Application REF: Safety Guidelines OBJ: Apply sterile gloves using the closed technique.

TOP: Applying Gloves via Closed Technique KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

6. The charge nurse is assigning members of the surgical team; the nurse recognizes that which

member is responsible for an expanded role in ensuring preoperative and postoperative patient management in collaboration with other health care providers? a. Registered nurse (RN) b. Licensed practical nurse (LPN) c. Circulating RN d. Registered nurse first assistant (RNFA) ANS: D

The role of the RNFA is an expansion of the traditional perioperative nursing role, and areas of responsibility will overlap. Responsibilities specific to the practice of first assisting include participating in “time-out” procedures with other surgical team members (safety measures taken to ensure correct patient, correct procedure, correct site and side, correct patient position, and correct implants/equipment present), providing surgical exposure (assisting in retraction of tissues and suctioning of surgical field), providing hemostasis (control of bleeding), handling and/or cutting tissue, using surgical instruments/medical devices and suturing, performing wound closure, applying human anatomical and physiological considerations in practice, recognizing structure, function, and location of tissues and organs, manipulating tissues accordingly to avoid injury, and ensuring preoperative and postoperative patient management in collaboration with other health care providers. The scrub nurse gowns and gloves surgeons and assistants as they enter the operating room, provides the surgeon with instruments and supplies, disposes of soiled sponges, and accounts for sponges, needles, and instruments in the surgical field.

DIF: Cognitive Level: Application REF: Box 38.1: Roles and Responsibilities of a Registered Nurse First Assistant NURSINGTB.COM OBJ: Describe the roles of a registered nurse in the operating room.

TOP: Role of the Registered Nurse First Assistant KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 7. While supervising the surgical team, the charge nurse notices that a team member’s nails are

long and chipped. Which action should the nurse take next? a. Allow the team member to complete the task. b. Remove the team member to have the nails cut. c. Turn the team member in to the RNFA. d. Ask the team member why the nails are long and chipped.

ANS: B

The team member must be removed immediately to allow cutting of the nails. Long nails and chipped or old polish harbour greater numbers of bacteria. Long fingernails can puncture gloves, causing contamination.

DIF: Cognitive Level: Application REF: Skill 38.1 OBJ: Describe the meaning of a sterile conscience.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. When does the intraoperative phase begin? a. When the patient is admitted to the preanaesthesia unit b. When the surgeon obtains consent

TOP: Surgical Hand Antisepsis

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY c. When the patient enters the operating room suite d. When the first incision occurs ANS: C

The intraoperative phase begins when the patient enters the operating room suite and ends with admission to the postanaesthesia care unit (PACU).

DIF: Cognitive Level: Understanding REF: Principles for Practice OBJ: Describe the roles of a registered nurse in the operating room.

TOP: The Intraoperative Phase KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. When does the intraoperative phase end? a. When the last stitch is placed b. When the patient rouses from anaesthesia c. When the patient is admitted to the postanaesthesia unit d. When the patient is discharged ANS: C

The intraoperative phase begins when the patient enters the operating room suite and ends with admission to the postanaesthesia care unit (PACU).

DIF: Cognitive Level: Understanding REF: Principles for Practice OBJ: Describe the roles of a registered nurse in the operating room.

TOP: The Intraoperative Phase KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 10. The

_ is a nurse with advanced education who assists the surgeon with the SbIiN surgical procedure, performingNaUcR om naGtiT onB. ofCnO urMsing and delegated medical functions and/or skills. a. surgical technician b. licensed practical nurse (LPN) c. circulating registered nurse (RN) d. registered nurse first assistant (RNFA) ANS: D

The RNFA is a nurse with advanced education who assists the surgeon with the surgical procedure, performing a combination of nursing and delegated medical functions and skills.

DIF: Cognitive Level: Understanding REF: Box 38.1: Roles and Responsibilities of a Registered Nurse First Assistant OBJ: Describe the roles of a registered nurse in the operating room.

TOP: The Registered Nurse First Assistant KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

is a “sterile” team member who provides the surgeon with instruments and supplies, disposes of soiled sponges, and accounts for sponges, sharps, and instruments in the surgical field. a. scrub nurse b. licensed practical nurse (LPN) c. circulating registered nurse (RN) d. registered nurse first assistant (RNFA)

11. The

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY ANS: A

The scrub nurse/technician is a “sterile” team member who provides the surgeon with instruments and supplies, disposes of soiled sponges, and accounts for sponges, sharps, and instruments in the surgical field.

DIF: Cognitive Level: Understanding REF: Box 38.2: Role of the Scrub Nurse OBJ: Describe the roles of a registered nurse in the operating room.

TOP: The Scrub Nurse KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Who can assume the role of the scrub nurse/assistant? (Select all that apply.) a. Registered nurse (RN) b. Licensed practical nurse (LPN) c. Surgical technician d. Unregulated care provider (UCP) e. Medical transcriptionist ANS: A, B, C

RNs, LPNs, and surgical technicians may assume the scrub nurse role.

DIF: Cognitive Level: Comprehension REF: Box 38.2: Role of the Scrub Nurse OBJ: Describe the roles of a registered nurse in the operating room.

TOP: The Scrub Nurse KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The consequences of double glN ovUinRgSdIuN riG ngTsBu. rgCerOyMinclude which of the following? (Select

all that apply.) a. Decreased need for handwashing b. Decreased risk for exposure to bloodborne pathogens c. Increased perforations to the innermost glove d. Decreased risk for surgical wound infection e. Increased patient cost ANS: B, D

Benefits of double gloving during surgery include decreasing the risk for exposure to bloodborne pathogens for surgical team members and decreasing the risk for surgical wound infection for the patient. Double gloving significantly reduces perforations to the innermost glove. Handwashing remains the cornerstone of surgical asepsis.

DIF: Cognitive Level: Comprehension REF: Evidence-Informed Practice OBJ: Identify guidelines for use of sterile technique in the operating room.

TOP: Double Gloving KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 3. Which of the following are principles of sterile procedure? (Select all that apply.) a. Gowns are sterile from the chest and shoulder to table level. b. Sterile persons must keep hands in view and above the waist and below the neck. c. Sterile persons must fold arms across chest with hands tucked into the axillary

region.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY d. Unscrubbed persons must stay at least 6 inches away from the sterile field. e. Sterile persons may position themselves with their back to the sterile field.

ANS: A, B

Once in place, gowns are sterile from the front chest and shoulders to table level and on the sleeves to 5 cm (2 inches) above the elbow. Sterile persons must keep their hands in view, above waist level and below the neckline, and must not turn their back to the sterile field to avoid contamination. When wearing a sterile gown, do not fold arms with hands tucked into the axillary region. This area is not considered sterile once operating room personnel have donned gowns. Perspiration can lead to strike-through, or contamination that occurs when moisture permeates a sterile barrier. Unscrubbed persons always stay at least 1 foot away from the sterile field while keeping it in constant view; they touch only unsterile areas.

DIF: Cognitive Level: Application REF: Safety Guidelines OBJ: Identify guidelines for use of sterile technique in the operating room.

TOP: Principles of Sterile Technique KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 4. Through the use of an antimicrobial agent and sterile brushes or sponges, which of the

following occurs? (Select all that apply.) a. Debris and transient microorganisms are removed from the nails, hands, and forearms. b. The resident microbial count is reduced to a minimum. c. The skin is sterilized. d. Rapid/rebound growth of microorganisms is inhibited. e. The need to wash between patients is reduced.

ANS: A, B, D

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Although the skin cannot be sterilized, operating room personnel can greatly reduce the number of microorganisms by chemical, physical, and mechanical means. Through the use of an antimicrobial agent and sterile brushes or sponges, the surgical hand scrub removes debris and transient microorganisms from the nails, hands, and forearms, and inhibits rapid/rebound growth of microorganisms.

DIF: Cognitive Level: Comprehension REF: Skill 38.1 OBJ: Perform surgical hand antisepsis correctly.

TOP: The Surgical Hand Scrub KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 5. Which of the following are sources of contamination in the operating room? (Select all that

apply.) a. A wristwatch b. Chipped nail polish c. Artificial fingernails d. Abrasions on the hands e. Tattoos to the arms ANS: A, B, C, D

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Jewellery harbours and protects microorganisms from removal. Allergic skin reactions may occur as a result of scrub agent or glove powder accumulating under jewellery. Long nails and chipped or old polish harbour great numbers of bacteria. Long fingernails can puncture gloves, causing contamination. Artificial nails harbour gram-negative microorganisms and fungus. Cuts, abrasions, exudative lesions, and hangnails tend to ooze serum, which may contain pathogens. Broken skin permits microorganisms to enter various layers of the skin, providing deeper microbial breeding.

DIF: Cognitive Level: Comprehension REF: Skill 38.1 OBJ: Identify guidelines for use of sterile technique in the operating room.

TOP: Sources of Contamination KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. The surgeon is about to finish surgery and requests a sponge count. Who would normally

perform this task? (Select all that apply.) a. Scrub nurse b. Registered nurse first assistant c. Circulating nurse d. Certified registered nurse anaesthetist e. Surgical technician ANS: A, C

Part of the role of the scrub nurse is to perform sponge, sharps, and instrument counts with the circulating nurse before an incision is made, at the beginning of wound closure, and at the end of the surgical procedure.

DIF: Cognitive Level: Comprehension REF: Box 38.1: Roles and RespoNnU siR biS litI ieN s oGfTa B R. egCisO teM red Nurse First Assistant | Box 38.2: Role of the Scrub Nurse OBJ: Describe the roles of a registered nurse in the operating room.

TOP: Role of the Scrub Nurse and Circulating Nurse KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. While the patient is in the operating room (OR) and the OR team is gowned and gloved, the

nurse recommends completion of a safety checklist. The nurse understands that the checklist verifies which of the following? (Select all that apply.) a. Patient identity b. Patient allergies c. Accurate marking of surgical site d. Patient cultural preferences e. Questions posed by the patient ANS: A, B, C

While the patient is in the OR and the OR team is gowned and gloved, it is recommended that a surgical safety checklist or the World Health Organization (WHO) checklist be conducted.

The WHO checklist verifies the patient’s identity, ascertains whether the patient has any allergies, checks if the surgical site is marked and reverifies the site marking, and asks the patient if he or she has any questions.

DIF: Cognitive Level: Application REF: Principles for Practice OBJ: Describe the roles of a registered nurse in the operating room.

TOP: Role of the Checklist Coordinator KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 39: Prevention and Care of Skin Breakdown Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The nurse is turning a patient when she notices an area with nonblanchable redness over the

patient’s coccyx. The patient complains of pain at the site, and the site feels cooler than the areas immediately around the site. The nurse recognizes that this patient has developed a. a stage 1 pressure injury. b. a stage 2 pressure injury. c. an unstageable pressure injury. d. deep tissue injury.

ANS: A

The hallmarks of a stage 1 pressure injury are intact skin with nonblanchable redness of a localized area, usually over a bony prominence. The area may be painful, firm, soft, and warmer or cooler compared with adjacent tissue. Stage 2 pressure injuries are defined by partial-thickness loss that presents as a shallow open ulcer with a red or pink wound bed, without slough. They also may present as intact or open/ruptured serum-filled blisters. They usually present as shiny or dry shallow ulcers without sloughing or bruising. Unstageable pressure injuries are characterized by full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, grey, green, or brown) and/or eschar (tan, brown, black) in the wound bed. Until enough slough and eschar are removed to expose the base of the wound, the true depth, and therefore the stage, cannot be determined. Deep tissue injury usually is characterized by purple or maroon localized areas of discoloured intact skin or blood-filled blisters caused by damage to unNdUeR rlySinIgNsGoT ft B ti. ssC ueOfMrom pressure or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, and warmer or cooler compared with adjacent tissue. The wound may further evolve and become covered by thin eschar.

DIF: Cognitive Level: Analysis OBJ: Perform a skin assessment.

KEY: Nursing Process Step: Assessment

REF: Box 39.1: Staging of Pressure Injuries TOP: Stage I Pressure Injury MSC: NCLEX: Physiological Integrity

2. In a patient with a stage 2 pressure injury, the nurse describes the wound as a. superficial blistering. b. nonblanchable redness. c. loss of skin without bone exposure. d. loss of skin with exposed muscle.

ANS: A

A stage 2 pressure injury is defined by partial-thickness loss presenting as a shallow open ulcer with a red to pink wound bed, without slough. It also may present as an intact or open/ruptured serum-filled blister. It usually presents as a shiny or dry shallow ulcer without sloughing or bruising. The hallmarks of a stage 1 pressure ulcer are intact skin with nonblanchable redness of a localized area, usually over a bony prominence. The area may be painful, firm, soft, and warmer or cooler compared with adjacent tissue. Stage 3 pressure injuries involve full-thickness skin loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Stage 4 pressure injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present in some parts of the wound bed.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

DIF: Cognitive Level: Analysis OBJ: Perform a skin assessment.

KEY: Nursing Process Step: Assessment

REF: Box 39.1: Staging of Pressure Injuries TOP: Stage II Pressure Injury MSC: NCLEX: Physiological Integrity

3. The nurse is caring for four patients during a shift. Which of the following patients is at

greatest risk for developing a pressure injury? a. The patient who is bedridden, but who turns himself randomly b. The patient whose Braden Scale score is 8 c. The patient who can ambulate to the bathroom independently d. The patient whose Braden Scale score is 18 ANS: B

Given the overall score on the Braden Scale, the patient will fall within one of these categories: mild risk, 16 to 18; moderate risk, 13 to 14; or high risk, 9 or less. Use these risk scores to plan care by looking at the individual risk factors that place the patient at risk and developing a care plan to decrease or eliminate the identified risk factors. Immobility often restricts the patient’s ability to change and control body position, thus increasing pressure over bony prominences. Patients who can turn themselves are at less risk than those who cannot.

DIF: Cognitive Level: Analysis REF: Table 39.1: Braden Scale for Predicting Pressure Ulcer Risk OBJ: Discuss the use of valid and reliable tools for assessing a patient’s risk for pressure injuries.

TOP: Braden Scale KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

shRoSuI ldNbG eT imBp.leCmOeM nted for a patient in the general 4. Aggressive prevention measureNsU population with a pressure ulcer risk on the Braden Scale of less than or equal to a. 16. b. 18. c. 20. d. 24.

ANS: A

Less than or equal to 16 is the risk cut score for the general population when the Braden Scale is used. Less than or equal to 18 is the risk cut score for older persons and black or Latino patients when the Braden Scale is used.

DIF: Cognitive Level: Comprehension REF: Table 39.2: Pressure Ulcer Braden Risk Scores by Patient Population OBJ: Discuss the use of valid and reliable tools for assessing a patient’s risk for pressure injuries.

TOP: Braden Scale KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. A patient with anemia is at risk for developing pressure injuries as a result of which of the

following? a. Increased sedation b. Edematous tissues c. Reduced tensile strength d. Diminished oxygen to the tissues

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY ANS: D

Decreased hemoglobin reduces the oxygen-carrying capacity of the blood and the amount of oxygen available to the tissues, thus increasing the risk for pressure injuries. Anemia does not cause increased sedation, edematous tissue, or reduced tensile strength.

DIF: Cognitive Level: Comprehension REF: Skill 39.1 OBJ: Identify risk factors for the development of skin breakdown (e.g., pressure injury).

TOP: Anemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. In a long-term care facility, how often should the nurse reassess a patient for risk of a pressure

ulcer? a. Every 1 to 2 days b. Every time the nurse sees the patient c. Weekly for the first few weeks of stay d. Monthly for the first 4 months of stay ANS: C

In a long-term care facility, the patient is assessed every week for 4 weeks and then quarterly, or whenever the patient’s condition changes. An assessment schedule of every 1 to 2 days would be more appropriate for acute care than in the long-term care setting. The patient is not reassessed for risk in the long-term setting every time the nurse sees the patient. The new patient in long-term care is reassessed weekly rather than monthly after he or she is admitted.

DIF: Cognitive Level: Understanding REF: Skill 39.1 OBJ: Describe guidelines for the prevention of skin breakdown.

TOP: Reassessment of Pressure Ulcer Risk KEY: Nursing Process Step: AssN esU sm EX: Physiological Integrity ReSntINM GSTCB: .NCCOLM 7. The patient with a nasogastric (NG) tube in place may experience skin breakdown a. in the nose. b. on the tongue. c. behind the ears. d. around the lips.

ANS: A

NG and oxygen cannulas can cause pressure on the nares, leading to pressure ulcers. Skin breakdown around the lips and tongue may result from oral airways or endotracheal (ET) tubes. Skin breakdown behind the ears may result from pressure from the oxygen cannula or the patient’s pillow.

DIF: Cognitive Level: Understanding REF: Skill 39.1 OBJ: Describe guidelines for the prevention of skin breakdown.

TOP: Reassessment of Pressure Ulcer Factors KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. The nurse is caring for a darkly pigmented patient who is immobile and needs turning every 2

hours. While turning the patient, to what should the nurse who is performing the assessment pay particular attention? a. Edema in the sacrum b. Skin texture c. Skin temperature

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY d. Pallor or mottling of the skin ANS: C

Darkly pigmented skin does not always have visible blanching. Its colour differs from that of surrounding skin. Skin temperature changes may be an important early indicator of a stage 1 pressure ulcer. Edema is not an initial indication of a pressure ulcer. Do not massage any reddened or discoloured pressure points. Areas of nonblanchable erythema or discoloured areas may indicate that deeper tissue damage is present. Massage in this area may worsen the inflammation by further damaging underlying damaged blood vessels. Pallor or mottling will be difficult or impossible to see in a patient with darkly pigmented skin.

DIF: Cognitive Level: Application REF: Skill 39.1 OBJ: Describe guidelines for the prevention of skin breakdown.

TOP: Reassessment of Pressure Ulcer Factors KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The patient is admitted with an open pressure injury with necrotic tissue around the base of

the wound. How would the nurse classify this ulcer? a. Stage 3 pressure injury b. Stage 4 pressure injury c. Wound that cannot be staged d. Stage 2 pressure injury ANS: C

To correctly stage a pressure injury, the nurse must be able to see the base of the wound.

Therefore pressure ulcers that are covered with necrotic tissue cannot be staged until the eschar has been debrided and thNeUbRasSeIoN fG thT eB w. ouCnOdMis visible. Until debridement occurs, the ulcer should be documented as unstageable.

DIF: Cognitive Level: Application REF: Box 39.1: Staging of Pressure Injuries OBJ: Perform a skin assessment.

TOP: Staging Pressure Ulcers KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. A nurse classifies a pressure ulcer according to the type of tissue in the wound bed. What does

it indicate if the wound bed has granulation in it? a. Wound needs debridement b. The presence of significant infection c. Colonization by bacteria d. Movement toward healing ANS: D

The presence of granulation tissue signifies a movement toward wound healing. Black tissue is necrotic tissue. A wound with a high percentage of black tissue will require debridement.

Yellow tissue or slough tissue indicates the presence of infection or colonization.

DIF: Cognitive Level: Comprehension REF: Box 39.3: Phases of Wound Healing (Full-Thickness Wounds) OBJ: Perform a skin assessment.

TOP: Colour Typing of Tissue KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

11. When evaluating a patient, the nurse observes an unexpected outcome of treatment when the

surrounding skin of a pressure injury becomes macerated. The nurse should a. obtain a wound culture. b. apply pressure-reducing devices. c. use dressings with increased moisture absorption. d. monitor the patient for systemic signs and symptoms.

ANS: C

Select a dressing that has increased moisture-absorbing capacity. Dressings that increase moisture absorption will result in dryer skin that is less macerated. A wound culture is not indicated for macerated skin unless an increase in drainage or development of necrotic tissue occurs. Pressure-reducing devices are not indicated for macerated skin. Macerated skin is a local reaction; the patient would not need systemic monitoring unless the pressure injury extended beyond the original margins.

DIF: Cognitive Level: Comprehension REF: Skill 39.2 OBJ: Identify outcome criteria for patients at risk for pressure injuries or impaired skin integrity.

TOP: Unexpected Outcomes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. After teaching a home caregiver how to manage a pressure ulcer, the nurse realizes that

further education is needed when the caregiver says: a. “I will be sure to reposition her frequently and keep her off of the pressure ulcer.” b. “I will wash the pressure ulcer with saline and report any changes in the drainage.” c. “I know that a thick, black covering will protect the pressure ulcer from getting worse.”

NURSINGTB.COM d. “I will let you know if the pressure ulcer starts to smell rotten.”

ANS: C

Black tissue in a pressure ulcer is eschar, a necrotic tissue that covers a section of the ulcer and prevents effective assessment. If the caregiver makes this statement additional education is needed. The other statements indicate that the caregiver understands how to care for pressure ulcers.

DIF: Cognitive Level: Analysis REF: Table 39.5: Wound Colour/Tissue OBJ: Discuss teaching needs of the patient and caregiver regarding prevention of and treatment for skin breakdown (particularly pressure injury).

TOP: Teaching Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. Healing by primary intention is expected to occur with which of the following situations? a. The wound is left open and is allowed to heal. b. A surgical wound is left open for 3 to 5 days. c. Connective tissue development is evident. d. The edges of a clean incision remain close together.

ANS: D

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Healing by primary intention occurs when the edges of a clean surgical incision remain close together. The wound heals quickly, and tissue loss is minimal or absent. The skin cells quickly regenerate, and the capillary walls stretch across under the suture line to form a smooth surface as they join. Wounds that are left open and are allowed to heal by scar formation are classified as healing by secondary intention. Connective tissue development is evident during healing by secondary intention. Healing by tertiary intention occurs when surgical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish.

DIF: Cognitive Level: Comprehension REF: Procedural Guideline 39.1 OBJ: Differentiate between primary- and secondary-intention wound healing.

TOP: Primary Intention KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. The nurse is caring for a patient who has a dressing over a surgical wound created the night

before. The dressing has never been changed. How should the nurse proceed? a. Change the dressing so she can assess the wound. b. Administer an analgesic 30 to 45 minutes before a dressing change. c. Culture the wound if wound exudate is present. d. Administer an analgesic 30 minutes after a dressing change.

ANS: B

To promote patient comfort, administer an analgesic as prescribed, usually 30 to 45 minutes before changing the dressing. However, the nurse will need to assess to determine the best time for analgesic administration before providing wound care. Do not remove an initial surgical dressing for direct wound inspection until a physician writes a medical prescription for removal. The presence of wound exudate is an expected stage of epithelial cell growth.

NURSINGTB.COM

DIF: Cognitive Level: Application REF: Safety Guidelines OBJ: Perform a skin assessment.

TOP: Medicating the Patient Before Dressing Changes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. The nurse is in the process of irrigating the wound for a patient who has a large pressure

injury on his buttock. How should the nurse proceed? a. Use irrigation pressures of less than 4 psi. b. Cleanse in a direction from most contaminated to least contaminated. c. Irrigate so that the solution flows from least contaminated to most contaminated. d. Irrigate with clean irrigation solution only.

ANS: C

When one is irrigating, all the solution flows from the least contaminated to the most contaminated area. The pressure needed to irrigate wounds is between 4 and 15 psi. Irrigating solutions are sterile.

DIF: Cognitive Level: Application REF: Skill 39.2 OBJ: Perform a wound irrigation.

TOP: Irrigation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. The nurse is changing a surgical dressing and is cleansing the wound. She knows that a. the incision line should be cleansed last.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY b. she should start at one end of the incision line and swab the entire length. c. she should start at the centre of the incision line and swab toward one end. d. she should work in a circular motion around the incision line.

ANS: C

The centre is the most important part of the suture line; therefore using a sterile swab or gauze, clean the suture line by starting at the centre of the suture line and working toward one end. With another sterile swab or gauze, start at the centre of the incision and work toward the other end. All other cleansing involves moving from one end to the other on each side of the incision. Work in straight lines, moving away from the suture line with each successive stroke.

DIF: Cognitive Level: Application REF: Skill 39.2 OBJ: Explain factors that promote or impair normal wound healing.

TOP: Cleansing an Incision KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. The nurse prepares to irrigate the patient’s wound. What is the primary reason for this

procedure? a. Decrease scar formation. b. Remove debris from the wound. c. Improve circulation from the wound. d. Decrease irritation from wound drainage.

ANS: B

Wound irrigations promote wound healing by removing debris from a wound surface, decreasing bacterial counts, and loosening and removing eschar. The primary purposes of wound irrigation do not includeNdUeR crSeaIsN inG gTscBa. r fCoO rm Mation, improving circulation, or decreasing irritation.

DIF: Cognitive Level: Application REF: Skill 39.2 OBJ: Explain factors that promote or impair normal wound healing.

TOP: Irrigation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. Which of the following approaches is correct technique when wound irrigation is performed? a. Placing the patient in supine position b. Placing the syringe directly into the wound c. Using sterile technique for a chronic wound d. Selecting a soft catheter for deep wounds with small openings ANS: D

If the patient has a deep wound with a narrow opening, attach a soft catheter to the syringe to permit the fluid to enter the wound. Position the patient comfortably to permit gravitational flow of irrigating solution through the wound and into the collection receptacle. Hold the syringe tip 2.5 cm (1 inch) above the upper end of the wound and over the area being cleansed; this prevents syringe contamination. Wound cleansing and irrigation are accomplished using sterile technique (surgical wounds) or clean technique (some chronic wounds).

DIF: Cognitive Level: Application REF: Skill 38.2 OBJ: Perform a wound irrigation.

TOP: Irrigation KEY: Nursing Process Step: Implementation

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY MSC: NCLEX: Physiological Integrity 19. On which types of wounds may the nurse use a pulsatile high-pressure lavage for irrigation? a. Graft sites b. Wounds with exposed blood vessels c. Necrotic tissue d. Wounds with exposed muscle or tendons ANS: C

Pulsatile high-pressure lavage is often the irrigation of choice for necrotic wounds. The amount of irrigant is wound size dependent. Pressure settings on the device need to remain between 4 and 15 psi. Do not use this type of irrigation with graft sites or exposed blood vessels, muscle, tendon, or bone.

DIF: Cognitive Level: Application TOP: Pulsatile High-Pressure Lavage MSC: NCLEX: Physiological Integrity

REF: Skill 38.2 OBJ: Perform a wound irrigation.

KEY: Nursing Process Step: Implementation

20. The nurse should consider culturing a wound when which one of the following situations

occurs? a. The tissue is clean and dry. b. Exudate is not present. c. The patient is afebrile. d. The surrounding area shows inflammation.

ANS: D

Consider culturing a wound if it has a foul, purulent odour; inflammation surrounds the wound; a nondraining wound bNegUiR nsStI oN drGaiTnB ; o.rCthOeMpatient is febrile.

DIF: Cognitive Level: Application REF: Skill 39.1 OBJ: Explain factors that promote or impair normal wound healing.

TOP: Wound Culture KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 21. When teaching about wound care in the home environment, the nurse instructs the patient and

caregiver to a. make normal saline with 8 teaspoons of salt and 3.5 L of distilled water. b. use normal saline for 1 week and then discard it. c. not apply topical anaesthetics before wound care. d. call the physician’s office to have someone come to the home and complete the wound care.

ANS: A

Teach the patient and caregiver how to make normal saline, especially if cost is an issue. They can make normal saline by using 8 teaspoons of salt in 3.5 L of distilled water and keeping it refrigerated for 1 month. The saline solution should be allowed to reach room temperature before use. Commonly used topical anaesthetic solutions include 2% and 4% lidocaine jelly, which inactivates exposed wound pain receptors. Some patients need to receive wound care management in an outpatient wound care clinic. Be sure the patient has directions to the clinic and knows where to park and where to obtain dressing supplies.

DIF: Cognitive Level: Application

REF: Care in the Community (Skill 39.2)

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY OBJ: Explain factors that promote or impair normal wound healing.

TOP: Teaching Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. Which situation noticed during evaluation would determine that the staples or sutures should

remain in place? a. The wound edges are separated. b. No drainage or erythema is present. c. The patient is anxious about their removal. d. A cosmetically aesthetic result would not be achieved.

ANS: A

Assess healing ridge and skin integrity of the suture line for uniform closure of wound edges, normal colour, and absence of drainage and inflammation that indicates adequate wound healing for support of internal structures without continued need for sutures or staples. If wound edges are separated or signs of infection are present, the wound has not healed properly. Notify the health care provider because sutures or staples may need to remain in place. Absence of drainage and erythema would indicate that sutures are ready for removal.

Steps could be taken to relieve the patient’s anxiety, but suture removal is based on the condition of the wound. Timing of suture removal is based on adequate wound healing.

DIF: Cognitive Level: Application TOP: Wound Assessment MSC: NCLEX: Physiological Integrity

REF: Skill 39.3 OBJ: Remove sutures or staples.

KEY: Nursing Process Step: Implementation

23. What should the nurse do when removing intermittent sutures? a. Snip both sides of the suture before removing. b. Snip the suture as close to tN heUkRnSoI t aNsGpT osBsi.bC leO . M c. Snip the suture as close to the skin as possible. d. Pull up the knot to apply as much tension as possible.

ANS: C

Snip the suture as close to the skin as possible at the end distal to the knot. Never snip both ends of the suture; there will be no way to remove the part of the suture situated below the surface. Grasp the knot of the suture with forceps, and gently pull up the knot while slipping the tip of the scissors under the suture near the skin.

DIF: Cognitive Level: Application TOP: Removing Sutures MSC: NCLEX: Physiological Integrity

REF: Skill 39.3 OBJ: Remove sutures or staples.

KEY: Nursing Process Step: Implementation

24. What should the nurse do when performing suture or staple removal? a. Snip both ends of the sutures. b. Apply tension to the suture line to remove the sutures. c. Pull the exposed surface of the suture through the tissue below the epidermis. d. Apply Steri-Strip if any separation greater than the width of two stitches is present.

ANS: D

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

To maintain contact between wound edges, apply Steri-Strip if any separation greater than two stitches or two staples in width is apparent. This supports the wound by distributing tension across the wound and eliminates closure technique scarring. Never snip both ends of the suture; there will be no way to remove the part of the suture situated below the surface.

Grasp the knotted end with forceps, and in one continuous smooth action, pull the suture through from the other side; this smoothly removes the suture without additional tension to the suture line. Tension on the suture line is not required. Never pull the exposed surface of any suture into tissue below the epidermis. The exposed surface of any suture is considered contaminated.

DIF: Cognitive Level: Application TOP: Removing Sutures MSC: NCLEX: Physiological Integrity

REF: Skill 39.3 OBJ: Remove sutures or staples.

KEY: Nursing Process Step: Implementation

25. The physician expects that the patient’s wound will have an output of close to 500 mL/day.

The nurse anticipates placement of which of the following? a. Dry sterile dressing b. Jackson-Pratt (JP) drain c. Hemovac drain d. No drain ANS: C

If drainage accumulates in the wound bed, wound healing is delayed. Drainage is removed by using a closed or an open drain system, even if the amount of drainage is small. A JP drain collects fluid that is in the 100 to 200 mL per 24-hour range; the Hemovac drain accommodates more drainage, usually up to 500 mL in 24 hours.

DIF: Cognitive Level: ApplicatiN onURSINRGETFB : .SC kiO llM 39.4 OBJ: Demonstrate care of a wound-drainage system.

TOP: Drainage Systems KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 26. What is an appropriate technique for the nurse to implement for drainage evacuation? a. Replace the Hemovac drain fully expanded. b. Attach the drainage tubing to the patient’s gown. c. Tilt the evacuator of the Hemovac away from the plug. d. Complete the dressing change before the drainage evacuation.

ANS: B

Pinning drainage tubing to the patient’s gown will prevent tension or pulling on the tubing and the insertion site. Check the evacuator for reestablishment of the vacuum, patency of drainage tubing, and absence of stress on the tubing. The Hemovac needs to be flattened (compressed) to create a vacuum. Tilt the evacuator in the direction of the plug. Drainage evacuation may be done at times other than dressing change times.

DIF: Cognitive Level: Application REF: Skill 39.4 OBJ: Demonstrate care of a wound-drainage system.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Drainage Systems

27. What should the nurse do to re-establish the vacuum of the Hemovac system after emptying? a. Place a safety pin on the part of the drain outside the body.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY b. Replace the cap immediately after emptying. c. Pin the drainage tubing to the patient’s gown. d. Place the Hemovac on a flat surface.

ANS: D

Place the evacuator on a flat surface with the open outlet facing upward; continue pressing downward until the bottom and the top are in contact; hold the surfaces together with one hand, quickly cleanse the opening and the plug with the other hand, and immediately replace the plug; and then secure the evacuator to the patient’s bed. Compression of the surface of the Hemovac creates a vacuum. Cleansing of the plug reduces transmission of microorganisms into the drainage evacuation. Be sure the Penrose drain has a sterile safety pin in place. This pin prevents the drain from being pulled below the skin’s surface. Compress the bulb of a JP drain over the drainage container. Cleanse the ends of the emptying port with an alcohol sponge while continuing to compress the container. Replacing the cap immediately prevents tension on the drainage tubing but does not help to re-establish the vacuum.

DIF: Cognitive Level: Application REF: Skill 39.4 OBJ: Demonstrate care of a wound-drainage system.

TOP: Re-establishing Vacuum of Drainage Systems KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 28. The nurse is explaining wound healing to a patient. Which of the following statements

explains the healing that occurs during the inflammatory stage of wound healing in a full-thickness wound? a. A reduction in the size of the wound is noted. b. The epithelial cells duplicate. c. Synthesis of collagen occurN sU atRtS heIsN itG e.TB.COM d. Blood flow to the wound and arrival of white blood cells are increased.

ANS: D

Vasodilation occurs, allowing plasma and blood cells to leak into the wound, noted as edema, erythema, and exudate. Leukocytes (white blood cells) arrive in the wound to begin wound cleanup. Macrophages, a type of white blood cell, appear and begin to regulate wound repair.

The result of the inflammatory phase is a clean wound bed in the patient with an uncomplicated wound. It is during the proliferative stage, not the inflammatory stage, that contraction causes a reduction in the size of the wound, duplication of epithelial cells occurs, and collagen is synthesized.

DIF: Cognitive Level: Application REF: Box 39.3: Phases of Wound Healing (Full-Thickness Wounds) OBJ: Discuss the response of the body during each stage of the wound-healing process.

TOP: Phases of Wound Healing KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 29. The nurse is educating a patient about his role in wound healing. Which of the following

factors, if modified by the patient, can support adequate oxygenation at the tissue level? a. Age b. Smoking c. Underlying cardiopulmonary conditions d. Hemoglobin

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY ANS: B

Factors that decrease oxygenation include decreased hemoglobin level, smoking, and underlying cardiopulmonary conditions. Smoking is the only one of these factors that can be modified by the patient alone. Age causes vascular changes.

DIF: Cognitive Level: Application REF: Safety Guidelines OBJ: Explain factors that promote or impair normal wound healing.

TOP: Skin KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 30. The nurse is caring for a patient with a postsurgical wound dehiscence who is being treated

with a wet-to-dry dressing. Which of the following can be appropriately delegated to an unregulated care provider? a. Performing a sterile dressing change b. Observing for any drainage on the dressing c. Performing wound assessment during the dressing change d. Notifying the physician of drainage present on the dressing ANS: B

Wound assessment and sterile dressing changes cannot be delegated to unregulated care providers (UCP). The nurse can direct the UCP to report any drainage from the wound that is present on the sheets or as strike through from the dressing. The UCP should not be reporting this to a physician.

DIF: Cognitive Level: Application REF: Procedural Guideline 39.1 OBJ: Perform a wound assessment.

TOP: Delegation KEY: Nursing Process Step: Implementation MSC: NCLEX: Management of C NaUreRSINGTB.COM 31. A

is a localized injury to the skin or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear or friction. a. pressure ulcer b. pressure injury c. contusion d. hematoma ANS: B

A pressure injury is a localized injury to the skin or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear or friction. The term pressure injury replaced pressure ulcer in the National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury Staging System as of April 2016. This update was the result of a consensus process to more accurately describe pressure injuries to both intact and ulcerated skin.

DIF: Cognitive Level: Understanding REF: Pressure Injury versus Pressure Ulcer OBJ: Identify risk factors for the development of skin breakdown (e.g., pressure injury).

TOP: Pressure Injury KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 32. When skin layers adhere to the linens and deeper tissue layer move downward,

damage occurs. a. adhesive

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY b. drying c. shear d. slough ANS: C

Shear damage is caused when pressure holds one layer of skill in place while the deeper layer is forced downward, as may happen when turning or moving in bed. This force causes reduced blood flow to the tissues.

DIF: Cognitive Level: Comprehension REF: Table 39.1: Braden Scale for Predicting Pressure Ulcer Risk OBJ: Identify risk factors for the development of skin breakdown (e.g., pressure injury).

TOP: Shear KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 33. The removal of devitalized tissue in a wound is known as a. eschar b. sloughing c. granulation d. debridement

_.

ANS: D

If the tissue in the wound is devitalized, consider debridement, which is the removal of devitalized tissue. Debridement is accomplished by selecting a dressing and using enzyme preparations or surgical or laser techniques.

DIF: Cognitive Level: Comprehension REF: Evidence-Informed Practice OBJ: Perform a wound irrigation.

TOP: Debridement NURSINGTB.COM KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 34. The healing ridge is composed of newly formed collagen, and the nurse can usually feel it

along a healing wound. The nurse knows it is usually present directly under the suture line on days a. 0 to 2. b. 3 to 4. c. 5 to 9. d. 10 to 14.

ANS: C

The healing ridge is composed of newly formed collagen, and it can usually be felt along a healing wound. It is usually present directly under the suture line between days 5 and 9. Lack of a ridge is cause for concern, and the nurse will need to begin interventions promptly to reduce mechanical strain on the wound.

DIF: Cognitive Level: Understanding REF: Procedural Guideline 39.1 OBJ: Discuss the response of the body during each stage of the wound-healing process.

TOP: The Healing Ridge KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 35. Healing by

intention occurs when surgical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. b. c. d.

primary secondary tertiary open

ANS: C

Healing by tertiary intention is sometimes called delayed primary intention or closure. It occurs when surgical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish. Then the wound edges are sutured or stapled closed.

Scarring is usually minimal.

DIF: Cognitive Level: Understanding REF: Box 39.3: Phases of Wound Healing (Full-Thickness Wounds) OBJ: Perform a skin assessment.

TOP: Tertiary Intention KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 36.

is black, brown, or tan tissue in the wound that should be removed before wound healing can begin. a. The epidermis b. The dermis c. Eschar d. Granulation ANS: C

Black, brown, or tan tissue in the wound is eschar that should be removed before wound healing can begin.

DIF: Cognitive Level: UnderstaN ndUinRgSINGTB.COM REF: Box 39.3: Phases of Wound Healing (Full-Thickness Wounds) OBJ: Perform a skin assessment.

TOP: Eschar KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 37.

uses the mechanical force (high or low) of a stream of solution to remove debris, bacteria, and necrotic tissue from a wound. a. Suturing b. Stapling c. Irrigation d. Debridement ANS: C

Irrigation uses the mechanical force (high or low) of a stream of solution to remove debris, bacteria, and necrotic tissue from a wound.

DIF: Cognitive Level: Understanding REF: Skill 39.2 TOP: Irrigation KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

OBJ: Perform a wound irrigation.

are threads of wire or other materials used to sew body tissues together.

38. a. b. c. d.

Sutures Staples Adhesions Lacerations

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

ANS: A

Sutures are threads of wire or other materials used to sew body tissues together.

DIF: Cognitive Level: Understanding REF: Skill 39.3 TOP: Sutures KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

OBJ: Remove sutures or staples.

39. The Jackson-Pratt (JP) drain relies on the presence of a vacuum to withdraw drainage and is

considered a(n) a. open b. closed c. venting d. suction

drainage system.

ANS: B

A closed drainage system such as the JP drain (see Fig. 38.8) or Hemovac drain relies on the presence of a vacuum to withdraw accumulated drainage from around the wound bed into the collection device.

DIF: Cognitive Level: Comprehension REF: Skill 39.4 OBJ: Demonstrate care of a wound-drainage system.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Closed Drain Systems

MULTIPLE RESPONSE 1. The nurse is aware that pressurN eU inR juSriI esNcGaT nB oc.cC urO(M Select all that apply.) a. from any position that causes soft tissue compression. b. because of lack of blood flow (ischemia). c. only in bed bound patients. d. in as little as 90 minutes.

ANS: A, B, D

Pressure injuries occur from any position that causes soft tissue compression. Compression of soft tissue interferes with blood flow to the tissue; if this compression continues for a prolonged time, the tissue dies from lack of blood flow, also known as ischemia. This pressure, if not relieved, can cause irreversible tissue damage in as little as 90 minutes. It is quite possible for an individual to develop a pressure injury even if not confined to bed.

DIF: Cognitive Level: Understanding REF: Principles for Practice OBJ: Identify risk factors for the development of skin breakdown (e.g., pressure injury).

TOP: Pressure Injury Etiology KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. Patients are at risk for developing pressure injuries on which areas of the body? (Select all

that apply.) a. Coccyx b. Nares c. Ears d. Genitalia

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY ANS: A, B, C, D

The most common sites of pressure ulcers are the sacrum, coccyx, ischial tuberosities, greater trochanters, elbows, heels, scapulas, iliac crests, and lateral and medial malleoli. Pressure ulcers can occur on any area of skin subjected to pressure. Nonbony locations in which pressure ulcers can occur include the nares, usually related to pressure caused by nasogastric (NG) tubes or oxygen cannulas; the ears, resulting from an oxygen cannula; and the genitalia, with ulcers resulting from Foley catheter tension.

DIF: Cognitive Level: Comprehension REF: Principles for Practice OBJ: Identify risk factors for the development of skin breakdown (e.g., pressure injury).

TOP: Pressure Injury Sites KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse knows that which of the following factors contribute to the development of pressure

injuries? (Select all that apply.) a. Friction and shear b. Immobility c. Poor nutrition d. Moisture and ammonia e. Uncontrolled pain ANS: A, B, C, D

Factors such as incontinence, friction and shear, immobility, loss of sensory perception, reduced level of activity, and poor nutrition contribute to pressure injury formation. Moisture and ammonia from incontinence soften the skin, allowing the skin to become susceptible to breakdown. Uncontrolled pain does not contribute to the development of pressure injuries.

DIF: Cognitive Level: ComprehN enUsiRoS n INRGETFB : .PC urOpM ose OBJ: Identify risk factors for the development of skin breakdown (e.g., pressure injury).

TOP: Pressure Injury Sites KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse is planning care for her patient who has a stage 2 pressure injury. Care should

include which of the following? (Select all that apply.) a. A heat lamp to dry the wound b. Application of topical antibiotics c. Nutritional assessment d. Maintaining moisture in the wound ANS: B, C, D

The treatment plan for a patient with a pressure injury must include elimination or reduction of the factors that have caused the pressure injury. A moist wound environment supports the growth of new tissue. If the wound is not free of necrotic tissue, the nurse needs to choose topical wound care that will cleanse the wound bed of devitalized tissue. Treat infection both systematically and topically. Wound healing in a patient with a pressure injury progresses if the patient has adequate nutritional status as well as control over preexisting conditions such as diabetes and cardiovascular and pulmonary disease.

DIF: Cognitive Level: Application REF: Skill 39.1 OBJ: Identify risk factors for the development of skin breakdown (e.g., pressure injury).

TOP: Treatment for Pressure Injury KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

5. How does the skin defend the body? (Select all that apply.) a. Skin serves as a sensory organ for pain. b. Skin serves as a sensory organ for touch. c. Skin serves as a sensory organ for temperature. d. Skin has an acid pH. ANS: A, B, C, D

The skin defends the body by serving as a sensory organ for pain, touch, and temperature, and it has an acid pH, which is often called the “acid mantle.”

DIF: Cognitive Level: Comprehension REF: Purpose OBJ: Explain factors that promote or impair normal wound healing.

TOP: Skin KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. The nurse is explaining healing of a full-thickness wound to a patient. Which of the following

phases should the nurse include in the explanation? (Select all that apply.) a. Hemostasis b. Inflammation c. Proliferation d. Maturation ANS: A, B, C, D

In a full-thickness wound, the phases include hemostasis, inflammation, proliferation, and maturation.

DIF: Cognitive Level: ApplicatiN onURSINGTB.COM REF: Box 39.3: Phases of Wound Healing (Full-Thickness Wounds) OBJ: Discuss response of the body during each stage of the wound-healing process.

TOP: Phases of Wound Healing KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The nurse is explaining negative-pressure wound therapy (NPWT) to a patient. Which of the

following statements will help reassure the patient that this type of therapy will support wound healing? (Select all that apply.) a. NPWT optimizes blood flow. b. NPWT will remove wound fluid. c. NPWT will maintain a moist environment. d. NPWT will apply positive pressure to the wound.

ANS: A, B, C

NPWT supports wound healing by optimizing blood flow, removing wound fluid, and maintaining a moist environment.

DIF: Cognitive Level: Application REF: Skill 39.5 OBJ: Discuss purpose and use of negative pressure wound therapy (NPWT) and wound vacuum treatment.

TOP: Negative-Pressure Wound Therapy (NPWT) KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 8. Wounds that have been approved for treatment using negative-pressure wound therapy

(NPWT) include which of the following? (Select all that apply.)

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. b. c. d.

Pressure ulcers Diabetic ulcers Traumatic wounds Venous stasis ulcers

ANS: A, B, C, D

Chronic wounds such as pressure ulcers, diabetic ulcers, traumatic wounds, and venous stasis ulcers are approved for NPWT. DIF: Cognitive Level: Application REF: Skill 39.5 OBJ: Discuss purpose and use of negative pressure wound therapy (NPWT) and wound vacuum treatment.

TOP: Negative-Pressure Wound Therapy (NPWT) KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 9. The nurse is caring for a patient who has had major abdominal surgery and is concerned about

the possibility of dehiscence. During the assessment, the nurse assesses for which of the following contributing factors? (Select all that apply.) a. Age b. Malnutrition/obesity c. Gender d. Use of steroids ANS: B, D

Factors that contribute to surgical wound dehiscence include anemia, malnutrition, obesity, and use of steroids.

DIF: Cognitive Level: Application REF: Safety Guidelines OBJ: Explain factors that promoN teUoR r iS mI paNirGnT orBm.alCw OoMund healing.

TOP: Dehiscence KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 40: Wound Care Management and Dressings Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The nurse is caring for a patient who is bleeding. To control bleeding, apply a a. pressure b. alginate c. foam d. hydrocolloid

dressing.

ANS: A

Apply a pressure dressing to control bleeding, but when wound drainage is present, use a highly absorbent dressing. Use an alginate, foam, or hydrocolloid dressing in a noninfected wound that is draining a moderate to large amount of exudate.

DIF: Cognitive Level: Application REF: Skill 40.2 OBJ: Understand how to choose the correct dressing for a wound based on its characteristics.

TOP: Pressure Dressings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse is changing a dry, woven gauze dressing when it is observed that the gauze has

inadvertently stuck to the wound. What should the nurse do? a. Pull the dressing off to aid in debridement. b. Recover the dressing and leave in place. c. Moisten the gauze to minimize trauma. d. Ensure that the shiny side oN fU thR eS drIyNgG auTzB e. drCeO ssM ing does not stick.

ANS: C

When a dry dressing inadvertently adheres to the wound, moisten the dressing with sterile normal saline or sterile water before removing the gauze to minimize wound trauma.

Moistening the gauze applies only to dry dressings and is not applicable for moist-to-dry dressings. A dry dressing is not used for debriding wounds. Telfa gauze dressings (not dry woven gauze dressings) contain a shiny, nonadherent surface on one side that does not stick to the wound.

DIF: Cognitive Level: Application REF: Person-Centred Care OBJ: Understand the purposes and techniques of dressings, bandages, and abdominal binders.

TOP: Dry Woven Gauze Dressings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The nurse is caring for a patient who has a wound healing by primary intention that has little

to no drainage. Which dressing is most appropriate for this type of wound? a. Moist-to-dry dressing b. Hydrocolloid dressing c. Dry dressing d. Hydrogel dressing ANS: C

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Dry dressings are used for wound healing by primary intention with little drainage. These dressings protect the wound from injury, prevent the introduction of bacteria, reduce discomfort, and speed healing. The primary purpose of moist-to-dry dressings is to mechanically debride a wound. Hydrocolloid dressings provide a moist environment for wound healing while facilitating softening and subsequent removal of wound debris.

Hydrogel dressings (e.g., hydrogel wound dressings, primary wound dressings, etc.) have a high moisture content (95%), causing them to swell and retain fluid. They are useful over clean, moist, or macerated tissues.

DIF: Cognitive Level: Analysis REF: Skill 40.1 OBJ: Understand how to choose the correct dressing for a wound based on its characteristics.

TOP: Dry Dressings KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse would consider a dry dressing appropriate for a wound that requires which of the

following? a. Protection b. Debridement c. Absorption of heavy exudate d. Healing by second intention ANS: A

A dry dressing may be chosen for management of a wound healing by primary intention with little drainage. The dressing protects the wound from injury, reduces discomfort, and speeds healing. The dry dressing does not interact with wound tissues and causes little wound irritation. A dry dressing is not appropriate for an open wound that is healing by secondary intention.

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DIF: Cognitive Level: Application REF: Skill 40.1 OBJ: Understand how to choose the correct dressing for a wound based on its characteristics.

TOP: Dry Dressings KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 5. The patient has a large, deep wound on the sacral region. The nurse correctly packs the wound

by a. b. c. d.

filling two-thirds of the wound cavity. leaving saline-soaked folded gauze squares in place. putting the dressing in very tightly. extending only to the upper edge of the wound.

ANS: D

Apply moist, fine-mesh, open-weave gauze as a single layer directly onto the wound surface.

If the wound is deep, gently pack the gauze into the wound with a sterile gloved hand or forceps until all wound surfaces are in contact with the moist gauze. Be sure that the gauze does not touch periwound skin. Moisture that escapes the dressing often macerates the periwound area. The gauze should be saturated with the prescribed solution, wrung out, unfolded, and lightly packed into the wound. Overpacking the wound may cause pressure on tissue in the wound bed.

DIF: Cognitive Level: Application TOP: Packing the Wound

REF: Skill 40.1 OBJ: Apply dressings correctly.

KEY: Nursing Process Step: Implementation

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY MSC: NCLEX: Physiological Integrity 6. What should the nurse do for a patient with a sudden severe hemorrhage? a. Go for help. b. Drape the patient. c. Apply direct pressure. d. Put on clean or sterile gloves.

ANS: C

Apply direct pressure immediately. Seek assistance after pressure is applied. Maintaining asepsis and privacy is considered only if time and severity of blood loss permit inclusion of these activities.

DIF: Cognitive Level: Application REF: Skill 40.2 OBJ: Understand how to choose the correct dressing for a wound based on its characteristics.

TOP: Hemostasis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. What should the nurse anticipate might happen to a patient if bleeding cannot be controlled? a. Skin dryness b. Bradycardia c. Hypovolemic shock d. Hypertension ANS: C

Findings of tachycardia, hypotension, diaphoresis, restlessness, and diminished urinary output indicate impending hypovolemic shock. Bradycardia is a decreased pulse rate. Dry skin is not an indicator of hypovolemic shN ocUkR . SI HypNeG rteTnB si. onCO isMan increase in blood pressure.

DIF: Cognitive Level: Application TOP: Hypovolemic Shock MSC: NCLEX: Physiological Integrity

REF: Skill 40.2 OBJ: Assess a wound correctly.

KEY: Nursing Process Step: Assessment

8. How should the nurse proceed when applying a pressure bandage? a. Elevate the extremity or area of bleeding. b. Wrap pressure-bandage gauze in a proximal-to-distal direction. c. Apply pressure to diminish the pulse to the distal body part. d. Wrap tape around the circumference of the site to secure the gauze padding.

ANS: A

As soon as possible, elevate the extremity or area of bleeding. Elevation assists in decreasing the rate of blood loss. Start the pressure bandage from distal to proximal, working toward the heart. Secure tape on the distal end, pull tape across the dressing, and maintain firm pressure as the proximate end of the tape is secured. To ensure blood flow to distal tissues and to prevent a tourniquet effect, adhesive tape must not be continued around the entire extremity.

DIF: Cognitive Level: Application TOP: Pressure Bandage MSC: NCLEX: Physiological Integrity

REF: Skill 40.2 OBJ: Apply dressings correctly.

KEY: Nursing Process Step: Implementation

9. Serious hemorrhaging has resulted in the patient experiencing a fluid and electrolyte

imbalance. How should the nurse respond?

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. b. c. d.

Initiate intravenous (IV) therapy.

Order blood for transfusions.

Remove and reapply any dressings.

Monitor vital signs every 15 minutes.

ANS: D

Monitor vital signs every 5 to 15 minutes (apical, distal rate, blood pressure). IV therapy and blood transfusions require a provider’s prescription. Reinforce the dressing with tape as needed to prevent seepage. If the dressing is saturated, replace only the top layers so as not to disturb any clot formation at the wound site.

DIF: Cognitive Level: Application REF: Skill 40.2 OBJ: Understand the purposes and techniques of dressings, bandages, and abdominal binders.

TOP: Hemorrhage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. The patient is being sent home from the hospital after a cardiac catheterization. What should

the nurse instruct the patient to do first if bleeding occurs at the femoral artery puncture site? a. Call the physician. b. Call 9-1-1. c. Apply pressure to the site. d. Apply a new bandage.

ANS: C

Wounds to the groin area can result in a large amount of blood loss, which is not always visible. If bleeding should occur at the femoral artery puncture site, the patient should apply direct pressure immediately. At home, the patient may apply pressure with clean towels or linen. The patient should call thNeUpR hySsI icN iaG nTasBs.oC onOaMs possible after homeostasis is established. The patient should call 9-1-1 as soon as possible after applying pressure to the site.

DIF: Cognitive Level: Application REF: Skill 40.2 TOP: Hemorrhage KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

OBJ: Assess a wound correctly.

11. The patient is brought from a construction site to the emergency department with a pipe

puncturing his abdomen. The pipe is still in place. The patient is triaged and is scheduled for the operating room. What should the nurse do while waiting for the surgeon? a. Pull the pipe out in the direction of entry. b. Push the pipe through to the other side, then out. c. Leave the pipe in place. d. Apply direct pressure to the insertion site of the pipe.

ANS: C

If a puncture wound occurs from a penetrating object (e.g., knife, toy, building materials), do not remove the object. Removal of the object will cause more rapid blood loss and may damage underlying structures. Do not push or apply direct pressure to the insertion site, because this may cause more damage to internal organs.

DIF: Cognitive Level: Application REF: Care in the Community (Skill 40.2) OBJ: Assess a wound correctly.

TOP: Penetrating Objects KEY: Nursing Process Step: Implementation

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY MSC: NCLEX: Physiological Integrity 12. For a patient with a transparent film dressing, the nurse assesses that there is white, opaque

fluid accumulation and the surrounding tissue is inflamed. How should the nurse respond? a. Culture the wound. b. Leave the current dressing in place. c. Apply gauze over the top of the dressing. d. Remove and stretch the film more tightly over the wound.

ANS: A

Accumulation of fluid with a white, opaque appearance and erythema of the surrounding tissue usually indicate an infectious process; the dressing should be removed and a wound culture obtained.

DIF: Cognitive Level: Application TOP: Film Dressings MSC: NCLEX: Physiological Integrity

REF: Skill 40.3 OBJ: Assess a wound correctly.

KEY: Nursing Process Step: Implementation

13. The nurse is changing a film dressing over a wound that is showing a large amount of

drainage. How should the nurse proceed? a. Apply a film dressing after culturing the wound. b. Apply a film dressing after cleansing the area. c. Choose another type of dressing for this wound. d. Keep the wound open to air.

ANS: C

If the wound has a large amount of drainage, choose another dressing that can absorb this amount of wound drainage, ratN heUr R thSanIN traGnT spBa. reC ntOfM ilm dressing, which can absorb only light to moderate amounts of drainage. Explain to the patient and caregiver that collection of wound fluid under the dressing is not “pus” but rather is a result of normal interaction of body fluids with the dressing.

DIF: Cognitive Level: Application REF: Table 40.1: Wound Care Dressing Categories OBJ: Understand how to choose the correct dressing for a wound based on its characteristics.

TOP: Film Dressings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. In what type of wound is a foam dressing contraindicated? a. Shallow stage 2 pressure injury b. Exudative stage 2 pressure injury c. Wound that has tunnelling d. Wound that is infected ANS: C

Foam dressings are not appropriate when there is wound tunnelling because the dressing expands, which can enlarge the tunnels. International pressure ulcer guidelines recommend foam for use on exudative stage 2 and shallow stage 2 pressure injuries. Foam dressings are also used to dress infected wounds.

DIF: Cognitive Level: Application REF: Skill 40.4 OBJ: Understand how to choose the correct dressing for a wound based on its characteristics.

TOP: Foam Dressings KEY: Nursing Process Step: Implementation

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY MSC: NCLEX: Physiological Integrity 15. When assessing a patient with a hydrocolloid dressing, the nurse finds the formation of a soft,

white-yellow gel that is adherent to the wound and has a very slight odour. The nurse evaluates this outcome as a. an expected occurrence. b. a wound infection requiring a culture. c. an adverse reaction to the hydrocolloid components. d. excessive exudate requiring a different type of dressing.

ANS: A

Hydrocolloid dressings interact with wound fluids and form a soft whitish-yellowish gel that is hard to remove and may have a faint odour. These are normal occurrences and should not be confused with pus or purulent exudate, wound infection, or deterioration of the wound.

DIF: Cognitive Level: Application REF: Skill 40.4 OBJ: Understand the purposes and techniques of dressings, bandages, and abdominal binders.

TOP: Hydrocolloid Dressings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. What should the nurse remember to do when applying a hydrocolloid dressing? a. Apply granules after applying the wafer. b. Never use a secondary dressing. c. Hold the dressing in place. d. Use silk tape to hold the dressing in place.

ANS: C

Hold the dressing in place for 3N0UtoR6S0IsNecGoTnB ds.aC ftO erMapplication. Hydrocolloid dressings are most effective at body temperature. Holding the dressing in place for a short time facilitates dressing action. In the case of a deep wound, hydrocolloid granules or paste is applied before the wafer. Hydrocolloid granules/paste assists in absorbing drainage to increase the wearing time of the dressing. Apply a secondary dressing (e.g., ABD pad) if needed. When a secondary dressing is not used, apply nonallergic paper tape around the edges of the hydrocolloid dressing.

DIF: Cognitive Level: Application REF: Skill 40.4 OBJ: Understand the purposes and techniques of dressings, bandages, and abdominal binders.

TOP: Hydrocolloid Dressings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. Which of the following is an appropriate procedure for the nurse to implement during the

application of an absorption or alginate dressing? a. Never cut the dressing to fit the wound. b. Irrigate the wound gently to remove residual gel. c. Fill the wound cavity entirely with the dressing material. d. Never use a secondary dressing.

ANS: B

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TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Cleanse the area gently with moist 4  4 sterile gauze pads, swabbing exudate away from the wound, or spray with a wound cleanser. Cleansing effectively removes any residual dressing gel without injuring newly formed delicate granulation tissue formed in the healing wound bed. With some brands, dressings can be trimmed to fit wound size, whereas other brands of dressings cannot be cut. Fill the wound cavity only one-half to two-thirds full to allow for expansion with absorption. Apply a secondary dressing, such as transparent film, hydrogen, foam, or hydrocolloid.

DIF: Cognitive Level: Application TOP: Alginate Dressings MSC: NCLEX: Physiological Integrity

REF: Skill 40.4 OBJ: Apply dressings correctly.

KEY: Nursing Process Step: Implementation

18. The nurse is preparing to apply a gauze bandage to a dressing on the patient’s wrist. How

should the nurse proceed? a. Use a 7.5-cm (3-inch) bandage. b. Use a 5-cm (2-inch) bandage. c. Apply from the elbow toward the wrist. d. Secure the bandage with a safety pin.

ANS: B

When applying a gauze or elastic bandage, select a type of bandage and bandage width dependent on the size and shape of the body part to be bandaged. For example, 7.5-cm (3-inch) bandages are used most commonly for the adult leg. A smaller, 5-cm (2-inch) bandage normally is used for the upper extremity. When applying an elastic bandage to an extremity, start the bandage at the site farthest from the heart (distal) and proceed toward the heart (proximal). Use adhesive tape or special clips rather than safety pins to fasten the bandage.

NURSINGTB.COM

DIF: Cognitive Level: Application REF: Procedural Guideline 40.1 OBJ: Understand the purposes and techniques of dressings, bandages, and abdominal binders.

TOP: Applying a Bandage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. Which of the following tasks might be delegated to unregulated care providers (UCP)? a. Pressure dressing to an actively bleeding wound b. Chronic wound that needs a nonsterile dry dressing change c. Hydrogel dressing change d. Wound assessment during the dressing change ANS: B

The task of applying dry and moist-to-dry dressings may sometimes be delegated to unregulated care providers if the wound is chronic (see employer policy). Wound assessments, care of acute new wounds, and wound care requiring sterile technique cannot be delegated. The application of hydrogel dressings or pressure dressings cannot be delegated.

DIF: Cognitive Level: Application REF: Delegation and Collaboration (Skill 40.1) OBJ: Understand the purposes and techniques of dressings, bandages, and abdominal binders.

TOP: Delegation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 20. A

dressing comes in direct contact with the wound bed.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. b. c. d.

primary secondary tertiary multi-layer

ANS: A

A primary dressing comes in direct contact with the wound bed.

DIF: Cognitive Level: Understanding REF: Skill 40.1 OBJ: Understand how to choose the correct dressing for a wound based on its characteristics.

TOP: Primary Dressing KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

dressings cover or hold primary dressings in place.

21. a. b. c. d.

Primary Secondary Tertiary Multi-layer

ANS: B

Secondary dressings cover or hold primary dressings in place.

DIF: Cognitive Level: Understanding REF: Skill 40.4 OBJ: Understand how to choose the correct dressing for a wound based on its characteristics.

TOP: Secondary Dressing KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

healing takes place when tissue is cleanly cut and the margins are

22.

reapproximated. a. Primary b. Secondary c. Tertiary d. Multi-layer

NURSINGTB.COM

ANS: A

Primary healing takes place when tissue is cleanly cut and the margins are reapproximated.

DIF: Cognitive Level: Understanding OBJ: Properly assess a wound.

KEY: Nursing Process Step: Assessment 23. A

REF: Principles for Practice TOP: Primary Healing MSC: NCLEX: Physiological Integrity

is a clear, adherent, nonabsorptive, polyurethane moisture- and vapour-permeable dressing that often is used for protection over high-friction areas and over intravenous (IV) catheters. a. gauze dressing b. transparent film c. hydrocolloid d. hydrofibre gel ANS: B

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

A transparent dressing is a clear, adherent, nonabsorptive, polyurethane moisture- and vapour-permeable dressing. These dressings manage superficial, minimally draining wounds and often are used for protection over high-friction areas and over IV catheters.

DIF: Cognitive Level: Understanding REF: Skill 40.3 OBJ: Understand how to choose the correct dressing for a wound based on its characteristics.

TOP: Film Dressings KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Dressings serve several functions. Which of the following is a function of a dressing? (Select

all that apply.) a. Maintains a moist environment b. Prevents the spread of microorganisms c. Increases patient comfort d. Controls bleeding ANS: A, B, C, D

Dressings serve several functions such as maintaining a moist environment, protecting from outside contaminants, protecting from further injury, preventing the spread of microorganisms, increasing patient comfort, and controlling bleeding.

DIF: Cognitive Level: Comprehension REF: Principles for Practice OBJ: Understand the purposes and techniques of dressings, bandages, and abdominal binders.

TOP: Functions of Dressings KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

NURSINGTB.COM

2. Which of the following are examples of wounds that heal by secondary intention? (Select all

that apply.) a. Burns b. Surgical incisions c. Infected wounds d. Deep pressure ulcers ANS: A, C, D

Healing by secondary intention occurs when a wound is left open. Healing results in the formation of granulation tissue from the bottom of the wound and eventual epithelialization from the sides of the wound to close the defect. During the process of epithelialization, epithelial cells migrate and proliferate from the wound edges to cover the wound surface.

Burns, infected wounds, and deep pressure ulcers heal in this manner.

DIF: Cognitive Level: Comprehension OBJ: Assess a wound correctly.

KEY: Nursing Process Step: Assessment

REF: Principles for Practice TOP: Secondary Intention MSC: NCLEX: Physiological Integrity

3. Hydrocolloid dressings are used for which of the following? (Select all that apply.) a. Maintaining a moist wound environment b. Autolytic debriding of necrotic wounds c. Absorption of moderately draining wounds d. Protecting from friction

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

ANS: A, B, C

Hydrocolloid dressings comprise elastomeric, adhesive, and gelling agents. They facilitate autolytic debridement of wounds through rehydration. They absorb exudate and encourage healing by maintaining a moist wound healing environment. Transparent dressings are more suitable for preventing friction.

DIF: Cognitive Level: Comprehension REF: Table 40.1: Wound Care Dressing Categories OBJ: Understand how to choose the correct dressing for a wound based on its characteristics.

TOP: Hydrocolloid Dressings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. In caring for a patient who has an abdominal binder, it is expected that the nurse will do which

of the following? (Select all that apply.) a. Remove the binder and assess the skin and wound every 8 hours. b. Evaluate the patient’s ability to breathe deeply and cough effectively every 4 hours. c. Evaluate the patient’s pulmonary function every 8 hours. d. Remove the binder at least daily.

ANS: A, B

Remove the binder and surgical dressing to assess the skin and wound characteristics every 8 hours to determine that the binder has not resulted in complications (e.g., rubbing or abrasion of skin, disruption of wound). Evaluate the patient’s ability to ventilate properly, including deep breathing and coughing, every 4 hours to help identify any impaired ventilation. A properly applied binder will have no effect on pulmonary function.

DIF: Cognitive Level: UnderstaN ndUinRgSINRGETFB : .SC kiO llM 40.2 OBJ: Apply an abdominal binder correctly.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Abdominal Binder

5. The nurse is demonstrating a dressing change to a nursing student. What key safety features

should be emphasized during the process? (Select all that apply.) a. Knowing the type of wound b. Knowing the expected amount of drainage c. Knowing the patient’s blood type d. Knowing whether drainage tubes are present ANS: A, B, D

It is important to know the cause or type of wound. Wounds caused by vascular insufficiency, diabetes mellitus, pressure, trauma, and surgery are all very different and must have individualized treatment plans. Not knowing the cause of a wound can have serious negative effects if treatments that are contraindicated for certain types of wounds are used. Know the expected amount and type of wound exudate or drainage. Wounds with large amounts of drainage require more frequent dressing changes or need an absorptive dressing. Determine whether wound drainage tubes are present to prevent their accidental dislocation when you remove the old dressing. Knowing the patient’s blood type is not necessary for the purposes of changing the dressing unless you are expecting a bleeding complication, and then it would be important for the patient to have a blood type and screen done.

DIF: Cognitive Level: Application

REF: Safety Guidelines

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY OBJ: Assess a wound correctly.

TOP: Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 6. Which of the following may dry gauze come impregnated with? (Select all that apply.) a. Zinc oxide paste b. Iodinated agents c. Petrolatum d. Crystalline sodium chloride ANS: A, B, C, D

Dry gauze may come impregnated with a variety of substances such as zinc oxide paste, iodinated agents, petrolatum, and crystalline sodium chloride. Impregnated gauze can hydrate a wound and absorb exudate or deliver antimicrobial agents.

DIF: Cognitive Level: Understanding REF: Skill 40.1 OBJ: Understand how to choose the correct dressing for a wound based on its characteristics.

TOP: Moist-to-Dry Dressing KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 41: Therapeutic Use of Heat and Cold Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. The nurse is using cryotherapy for a patient with a sprained ankle. The nurse explains the

benefits to her patient. Which of the following statements made about the benefits of cryotherapy is correct? a. It causes vasodilation. b. It provides local anaesthesia. c. It increases nerve conduction velocity. d. It increases blood flow.

ANS: B

The reduction in temperature creates positive physiological and biological effects such as pain relief, reduced muscle spasms, decreased nerve conduction velocity, and decreased inflammation edema caused by constriction of blood vessels.

DIF: Cognitive Level: Application REF: Principles for Practice OBJ: Identify the physiological effects of heat and cold.

TOP: Cryotherapy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 2. Therapeutic interventions designed to correct hypothermia and progressively raise body

temperature are essential to improve patient outcomes. The nurse understands that this is accomplished by correcting acid–base imbalances, body temperature, and which of the following additional clinical manifestations?

NURSINGTB.COM a. Coagulopathies b. Reduction of shearing forces c. Increase in nerve conduction d. Reduction in muscle spasms ANS: A

Therapeutic interventions are designed to correct hypothermia and progressively raise body temperature by correcting acid–base imbalances, body temperature, and coagulopathies.

Shearing forces, nerve conduction, and muscle spasms do not play a role in the correction of hypothermia and improved patient outcomes.

DIF: Cognitive Level: Application REF: Skill 41.4 OBJ: Identify the physiological effects of heat and cold.

TOP: Prevention of Intraoperative Hypothermia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 3. When reviewing the documentation of patients on the unit, a nurse determines that one of the

patients is at higher risk for injury from a local heat application to an extremity. Which condition poses this risk? a. Arthritis b. Renal calculi c. Pulmonary disease d. Peripheral neuropathy ANS: D

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Patients with diabetes, victims of stroke or spinal cord injury, and patients with peripheral neuropathy and rheumatoid arthritis are particularly at risk for thermal injury. Arthritis, renal calculi, and pulmonary disease do not increase the patient’s risk for thermal injury.

DIF: Cognitive Level: Analysis REF: Skill 41.1 OBJ: Identify the potential risks related to heat and cold applications.

TOP: Risk for Heat Injury KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. What procedure should the nurse follow when applying hot compresses to an open wound? a. Apply clean gloves. b. Cover all wound surfaces. c. Leave the application in place for 30 to 40 minutes. d. Apply an electrical heating unit directly over the compress.

ANS: B

Pack gauze snugly against the wound. Be sure that all wound surfaces are covered by a warm compress. Packing of compresses prevents rapid cooling from underlying air currents. Sterile gloves are used to contact an open wound. Apply heat for 20 to 30 minutes every 2 hours.

Cover the moist compress with dry sterile dressing and a bath towel. Apply an aquathermia pad or a waterproof heating pad over the towel.

DIF: Cognitive Level: Application REF: Skill 41.1 OBJ: Correctly apply heat and cold applications.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Sterile Warm Compress

eS unIitN. G ThTeBc. haCrO geMnurse evaluated that the new staff 5. A new staff nurse is assigned toNtUhR member knows proper use of the aquathermia pad when the: a. temperature is set between 35°C and 36.6°C (95°F and 98°F). b. water in the reservoir is allowed to run out. c. pad is covered with a towel or a pillowcase. d. patient is positioned to lie directly over the pad.

ANS: C

Aquathermia pads and heating pads are common forms of dry heat therapy. Both are covered and applied directly to the skin’s surface; for this reason, the nurse needs to take extra precautions to prevent burns. In most health care institutions, the central supply department sets the temperature regulators to the recommended temperature, approximately 40.5°C to 43°C (105°F–109.4°F). Never position the patient so that the patient is lying directly on the pad. This position prevents dissipation of heat and increases risk for burns.

DIF: Cognitive Level: Application REF: Skill 41.2 OBJ: Correctly apply heat and cold applications.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Aquathermia Pads

6. The nurse is removing a heating pad and notices that the skin beneath the pad is pink and

warm to touch. How should the nurse respond? a. Keep the pad in place the next time by pinning it with a safety pin. b. Position the patient next time so that the patient is lying directly on the pad. c. Document the findings.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY d. Put the pad back on for an additional 20 to 30 minutes.

ANS: C

Vasodilation from heat exposure increases blood flow to the affected part. Do not pin the wrap to the pad because this may cause a leak in the device. Never position the patient so that patient is lying directly on the pad. This position prevents dissipation of heat and increases risk for burns. After 20 to 30 minutes (or time prescribed by the health care provider), remove the pad and store. Continued exposure will result in burns.

DIF: Cognitive Level: Analysis REF: Communication and Documentation (Skill 41.2) OBJ: Correctly apply heat and cold applications.

TOP: Heat Application KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. Assessment of a patient reveals that the area directly under the heating pad is slightly red.

How should the nurse respond? a. Continue the therapy. b. Apply a cold compress. c. Reduce the amount of heat. d. Remove the pad and notify health care provider.

ANS: D

If skin is reddened and sensitive to touch, the symptoms indicate first-degree burn. Remove the pad and notify health care provider.

DIF: Cognitive Level: Application REF: Skill 41.1 OBJ: Correctly apply heat and cold applications.

TOP: Heat Application KEY: Nursing Process Step: EvaN luU atR ioS n INM S C : N C L EX: Physiological Integrity GTB.COM 8. For which patient should the nurse consider an application of cold? a. Menstrual cramping b. Infected wound c. Fractured ankle d. Degenerative joint disease ANS: C

Cold exerts a profound physiological effect on the body, reducing inflammation caused by injury to the musculoskeletal system. Application of cold is not indicated for the patient with an infected wound because it reduces blood flow to the area. Application of heat to reduce muscle tension and pain would be more appropriate for the patient with menstrual cramping.

The effects of heat application would also be more beneficial for the patient with degenerative joint disease.

DIF: Cognitive Level: Application REF: Skill 41.3 OBJ: Correctly apply heat and cold applications.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Cold Therapy

9. If a patient is prescribed to receive a cold application for a sprain, the nurse should ensure that a. a prolonged application time is available. b. the body part is carefully aligned. c. a colder temperature is applied.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY d. extra packing is available under the cooling device.

ANS: B

Keep the injured part immobilized and in alignment. Movement can cause further injury to strains, sprains, or fractures. Cold should be applied directly over the injury. Extreme temperatures can cause tissue damage. After 15 to 20 minutes (or as prescribed by the health care provider), apply clean gloves, remove the compressor pad, and gently dry off any moisture.

DIF: Cognitive Level: Application REF: Skill 41.3 OBJ: Correctly apply heat and cold applications.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Cold Therapy

10. The nurse removes an ice pack and notices that the area underneath the ice pack is blue. What

action should the nurse take? a. Reapply the ice pack. b. Discontinue the use of ice packs. c. Refill the ice pack to the top. d. Reapply the ice pack without the wrapping.

ANS: B

Do not reapply the ice pack to red or bluish areas; continual use of the ice pack makes ischemia worse. When filling an ice pack, fill the bag two-thirds full with small ice chips. The bag is easier to mould over a body part when it is not full. However, in this case, do not reapply the ice pack.

DIF: Cognitive Level: ApplicatiN onURSINRGETFB : .SC kiO llM 41.3 OBJ: Correctly apply heat and cold applications.

TOP: Cold Therapy on Red or Bluish Areas KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. The patient is receiving cold therapy and complains to the nurse that the area being treated is

numb. How should the nurse respond? a. Continue application of therapy. b. Stop cold therapy. c. Apply more ice to the ice pack. d. Check for moisture on the ice pack, indicating leakage.

ANS: B

Stop cold therapy when the patient complains of a burning sensation or when skin begins to feel numb.

DIF: Cognitive Level: Application REF: Skill 41.3 OBJ: Correctly apply heat and cold applications.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Numbness

12. When applying a hypothermia or hyperthermia blanket, the nurse should a. wrap the patient’s hands and feet in gauze. b. monitor the patient’s axillary temperature every hour.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY c. put the patient directly onto the heating or cooling blanket. d. place the patient onto the blanket and then start the heating or cooling process.

ANS: A

Wrap the patient’s hands and feet in gauze. This reduces the risk for thermal injury to the body’s distal areas. Monitor the patient’s temperature and vital signs every 15 minutes during the first hour and after every 30 minutes of therapy thereafter. Cover the hypothermia or hyperthermia blanket with a thin sheet or bath blanket. Precool or prewarm the blanket, setting the pad temperature to the desired level.

DIF: Cognitive Level: Application REF: Skill 41.4 OBJ: Explain common guidelines used to protect patients from risks associated with heat and cold applications.

TOP: The Hypothermia-Hyperthermia Blanket KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. If a patient on a hypothermia blanket starts to shiver, what action should the nurse take? a. Discontinue treatment. b. Place more padding around the patient. c. Discuss with the health care provider the use of a metabolic stimulant. d. Increase the temperature to a more comfortable range.

ANS: D

Adjust the temperature to a more comfortable range and assess whether shivering decreases. If shivering continues, stop treatment and notify the health care provider.

DIF: Cognitive Level: Application REF: Skill 41.4 OBJ: Correctly apply heat and cold applications.

NURSINGTB.COM TOP: The Hypothermia-Hyperthermia Blanket KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. Which of the following conditions would require using caution in applying cold therapy? a. Chronic pain b. Joint trauma c. Circulatory insufficiency d. Sprains ANS: C

Conditions that require caution with cold therapy include circulatory insufficiency, cold allergy, and advanced diabetes. Cold therapy is used immediately after direct trauma such as sprains, strains, fractures, or muscle spasms; after superficial lacerations or puncture wounds; after minor burns; with chronic pain of arthritis and joint trauma; with delayed-onset muscle soreness; and with inflammation.

DIF: Cognitive Level: Application REF: Table 41.2: Characteristics of Heat and Cold Application OBJ: Correctly apply heat and cold applications.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Cold Therapy Precautions

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 15. The nurse is explaining to the patient the rationale for the use of dry heat. Which of the

following statements indicates understanding of the advantage of dry heat application for the patient? a. It maintains temperature changes longer. b. It reduces drying of the skin. c. It penetrates tissue layers deeply. d. It conforms better to body surfaces.

ANS: A

Dry heat maintains temperature changes longer than moist heat treatments. Moist heat reduces the drying of skin and softens wound exudate. Moist heat also penetrates more deeply into tissue layers and conforms better to the body area being treated.

DIF: Cognitive Level: Application REF: Skill 41.2 OBJ: Correctly apply heat and cold applications.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16.

TOP: Advantages of Dry Heat

exert(s) a profound physiological effect on the body, reducing inflammation caused by injury to the musculoskeletal system. a. Cold applications b. Moist heat c. Dry heat d. Normothermia ANS: A

Cold exerts a profound physiological effect on the body, reducing inflammation caused by injury to the musculoskeletal syNsU teR mS. INGTB.COM DIF: Cognitive Level: Understanding REF: Principles for Practice OBJ: Correctly apply heat and cold applications.

TOP: Cold Application KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 17. In addition to monitoring the controls on the hypothermia blanket every 30 minutes, the nurse

will need to assess the patient’s a. heart rate b. respiratory rate c. axillary temperature d. rectal temperature

every 4 hours.

ANS: D

The patient’s core body temperature must be monitored by taking a rectal temperature reading every 4 hours to assess the effectiveness of the treatment and to indicate when it may be discontinued.

DIF: Cognitive Level: Application REF: Skill 41.4 OBJ: Correctly apply heat and cold applications.

TOP: The Hypothermia-Hyperthermia Blanket KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

1. When the skin is exposed to warm or hot temperatures, which of the following occurs? (Select

all that apply.) a. Vasodilation b. Vasoconstriction c. Perspiration d. Piloerection ANS: A, C

Systemically, when the skin is exposed to warm or hot temperatures, vasodilation and perspiration occur to promote heat loss. As perspiration evaporates from the skin, cooling occurs. In cryotherapy, when the skin is exposed to cool or cold temperatures, the systemic response includes vasoconstriction and piloerection to conserve heat. Shivering occurs in response to cooler temperatures, producing heat through skeletal muscle contraction.

DIF: Cognitive Level: Comprehension REF: Principles for Practice OBJ: Identify the physiological effects of heat and cold.

TOP: The Hypothalamus KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The use of cold (cryotherapy) to treat certain injuries is beneficial because of which of the

following effects? (Select all that apply.) a. Relief of pain b. Decreased muscle spasm c. Increased nerve conduction d. Decreased edema ANS: A, B, D

The reduction in temperature cN reU atR esSpIoN siG tivTeBp.hC ysOioMlogical and biological effects, such as pain relief, reduction in muscle spasm, decreased nerve conduction velocity, and decreased inflammation edema, caused by constriction of blood vessels.

DIF: Cognitive Level: Comprehension REF: Table 41.2: Characteristics of Heat and Cold Application OBJ: Identify the physiological effects of heat and cold.

TOP: Cryotherapy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 3. Which of the following conditions can be treated with cold therapy? (Select all that apply.) a. Localized inflammatory responses b. Hemorrhage c. Muscle spasm d. Pain ANS: A, B, C, D

Cold therapy treats localized inflammatory responses that lead to edema, hemorrhage, muscle spasm, or pain.

DIF: Cognitive Level: Comprehension REF: Table 41.2: Characteristics of Heat and Cold Application OBJ: Differentiate the types of injuries or conditions that benefit from heat and cold applications.

TOP: Cold Application KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 4. Hot applications are used with caution in which of the following conditions? (Select all that

apply.) a. Pregnancy b. Laminectomy sites c. Malignancy d. Spinal cord injury ANS: A, B, C, D

Caution is used with heat therapy in cases of pregnancy, at laminectomy sites, with spinal cord injury, malignancy, or vascular insufficiency, and near the eyes or testes.

DIF: Cognitive Level: Comprehension REF: Table 41.2: Characteristics of Heat and Cold Application OBJ: Correctly apply heat and cold applications.

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Heat Therapy Precautions

5. Advantages of moist heat over dry heat include which of the following manifestations? (Select

all that apply.) a. Reduces drying of skin b. Softens wound exudate c. Does not cause skin maceration d. Penetrates deeply into tissue layers ANS: A, B, D

Advantages of moist heat include reduced drying of skin and softening of wound exudate, conforming well to the body area being treated, penetration deeply into tissue layers, and decreased sweating and insensiN blUeRflS uiIdNloGsT s.BH.oC wO evMer, moist heat can cause maceration of the skin with prolonged exposure.

DIF: Cognitive Level: Comprehension REF: Skill 41.1 OBJ: Correctly apply heat and cold applications.

TOP: Advantages of Moist Heat KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 6. When may therapeutic (induced) hypothermia be used? (Select all that apply). a. After neurosurgery b. After traumatic brain injury c. After an acute stroke d. For a mild fever ANS: A, B, C

Induced hypothermia prevents or moderates neurological outcomes after neurosurgery, traumatic brain injury, and acute stroke. Therapeutic hypothermia decreases cerebral metabolic rate and oxygen demand and has been found to improve neurological outcomes and survival.

DIF: Cognitive Level: Understanding REF: Skill 41.4 OBJ: Correctly apply heat and cold applications.

TOP: The Hypothermia-Hyperthermia Blanket KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 42: Safety in the Community Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. Patients who require home care often experience physical alterations that require changes in

their home environment. In the case of older persons, what is the best way to implement these changes? a. Quickly to prevent problems b. Limit the patient’s need to move around c. Complement the patient’s strengths d. Without consideration of the patient’s previous sense of personal space ANS: C

In the case of older persons, the progressive physical changes of aging create the same type of need. Changes made should complement the patient’s remaining strengths. Making changes too rapidly without the patient’s consent will cause more problems than benefits. Appreciate the arrangement of the patient’s space within the home, and do not move things or suggest modifications without permission. Respect the concept of personal space.

DIF: Cognitive Level: Comprehension REF: Skill 42.1 OBJ: Identify interventions that modify the home environment for physical safety.

TOP: Modifying Safety Risks KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 2. The nurse is assessing a patient for mobility problems that could lead to falls. The nurse has

GUTG B).tC the patient perform a Timed UpNaUnR dSGIoN(T esO tM and uses this test to gauge a. the patient’s ability to perform advanced ambulation manoeuvres. b. whether the patient can walk 30 feet without fatiguing. c. whether the patient can tolerate the activity for longer than 30 seconds. d. a patient’s balance and gait.

ANS: D

Conduct a TUG for basic mobility. This simple screening examination is useful in detecting difficulties with balance or gait.

DIF: Cognitive Level: Application REF: Skill 42.1 OBJ: Perform a geriatric fall risk assessment.

TOP: Timed Up and Go (TUG) Test KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 3. When teaching an elderly patient about safety in the bathroom, which of the following

recommendations should the nurse make? a. Use bath oils to maintain skin integrity and suppleness. b. Hang towels on grab bars for easy access. c. Make sure the bathroom door can be locked from the inside only for privacy. d. Shower using a shower stool and a handheld sprayer.

ANS: D

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

A shower stool allows the patient to sit while showering. Use of bath oils makes the tub surface slippery and increases the risk for falls. Do not hang towels on grab bars. Some patients accidentally grab the towel instead of the bar when needing support. Be sure that bathroom doors can be unlocked from both sides of the door. Functional locks prevent the person from becoming trapped in the bathroom.

DIF: Cognitive Level: Analysis REF: Skill 42.1 OBJ: Perform a home safety risk assessment.

TOP: Home Safety KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 4. Which of the following is a safety measure that the patient should implement in the home

environment? a. Using fluorescent lighting b. Wearing extra clothing for padding c. Obtaining a large fire extinguisher d. Installing additional towel bars for support in the shower ANS: B

Have the patient use padding or types of clothing that will cushion bony prominences, especially high-risk bony prominences (e.g., hips). Specially designed hip protectors are available; they help absorb the impact of a falling body. Provide a direct light source in areas where the patient reads, cooks, uses tools, or conducts hobby work. Avoid fluorescent lighting because it creates excessive glare. Have the patient select a fire extinguisher that is easy to handle and manipulate. Have a grab bar installed into wall studs at the tub, toilet, and/or shower. Towel bars are not designed to support the weight of the patient.

DIF: Cognitive Level: Application REF: Skill 42.1 OBJ: Identify interventions usedNtoUrRedSuI ceNsG afT etB y. riC skO sM for patients with sensory, cognitive, and mental status alterations.

TOP: Padded Clothing KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 5. When discussing safety measures for the home environment, the nurse should remind the

patient of which key element? a. Set the hot water heater to only 60°C. b. Turn on the cold-water faucet first. c. Use small throw rugs on slippery wood floors. d. Put high-wattage bulbs into all lamps.

ANS: B

Instruct the patient to always turn cold water on first to prevent direct exposure to hot water.

Have the setting on the hot water heater adjusted to 48.8°C or lower. Secure all carpeting, mats, and tile; place nonskid backing under small rugs and door mats. Have the patient check light bulb wattage in all fixtures; this ensures that proper wattage is being used.

DIF: Cognitive Level: Application REF: Skill 42.1 OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations.

TOP: Preventing Scalding KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 6. The patient has been brought to the emergency department by a family member, who states

that she just “doesn’t know what to do.” The patient often forgets where he is and refuses to bathe or change clothes. He will put things on the stove and forget that he has something cooking. She is obviously concerned for her loved one’s safety. The nurse is likely to interpret these symptoms as signs of a. depression. b. amnesia. c. aphasia. d. Alzheimer’s disease.

ANS: D

Alzheimer’s disease is a form of dementia that causes problems with memory, thinking, or behaviour. There is also a risk for wandering, where patients repeatedly try to carry out tasks or leave the place of residence. Depression is a chronic, insidious emotional disorder characterized by feelings of sadness, melancholy, dejection, and worthlessness that are inappropriate and out of proportion to reality. Amnesia is loss of memory. This is only one symptom of Alzheimer’s disease. The patient has several symptoms. Aphasia is the loss of language skills. This is only one symptom of Alzheimer’s disease, and it is not one that the patient’s family member has identified.

DIF: Cognitive Level: Analysis REF: Skill 42.2 OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations.

TOP: Alzheimer’s Disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. While performing a home visit with an elderly patient, the nurse notices that the patient’s

dress is less tidy than in previous visits and finds an open orange juice container in the pantry cabinet instead of the refrigeratN orUaRnS dI aN roGllToB f. paCpO erMtowels in the refrigerator. How should the nurse respond? a. Begin rearranging the patient’s storage, and show her how it needs to be done. b. Tell the patient that this is not acceptable. c. Complete a Mini-Mental State Examination (MMSE) or short Geriatric Depression Scale (SGDS). d. Realize that elderly patients do things differently.

ANS: C

Behavioural changes associated with cognitive dysfunction are evident in a disorderly home and inappropriate placement of objects (e.g., carton of orange juice placed inside kitchen cabinet instead of in refrigerator). If the nurse suspects a cognitive or mental status change, complete an MMSE (e.g., Folstein’s examination) for dementia and/or complete a short GDS for depression. Speak clearly and in a normal tone of voice.

DIF: Cognitive Level: Application REF: Skill 42.2 OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations.

TOP: Cognitive Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 8. A patient with a cognitive deficit becomes agitated and upset about not being able to

remember daily activities. How should the nurse respond to this agitation? a. Tell the patient not to worry about it. b. Provide an easy-to-follow calendar and reinforce the information.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY c. Explain that becoming upset is not going to help the situation. d. Remind the patient that now is the time to rest and relax.

ANS: B

If the patient has difficulty remembering when to perform tasks (e.g., paying bills, taking medicines), help the patient create a list, or post reminder notes in a conspicuous location (e.g., bulletin board, front of refrigerator), provide a medication container organized by days of the week, and recommend a wristwatch with alarm to signal medication administration times. Memory function in older persons tends to be preserved for relevant, well-learned material. Lists and organizers will help the patient cope with memory loss and safely perform activities. Telling the patient not to worry negates the patient’s feelings. Reminding the patient that it is his or her “time to rest and relax” may be seen as a dismissal. False reassurance is not helpful to the patient. Focus on the patient’s abilities, and modify approaches used to perform daily activities.

DIF: Cognitive Level: Application REF: Skill 42.2 OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations.

TOP: Cognitive Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. When communicating with a patient with a cognitive deficit, what is the best way for the

nurse to respond? a. “You managed all of your medications very well today.” b. “Your family should really take over the cooking. It’s too hard for you to do.” c. “I don’t see how you will be able to shop for yourself anymore. Someone will have to do it for you.”

NURSINGTB.COM d. “This schedule will be too difficult for you to remember. I better write it all down.”

ANS: A

Focus on the patient’s abilities rather than disabilities; this retains the patient’s autonomy and sense of self-worth.

DIF: Cognitive Level: Application REF: Skill 42.2 OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations.

TOP: Patient Autonomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. The nurse is visiting an elderly patient who lives with his wife and daughter. He takes several

daily medications, including antihypertensives, antiarrhythmics, diuretics, and pain medication. The patient’s wife states that he takes all of the pills in the morning and some at night. The nurse should examine the pills and suggest which of the following? a. Take the antiarrhythmics and antihypertensives together in the morning to prevent hypotension during sleep. b. Take the diuretics at bedtime. c. Increase the different types of pain medication to prevent addiction to one. d. Administer at bedtime medications that are likely to cause confusion.

ANS: D

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Administer at bedtime medications that are likely to cause confusion to reduce the risk for confusion during waking hours, which contributes to disorientation and the risk for falling.

However, do not recommend this if the patient has nocturia. Space antihypertensives and antiarrhythmics at different times to minimize side effects. Have diuretics taken early in the day and not at night, so that the diuretic effect occurs during the day, while the patient is awake. Reduce the number of pain medications used when possible. Medications create sedative effects, increasing the risk for falls.

DIF: Cognitive Level: Application REF: Skill 42.3 OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations.

TOP: Medication Changes KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 11. Which assistive device would most benefit a patient with a neuromuscular weakness? a. Large-print labels b. A syringe with a magnifier c. Screw-top medication containers d. Colour-coded tops for medications ANS: C

For patients with a weakened grasp or pain in the hands and fingers, have the local pharmacist place medications in a screw-top container. Larger labels and syringe magnifiers are used for patients with visual alterations. Colour-coding systems are designed for patients taking multiple medications.

DIF: Cognitive Level: Application REF: Skill 42.3 N U R S I N GeTdBic. OBJ: Recommend strategies to ensure safe m atC ioO nM administration within the home.

TOP: Medication Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 12. The patient is on neutral protamine Hagedorn (NPH) insulin and regular insulin at home. How

should the nurse teach the patient and the patient’s caregiver to store the insulin? a. In the refrigerator and removed only for administration b. In a warm place such as in a cabinet above the stove c. In the dairy bin of the refrigerator with the cheese and eggs d. At room temperature for up to 30 days ANS: D

Insulin may be stored in the refrigerator, but this is not necessary. Patients can store insulin at room temperature for up to 30 days without losing potency as per the manufacturer’s guidelines. Insulin should be kept in a cool place and away from very warm temperatures. If insulin is stored in the refrigerator, be sure that the medication is in a bin or container away from food.

DIF: Cognitive Level: Application REF: Skill 42.3 OBJ: Recommend strategies to ensure safe medication administration within the home.

TOP: Insulin Storage KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 13. When teaching about medication use in the home, what instructions should the nurse provide

to the patient?

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. b. c. d.

Always keep insulin in the refrigerator.

Put used needles in double paper bags.

Put all of the medication to be taken in one bottle.

Return expired medications to the pharmacy.

ANS: D

Return expired and unused prescription medications to the pharmacy for disposal. This ensures that no one in the household uses a medication not prescribed for their use or that will be ineffective pharmacologically. Insulin may be stored in the refrigerator, but this is not necessary. Discard sharps in puncture-resistant sharps containers or in a 2-L soda bottle with a cap. Do not place different medicines in the same container.

DIF: Cognitive Level: Application REF: Skill 42.3 OBJ: Recommend strategies to ensure safe medication administration within the home.

TOP: Disposal of Outdated Medication KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 14.

is a generalized impairment of intellectual functioning, with the most common form being Alzheimer’s disease. a. Depression b. Dementia c. Delirium d. Stroke ANS: B

Dementia is a generalized impairment of intellectual functioning, with the most common form being Alzheimer’s disease.

NURSINGTB.COM DIF: Cognitive Level: Understanding REF: Skill 42.2 OBJ: Identify patients at risk for safety problems and possible accidents in the home.

TOP: Dementia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Common causes of falls in older patients include which of the following? (Select all that

apply.) a. Gait disturbances b. Muscle weakness c. Visual impairments d. Environmental hazards ANS: A, B, C, D

Environmental hazards, gait disturbances, muscle weakness, and visual impairments are some of the causes of falls in older patients. Polypharmacy adds to the risk.

DIF: Cognitive Level: Comprehension REF: Skill 42.1 OBJ: Describe the factors within a home environment that create risks for patient injury.

TOP: Causes of Falls KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 2. In determining the causes of falls or other injuries within the home, the nurse should assess for

which of the following? (Select all that apply.) a. Symptoms at time of fall b. Activity at the time of the fall c. Date and time of fall d. Injury after fall ANS: A, B, C, D

Encourage patients and caregivers to keep a notebook with information about falls. The notebook should have the headings: “Date,” “Time of Fall,” “Activity at Time of Fall,” “Symptoms,” and “Injury.”

DIF: Cognitive Level: Analysis REF: Skill 42.1 OBJ: Identify interventions that modify the home environment for physical safety.

TOP: SPLATT Mnemonic KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 3. The nurse is assessing the home of an elderly patient for safety issues. Which of the following

actions would reassure the nurse? (Select all that apply.) a. Cleaning the stove top b. Putting a shower chair in the bathroom c. Installing adequate lighting in all living areas d. Placing emergency numbers close to the telephone ANS: A, B, C, D

The kitchen is one of the most hazard-oriented rooms in a home and poses serious hazards for fire. Grease is highly flammable. Stove tops and ovens should be kept clean and grease free. A shower stool allows patients toNsiUt R wS hiI leNsG hoTwBe.riC ngO.MAdequate lighting helps persons see any barriers or uneven walking surfaces. Emergency numbers near the phone are important for all home care patients.

DIF: Cognitive Level: Analysis REF: Skill 42.1 OBJ: Perform a home safety risk assessment.

TOP: Home Safety KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 4. When a caregiver is communicating with a patient, which of the following actions may

facilitate communication? (Select all that apply.) a. Face the patient who has a hearing impairment. b. Avoid eye contact. c. Use simple words. d. Be aware of nonverbal gestures.

ANS: A, C, D

Instruct the caregiver on how to use simple and direct communication: Sit or stand in front of the patient in full view. This promotes reception of verbal and nonverbal messages. Face the patient who has a hearing impairment while speaking so that the patient can see the speaker’s lips. Use a calm and relaxed approach. Use eye contact and touch to help reinforce messages.

Speak slowly, in simple words and short sentences, to enhance understanding of messages.

Use nonverbal gestures that complement verbal messages.

DIF: Cognitive Level: Application REF: Skill 42.2 OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY mental status alterations.

TOP: Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. Activities of daily living (ADLs) include the ability to (Select all that apply.) a. put on clothing. b. go to the toilet. c. feed oneself. d. use a telephone.

ANS: A, B, C

ADLs include the patient’s ability to bathe, dress, go to the toilet, transfer, maintain continence, and feed himself; instrumental ADLs (IADLs) include the ability to use a telephone, prepare meals, travel, do housework, take medication, and shop.

DIF: Cognitive Level: Understanding REF: Skill 42.2 OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations.

TOP: ADLs/IADLs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. Instrumental activities of daily living (IADLs) include the ability to (Select all that apply.) a. prepare meals. b. do housework. c. take medications. d. maintain continence.

ANS: A, B, C

IADLs include the ability to usN eU aR teS leI phNoGnT e,Bp. reC paOrM e meals, travel, do housework, take medication, and shop; ADLs include the patient’s ability to bathe, dress, go to the toilet, transfer, maintain continence, and feed him- or herself.

DIF: Cognitive Level: Understanding REF: Skill 42.2 OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations.

TOP: ADLs/IADLs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. Which of the following are progressive illnesses? (Select all that apply.) a. Dementia b. Depression c. Delirium d. Injury from falls ANS: A, B

Dementia is characterized by a gradual, progressive, irreversible cerebral dysfunction.

Depression is also a progressive illness, and is characterized by functional impairment, lethargy and isolation. Delirium is an acute cognitive condition. Injuries from falls are also acute conditions, which may be influenced by progressive and acute conditions.

DIF: Cognitive Level: Understanding REF: Skill 42.2 OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations.

TOP: Dementia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Chapter 43: Self-Care Teaching in the Community Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition MULTIPLE CHOICE 1. Of the following types of thermometers available, which is not recommended for home use? a. Digital b. Tympanic c. Mercury d. Disposable single-use ANS: C

If a mercury thermometer breaks, and it is not disposed of properly, the mercury gets into the air, posing a major health risk in the home. Educate patients and caregivers about the environmental hazards associated with mercury in the home, and encourage patients to purchase mercury-free thermometers.

DIF: Cognitive Level: Analysis REF: Skill 43.1 OBJ: Discuss situations and conditions that require a patient and/or caregiver to learn skills that support and achieve health maintenance.

TOP: Mercury Thermometers KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 2. Which of the following is essential in teaching the patient how to use a thermometer? a. Reading a digital thermometer b. Shaking down the thermometer before use c. Using the axillary thermometer d. Selecting the most appropriN atUeRthSeI rmNoGmTeB te. r COM ANS: D

Help a patient choose the most appropriate thermometer to use in the home based on the patient’s dexterity, vision, and financial resources. For example, a patient with visual changes from glaucoma or retinopathy is able to read more easily a thermometer with a large digital display. The need for an oral, rectal, or axillary temperature depends on the patient’s age and health status.

DIF: Cognitive Level: Analysis REF: Skill 43.1 OBJ: Identify factors that influence patients’ abilities to learn and care for themselves at home.

TOP: Choosing the Right Thermometer KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 3. What should the nurse first assess when preparing to teach a patient and/or caregiver how to

read a thermometer? a. Patient’s actual temperature b. Patient’s ability to manipulate the thermometer c. Caregiver’s temperature d. Patient’s ability to take a pulse and respiratory rate ANS: B

Assess the patient’s ability to manipulate and read the thermometer. Physical restrictions in handling or reading the thermometer prevent patients from being able to read the thermometer and often require instruction of a caregiver or significant other instead of the patient.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

DIF: Cognitive Level: Analysis REF: Skill 43.1 OBJ: Identify factors that influence patients’ abilities to learn and care for themselves at home.

TOP: Choosing the Right Thermometer KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 4. Which of the following is an appropriate step when teaching temperature monitoring in the

home? a. Suggest aspirin to decrease fevers. b. Recommend using only tympanic membrane sensors. c. Encourage the use of alcohol rubs to reduce fevers. d. Demonstrate the technique and have the patient/caregiver perform it.

ANS: D

Demonstration is the best technique for teaching psychomotor skills. It allows for correction of errors in technique as they occur and for discussion of potential consequences of errors.

Provide rationale for steps to the patient or caregiver. Use caution in recommending aspirin or any other over-the-counter medication or antipyretic medicine for patients whose conditions contraindicate their use. The type of thermometer needed is determined on the basis of the patient’s age and health status. Instruct the patient or caregiver to never use sponging with isopropyl alcohol to lower fever because of the neurotoxic effects that have been reported.

DIF: Cognitive Level: Application REF: Skill 43.1 OBJ: Implement and evaluate evidence-informed learning strategies that support patients’ ability to care for themselves in the home.

TOP: Teaching How to Use the Thermometer KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment

NURSINGTB.COM 5. What should the nurse instruct the patient to do when teaching the patient how to take a

temperature? a. Wait 20 to 30 minutes after smoking or ingesting hot or cold foods. b. Take the temperature immediately upon seeing chills or shivering. c. Wear sterile rubber gloves when taking a rectal temperature. d. Lubricate an oral thermometer with water-soluble lubricant only.

ANS: A

Instruct the patient to take the temperature 20 to 30 minutes after smoking or ingesting hot or cold liquids or foods. This improves the accuracy of temperature readings. To ensure accuracy, teach the patient to take the temperature after chills or shivering subsides. If taking rectal temperature, instruct the patient to lubricate the thermometer tip with water-soluble lubricant, to wear clean, disposable gloves, and to use only a rectal thermometer. Lubrication normally is not needed when one is taking an oral temperature.

DIF: Cognitive Level: Application REF: Skill 43.1 OBJ: Implement and evaluate evidence-informed learning strategies that support patients’ ability to care for themselves in the home.

TOP: Teaching How to Use the Thermometer KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 6. What should the nurse instruct the parents to do when teaching them about temperature

monitoring for a child? a. Use only a glass mercury thermometer.

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY b. Take the temperature after shivering subsides. c. Avoid the use of tepid water sponging for fever. d. Adjust the temperature reading if the child has eaten a popsicle.

ANS: B

Teach the patient to take the temperature after chills or shivering subsides to obtain an accurate temperature. Nurses in home care need to encourage their patients to purchase mercury-free thermometers. Applying cool, moist compresses to the skin is a common therapy for temperature reduction that is safe to perform at home. Wait 30 minutes to take the temperature after the patient has ingested a popsicle.

DIF: Cognitive Level: Application REF: Skill 43.1 OBJ: Implement and evaluate evidence-informed learning strategies that support patients’ ability to care for themselves in the home.

TOP: Utilizing the Thermometer KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 7. In teaching the patient how to take his own blood pressure, which of the following is true? a. Blood pressure cuffs that are too small will give a falsely low reading. b. Blood pressure cuffs that are too large will give a falsely high reading. c. Electronic blood pressure cuffs are just as accurate as other methods. d. The cuff should be placed directly over the skin and not over clothing.

ANS: D

Have clients place the cuff directly on the skin, not over clothing. Blood pressure cuffs that are too small tend to overestimate blood pressure, and cuffs that are too large tend to underestimate blood pressure. Although electronic monitors are easier to use, their accuracy is still a focus of debate.

NURSINGTB.COM DIF: Cognitive Level: Application REF: Skill 43.2 OBJ: Choose evidence-informed teaching strategies to use in the home setting.

TOP: Blood Pressure Devices KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 8. The patient is taking levothyroxine (a thyroid medication) for hypothyroidism. What should

the nurse instruct the patient to do when teaching the patient how to assess her own blood pressure and pulse? a. Withhold the medication if her blood pressure is above the normal range or if her pulse is more than 100 beats per minute. b. Withhold the medication if her blood pressure is below the normal range or if her pulse is less than 60 beats per minute. c. Never withhold her medication. Have the patient take it and notify the physician at the next office visit. d. Withhold her medication only if both her blood pressure and pulse rate are too high.

ANS: A

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Instruct patients taking thyroid medications to withhold medications when blood pressure is above the normal range or when pulse is more than 100 beats per minute. Confirm with the prescriber specific guidelines for blood pressure and pulse, document information in the home care record, and provide clear, written instructions for the patient. Beta-blockers (e.g., propranolol), calcium channel blockers (e.g., verapamil hydrochloride), or cardiac glycosides (e.g., digoxin) often are withheld if blood pressure is below normal range and/or pulse is less than 60 beats per minute.

DIF: Cognitive Level: Analysis REF: Skill 43.2 OBJ: Choose evidence-informed teaching strategies to use in the home setting.

TOP: Teaching Considerations KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 9. In teaching the patient how to perform intermittent self-catheterization, the nurse instructs

which of the following? a. Only strict aseptic technique should be used. b. Intermittent self-catheterization should only be done once a day. c. Clean intermittent self-catheterization increases the chance for infection. d. Clean intermittent self-catheterization is a safe and effective method.

ANS: D

Clean intermittent self-catheterization (CISC) is a safe and effective way to empty the bladder.

Current practice supports CISC for use in the home to provide a means to completely empty the bladder, prevent urinary tract infection, and prevent further bladder and kidney damage.

Some hospital policies recommend sterile technique; others recommend clean technique.

DIF: Cognitive Level: Application REF: Skill 43.3 OBJ: Choose evidence-informedNtU eaR chSinIgNstG raT teB gi. esCtO oM use in the home setting.

TOP: Clean Intermittent Catheterization KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 10. When teaching the patient and caregiver about clean intermittent self-catheterization (CISC),

why is it important for the nurse to teach about the signs and symptoms of complications? a. Although rare, complications are always severe. b. It is part of the process; complications almost never occur. c. Urinary complications are common with CISC. d. The only major complication is infection.

ANS: C

Urinary complications are common in patients who use CISC. Verbalization of signs and symptoms of complications helps patients identify potential problems early and seek appropriate care. Signs and symptoms of complications of CISC include urinary tract infection (UTI) and urethral trauma and bleeding.

DIF: Cognitive Level: Application REF: Skill 43.3 OBJ: Choose evidence-informed teaching strategies to use in the home setting.

TOP: Clean Intermittent Catheterization KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 11. When being taught clean intermittent self-catheterization (CISC), at what interval should the

patient be taught to replace the catheter? a. With each use

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY b. Daily c. Weekly d. Monthly ANS: D

Teach the patient to replace the catheter every 2 to 4 weeks or when it becomes cracked or brittle, has any buildup of sediment, or loses its form.

DIF: Cognitive Level: Comprehension REF: Skill 43.3 OBJ: Choose evidence-informed teaching strategies to use in the home setting.

TOP: Replacing the Catheter KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 12. What is the principal difference in tracheostomy care between care given in the acute care

setting and care given in the home care environment? a. In the acute care setting, the inner cannula is cleaned. b. In the home care setting, dressings are not necessary. c. In the acute care setting, hydrogen peroxide is used for cleaning. d. In the home care setting, the procedure may be done with clean technique.

ANS: D

The indications for performing tracheostomy care and suctioning in the home are similar to those for tracheostomy care and suctioning in the hospital, except for one key variable: the use of medical asepsis or clean technique. In the hospital, principles of surgical asepsis are used because the patient is more susceptible to infection and because the hospital contains more virulent or pathogenic microorganisms than are usually present in the home setting. In the home setting, most patients use clean technique. Inner cannula care is performed both at home and in the acute care setting. ThNeUiR nnSeI r cNaG nnTuBla.iC sO avMailable in both disposable and nondisposable forms. Fresh tracheostomy dressings protect the skin around the stoma from pressure breakdown and collect secretions; they are necessary in both acute care and home care settings. Hydrogen peroxide may be used in both home care and acute care settings.

DIF: Cognitive Level: Comprehension REF: Skill 43.5 OBJ: Discuss situations and conditions that require a patient and/or caregiver to learn skills that support and achieve health maintenance.

TOP: Differences in Tracheostomy Care Between Home Care and Acute Care Settings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. What is an expected outcome after tracheostomy care is successfully performed? a. A stoma site that is hard to the touch b. An inner cannula that is free of secretions c. Copious secretions obtained from suctioning d. Bloody secretions that have been suctioned ANS: B

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

A stoma site that is clean and free of infection and transesophageal fistula and an inner cannula that is free of secretions indicate that tracheostomy care is successful. If the stoma site is reddened or hard, with or without drainage, evaluate the cleaning regimen for continued use of clean technique and increase tracheostomy care frequency. This is an unexpected outcome.

Copious coloured secretions present around the stoma or when the patient is suctioned are an unexpected outcome. Bloody secretions are an unexpected outcome and require evaluation of suctioning technique and frequency and size of the catheter.

DIF: Cognitive Level: Application REF: Skill 43.5 OBJ: Discuss situations and conditions that require a patient and/or caregiver to learn skills that support and achieve health maintenance.

TOP: Unexpected and Expected Outcomes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. The nurse is teaching the patient and caregiver how to perform tracheal suctioning. What does

proper technique include? a. Teaching how to instill normal saline before suctioning b. Suctioning the nasal and oral pharynx before the trachea c. Encouraging daily brushing of the teeth and oral hygiene d. Having the patient take two to three deep breaths after the procedure ANS: D

At the conclusion of the procedure, have the patient take two to three deep breaths, and determine whether symptoms that necessitated suctioning are no longer present. Deep breathing reduces oxygen loss and prevents hypoxia. Expect the patient’s respiratory status to improve after suctioning. Use of normal saline adversely affects arterial and global tissue oxygenation and dislodges bacterial colonies; therefore this can contribute to lower airway contamination. After suctioningNU thR eS paItiN enGt,TtB ea.chCO hiM m or her to suction the nasal and oral pharynx, and give mouth care. Encourage the patient or caregiver to brush the teeth with a small, soft toothbrush two times a day, and to use mouth moisturizer and moisturize the lips every 2 to 4 hours.

DIF: Cognitive Level: Application REF: Skill 43.5 OBJ: Discuss situations and conditions that require a patient and/or caregiver to learn skills that support and achieve health maintenance.

TOP: Suctioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 15. When teaching the patient about performing tracheostomy care, which of the following

actions is an acceptable technique? a. Remove the old ties before applying the new. b. Keep two tracheostomy tubes of the same size at the bedside. c. Place the new tracheostomy tie, then remove the old tie. d. Dispose of all old supplies and replace with new.

ANS: C

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

During tracheostomy care, the patient is at risk for the tracheostomy tube coming out. Never remove the old tracheostomy tube ties until the new ties have been secured properly. Keep two tracheostomy tubes, one the same size as the patient’s and one a size smaller, at the patient’s bedside, so you can insert a new tube if the tube comes out. Clean reusable supplies in warm, soapy water. Rinse thoroughly, and dry between two layers of clean paper towels.

Store supplies in a loosely closed clear plastic bag.

DIF: Cognitive Level: Application REF: Skill 43.5 OBJ: Discuss situations and conditions that require a patient and/or caregiver to learn skills that support and achieve health maintenance.

TOP: Tracheostomy Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 16. What is an appropriate technique to use when teaching an older patient about self-medication

in the home? a. Speak very loudly. b. Teach the caregiver separately. c. Provide frequent pauses. d. Provide fewer but longer teaching sessions.

ANS: C

Provide frequent pauses so the patient can ask questions and express understanding of content.

Use short sentences and speak in a slow, low-pitched voice. Effective teaching strategies for older persons may include involvement of a family member or caregiver. Provide frequent, short teaching sessions.

DIF: Cognitive Level: Application REF: Skill 43.6 N U R S I N TeBd.leCarOniMng strategies that support patients’ ability to OBJ: Implement and evaluate evidence-infoG rm care for themselves in the home.

TOP: Teaching Older Patients KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 17. The patient’s caregiver is checking the patient’s nasogastric (NG) tube for gastric residual

before proceeding with the patient’s next feeding. The patient aspirates 150 mL of residual.

What should the caregiver do now? a. Hold the feeding. b. Contact the health care provider. c. Proceed with the feeding, but do not return the aspirated contents to the stomach. d. Proceed with the feeding after returning the aspirated contents to the stomach.

ANS: D

Have the patient return aspirated contents to stomach and continue feed if volume is less than or equal to 250 mL. The feeding should not be held, and this is not a reason to contact the health care provider.

DIF: Cognitive Level: Application REF: Skill 43.7 OBJ: Implement and evaluate evidence-informed learning strategies that support patients’ ability to care for themselves in the home.

TOP: Gastric Residual KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. What does the nurse teach the patient and caregiver to do when setting up and changing

administration sets for continuous tube feedings to preserve medical asepsis?

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY a. b. c. d.

Add formula to formula already hung to prevent waste.

Store unused formula at room temperature to prevent spasm.

Hang only enough formula that will be infused in a 4- to 6-hour period.

Change the administration set every 48 hours.

ANS: C

Limit the amount of formula “hung” at one time to an amount that can be infused in a 4- to 6-hour period (less time in warmer weather to minimize risk for microorganism contamination). Do not add formula to a hanging bag. Using refrigeration and limiting “hang” time reduce microorganisms. Changing administration sets every 24 hours reduces microorganism growth.

DIF: Cognitive Level: Application REF: Skill 43.7 OBJ: Implement and evaluate evidence-informed learning strategies that support patients’ ability to care for themselves in the home.

TOP: Asepsis with Tube Feedings KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 19. Information that should be provided to the caregiver of a patient with a nasogastric (NG) tube

includes a. keeping the head of the bed lowered for feedings. b. keeping unused formula at room temperature. c. aspirating every 4 hours when receiving continuous drip feedings. d. returning the gastric contents if the residual exceeds 250 mL. ANS: C

Patients and caregivers need to document intake and output (I&O), daily weights, amount of gastric fluid aspirated before eaNcU hR feS edIinNgG(T orBe.vC erO yM4 hours if receiving continuous feeding), date and time of feedings, amount and type of formula, any additives, and date and time administration sets are changed. Instruct the patient or caregiver that the patient should sit up in a chair or have the head of the bed elevated at least 30 to 45 degrees while receiving feedings or medications, or when the tube is flushed. Refrigerate unused formula. Have the patient return aspirated contents to stomach and continue feed if aspirated gastric volume is less than or equal to 250 mL. DIF: Cognitive Level: Application REF: Skill 43.7 OBJ: Implement and evaluate evidence-informed learning strategies that support patients’ ability to care for themselves in the home.

TOP: Management of Tube Feedings KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 20. A patient is discharged and is sent home with enteral feedings. What instructions should the

nurse give to the caregiver? a. Flush the tube out after administering medications. b. Keep the tube loose to allow for patient movement. c. Use sterile technique when preparing and administering feedings. d. Hang enough formula each time to cover 8 to 12 hours of feeding.

ANS: A

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

Discuss flushing of the tube after administration of feedings or medications to prevent clogging. Discuss measures to stabilize the feeding tube in patients with abdominal tubes and to protect skin integrity. Perform hand hygiene to reduce the transfer of microorganisms.

Sterile technique is not needed. Limiting the amount of formula “hung” at one time to an amount that can be infused in a 4- to 6-hour period will help limit bacterial growth.

DIF: Cognitive Level: Application REF: Skill 43.7 OBJ: Implement and evaluate evidence-informed learning strategies that support patients’ ability to care for themselves in the home.

TOP: Management of Tube Feedings KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 21. What instructions should the nurse provide when teaching the patient and the patient’s

caregiver how to administer parenteral nutrition (PN)? a. PN solution should be kept refrigerated until time of administration. b. Remixing separated mixture components by shaking the bag is common. c. PN is incompatible with most intravenous (IV) medications. d. Blood glucose monitoring will be necessary.

ANS: D

PN increases blood glucose levels, which negatively affects patient outcomes. Frequent monitoring of glucose helps the caregiver detect problems early. Expect testing frequency to decrease as the patient’s condition and response to PN stabilize. Suggest taking PN solution out of the refrigerator for 30 to 60 minutes before scheduled infusion time. Chilled solution often causes discomfort; allowing the solution to warm enhances comfort during infusion. If a precipitate appears, if components of the mixture are separated, or if the colour changes, explain that the solution needs to be discarded. Explain that PN is incompatible with most medications; do not add medicaNtiUoR nsStI oN thGeTPB N.thCaO tM are not prescribed to be added.

DIF: Cognitive Level: Application REF: Skill 43.8 OBJ: Implement and evaluate evidence-informed learning strategies that support patients’ ability to care for themselves in the home.

TOP: Glucose Monitoring With PN KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 22. Temperatures in the older person are different from those in the younger adult. The nurse

knows that older persons’ normal temperatures often range less than a. 34.2°C b. 34.8°C c. 35°C d. 36.1°C ANS: D

Mean oral temperature for older persons often ranges less than 36.1°C (97°F); therefore temperatures considered within the normal range sometimes reflect a fever in the older person.

DIF: Cognitive Level: Understanding REF: Gerontological (Skill 43.1) OBJ: Discuss situations and conditions that require a patient and/or caregiver to learn skills that support and achieve health maintenance.

TOP: Temperature of Older Persons KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 23. Oxygen-conserving devices (OCDs) reduce the amount of oxygen the patient uses, resulting

in an overall cost reduction to the patient. The type of OCD that stores oxygen in a chamber during the expiratory phase of respirations is known as the a. reservoir nasal cannula. b. demand pulsing oxygen-delivery systems. c. transtracheal oxygen catheter. d. nonrebreather mask.

ANS: A

The reservoir nasal cannula stores oxygen in a chamber during the expiratory phase of respirations. Demand pulsing oxygen-delivery systems deliver a burst of oxygen at the onset of inspiration. Transtracheal oxygen catheters deliver oxygen directly through a catheter placed between the second and third tracheal rings. The nonrebreather mask is used for patients in acute respiratory failure.

DIF: Cognitive Level: Understanding REF: Skill 43.4 OBJ: Discuss situations and conditions that require a patient and/or caregiver to learn skills that support and achieve health maintenance.

TOP: Reservoir Nasal Cannula KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 24. Oxygen-conserving devices (OCDs) reduce the amount of oxygen the patient uses, resulting

in an overall cost reduction to the patient. The type of OCD that delivers oxygen only during inspiration is called a . a. reservoir nasal cannula b. demand pulsing oxygen-delivery system c. transtracheal oxygen catheter d. nonrebreather mask

NURSINGTB.COM

ANS: B

Demand oxygen delivery systems deliver a burst of oxygen only during inspiration. The reservoir nasal cannula stores oxygen in a chamber during the expiratory phase of respirations. Transtracheal oxygen catheters deliver oxygen directly through a catheter placed between the second and third tracheal rings. The nonrebreather mask is used for patients in acute respiratory failure.

DIF: Cognitive Level: Understanding REF: Skill 43.4 OBJ: Discuss situations and conditions that require a patient and/or caregiver to learn skills that support and achieve health maintenance.

TOP: Reservoir Nasal Cannula KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 25. A

delivers oxygen through a catheter permanently inserted into the trachea, thus allowing the patient to speak and bypassing anatomical dead space. a. reservoir nasal cannula b. demand pulsing oxygen-delivery systems c. transtracheal oxygen catheter d. nonrebreather mask ANS: C

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

A transtracheal oxygen catheter delivers oxygen through a catheter permanently inserted into the trachea, thus allowing the patient to speak and bypassing anatomical dead space. The reservoir nasal cannula stores oxygen in a chamber during the expiratory phase of respirations. Demand pulsing oxygen-delivery systems deliver a burst of oxygen at the onset of inspiration. The nonrebreather mask is used for patients in acute respiratory failure.

DIF: Cognitive Level: Understanding REF: Skill 43.4 OBJ: Discuss situations and conditions that require a patient and/or caregiver to learn skills that support and achieve health maintenance.

TOP: Reservoir Nasal Cannula KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 26. While teaching how to check for gastric residual volume (GRV), the nurse instructs the

caregiver to refeed the tube feeding if he or she obtains less than aspirate. a. 250 b. 300 c. 350 d. 500

mL of gastric

ANS: A

If gastric aspirates are less than 250 mL, instruct the patient or caregiver to return gastric contents and continue the feed.

DIF: Cognitive Level: Understanding REF: Skill 43.7 OBJ: Implement and evaluate evidence-informed learning strategies that support patients’ ability to care for themselves in the home.

TOP: Gastric Residual KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance

NURSINGTB.COM MULTIPLE RESPONSE 1. Expected outcomes for patients who are being taught how to use a thermometer include which

of the following outcomes? (Select all that apply.) a. Ability to correctly measure temperature b. Ability to properly clean and store the thermometer c. Knowledge of normal temperature ranges d. Knowledge of signs and symptoms of fever ANS: A, B, C, D

Expected outcomes after completion of the procedure include that the patient is able to correctly measure temperature; demonstrate proper cleaning and storage of equipment; and state normal temperature range and factors that affect temperature, signs and symptoms of fever and hypothermia, and measures to take with abnormal temperatures.

DIF: Cognitive Level: Analysis REF: Skill 43.1 OBJ: Implement and evaluate evidence-informed learning strategies that support patients’ ability to care for themselves in the home.

TOP: Expected Outcomes of Teaching How to Use the Thermometer KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 2. Which of the following clinical findings are signs of hyperthermia? (Select all that apply.) a. Dry, warm, flushed skin

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY b. Chills and piloerection c. Uncontrolled shivering d. Loss of memory ANS: A, B

Symptoms of fever include warm, dry, flushed skin; feeling warm; chills; piloerection; malaise; and restlessness. The patient needs to recognize the onset of fever in him- or herself or family members for early detection and intervention. Symptoms of hypothermia include cool skin, uncontrolled shivering, loss of memory, and signs of poor judgment.

DIF: Cognitive Level: Analysis REF: Skill 43.1 OBJ: Implement and evaluate evidence-informed learning strategies that support patients’ ability to care for themselves in the home.

TOP: Signs of Hyperthermia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse is teaching the patient about the signs of hypothermia. He or she teaches that signs

of hypothermia include which of the following clinical manifestations? (Select all that apply.) a. Piloerection b. Restlessness c. Cool skin d. Uncontrolled shivering ANS: C, D

Symptoms of hypothermia include cool skin, uncontrolled shivering, loss of memory, and signs of poor judgment. Symptoms of fever include warm, dry, flushed skin; feeling warm; chills; piloerection; malaise; and restlessness. The patient needs to recognize onset of fever in him- or herself or family members for early detection and intervention.

NURSINGTB.COM DIF: Cognitive Level: Analysis REF: Skill 43.1 OBJ: Implement and evaluate evidence-informed learning strategies that support patients’ ability to care for themselves in the home.

TOP: Signs of Hypothermia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. In teaching the patient how to take his or her own blood pressure, the nurse instructs the

patient to avoid which of the following actions 30 minutes before taking blood pressure (BP)?

(Select all that apply.) a. Exercise b. Caffeine c. Smoking d. Resting ANS: A, B, C

Encourage the patient to avoid exercise, caffeine, and smoking for 30 minutes before assessment to avoid an inaccurate reading. These factors cause elevations in BP and pulse.

Have the patient rest at least 5 minutes before measurement to reduce anxiety that can falsely elevate readings.

DIF: Cognitive Level: Comprehension REF: Skill 43.2 OBJ: Choose evidence-informed teaching strategies to use in the home setting.

TOP: Factors That Affect Blood Pressure KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY 5. In teaching the patient the best sites for assessing blood pressure (BP), which of the following

actions should the patient be taught to avoid? (Select all that apply.) a. Sites with intravenous catheters b. Arms with arteriovenous shunts c. Arms on the side of mastectomy d. The left arm after a heart attack ANS: A, B, C

The patient should be taught to avoid applying the cuff to an arm with an intravenous (IV) catheter with or without fluids infusing, an arteriovenous shunt, breast or axillary surgery, trauma, inflammation, disease, or a cast or bulky bandage. Application of pressure from an inflated bladder temporarily impairs blood flow and compromises circulation in the extremity that already has impaired circulation. There is no restriction on the BP cuff site in a heart attack patient unless he or she has one of the previously listed conditions.

DIF: Cognitive Level: Analysis REF: Skill 43.2 OBJ: Choose evidence-informed teaching strategies to use in the home setting.

TOP: Factors That Affect Blood Pressure Site Selection KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 6. The patient needs to be taught the signs of hypoxia. Which of the following outcomes are

causes of hypoxia? (Select all that apply.) a. Incorrect flow rate b. Poor oxygen tubing connection c. Use of long oxygen tubing d. Airway plugging ANS: A, B, C, D

NURSINGTB.COM

Hypoxia sometimes occurs at home when a patient uses oxygen. Possible causes of hypoxia include poor tubing connections, use of long oxygen tubing, and worsening of the patient’s physical problem with changes in respiratory status. Assess the patient for changes in respiratory status, such as airway plugging, respiratory tract infection, or bronchospasm.

DIF: Cognitive Level: Comprehension REF: Skill 43.4 OBJ: Implement and evaluate evidence-informed learning strategies that support patients’ ability to care for themselves in the home.

TOP: Causes of Hypoxia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The nurse will train the tracheostomy patient and caregiver that reusable supplies need to be

disinfected at least weekly. Which of the following methods is recommended for cleaning tracheostomy supplies at home? (Select all that apply.) a. Boil reusable (boilable) supplies for 5 minutes. Allow to cool and dry. b. Boil reusable (boilable) supplies for 15 minutes. Allow to cool and dry. c. Soak reusable supplies in equal parts of vinegar and water for 30 minutes.

Remove, rinse thoroughly, and dry. d. Soak reusable supplies in prepared solutions of quaternary ammonium chloride compounds according to the manufacturer’s instructions. Rinse and dry.

ANS: B, C, D

TEST BANK FOR CANADIAN CLINICAL NURSING SKILLS AND TECHNIQUES 1ST EDITION BY PERRY

To disinfect supplies, use one of these methods as described: (1) Boil reusable (boilable) supplies for 15 minutes. Allow to cool and dry. (2) Soak reusable supplies in equal parts of vinegar and water for 30 minutes. Remove, rinse thoroughly, and dry. (3) Soak reusable supplies in prepared solutions of quaternary ammonium chloride compounds according to the manufacturer’s instructions. Rinse and dry.

DIF: Cognitive Level: Application REF: Skill 43.5 OBJ: Discuss situations and conditions that require a patient and/or caregiver to learn skills that support and achieve health maintenance.

TOP: Tracheostomy Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 8. In preparing to teach a patient how to self-administer mediation, the nurse realizes that many

patients who are instructed to self-medicate for preventative care fail to do so. Reasons for this include which of the following rationales? (Select all that apply.) a. Fear of adverse events b. Inconvenient medication regimens c. Costly prescriptions d. Forgetfulness ANS: A, B, C, D

Some barriers to medication adherence include fear of adverse reactions from medications, belief that a medication does not help, inconvenience of taking medication, cost of medication, inadequate knowledge, forgetfulness, and lack of social support.

DIF: Cognitive Level: Comprehension REF: Skill 43.6 OBJ: Discuss situations and conditions that require a patient and/or caregiver to learn skills that support and achieve health mainteN naUnR ceS. INTGOTPB : .FC aiO luM re to Self-Medicate KEY: Nursing Process Step: Planning MSC: NCLEX: Safe and Effective Care Environment