Chapter 34: Infection Prevention and Control Nursing School Potter & Perry: Fundamentals, Exams of Nursing

Download Chapter 34: Infection Prevention and Control Nursing School Potter & Perry: Fundamentals and more Exams Nursing in PDF only on Docsity! Chapter 34: Infection Prevention and Control Nursing School Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank Latest Update ,GRADED A+ MULTIPLE CHOICE 1. The client has a 6-inch laceration on his right forearm. The arm develops an infection. Which of the following is a sign of an acute inflammatory process? 1. A blanching of the skin 2. A decrease in temperature at the site 3. A decrease in the number of white blood cells 4. A release of histamine that adds to the pain response ANS: 4 A sign of an acute inflammatory process is pain. The swelling of inflamed tissues increases pressure on nerve endings, causing pain. Chemical substances such as histamine also stimulate nerve endings, adding to the pain response. The skin is not blanched; but rather, with the increase in local blood flow; it is reddened. The symptom of localized warmth results from a greater volume of blood at the inflammatory site. The cellular response of acute inflammation involves WBCs arriving at the site. There is an increase in WBCs, rather than a decrease. 2. A female client has been undergoing diagnostic testing since admission to the medical unit in the hospital. The results of blood testing are sent back to the unit. Upon reviewing the results, the nurse will report which of the following findings to the physician, which is abnormal? 1. Erythrocyte sedimentation rate (ESR) 35 mm/hr 2. White blood cell (WBC) count 8000/mm3 3. Neutrophils 65% 4. Iron 75 g/100 mL ANS: 1 The normal erythrocyte sedimentation rate for women is 20 mm/hr. The client’s ESR is 35 mm/hr., indicating the presence of the inflammatory process. The normal WBC count is 5000-10,000/mm3. The client is within normal limits at 8000/mm3. The normal neutrophil count is 55-70%. The client is within normal limits at 65%. The normal iron level is 60-90 g/100 mL. The client is within normal limits at 75 g/100 mL. 3. The nurse is observing the new staff member work with the client. Of the following activities, which one has the greatest possibility of contributing to a nosocomial infection and requires correction? 1. Washing hands before applying a dressing 2. Taping a plastic bag to the bed rail for tissue disposal 3. Placing a Foley catheter bag on the bed when transferring a client 4. Using alcohol to cleanse the skin before starting an intravenous line ANS: 3 The staff member who places the Foley catheter bag on the bed when transferring the client is placing the client at risk for a nosocomial infection because urine in the catheter or drainage tube may reenter the bladder (reflux). Washing hands before applying a dressing is a correct action to help prevent a nosocomial infection. Taping a plastic bag to the bed rail for tissue disposal is a correct action to aid the client in proper disposal of secretions. Using alcohol to cleanse the skin before starting an intravenous line is a correct action to prevent a nosocomial infection of the bloodstream. 4. Droplet precautions will be instituted for the client admitted to the infectious disease unit with: 1. Streptococcal pharyngitis 2. Herpes simplex 3. Pertussis 4. Measles ANS: 1 Droplet precautions are instituted when droplets are larger than 5 micrometers, such as in the case of streptococcal pharyngitis. Contact precautions are instituted for herpes simplex. Airborne precautions are instituted with pulmonary TB. Airborne precautions are instituted with measles. 5. In a small rural hospital they work with a wide variety of clients. Of this afternoon clients admitted, the nurse acknowledges the client with the highest susceptibility to infection is the individual with: 1. Burns 2. Diabetes 3. Pulmonary emphysema 4. Peripheral vascular disease ANS: 1 Burn clients have a very high susceptibility to infection because of the damage to skin surfaces. This would be the individual with the highest risk for infection. Victims of chronic diseases such as diabetes To prevent the transmission of hepatitis A, the nurse needs to take special care when handling feces. Hepatitis B and C may be found in blood. Hepatitis A is not found in saliva. Hepatitis A is not found in vaginal secretions. 11. The parent of a preschool child asks the nurse how chickenpox (varicella zoster) is transmitted. The nurse identifies that the virus is: 1. Carried by a vector organism 2. Carried through the air in droplets after sneezing or coughing 3. Transmitted through person-to-person contact 4. Acquired through contact with contaminated objects ANS: 2 Varicella zoster virus (chickenpox) is transmitted by droplets carried through the air after sneezing or coughing. Varicella zoster virus (chickenpox) is not transmitted by a vector. Person-to-person contact is not responsible for varicella zoster virus (chickenpox) transmission. The transmission of varicella zoster virus (chickenpox) does not occur by contact with contaminated objects. 12. While working with clients in the postoperative period, the nurse is very alert to the results of laboratory tests. Which one of the following results is indicative of an infectious process? 1. Iron 80 g/100 mL 2. Neutrophils 65% 3. White blood cells (WBC) 18,000/mm3 4. Erythrocyte sedimentation rate (ESR) 15 mm/hr ANS: 3 An elevated WBC count is indicative of an acute infection. The normal WBC count is 5000 to 10,000/mm3. The normal neutrophil count is 55%-70%. The client is within normal limits at 65%. The normal iron level is 60-90 g/100 mL. The client is within normal limits at 80 g/100 mL. The normal erythrocyte sedimentation rate (ESR) is up to 15 mm/hr for men and up to 20 mm/hr for women. The client is within normal limits at 15 mm/hr. 13. Which of the following is an example of a nursing intervention that is implemented to reduce a reservoir of infection for a client? 1. Covering the mouth and nose when sneezing 2. Wearing disposable gloves 3. Isolating client’s articles 4. Changing soiled dressings ANS: 4 To control or eliminate reservoir sites for infection, the nurse eliminates or controls sources of body fluids, drainage, or solutions that might harbor microorganisms. The nurse also carefully discards articles that become contaminated with infectious material such as in changing soiled dressings. Covering the mouth and nose when sneezing is an intervention to control a portal of exit. Wearing disposable gloves helps protect the susceptible host. Isolating client’s articles is an intervention to control transmission. 14. In preventing and controlling the transmission of infections, the single most important technique is: 1. Hand hygiene 2. The use of disposable gloves 3. The use of isolation precautions 4. Sterilization of equipment ANS: 1 The most important and most basic technique in preventing and controlling transmission of infections is hand hygiene. Use of disposable gloves may help reduce the transmission of infections, but is not the single most important technique to prevent and control the transmission of infections. The use of isolation precautions is not the single most important technique to prevent and control the transmission of infections. Sterilization of equipment is not the single most important technique to prevent and control the transmission of infections. 15. A client with active tuberculosis is admitted to the medical center. The nurse recognizes that admission of this client to the unit will require the implementation by the staff of: 1. Airborne precautions 2. Droplet precautions 3. Contact precautions 4. Reverse isolation ANS: 1 A client with active tuberculosis requires airborne precautions. A client with active tuberculosis does not require droplet precautions, as the droplet nuclei of tuberculosis are smaller than 5 micrometers. Contact precautions are not necessary for the client with active tuberculosis. Reverse isolation is not required for the client with active tuberculosis 16. The nurse recognizes the appropriate procedures for sterile asepsis. Of the following, which action is consistent with sterile asepsis? 1. Clean forceps may be used to move items on the sterile field. 2. Sterile fields may be prepared well in advance of the procedures. 3. The first small amount of sterile solution should be poured and discarded . 4. Wrapped sterile packages should be opened starting with the flap closest to the nurse. ANS: 3 Before pouring the solution into the container, the nurse pours a small amount (1 to 2 mL) into a disposable cap or plastic-lined waste receptacle. The discarded solution cleans the lip of the bottle. This action is consistent with sterile asepsis. Sterile forceps should be used to move items on a sterile field when using sterile asepsis. Sterile fields should not be prepared well in advance of a sterile procedure. A sterile object or field becomes contaminated by prolonged exposure to air. Wrapped sterile packages should be opened starting with the flap farthest away from the nurse (i.e., the top flap). 17. Older adult clients may react differently to infectious processes and a nurse suspects that her older adult client may be experiencing hypostatic pneumonia. The nurse must be alert to atypical signs and symptoms, such as: 1. Hypotension 2. Confusion 3. Erythema – inflammation of skin cells 4. Chills ANS: 2 An infection in older adults may not present with typical signs and symptoms. Atypical symptoms such as confusion, incontinence, or agitation may be the only symptoms of an infectious illness. An unexplained increased heart rate, confusion, or generalized fatigue may be the only symptoms of pneumonia in the older adult. Hypotension is not one of the atypical symptoms of an older adult experiencing infection. It may be a symptom of a systemic infection related to an elevation in body temperature (regardless of age). Erythema is a typical symptom of a localized infection. Chills are a typical symptom of a systemic infection. 18. What is the correct order for a nursing assistant for putting on the protective equipment when caring for a client in isolation? 1. A 56-year-old with a urinary catheter 2 days after prostatectomy 2. A 27-year-old diagnosed with human immunodeficiency virus (HIV) 3. A 43-year-old who is 3 days post appendectomy and is currently afebrile –without fever 4. A 16-year-old with a compound fractured femur as a result of a bike accident ANS: 4 Clients are at risk for acquiring infections because of lower resistance to infectious microorganisms, increased exposure to numbers and types of disease-causing microorganisms, and invasive procedures. The exposure to earth-bound microorganisms makes the compound fracture client at the greatest risk since that risk is uncontrollable. 24. A nurse is caring for a client who has colonized methicillin-resistant Staphylococcus aureus (MRSA). Which of the following statements reflects the best understanding of the client’s condition? 1. This client has the bacteria present but it hasn’t become infected. 2. This makes the clients MRSA very infectious and so a danger to others. 3. Just be sure to follow standard precautions and there won’t be a problem. 4. The client needs to be watched closely for a conversion to active MRSA. ANS: 1 If a microorganism is present or invades a host, grows, and/or multiplies but does not cause infection, this is referred to as colonization. 25. The greatest drawback to the routine use of antibacterial hand soaps and gels is that they: 1. Are expensive 2. Irritate the skin 3. Kill resident flora 4. Encourage resistant bacteria ANS: 3 Antibacterial products kill resident flora and that can lead to the development of infection. The remaining options may be true but they are not the primary negative outcome of the regular use of antibacterial hand cleansing products. 26. The nurse knows that Staphylococcus aureus found normally on the skin of a client who has had surgery poses a particular risk for that client developing: 1. A cold sore 2. Gastroenteritis 3. A wound infection 4. A urinary tract infection ANS: 3 Staphylococcus aureus found normally on/in skin, hair, anterior nares, and the mouth can result in wound infections, pneumonia, food poisoning, and cellulitis. Streptococcus (-hemolytic group B) organisms may result in urinary tract infections or gastroenteritis while herpes simplex is viral in nature. 27. What is the most appropriate answer to the client’s question, What is the difference between antibacterial and antimicrobial hand soaps? 1. There is no real difference; use the less expensive. 2. Antibacterial soaps are more effective at preventing infections. 3. Antimicrobial soap is better since it won’t kill the good bacteria on the skin. 4. Any soap will do; it’s the technique for proper hand washing that is the key. ANS: 3 The use of antimicrobial hand hygiene products is recommended because they remove transient organisms but leave resident flora intact. There is a difference in the products and it is true that the effectiveness of hand hygiene is dependent on proper technique, but the clients question is best answered by the information provided in option 3. 28. A presurgical client asks the nurse why it seems so easy to get an infection in the wound after surgery. The nurse’s most appropriate response to this question is: 1. The contaminated dressing acts as a breeding ground for microorganisms that then infect the wound. 2. The body’s immune system is weakened by the surgery and can’t fight off the infection as effectively. 3. While infections occur, there are many very effective antibiotics available to help minimize the risk of that happening. 4. The surgical wound provides the microorganisms on the surrounding skin a path to enter deep into the body’s tissues. ANS: 4 Resident skin microorganisms are not virulent. However, they can cause serious infection when surgery or other invasive procedures allow them to enter deep tissues. While the other options are not incorrect, they do not answer the clients question as effectively. 29. The nurse obtains a new, dry nebulizer when preparing to give an elderly asthmatic client a nebulizer treatment because the risk of infection is increased because: 1. The client’s age increases the risk factor for potential infection 2. The client’s immune system is compromised as a result of asthma 3. There is a potential presence of Pseudomonas organisms in the reservoir 4. There is a chance for microorganisms to enter the body via the respiratory system ANS: 3 Pseudomonas organisms survive and multiply in nebulizer reservoirs used in the care of clients with respiratory problems. While the remaining options are correct, they are not the primary reason for getting a new, dry nebulizer. 30. A client is told that he is a carrier of the hepatitis B virus. When asked to explain this situation in more detail, the nurse’s best response is: 1. You need to be careful not to pass the virus to other people. 2. You aren’t sick, but you do have the virus within your body. 3. Be tested often so as to monitor whether the virus becomes active. 4. While you show no signs of the illness, you can pass the virus to others. ANS: 4 Carriers are persons who show no symptoms of illness but who have pathogens on or in their bodies that are transferred to others. While the other options are not incorrect, they do not address the clients questions as directly as does the answer. 31. The nurse can best minimize the risk for infection when initiating an intravenous site by: 1. Proper vein site selection 2. Effective topical skin preparation 3. Appropriate site dressing 4. Gloving for the procedure ANS: 3 The number of health care employees having direct contact with a client, the type and number of invasive procedures, the therapy received, and the length of hospitalization influence the risk of infection. The other options do not have the potential for infection as does the client who has been treated in various locations within the health care facility. 36. A client is admitted for treatment of various poorly healing, infected leg ulcers. The nurse recognizes that the client’s nutritional history is of primary importance since: 1. Nutrition is vital to the clients overall health status 2. The client’s food intake will likely be decreased as a result of the illness 3. Wound healing and infection prevention are negatively impacted by poor nutrition 4. The client’s habits regarding food intake are directly related to this hospitalization ANS: 3 A reduction in protein, carbohydrates, and fats as a result of illness, inadequate diet, or debility increases a clients susceptibility to infection and delays wound healing. While the other options are not incorrect, they are not as directly related to the cause of the clients poorly healing, infected wounds. 37. A client admitted for an abdominal hysterectomy reports that she has been under a lot of stress since the death of her mother and wonders how that will affect her surgery and recovery. Which of the following nursing statements reflects the most therapeutic response to the clients question? 1. Being under stress isn’t going to help your recovery; you need to relax and focus on yourself and getting well. 2. Your mother’s death must be very stressful for you but she would want you to concentrate on getting healthy. 3. Stress does have a negative effect on the body’s ability to heal; is there anything I can do to help you minimize the stress you feel? 4. Your health care provider can prescribe you some medication to help you cope with the stress; would you like me to mention it? ANS: 3 Increased stress elevates cortisone levels, causing decreased resistance to infection and the ability to heal. While the other options may not be incorrect, they do not have the degree of therapeutic value as does the answer since it explains the effects of stress and also offers support. 38. A client admitted for an abdominal hysterectomy reports that she has been under a lot of stress since the death of her mother and wonders how that will affect her surgery and recovery. Which of the following nursing interventions reflects the most therapeutic understanding of the relationship stress has on the body and its ability to recover from surgery? 1. Suggest a demonstration of relaxation techniques 2. Arrange for the hospital chaplain to visit the client 3. Offer to call and get an order for an antianxiety medication 4. Share a personal antidote concerning a similarly stressful situation ANS: 1 Increased stress elevates cortisone levels, causing decreased resistance to infection and the ability to heal. Reinforcement of relaxation techniques would be the most therapeutic response because it would provide the client with a long-term, self-initiated coping mechanism. It would not be appropriate to arrange for a clergy visit without first discussing it with the client. Sharing a similar personal situation would have little therapeutic value, and such a personal nurse-oriented conversation should be avoided. While facilitating anti-anxiety medication may not be incorrect, it is premature at this time. 39. The nurse is providing care for a client who postoperatively has developed an infected incisional wound and is depressed and anorexic. Which of the following nursing interventions has priority? 1. Sterile wound care 2. Frequent small meals 3. Administration of antidepressant medication 4. Educating the client regarding wound care at home ANS: 1 The priority of administering therapies to promote wound healing overrides the goal of educating the client to assume self-care therapies at home. While the other options reflect appropriate interventions for this client, none has priority over wound care. 40. The nurse is educating a client diagnosed with type 2 diabetes, who is susceptible to foot wounds, on how to minimize the risk for infection related to poor wound healing by not being a susceptible host. The most appropriate suggestion would be to: 1. Inspect feet and legs daily for skin breakdown 2. See a podiatrist regularly for appropriate foot care 3. Keep blood sugar levels within normal range to maximize the ability to heal 4. Eat well-balanced meals in order to provide the nutrients necessary for healing ANS: 4 Good infection control begins with prevention. Review with clients and their families preventive measures to strengthen their defenses. In the case of a diabetic client, keeping blood sugar levels within normal limits maximizes the clients ability to both heal and fight infection. While the other options are not incorrect, they are more directed towards healing than prevention. MULTIPLE RESPONSE 1. For infectious organisms to grow and multiply enough to cause illness, they need an environment that has appropriate amounts of: (Select all that apply.) 1. Food 2. Space 3. Water 4. Oxygen 5. Warmth 6. Darkness ANS: 1, 3, 4, 5, 6 To thrive, organisms require a proper environment, including appropriate food, oxygen, water, temperature, pH, and light. Space does not generally affect microorganism growth. 2. Which of the following are considered portals of exit in the chain of infection? (Select all that apply.) 1. A bleeding cut 2. A hardy sneeze 3. A kiss on the lips 4. A urinary catheter 5. A scraped knuckle 6. A friendly handshake ANS: 1, 2, 3, 4, 5 After microorganisms find a site to grow and multiply, they must find a portal of exit if they are to enter another host and cause disease. Portals of exit include sites such as blood, skin/mucous membranes, a. Encourage preschool children to eat a nutritious diet. b. Encourage parents to provide a multivitamin to the children. c. Clean the toys every afternoon before putting them away. d. Wash their hands between each interaction with children. ANS: D The single most important thing that individuals can do to prevent the spread of infection is to wash their hands before and after eating, going to the bathroom, changing a diaper, and wiping a nose, as well as after cleaning toys or tables, after picking up after the children, and between touching each individual child. It is important for preschool children to have a nutritious diet; a healthy individual can fight infection more effectively. A physician, along with the parent, makes decisions about dietary supplements. Cleaning the toys can decrease the number of pathogens but is not the most important thing to do in this scenario. 4. The nurse is admitting a patient with an infectious disease process. What question would be appropriate for a nurse to ask this patient? a. Do you have a chronic disease, and how long have you had it? b. Do you have any children living in the home? c. What is your marital status, single, married, or divorced? d. Do you have any cultural or religious beliefs that will influence your care? ANS: A Some factors increase the susceptibility of an individual to acquire an infection. These include age, nutritional status, presence of chronic disease, trauma, and smoking. The other questions are part of an admission assessment process but are not pertinent to the infectious disease process. 5. The patient experienced a surgical procedure, and Betadine was utilized as the surgical prep. Two days postoperatively, the nurse’s assessment indicates that the incision is red and has a small amount of purulent drainage. The patient reports tenderness at the incision site. The patient’s temperature is 100.5 F and the WBC is 10,500/mm3. Which nursing action should the nurse take? a. Plan to change the surgical dressing during the shift. b. Check to see what solution was used for skin preparation in surgery. c. Collect supplies to culture the surgical incision. d. Utilize SBAR to call and communicate the patients needs to the physician. ANS: D Organisms enter the body in several different ways. Proper skin preparation for surgery is essential to decrease the chance of infection. The nursing assessment indicates signs and symptoms of infection. The physician needs to be called and notified of the patients needs. SBAR - Situation, Background, Assessment, and Recommendation can be utilized to organize thoughts and data and to provide a through explanation of the patients current status. Changing the dressing may be a need during the shift but is not a first priority. Checking to see about the skin prep used 2 days ago may or may not be useful information at this time. Collecting supplies for culture may be necessary after talking with the physician. 6. The nurse is providing an education session to an adult community group about the effects of smoking. Which of the following is the most important point to be included in the educational session? a. Smoke from tobacco products clings to your clothing and hair. b. Smoking affects the cilia lining the upper airways in the lungs. c. Smoking tobacco products can be very expensive. d. Smoking can affect the color of the patient’s fingernails. ANS: B A normal defense mechanism against infection in the respiratory tract is the cilia lining the upper airways of the lungs and normal mucus. When a patient inhales a microbe, the cilia and mucus trap the microbe and sweep them up and out to be expectorated or swallowed. Smoking may alter this defense mechanism and increase the patients potential for infection. Smoking can be expensive, the smell does cling to hair and clothing, and the tar within the smoke can alter the color of a patients nails. This information can be included in the education but does not constitute the most important point. 7. A female adult patient presents to the clinic with reports of a white discharge and itching in the vaginal area. During the health history, which of these questions should the nurse prioritize? a. When was the last time you visited the physician? b. Has this condition affected your eating habits? c. What medications are you currently taking? d. Are you able to sleep at night? ANS: C The body contains normal flora (microorganisms) that live on the surface of skin, saliva, oral mucosa, gastrointestinal tract, and genitourinary tract. The normal flora of the vagina causes vaginal secretions to achieve a low pH. This inhibits the growth of many microorganisms. Antibiotics and oral contraceptives can disrupt normal flora in the vagina, causing an overgrowth of Candida albicans in that area. It is important to ask the patient about current medications to obtain information that may assist with diagnosis. Visiting the physician is important for the patients health maintenance. Learning about the patients eating and sleeping habits will assist in the plan of care. 8. The nurse is caring for a school-aged child who has injured his leg after a bicycle accident. To determine whether the child is experiencing a localized inflammatory response, the nurse should assess for which of these signs and symptoms? a. Fever, malaise, anorexia, and nausea and vomiting b. Chest pain, shortness of breath, and nausea and vomiting c. Dizziness and disorientation to time, date, and place d. Edema, redness, tenderness, and loss of function ANS: D The body’s cellular response to an injury is seen as inflammation. Inflammation can be triggered by physical agents, chemical agents, or microorganisms. Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of function in the affected body part. Systemic signs of inflammation include fever, malaise, and anorexia, as well as nausea and vomiting. Chest pain, shortness of breath, and nausea and vomiting are signs and symptoms of a cardiac alteration. Dizziness and disorientation to time, date, and place may indicate a neurologic alteration. 9. Which interventions utilized by the nurse would indicate the ability to recognize the inflammatory response? a. Rest, ice, compression, and elevation b. Turn, cough, and deep breathe c. Orient to date, time, and place d. Passive range-of-motion exercises ANS: A One sign of the inflammatory response, particularly after an injury, is swelling or edema. Resting the affected injured area, using ice as ordered, wrapping the area to provide support particularly if it is an extremity and elevating the injured area will help to decrease swelling or edema. Turn, cough, and deep breathe is utilized for postoperative patients and for immobilized patients to help prevent an infectious process such as pneumonia. Orientation to date, time, and place is an intervention utilized with many different types of patients who may be confused. Passive range of motion is utilized for individuals who need to improve movement of their extremities, including immobilized patients. ANS: C Localized infections are most common in the skin or with mucous membrane breakdown. Wear gloves and other personal protective equipment as appropriate when examining or providing treatment to localized infected areas. Positioning the patient, explaining the procedure, and reviewing the medication list are all tasks that need to be completed, but preventing the spread of infection takes precedence. 15. Which of these interventions would take priority and should be included in a plan of care for a patient who presents with pneumonia? a. Observe the patient for decreased activity tolerance. b. Assume that the patient is in pain and treat accordingly. c. Maintain the temperature at 65 F. d. Provide the patient ice chips as requested. ANS: A Systemic infection causes more generalized symptoms than local infection. This type of infection can result in fever, fatigue, nausea and vomiting, and malaise. Be alert for changes in the patients level of activity and responsiveness. Respiratory infection may result in a productive cough with purulent sputum, shortness of breath, and activity intolerance. Nurses do not assume but assess and communicate with the patient about pain, temperature, and ice chips. Asking these questions would not be a priority as much as assessing the patient and determining the effect that the systemic infection is having on the patient. 16. The nurse is inserting a peripherally inserted central catheter (PICC) into the patient. Aware of the potential for health care associated infection, the nurse is careful to a. Prepare the skin with 2% chlorhexidine gluconate. b. Select a catheter of appropriate size for the appropriate vein. c. Use non-allergenic tape and dressings on the patient. d. Utilize local anesthetic on the site as ordered. ANS: A One of the sites for health care associated infection is the bloodstream. Bloodstream infection can be caused by improper care of the needle insertion site. Two percent chlorhexidine gluconate is an antiseptic solution that when applied properly and allowed to dry reduces microbial counts at the insertion site. Selecting the correct catheter size, using non-allergenic tape and dressings, and utilizing local anesthetic are important steps for individualized patient care and are typically part of the procedure, but they do not affect the cause of a health care-associated infection by, for example, decreasing microbial counts at the insertion site. 17. The infection control nurse is reviewing data for the medical-surgical unit. The nurse notices a spike in postoperative infections on this unit and categorizes this type of health care associated infection as infections. a. Iatrogenic b. Exogenous c. Endogenous d. Nosocomial ANS: B An exogenous organism is one that is present outside the patient. A postoperative infection is an exogenous infection because the organism that has caused the infection presents from outside the body. An example is Staphylococcus aureus. An endogenous organism is part of the normal flora of residing virulent organisms that could cause infection. An endogenous infection can occur when part of the patient’s flora becomes altered, and overgrowth results. Iatrogenic infection results from a diagnostic or therapeutic procedure such as a colonoscopy. Nosocomial infection is the term formerly used for health care acquired infection. 18. The patient has contracted a urinary tract infection while in the hospital. Which of these actions would most likely increase the risk of a patient contracting a urinary tract infection (UTI)? a. Emptying the urinary drainage bag once a shift b. Reusing the patients graduated receptacle to empty the drainage bag c. Allowing the drainage bag port to touch the graduated receptacle d. Providing perineal hygiene at least once a shift ANS: C Allowing the urinary drainage bag port to touch contaminated items may introduce bacteria into the system and contribute to a urinary tract infection. The urinary drainage bag should be emptied at least once every 8 hours. Each patient should have his own receptacle for measurement to prevent cross- contamination. Perineal hygiene should be provided every 8 hours and after bowel movements to assist in preventing a UTI. 19. Which of the following nursing actions would most increase a patients risk for developing a health care associated infection? a. Use of surgical aseptic technique to suction an airway b. Urinary catheter drainage bag placed below the level of the bladder c. Clean technique for inserting a urinary catheter d. Use of a sterile bottled solution more than once within a 24-hour period ANS: C Using clean technique (medical asepsis) to insert a urinary catheter would place the patient at risk for a health care associated infection. Urinary catheters need to be inserted using sterile technique, also referred to as surgical asepsis. This involves eliminating all microorganisms, including pathogens and spores, from an object or area. Placing a catheter into a sterile body cavity such as the bladder requires sterile technique. Surgical aseptic technique (also called sterile technique) should be used when suctioning an airway because it is considered a sterile body cavity. Keeping the urinary catheter drainage bag below the bladder helps decrease the risk of developing a health care associated infection because it prevents reflux of urine from the bag back into the bladder. Bottled solutions may be used repeatedly during a 24-hour period; however, special care is needed to ensure that the solution in the bottle remains sterile. After 24 hours, the solution should be discarded. 20. The nurse is caring for a patient in labor and delivery. When near completing an assessment of the patient for dilatation and effacement, the electronic infusion device being used on the intravenous infusion alarms. Which of these actions is most appropriate for the nurse to take? a. Complete the assessment, remove gloves, and silence the alarm. b. Discontinue the assessment, and assess the intravenous infusion. c. Complete the assessment, remove gloves, wash hands, and assess the intravenous infusion. d. Discontinue the assessment, remove gloves, use hand gel, and assess the intravenous infusion. ANS: C Medical asepsis or clean technique includes procedures to decrease the number of organisms present and to prevent the transfer of organisms. Wearing gloves while assessing the dilatation and effacement of a labor and delivery patient, removing gloves, washing hands after contact with body fluids, and then assessing the intravenous infusion will assist in the prevention and transfer of any potential organisms to this intravenous line. Completing the assessment, removing gloves, and silencing the alarm leaves out the crucial step of decontaminating and washing the hands. Discontinuing the assessment and assessing the IV leaves out removing the gloves and decontamination, as well as completing the assessment for the patient. Discontinuing the assessment, removing gloves, using hand gel, and assessing the IV is incorrect because upon exposure to body fluids, washing hands is appropriate. 26. The nurse is caring for a patient in the hospital. The nurse observes the nursing assistant turning off the handle faucet with his hands. What professional practice supports the need for follow-up with the nursing assistant? a. The nurse is responsible for providing a safe environment for the patient. b. This is a key step in the procedure for washing hands. c. Allowing the water to run is a waste of resources and money. d. Different scopes of practice allow modification of procedures. ANS: A The nurse is responsible for providing a safe environment for the patient. The effectiveness of infection control practices depends on conscientiousness and consistency in using effective aseptic technique. It is human nature to forget key procedural steps or to take shortcuts. However, failure to comply with basic procedures places the patient at risk for infection that can impair recovery or lead to death. After washing hands, turn off a handle faucet with a dry paper towel and avoid touching the handles with your hands to assist in preventing the transfer of microorganisms. Wet towels and hands allow the transfer of pathogens from faucet to hands. The principles and procedures for washing hands are universal and apply to all members of health care teams. Being resourceful and aware of the cost of health care is important, but taking shortcuts that may endanger an individual’s health is not a prudent practice. 27. The nurse is caring for a patient who becomes nauseated and vomits without warning. The nurse has contaminated hands. The nurse’s best next step is to a. Clean hands with wipes from the bedside table. b. Wash hands with an antimicrobial soap and water. c. Use an alcohol-based waterless hand gel. d. Instruct the patient to wash his face and hands. ANS: B The Centers for Disease Control recommends that when hands are visibly soiled, one should wash with a non-antimicrobial soap or with antimicrobial soap. Cleaning hands with wipes or using waterless hand gel does not meet this standard. If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely decontaminating hands. The patient may very well need to wash his face and hands, but this is not the best next step. 28. The nurse is performing hand hygiene before assisting a physician with insertion of a chest tube. While washing hands, the nurse touches the sink. What is the next action the nurse should take? a. Inform the physician and recruit another nurse to assist. b. Rinse and dry hands, and begin assisting the physician. c. Repeat hand-washing using antiseptic soap, d. Extend the hand-washing procedure to 5 minutes. ANS: C The inside of the sink and the counter at the edges of the sink, faucet, and handles are considered contaminated areas. If the hands touch any of these areas during hand-washing, repeat the hand- washing procedure utilizing antiseptic soap. There is no need to inform the physician or be relieved of this assignment. If the hands are contaminated when touching the sink, drying hands and proceeding with the procedure could possibly contaminate and contribute to increased microbial counts during the procedure, resulting in infection for the patient. Extending the time for washing the hands (although this is what will happen when the procedure is repeated) is not the focus. The focus is to repeat the whole hand hygiene procedure utilizing antiseptic soap. 29. The nurse is caring for a patient on the medical-surgical unit. The nurse and the physician have completed an invasive procedure. What is the next step in handling the instruments used during the procedure? a. Don gloves, gather instruments, place in transport carrier, and send to central sterile for cleaning and sterilization. b. Don gloves, gather instruments, place in transport carrier, and send to central sterile for cleaning and disinfection. c. Don gloves, gather instruments, place in transport carrier, and send to central sterile for cleaning and boiling. d. Don gloves, gather instruments, place in transport carrier, and send to central sterile for cleaning. ANS: A Instruments need to be cleaned and sterilized. Disinfecting, boiling, or cleaning is not utilized on critical items that will be reused on patients in the hospital environment. Items that are used on sterile tissue or in the vascular system present a high risk of infection if they become contaminated with bacteria. 30. The nurse is observing a family member changing a dressing for a patient in the home health environment. Which of these observations would indicate that the family member has a correct understanding of how to manage contaminated dressings? a. The family member removes gloves and gathers items for disposal. b. The family member places the used dressings in a plastic bag. c. The family member saves part of the dressing because it is clean. d. The family member wraps the used dressing in toilet tissue before placing in the trash. ANS: B Contaminated dressings and other infectious items should be placed in impervious plastic or brown paper bags and then disposed of properly in garbage containers. Gloves should be worn during this process. Parts of the dressing should not be saved, even though they may seem clean, because microbes may be present. 31. The nurse is caring for a home health patient. After completing an assessment, the nurse has diagnosed the patient as being at risk for infection. Which of the following orders would the nurse question? a. Urinary catheter to bedside drainage bag. May change to leg bag during the day. b. May reuse nebulizer equipment. Clean with mild soap and warm water, and allow to dry. c. Prepare enough enteral feedings for 12 hours. Rinse feeding bag and tubing daily. d. Call for temperature greater than 100.5, heart rate greater than 100, and respiratory rate greater than 24. ANS: C For patients who receive tube feedings in the home, to decrease the risk of bacterial contamination it is important to prepare enough commercially prepared formula for only 8 hours and home-prepared formula for 4 hours. Sometimes the urinary drainage system is disrupted in the home to place the patient on a leg bag system when up and about. Nebulizer equipment is cleaned and reused in the home health environment. Notifying the physician about potential signs and symptoms of infection would be common practice in the home health environment. 32. The home health nurse is teaching a patient and family about hand hygiene in the home. The nurse is sure to emphasize washing hands before a. And after shaking hands. b. And after treatments. c. Opening the refrigerator. d. And after using a computer. ANS: B c. Delay washing of the site until the nurse is finished providing care to the patient. d. Do nothing; accidentally getting splashed with blood happens frequently and is part of the job. ANS: B After getting splashed with blood from a patient who has a known bloodborne pathogen, it is important to cleanse the site immediately and thoroughly with soap and running water and notify the manager and employee health for guidance on next steps in the process. Removing the blood with an alcohol swab, delaying washing, and doing nothing because the splash was to intact skin could possibly spread the blood within the room and could spread the infection. Contain contamination immediately to prevent contact spread. 38. What would be required after exposure of a nurse to blood by a cut from a scalpel in the perioperative area? a. Removing sterile gloves and disposing of in kick bucket b. Placing the scalpel in a needle safe container c. Testing the patient and offering treatment to the nurse d. Providing a medical evaluation of the nurse to the manager ANS: C Follow-up for risk of infection begins with patient testing. Patients should be tested for HIV and hepatitis B and C. Syphilis may be indicated if the patient is HIV positive. Testing of the nurse is dependent on the results of patient testing; if the patient is positive for one of these infections, the nurse will be started on testing and treatment. Removing sterile gloves and placing sharps in appropriate containers are always part of the perioperative process. A confidential medical evaluation is provided to the nurse. MULTIPLE RESPONSE 1. The nurse is caring for a patient in Contact Precautions. The nurse includes hand hygiene as part of the plan of care to (Select all that apply). a. Provide an uninterrupted chain of infection. b. Decrease the incidence of health care associated infection. c. Protect the nurse from transmission of the microbes. d. Decrease the transmission of microbes to other patients. e. Prevent contamination of clean supplies. f. Decrease the drying effects of soap. ANS: B, C, D, E Hand-washing is part of Contact Precautions and assists in interrupting the chain of infection. Washing hands can assist in decreasing the incidence of health care associated infection, protect the nurse from the transfer of microorganisms, decrease the transmission of microbes to other patients, and prevent contamination of clean supplies. Hands are a common means of transmission of bacteria from one place to another. Proper hand hygiene does not decrease the drying effects of soap infact, it increases the drying effects of soap. 2. The nurse is assessing a new patient admitted to home health. To decrease the risk of infection, which of these questions would be most appropriate to ask? (Select all that apply.) a. Will you demonstrate how to wash your hands? b. Do you have a working refrigerator? c. Can you explain the risk for infection in your home? d. What are the signs and symptoms of infection? e. Who runs errands for you? f. Are you able to walk to the mailbox? ANS: A, B, C, D In the home setting, the objective is that the patient and or family will utilize proper infection control techniques. Asking the patient and family about hand washing, risk of infection, and signs and symptoms of infection is important in evaluating the patient’s knowledge base on infection control strategies. Refrigeration is essential in keeping perishables cold and in preventing food-borne illnesses and in allowing storage of enteral feedings or refrigerated medications. Activity assessment is important for evaluation of the overall status of the patient, and knowing who runs errands gives you information on who is helping to meet the needs of the patient, but neither of these relate to decreasing the risk of infection. 3. The circulating nurse in the perioperative area is observing the surgical technologist while applying a sterile gown and gloves to care for a patient having an appendectomy. Which of the following behaviors indicate to the nurse that the procedure has been done correctly? (Select all that apply.) a. Surgical cap and face mask are in place. b. Surgical technologist ties the back of the gown. c. Surgical technologist touches only inside of gown. d. Surgical technologist slips arms into arm holes simultaneously. e. Surgical technologist uses hands covered by sleeves to open gloves. f. Fingers are extended fully into both gloves. ANS: C, D, E, F To maintain sterility, the surgical technologist (ST) touches the inside of the gown that will be against the body. Arms are slipped simultaneously into the gown to prevent contamination. Using the sleeves covering the hands maintains the principle of sterile only touching sterile. Extending the fingers fully into both gloves ensures that the ST has full dexterity while using the sterile gloved hand. Surgical cap, face mask, and eye wear are applied before entering the surgical area and completing the surgical scrub. Reaching behind to tie the back of the gown will contaminate the sterile area of the gown. 4. The nurse is preparing to insert a urinary catheter. The nurse is using open gloving to don the sterile gloves. Which steps are included in this process? (Select all that apply.) a. Lay glove package on clean flat surface above waistline. b. Remove outer glove package by tearing the package open. c. Glove the dominant hand of the nurse first. d. While putting on the first glove, touch only the outside surface of the glove. e. With gloved dominant hand, slip fingers underneath second glove cuff. f. After second glove is on, interlock hands. ANS: A, C, E, F Sterile objects held below the waist are considered contaminated. Gloving the dominant hand helps to improve dexterity. Slipping the fingers underneath the second glove cuff helps to protect the gloved fingers. Sterile touching sterile prevents glove contamination. Interlocking fingers ensures a smooth fit over the fingers. Sterile supplies are opened by carefully separating and peeling apart the sides of the package; this presents the sterile contents from accidentally opening and touching contaminated objects. Touching the outside of the glove surface will contaminate the sterile item; touch only the inside of the glove, the piece that will be against the skin. 5. The nurse has received a report from the emergency department that a patient with tuberculosis will be coming to the unit. What items will the nurse need to care for this patient? (Select all that apply.) a. Private room b. Negative-pressure airflow in room c. Communication signs for Droplet Precautions d. Communication signs for Airborne Precautions directing actions toward those steps have the potential to decrease infection in the setting. For spread of infection, the chain has to be uninterrupted with an infectious agent, a reservoir and portal of exit, a mode of transmission, a portal of entry, and a susceptible host. Taylor Fundamental of Nursing Seventh Edition 1. Which of the following most accurately defines an infection? A) an illness resulting from living in an unclean environment B) the result of lack of knowledge about food preparation C) a disease resulting from pathogens in or on the body **** D) an acute or chronic illness resulting from traumatic injury 1. A patient who has had abdominal surgery develops an infection in the wound while still hospitalized. Which of the following agents is most likely the cause of the infection? A) virus B) bacteria **** C) fungi D) spores 2. A nurse caring for a patient who has gas gangrene knows that this infection originated in which of the following reservoirs? A) other people B) food C) soil **** D) animals 3. A patient with an upper respiratory infection (common cold) tells the nurse, I am so angry with the nurse practitioner because he would not give me any antibiotics. What would be the most accurate response by the nurse? A) Antibiotics have no effect on viruses. **** B) Let me talk to him and see what we can do. C) Why do you think you need an antibiotic? D) I know what you mean; you need an antibiotic. 4. A woman tests positive for the human immunodeficiency virus antibody but has no symptoms. She is considered a carrier. What component of the infection cycle does the woman illustrate? A) a reservoir **** B) an infectious agent C) a portal of exit D) a portal of entry 5. A man on an airplane is sitting by a woman who is coughing and sneezing. If she has an infection, what is the most likely means of transmission from the woman to the man? A) direct contact B) indirect contact C) vectors D) airborne route **** 6. A nurse is caring for an adolescent who is diagnosed with mononucleosis, commonly called the kissing disease. The nurse explains that the organisms causing this disease were transmitted by: A) Direct contact. **** B) Indirect contact. C) Airborne route. D) Vectors. 7. Of all possible nursing interventions to break the chain of infection, which is the most effective? A) administering medications B) providing good skin care C) practicing hand hygiene **** D) wearing gloves at all times 8. A nurse teaches a rural community group how to avoid contracting West Nile virus by using approved insect repellant and wearing proper coverings when outdoors. By what means is the pathogen involved in West Nile virus transmitted? A) direct contact B) indirect contact C) airborne route D) vectors **** 9. Which of the following questions asked by the nurse when taking a patient’s health history would collect data about infection control? A) Tell me what you eat in each 24-hour period. B) Do you sleep well and wake up feeling healthy? C) What were the causes of death for your family members? D) When did you complete your immunizations? **** 10. A college-aged student has influenza. At what stage of the infection is the student most infectious? A) incubation period B) prodromal stage **** C) full stage of illness D) convalescent period 11. Which of the following are characteristics of the stage of infection known as full stage of illness? Select all that apply. A). It is the interval between the pathogens invasion of the body and the appearance of symptoms of infection. B) The presence of specific signs and symptoms indicates the full stage of illness. **** A) liquid or bar hand soap B) cold water C) hot water D) antimicrobial products **** 21. A nurse has completed morning care for a patient. There is no visible soiling on her hands. What type of technique is recommended by the CDC for hand hygiene? A) Do not wash hands, apply clean gloves. B) Wash hands with soap and water. C) Clean hands with an alcohol-based hand-rub. **** D) Wash hands with soap and water, follow with hand-rub. 22. How long should a healthcare worker scrub hands that are not visibly soiled for effective hand hygiene? A) 15 seconds **** B) 30 seconds C) 1 minute D) 5 minutes 23. Which of the following statements is true of healthcare personnel and good hand hygiene? A) Hand hygiene is carefully followed. B) Compliance is difficult to achieve. **** C) Only nurses need to practice hand hygiene. D) Wearing gloves reduces the need for hand hygiene. 24. A home health nurse is completing a health history for a patient. What is one question that is important to ask to identify a latex allergy for this patient? A) Have you ever had an allergic reaction to shellfish or iodine? B) Tell me what you use to wash your hands after toileting. C) When you were a child, did you have frequent infections? D) Have you had any unusual symptoms after blowing up balloons? **** 25. A nurse is caring for a patient with a serious bacterial infection. The patient is dehydrated. Knowledge of the physical effects of the infection would support which of the following nursing diagnoses? A) High Risk for Infection B) Excess Fluid Volume C) Risk for Imbalanced Body Temperature **** D) Risk for Latex Allergy Response 26. What is the correct rationale for using body substance precautions? A) The risk of transmitting HIV in sputum and urine is nonexistent. B) Disease-specific isolation procedures are adequate protection. C) Only actively infected patients are considered contagious. D) All body substances are considered potentially infectious. **** 27. The latest CDC guidelines designate standard precautions for all substances except which of the following? A) urine B) blood C) sweat **** D) vomitus 28. A student nurse is performing a urinary catheterization for the first time and inadvertently contaminates the catheter by touching the bed linens. What should the nurse do to maintain surgical asepsis for this procedure? A) Nothing, because the patient is on antibiotics. B) Complete the procedure and then report what happened. C) Apologize to the patient and complete the procedure. D) Gather new sterile supplies and start over. **** 29. A nurse is performing a sterile dressing change. If new sterile items or supplies are needed, how can they be added to the sterile field? A) with sterile forceps or hands wearing sterile gloves **** B) by carefully handling them with clean hands C) with clean forceps that touch only the outermost part of the item D) by clean hands wearing clean latex gloves 30. A nurse is positioning a sterile drape to extend the working area when performing a urinary catheterization. Which of the following is an appropriate technique for this procedure? A) Use sterile gloves to handle the entire drape surface. **** B) Fold the lower edges of the drape over the sterile-gloved hands. C) Touch only the outer 2 inches of the drape when not wearing sterile gloves. D) When reaching over the drape do not allow clothing to touch the drape. Patient Safety Taylor Seventh Edition 1. What generalization can be made about safety in patient care? A) Healthcare providers exclude safety as a patient need. B) Although safety is a basic human need, it is provided by self-care. C) Safety is an important need, but not as important as self-actualization. D) Safety is a paramount concern underlying all nursing care. **** 2. A nurse making a home visit for a patient living in a high-crime area observes that the apartment building does not have outside lighting. Why is this an important assessment? A) It will make the patient less able to go to social gatherings. B) Assessment includes risk factors in the home. **** C) Although important, this assessment is irrelevant to care. D) Nurses in home healthcare are not concerned with safety. 3. Which of the following are examples of developmental risk factors? Select all that apply. A) A toddler is allowed to crawl in a house that has not been childproofed. **** B) A machinist works in an environment that exposes him to loud noises. C) A sales executive worries that he won’t make his yearly sales quota. D) An elderly woman in a long-term healthcare facility is at high risk for falls. **** E) A 42-year-old woman is unable to move her left side following a stroke. F) A teenager has difficulty ambulating following multiple fractures from a MVA. 4. A patient is very anxious and states, I am so stressed. Why do these factors affect the patient’s safety? A) stress increases retention of information B) stress affects interpersonal relationships C) stress increases concern about hazards D) stress tends to narrow the attention span **** B) Booster seats should be used for children until they are 4-feet 9-inches tall or at least 8 years of age. **** C) Children under 8 years old should ride in the back seat. D) All school-aged children need to be secured in lap seat belts. 16. An adolescent has recently had a ring inserted into her navel. What is the adolescent at risk for developing? A) a scar over the navel B) a local and/or systemic infection **** C) a greater acceptance by peers D) a strained relationship with parents 17. A nurse is teaching parents about Internet safety for their children. Which of the following are recommended guidelines for Internet use? Select all that apply. A) Keep identifying information posted on the Web sites. B) Use filtering software to block objectionable information. **** C) Investigate any public chat rooms used by the children. D) Emphasize that everything read online is usually true. E) Be alert for downloaded files with suffixes that indicate images or pictures. **** F) Consider locating the computer in a central location in the house. **** 18. A nurse specializes in caring for victims of domestic violence. Which of the following statements accurately describes domestic violence in the United States? Select all that apply. A) Studies indicate that each year, more than 2,000,000 adults in the United States are victims of intimate partner violence. **** B) Intimate partner violence is domestic violence or battering between two people who are married. C) More than 85% of those abused in intimate partner violence are women. **** D) Many men who batter their spouses also batter their children. E) There is no evidence linking childhood sexual abuse to adult physical symptoms or substance abuse. F) Nurses are advised to suggest other resources for the victims of violence instead of providing their own counseling. **** 19. Nurses provide many interventions to prevent falls in healthcare settings. Which of the following would be an appropriate fall-prevention intervention? A) Keep bed in the high position. B) Keep side rails up at all times. **** C) Apply restraints to all confused patients. D) Lock wheels on beds and wheelchairs. 20. A nurse has conducted a timed get up and go test to assess an older adults risk for a fall. The patient completes the test in 30 seconds. Based on the finding, what will the nurse do? A) Continue with the plan of care for this fully mobile patient. B) Document the time of the test and observe the patient. C) Develop a care plan for Impaired Physical Mobility. **** D) Maintain the patient on bed-rest to prevent falling. 21. An elderly woman in a long-term care facility has fallen and sustained several injuries. Which of her injuries would be the most serious fall-related injury? A) Fractured hip **** B) Fractured ulna C) Lacerated lip D) Thigh contusion 22. The nurse is following the Joint Commissions national patient safety goals when giving medications. Based on these goals, how can the nurse improve the accuracy of patient identification? A) Use two patient identifiers (neither to be the room number). **** B) Use two patient identifiers (one may be the room number). C) Check the patient’s armband three times. D) Say to the patient, are you Mrs. Jones? 23. A nurse makes a medication error and fills out an incident report. What will the nurse do with the incident report once it is filled out? A) Place it in the patient’s medical record. B) Take it home and keep it locked up. C) Maintain it according to agency policy. **** D) Include it with documentation of the error. 24. In what situation would the use of side rails not be considered a restraint? A) The nurse keeps them raised at all times. B) The institutions policies mandate using side rails. C) A visitor requests their use. D) A patient requests they be up at night. **** 25. Bioterrorism has become a commonly used term. What is the definition of bioterrorism? A) a verbal threat by those wishing to harm specific individuals B) a written threat calculated to produce terror in a family C) the deliberate spread of pathogens into a community **** D) a worldwide plan to produce illness and injury 26. A patient arrives at the Emergency Department with nausea, hematemesis, fever, abdominal pain, and severe diarrhea. There is a suspicion the patient has been exposed to the anthrax bacillus. What category of medications will be administered? A) antimicrobials **** 1. A home health nurse is performing a home assessment for safety. Which of the following comments by the patient would indicate a need for further education? a. I will schedule an appointment with a chimney inspector next week. b. Daylight savings is the time to change batteries on the carbon monoxide detector. c. If I feel dizzy when using the heater, I need to have it inspected. d. When it is cold outside in the winter, I can warm my car up in the garage. ANS: D Allowing a car to run in the garage introduces carbon monoxide into the environment and decreases the available oxygen for human consumption. Garages should be opened and not just cracked to allow fresh air into the space and allay this concern. Checking the chimney and heater, changing the batteries on the detector, and following up on symptoms such as dizziness, nausea, and fatigue are all statements that would indicate that the individual has understood the education. 2. The nurse is caring for an elderly patient admitted with nausea, vomiting, and diarrhea. Upon completing the health history, which priority concern would require collaboration with social services to address the patient’s health care needs? a. The electricity was turned off 2 days ago. b. The water comes from the county water supply. c. A son and family recently moved into the home. d. The home is not furnished with a microwave oven. ANS: A Electricity is needed for refrigeration of food, and lack of electricity could have contributed to the nausea, vomiting, and diarrhea potential food poisoning. This discussion about the patient’s electrical needs can be referred to social services. The water supply, the increased number of individuals in the home, and not having a microwave may or may not be concerns but do not pertain to the current health care needs of this patient. 3. The patient has been diagnosed with a respiratory illness and complains of shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. What is the usual comfort range for most patients? a. 65 F to 75 F b. 60 F to 75 F c. 15 C to 17 C d. 25 C to 28 C ANS: A The comfort zone for most individuals is the range between 65 F and 75 F (18.3 C to 23.9 C). The other ranges do not reflect the average persons comfort zone. 4. A homeless adult patient presents to the emergency department. The nurse obtains the following vital signs: temperature 94.8 F, blood pressure 100/56, apical pulse 56, and respiratory rate 12. Which of the vital signs should be addressed immediately? a. Respiratory rate b. Temperature c. Apical pulse d. Blood pressure ANS: B Hypothermia is defined as a core body temperature of 95 F or below. Homeless individuals are more at risk for hypothermia owing to exposure to the elements. 5. The nurse is caring for a patient with a urinary catheter. After the nurse empties the collection bag and disposes of the urine, the next step is to a. Use alcohol-based gel on hands. b. Wash hands with soap and water. c. Remove eye protection and dispose of in garbage. d. Remove gloves and dispose of in garbage. ANS: D After disposing of the urine, the first step in removing personal protective equipment is removing gloves and disposing of them properly. In this scenario, the next step would be to remove eye protection followed by hand hygiene. Wash hands if the hands are visibly soiled; otherwise the use of alcohol- based gel is indicated for routine decontamination of hands. 6. The nurse is preparing a patient for surgery. The nurse explains that the reason for writing in indelible ink on the surgical site the word correct is to a. Distinguish the correct surgical site. b. Label the correct patient. c. Comply with the surgeon’s preference. d. Adhere to the correct regulatory standard. ANS: A The purpose of writing on the surgical site as part of the Universal Protocol from the Joint Commission is to distinguish the correct site on the correct patient and match with the correct surgeon for patient safety and prevention of wrong site surgery. All patients who are having an invasive procedure should receive labeling in many different ways, including the record and patient armbands. Writing in indelible ink may comply with the surgeon’s preference, but safety is the driving factor. Although labeling of the site helps to meet regulatory standards, this is not the reason to do this activity; the reason is to keep the patient safe. 7. The nurse identifies that a patient has received Mylanta (simethicone) instead of the prescribed Pepto-Bismol (bismuth subsalicylate) for the problem of indigestion. The nurse’s next intervention is to a. Do nothing, no harm has occurred. b. Assess and monitor the patient. c. Notify the physician, treat and document. d. Complete an incident report. ANS: B After providing an incorrect medication, assessing and monitoring the patient to determine the effects of the medication is the first step. Notifying the physician and providing treatment would be the best next step. After the patient has stabilized, completing an incident report would be the last step in the process. 8. The nurse preceptor recognizes the new nurse’s ability to determine patient safety risks when which behavior is observed? a. Checking patient identification once every shift b. Multitasking by gathering two patients medications c. Disposing of used needles in a red needle container d. Raising all four side rails per family request ANS: C Needles, syringes, and other single-use injection devices should be used once and disposed of in safety red needle containers that will be disposed of properly. Patient identification should be checked multiple times a day, including before each medication, treatment, procedure, blood administration, and transfer, and at the beginning of each shift. Gathering more than one patients medication increases the likelihood c. Are you able to remember the name of the person you just met? d. Are you able to open a jar of pickles? ANS: A The ability to hear safety alerts and seek shelter is imperative to life safety. Although age-related changes may cause a decrease in sight that affects reading, and although difficulties in remembering short-term information and opening jars as arthritis sets in are important to patients and to those caring for them, being able to hear safety alerts is the priority. 15. The nurse is caring for a hospitalized patient. Which of the following behaviors alerts the nurse to consider the need for restraint? a. The patient refuses to call for help to go to the bathroom. b. The patient continues to remove the nasogastric tube. c. The patient gets confused regarding the time at night. d. The patient does not sleep and continues to ask for items. ANS: B Restraints are utilized only when alternatives have been exhausted, the patient continues a behavior that can be harmful to himself or others, and the restraint is clinically justified. In this circumstance, continuing to remove a needed nasogastric tube would meet these criteria. Refusing to call for help, although unsafe, is not a reason for restraint. Getting confused at night regarding the time or not sleeping and bothering the staff to ask for items is not a reason for restraint. 16. The nurse is discussing with a patient’s physician the need for restraint. The nurse indicates that alternatives have been utilized. What behaviors would indicate that the alternatives are working? a. The patient continues to get up from the chair at the nurse’s station. b. The patient apologizes for being such a bother. c. The patient folds three washcloths over and over. d. The sitter leaves the patient alone to go to lunch. ANS: C Offering diversionary activities such as something to hold is a way to keep the hands busy and provides an alternative to restraints. Assigning a room near the nurse’s station or a chair at the desk can be an alternative for continuous monitoring. Getting up constantly can be cause for concern. Apologizing is not an alternative to restraints. Having a sitter sit with the patient to keep him occupied can be an alternative to restraints, but the sitter needs to be continuous. 17. The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous infusion. The nurse begins to develop a plan to care for the patient. Which nursing intervention should take priority? a. Gather restraint supplies. b. Try alternatives to restraint. c. Assess the patient. d. Call the physician for a restraint order. ANS: C When a patient becomes suddenly confused, the priority is to assess the patient, including checking laboratory test and oxygen status and treating and eliminating the cause of the change in mental status. If interventions and alternatives are exhausted, the nurse working with the physician may determine the need for restraints. 18. The nurse knows that four categories of risk have been identified in the health care environment. Which of the following provides the best examples of those risks? a. Tile floors, cold food, scratchy linen, and noisy alarms b. Carpeted floors, ice machine empty, unlocked supply cabinet, and call light in reach c. Wet floors, pinching fingers in door, failure to use lift for patient, and alarms not functioning properly d. Dirty floors, hallways blocked, medication room locked, and alarms set ANS: C The four categories are falls, patient-inherent accidents, procedure-related accidents, and equipment- related accidents. Wet floors contribute to falls, pinching finger in door is patient inherent, failure to use the lift is procedure related, and an alarm not functioning properly is equipment related. Tile floors and carpeted or dirty floors do not necessarily contribute to falls. Cold food, ice machine empty, and hallways blocked are not patient-inherent issues in the hospital setting but are more of patient satisfaction or infection control issues or fire safety issues. Scratchy linen, unlocked supply cabinet, and medication room locked are not procedure-related accidents. These are patient satisfaction issues and control of supply issues, and are examples of actually following a procedure correctly. Noisy alarms, call light within reach, and alarms set are not equipment-related accidents but are patient satisfaction issues and examples of following a procedure correctly. 19. Equipment-related accidents are risks in the health care agency. The nurse assesses for this risk when using a. Sequential compression devices. b. A measuring device that measures urine. c. Computer-based documentation. d. A manual medication-dispensing device. ANS: A Sequential compression devices are used on a patients extremities to assist in prevention of deep vein thrombosis and have the potential to malfunction and harm the patient. Measuring devices used by the nurse to measure urine, computer documentation, and manual dispensing devices can break or malfunction but are not used directly on a patient. 20. A patient has been admitted and placed on fall precautions. The nurse explains to the patient that interventions for the precautions include a. Encouraging visitors in the early evening. b. Placing all four side rails in the up position. c. Checking on the patient once a shift. d. Placing a high risk for falls armband on the patient. ANS: D Placing a high risk for falls armband on the patient encourages communication among the whole interdisciplinary team. Anyone who interacts with the patient should see this armband, understand its meaning, and assist the patient as necessary. The timing of visitors would not affect falls. All four side rails are considered a restraint and can contribute to falling. Individuals on high risk for fall alerts should be checked frequently, at least every hour. 21. A patient with an intravenous infusion requests a new gown after bathing. Which of the following actions is most appropriate? a. Disconnect the intravenous tubing, thread the end through the sleeve of the old gown and through the sleeve of the new gown, and reconnect. b. Thread the intravenous bag and tubing through the sleeve of the old gown and through the sleeve of the new gown without disconnecting. c. Inform the patient that a new gown is not an option while receiving an intravenous infusion in the hospital. d. Call the charge nurse for assistance because linen use is monitored and this is not a common procedure. 27. The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. These data would help to support a nursing diagnosis of a. Risk for poisoning. b. Knowledge deficit. c. Impaired home maintenance. d. Risk for injury. ANS: D The patients behaviors support the nursing diagnosis of risk for injury. The patient is confused, is pulling at the intravenous line, and is trying to climb out of bed. Injury could result if the patient falls out of bed or begins to bleed from a pulled line. Nothing in the scenario indicates that this patient lacks knowledge or is at risk for poisoning. Nothing in the scenario refers to the patients home maintenance. 28. A confused patient is restless and continues to try to remove his oxygen and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient? a. Risk for injury: Prevent harm to patient, use restraints if alternatives fail. b. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter. c. Disturbed body image: Encourage patient to express concerns about body. d. Caregiver role strain: Identify resources to assist with care. ANS: A The priority nursing diagnosis is risk for injury. This patient could cause harm to himself by interrupting the oxygen therapy or by damaging the urethra by pulling the urinary catheter out. Before restraining a patient, it is important to implement and exhaust alternatives to restraint. Alternatives can include distraction and providing companionship or supervision. Patients may be moved to a location closer to the nurse’s station; trained sitters or family members may be involved. Nurses need to ensure that patients are provided adequate food, liquid, toileting, and relief from pain. If these and other alternatives fail, this individual may need restraints; in this case, an order would need to be obtained for the restraint. This patient may have deficient knowledge; educating the patient about treatments could be considered as an alternative to restraints; however, the nursing diagnosis of highest priority is risk for injury. This scenario does not indicate that the patient has a disturbed body image or that the patients caregiver is strained. 29. The patient applies sequential compression devices after going to the bathroom. The nurse checks the patient’s application of the devices and finds that they have been put on upside down. Which of the following nursing diagnoses will the nurse add to the patient’s plan of care? a. Risk for poisoning b. Deficient knowledge c. Risk for imbalanced body temperature d. Risk for suffocation ANS: B The patient needs to understand the purpose of the compression devices and that proper application is needed for them to be effective. The patient has a knowledge need and requires instruction regarding the device and its purpose and procedure. The nurse will intervene by teaching the patient about the sequential compression device and instructing the patient to call for assistance when getting up to go to the bathroom in the future, so that the nurse may assist with removal and proper reapplication. No data support a risk for poisoning, imbalanced body temperature, or suffocation. 30. The nurse enters the patients room and notices a small fire in the headlight above the patients bed. Immediately, the nurse assigns a nursing diagnosis of risk for injury with a goal for the patient to be safe. Which of the following actions should the nurse take first? a. Activate the alarm. b. Extinguish the fire. c. Remove the patient. D. Confine the fire. ANS: C Nurses use the mnemonic RACE to set priorities in case of fire. All of these interventions are necessary, but this patient is in immediate danger with the fire being over his head and should be rescued and removed from the situation. 31. The nurse is providing information regarding safety and accidental poisoning to a grandmother who will be taking custody of a 1-year-old grandchild. Which of the following comments would indicate that the grandmother needs further instruction? a. The number for poison control is 800-222-1222. b. Never induce vomiting if my grandchild drinks bleach. c. I should call 911 if my grandchild loses consciousness. d. If my grandchild eats a plant, I should provide syrup of ipecac. ANS: D Syrup of ipecac to induce vomiting after ingestion of a poison has not been proven effective in preventing poisoning. This medication should not be administered to the child. The poison control number is 800-222-1222. After a caustic substance such as bleach has been drunk, do not induce vomiting. This can cause further burning and injury as the medication is eliminated. Loss of consciousness associated with poisoning requires calling 911. 32. An elderly patient presents to the hospital with a history of falls, confusion, and stroke. The nurse determines that the patient is at high risk for falls. Which of the following interventions is most appropriate for the nurse to take? a. Place the patient in restraints. b. Lock beds and wheelchairs when transferring. c. Place a bath mat outside the tub. d. Silence fall alert alarm upon request of family. ANS: B Locking the bed and wheelchairs when transferring will help to prevent these pieces of equipment from moving during transfer and will assist in the prevention of falls. Patients are not automatically placed in restraints. The restraint process consists of many steps, including thorough assessment and exhausting of alternatives. All mats and rugs should be secured to help prevent falls. Silencing alarms upon the request of family is not appropriate and could contribute to an unsafe environment. 33. The nurse has been called to a hospital room where a patient is using a hair dryer from home. The patient has received an electrical shock from the dryer. The patient is unconscious and is not breathing. What is the best next step? a. Ask the family to leave the room. b. Check for a pulse. c. Begin compressions. d. Defibrillate the patient. ANS: B In this scenario, the patient is in a hospital setting, and it has been determined that the patient is not conscious and is not breathing. The next step is to check the pulse. An electrical shock can interfere with the hearts normal electrical impulses and can cause arrhythmias. Checking the pulse helps to determine the need for cardiopulmonary resuscitation (CPR) and defibrillation. 34. A nurse is in the hallway assisting a patient to ambulate and hears an alarm sound. What is the best next step for the nurse to take? f. Walking to the mailbox in the summer ANS: A, C, D, E Unsecured rugs, using a hose to water plants, missing yearly eye examinations, and using tubs without safety strips are all items the patient should avoid to help in the prevention of falls in the home. Exercise is beneficial and increases strength, which helps with the prevention of falls. It is important that the home is well lit, so encourage the purchase of bulbs with strength of 60 watts or higher for the home. 3. Which of the following concepts are important to utilize when evaluating orders for restraints? (Select all that apply.) a. Behaviors that necessitate the use of restraint are part of the nursing plan of care. b. A physicians order is required for restraint and includes a face-to-face evaluation. c. The physician’s preference for the format of the order can override agency policy. d. Orders are time limited. Restraints are not ordered prn (as needed). e. It should be specified that restraints are to be removed periodically. F .Restraint orders are time dated and signed by the physician. ANS: B, D, E, F Physicians are responsible for writing restraint orders and conducting face-to-face evaluations, as well as for putting time limits, specifying when to remove, and time dating and signing orders. Behaviors that necessitate the use of restraint not only are part of the nursing documentation but are to be included as part of the order for restraint. The physician’s formatting is not a consideration for evaluating restraint orders. Formatting of restraint orders typically follows state rules and regulations, as well as regulatory agency standards. 4. The nurse suspects the possibility of a bioterrorist attack. Which of the following factors is most likely related to this possibility? (Select all that apply.) a. A rapid increase in patients presenting with fever or respiratory or gastrointestinal symptoms b. Lower rates of symptoms among patients who spend time primarily indoors c. Large number of rapidly fatal cases of patients with presenting symptoms d. Shortage of personal protective equipment available from central supply e. An increase in the number of staff calling in sick for their assigned shift f. Patients with symptoms all coming from one location in the area ANS: A, B, C, F A rapid increase in patients presenting with a specific symptom, lower rates of symptoms among individuals indoors, and large numbers of fatalities with these symptoms all coming from one location are triggers that lead the nurse to suspect a bioterrorist attack. A shortage of personal protective equipment and an increase in the number of staff calling in sick can occur and does occur at times in the hospital setting and may have nothing to do with bioterrorism. 5. The nurse is completing an admission history on a new home health patient. The patient has been experiencing seizures as the result of a recent brain injury. The nurse diagnoses risk for injury with a goal of keeping the patient safe in the event of a seizure. Which interventions should the nurse utilize for this patient? (Select all that apply.) a. Teach the family how to insert an oral airway during the seizure. b. Assess the home for items that could harm the patient during a seizure. c. Provide information on how to obtain a Medical Alert bracelet. d. Teach the patient to communicate to the caregiver plans for bathing. e. Discuss with family steps to take if the seizure does not discontinue. f. Demonstrate how to restrain the patient in the event of a seizure. ANS: B, C, D, E Assessment of the home for safety, providing information on Medical Alert bracelets, teaching the patient to communicate before bathing, and discussing steps to take with status epilepticus are important interventions for the patient who is having seizures. Inserting an airway may harm the patient by forcing the object into the mouth or by biting down on a hard object. Never restrain a patient who is having a seizure, but protect the patient from hitting his body on objects around him to prevent traumatic injury. 6. The home health nurse is caring for a patient in the home who is using an electrical infusion device. While visiting the patient, the nurse smells smoke and notices an electrical fire started by this device. The nurse uses the fire extinguisher and fights the fire when (Select all that apply.) a.All occupants have left the home. b.Fire department has been called. c.Fire is confined to one room. d.An exit route is available. e.The correct extinguisher is available. f.The nurse thinks she can use the fire extinguisher. ANS: A, B, D, E In a home setting, if the nurse is present during a fire, she first should remove all occupants and then should call the fire department by dialing 911. If the fire is smallnot confined to just one room (this could be too large for the fire extinguisher), if the correct extinguisher is available, and if the nurse knows (not thinks) that she can use it, the nurse may attempt to extinguish the fire. Utilize PASS (Pull the pin, Aim low, Squeeze the handles, Sweep area from side to side) to activate the extinguisher. 7. The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which of the following should the nurse implement? (Select all that apply.) a. Close all doors. b. Note evacuation routes. c. Note oxygen shut-offs. d. Await direction from the fire department. e. Evacuate everyone from the building. f. Review Stop, drop, and roll with the nursing staff. ANS: A, B, C, D Closing all doors helps to contain smoke and fire. Noting the evacuation routes and oxygen shut-offs is important in case the direction to evacuate comes from established channels. Evacuation from the building is determined by the established chain of command or the fire department. Evacuation is done only when necessary. Review of stop, drop, and roll, although important, is not a priority at this time. 8. The nurse is caring for a patient in restraints. Which of the following pieces of information about restraints requires nursing documentation in the medical record? (Select all that apply.) a. The patient states that her gown is soiled and needs changing. b. Attempts to distract the patient with television are unsuccessful. c. The patient has been placed in bilateral wrist restraints at 0815. d. One family member has gone to lunch. e. Bilateral radial pulses present, 2+, hands warm to touch f. Released from restraints, active range-of-motion exercises complete D) peripheral chemoreceptors 9. A patient is constipated and trying to have a bowel movement. How does holding the breath and pushing down (the Valsalva maneuver) affect the pulse? A) left ventricle pumps more forcefully; pulse is stronger B) stimulates the vagus nerve to increase the rate C) stimulates the vagus nerve to decrease the rate D) right ventricle is less efficient; pulse is thready 10. The arterial blood gases for a patient in shock demonstrate increased carbon dioxide and decreased oxygen. What type of respirations would the nurse expect to assess based on these findings? A) absent and infrequent B) shallow and slow C) rapid and deep D) noisy and difficult 11. A nurse walks into a patient’s room and finds him having difficulty breathing and complaining of chest pain. He has bradycardia and hypotension. What should the nurse do next? A) Take vital signs again in 15 to 30 minutes. B) Document the data and report it later. C) Ask the patient if he is anxious or afraid. D) Report findings to the physician immediately. 12. Which of the following pathologic conditions would result in release of ADH by the posterior pituitary? A) hemorrhage B) allergies C) obesity D) asthma 13. A student is reading the medical record of an assigned patient and notes the patient has been afebrile for the past 12 hours. What does the term afebrile indicate? A) normal body temperature B) decreased body temperature C) increased body temperature D) fluctuating body temperature 14. A nurse is assessing a patient who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would be likely? A) Bradycardia B) Tachycardia C) Dysrhythmia D) bigeminal 15. While assessing vital signs of a patient with a head injury and increased intracranial pressure (IICP), a nurse notes that the patient’s respiratory rate is 8 breaths/min. How will the nurse interpret this finding? A) bradypnea is uncommon in patient with IICP B) IICP most commonly results in tachypnea C) bradypnea is a response to IICP D) this is a normal respiratory rate 16. A nurse is conducting a health history for a patient with a chronic respiratory problem. What question might the nurse ask to assess for orthopnea? A) Do you have problems breathing when you walk up stairs? B) Does your medication help you breathe better? C) How many pillows do you sleep on at night to breathe better? D) Tell me about your breathing difficulties since you stopped smoking. 17. What population is at greatest risk for hypertension? A) Hispanic B) White C) Asian D) African American 18. A middle-aged, overweight adult man has had hypertension for 15 years. What pathologic event is he most at risk for? A) stroke B) anemia C) cancer D) infection 19. A nurse educator is teaching a patient about a healthy diet. What information would be included to reduce the risk of hypertension? A) Eat a diet high in fruits and vegetables. B) Remember to drink 8 to 10 glasses of water a day. C) It is important to have increased fats in your diet. D) Put away the salt shaker and eat low-salt foods. 20. A nurse is caring for a patient who is ambulating for the first time after surgery. Upon standing, the patient complains of dizziness and faintness. The patient’s blood pressure is 90/50. What is the name for this condition? A) orthostatic hypotension B) orthostatic hypertension C) ambulatory bradycardia D) ambulatory tachycardia 21. What site for taking body temperature with a glass thermometer is contraindicated in patients who are unconscious? A) rectal B) tympanic C) oral D) axillary 22. A patient has been diagnosed with peripheral vascular disease of the lower extremities. What site would the nurse use to assess circulation of the legs? A) radial artery B) dorsalis pedis artery C) temporal artery D) carotid artery 23. A nurse is taking a patients temperature and wants the most accurate measurement, based on core body temperature. What site should be used? A) rectal B) oral C) axillary D) forehead 24. A student nurse assesses a blood pressure on an adult and finds it to be 140/86. What term is used for the top number (140)? A) systolic pressure B) diastolic pressure C) pulse pressure D) hypotension 25. A hospital unit has a policy that rectal temperatures may not be taken on patients who have had cardiac surgery. What rationale supports this policy? A) It is an embarrassing and painful assessment. B) Thermometer insertion stimulates the vagus nerve. C) It is less expensive to take oral temperatures. D) It is to avoid perforating the wall of the rectum. 26. As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure? A) The blood pressure does not change. B) The blood pressure is erratic. C) The blood pressure decreases. D) The blood pressure increases. 4. A 5. B 6. D 7. A 8. B 9. C 10. C 11. D 12. A 13. A 14. B 15. C 16. C 17. D 18. A 19. D 20. A 21. C 22. Chapter 33- Activity Nursing School Test Banks 1. What function of the skeletal system is essential to proper function of all other cells and tissues? A) supporting soft tissues of the body B) protecting delicate body structures C) providing storage area for fats D) producing blood cells 2. What is the role of the flat bones in the body? A) height B) shape C) movement D) length 3. A patient with severe osteoarthritis is having a surgical hip replacement. This is possible because of the type of joint found in the hip. What type is it? A) pivot joint B) gliding joint C) ball-and-socket joint D) eversion 6. What term is used to describe the correction or prevention of disorders of body structures used in locomotion? A) pediatrics B) obstetrics C) geriatrics D) orthopedics 7. A nurse is assessing the activity level of a 5-month-old baby. What normal findings would be assessed? A) ability to sit and head control B) ability to pick up small objects C) progress toward running and jumping D) progress toward unassisted walking 8. Which of the following activities are normally acquired in the toddler years? Select all that apply A) rolling over B) pulling to a standing position C) walking D) running E) jumping F) climbing stairs 9. A nurse is teaching an older adult about activity. What information would be included in the teaching plan? osteoporosis D) scoliosis 12. A nurse is providing home care for an older woman with severe osteoporosis. What complication of this disease process must the nurse consider in the plan of care? A) diarrhea B) fractures C) visual deficits D) skin disorders 13. A nurse is teaching an older woman how to move and lift her disabled husband. The woman has osteoarthritis of the hips and knees. What is the goal of the nurses teaching plan? A) minimize stress on the wifes joints B) provide exercise for the husband C) increase socialization with neighbors D) maintain self-esteem of the wife 14. Why is it important for the nurse to teach and role model proper body mechanics? A) to ensure knowledgeable patient care B) to promote health and prevent illness C) to prevent unnecessary insurance claims D) to demonstrate knowledge and skills 15. Bedrest, with resultant immobility, affects the whole body. What is one effect on the musculoskeletal system? A) impaired gas exchange