Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023, Exams of Nursing

Download Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 and more Exams Nursing in PDF only on Docsity! Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ Chapter 34: Infection Prevention and Control 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 Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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 Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 3. Pick up the packing with sterile forceps, and gently place it into the incision 4. Rinse the packing with sterile water, and put the packing into the incision with sterile gloves ANS: 2 A sterile object (the packing) remains sterile only when touched by another sterile object. The client’s abdomen is not sterile; therefore, the nurse should throw the packing away and prepare a new one. The nurse should not add alcohol to the packing and insert it into the incision. The packing is considered contaminated as it touched a nonsterile surface and should be discarded. The nurse should not rinse the packing with sterile water and put the packing into the incision as it is considered contaminated. It touched a nonsterile surface. The nurse should throw the packing away and prepare a new one. 9. A client has a viral infection. Which of the following is typical of the illness stage of the course of her infection? 1. There are no longer any acute symptoms. 2. An oral temperature reveals a febrile state. 3. The client was first exposed to the infection 2 days ago but has no symptoms. 4. The client feels sick but is able to continue her normal activities. ANS: 2 During the illness stage the client manifests signs and symptoms specific to the type of infection. The client with a viral infection would likely exhibit a fever. There are no longer any acute symptoms during the convalescent period. An example of a client in the incubation period is when the client was first exposed to the infection 2 days ago, but has no symptoms. The client who feels sick but is able to continue normal activities is in the prodromal stage of a course of infection. 10. The nurse recognizes that special care must be taken in the handling of which of the following to prevent the transmission of hepatitis A? 1. Blood 2. Feces 3. Saliva 4. Vaginal secretions ANS: 2 Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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 Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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. Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 1. Wash her hands, apply the mask and eyewear, put on the gown, and then apply gloves 2. Apply the mask and eyewear, put on the gown, wash her hands, and then apply gloves 3. Wash her hands, put on the gown, apply the mask and eyewear, and then apply the gloves 4. Put on the gown, apply the mask and eyewear, wash her hands, and then apply gloves ANS: 1 The correct sequence for putting on protective equipment is to perform hand hygiene, apply the mask and eyewear, apply gown, and then apply gloves. Apply the mask and eyewear, put on the gown, wash her hands, and then apply gloves; wash her hands, put on the gown, apply the mask and eyewear, and then apply the gloves; put on the gown, apply the mask and eyewear, wash her hands, and then apply gloves are not the correct sequences for putting on protective equipment. 19. A client has requires a mid-abdominal surgical incision which necessitates a sterile dressing. An appropriate intervention for the nurse to implement in maintaining sterile asepsis is to: 1. Put sterile gloves on before opening sterile packages 2. Discard packages that may have been in contact with the area below waist level 3. Place the cap of the sterile solution well within the sterile field 4. Place sterile items on the very edge of the sterile drape ANS: 2 A sterile object held below a persons waist is considered contaminated. To maintain sterile asepsis, packages that may have been in contact with the area below waist level should be discarded. Sterile gloves are not put on before opening sterile packages as the outside of the packages is not sterile. The nurse uses hand hygiene and opens sterile packages, being careful to keep the inner contents sterile. After a cap or lid is removed, it is held in the hand or placed sterile side (inside) up on a clean surface. A bottle cap or lid should never rest on a sterile surface, even though the inside of the cap is sterile. The edges of a sterile field are considered to be contaminated. Sterile items should be placed in the middle of the sterile field to maintain sterile asepsis. 20. The nurse is preparing to assist with a sterile procedure in the surgical suite. An appropriate technique that the nurse includes in the surgical scrub is to: 1. Keep the hands below the elbows throughout the scrub 2. Use a brush on the palms and dorsal surface of the hands 3. Maintain the scrub for at least 2 to 5 minutes 4. Wash well around all jewel Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ ANS: 3 A surgical scrub should be maintained for at least 2 to 5 minutes. To avoid contamination during a surgical hand scrub, the nurse holds the hands above the elbows. Several studies suggest that neither a brush nor a sponge is necessary to reduce bacterial counts on the hands, especially when an alcohol- based product is used. For maximum elimination of bacteria, all jewelry should be removed. 21. An appropriate isolation procedure for the nurse to implement when working with a client who is found to have methicillin-resistant Staphylococcus aureus (MRSA) is to: 1. Leave all linen in the client’s room 2. Place specimen containers in plastic bags for transport 3. Wipe the stethoscope off before removing it from the room 4. Remove the mask and goggles first when leaving the clients room ANS: 2 Specimen containers should be placed in plastic bags for transport with a label on the outside of the bag. Linen should be placed in an impervious linen bag and may be removed from the client’s room. Bags should be tied securely at the top with a knot. For the person infected with MRSA, equipment remains in the room. After discharge or with the discontinuation of isolation, client care equipment is properly cleaned and reprocessed and single-use items are discarded. Gloves should be removed first when leaving the clients room. 22. A client is found to have a bacterial infection of Escherichia coli. The nurse, recognizing the effects of this bacterium, anticipates that the client will demonstrate: 1. Diarrhea 2. Coughing 3. Cold sores around the mouth 4. Discharge from the eyes ANS: 1 Escherichia coli causes gastroenteritis and urinary tract infections. The client with E. coli infection is likely to demonstrate diarrhea. E. coli is found in the colon, not the respiratory tract. Cold sores are seen with herpes simplex virus (type 1), not with E. coli. Discharge from the eyes is not seen with E. coli infection. It may be seen with Neisseria gonorrhea. 23. Which of the following clients is at greatest risk for acquiring an infection? Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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: Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ ANS: 2 When a needle pierces a clients skin regardless of the location, organisms enter the body if proper skin prepping was not performed. The remaining options have an effect on infection control but not to the degree that skin prepping does. 32. A client enters a neighborhood walk-in clinic reporting the symptoms of a head cold. When the health care provider does not prescribe an antibiotic, the client asks the nurse to explain why not. The nurse’s most appropriate response is: 1. Antibiotics aren’t usually necessary for colds, and they are really very expensive if you don’t have insurance. 2. You know what they say; a cold will go away with medication in 2 weeks; without medication in 14 days. 3. Your health care provider believes in treating the symptoms since there are so many different strains of the common cold. 4. Common colds don’t usually require an antibiotic, and taking one results in making it harder to treat infections when they do occur. ANS: 4 Organisms with resistance to key antibiotics are becoming more common in acute care settings. This is associated with the frequent and sometimes inappropriate use of antibiotics. While the remaining options are not incorrect, they may seem insensitive or incomplete in answering the clients question. 33. The nurse is caring for a postoperative client with a localized sinus infection. The most appropriate means by which the nurse can minimize the risk of this client developing a systemic infection is to: 1. Adhere strictly to standard precaution techniques 2. Dispense prescribed anti-infective medication as ordered 3. Monitor the client regularly for exacerbation of the sinus infection 4. Review lab work daily to determine the presence of increased white cell count Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ ANS: 1 If an infection is localized (e.g., a wound infection), use of standard precautions and personal protective equipment (PPE) will block the spread of infection to other sites, thus preventing an infection that affects the entire body instead of just a single organ or part (systemic). While the other options are not incorrect, they are not as directed at minimizing the risk of infection as is the answer. 34. The nurse and a client are discussing the client’s tendency to develop numerous colds during the winter months. The client’s health history reveals that he is a 1 pack a day smoker. Which of the following nursing statements is most appropriate regarding the possible relationship between the client’s cigarette smoking and the frequency of winter colds? 1. Smoking decreases your body’s immune system, and so you can’t fight off the colds as effectively. 2. If you stopped smoking you would have fewer colds and just generally feel better all year around. 3. The nicotine in the cigarettes has an effect on your blood vessels, decreasing the circulation of antibodies that would attack the cold viruses. 4. Smoking damages the little hairs in your nose and airways so they can’t trap the airborne cold viruses and keep them from entering your body. ANS: 4 Cilia lining the upper airway trap inhaled microbes and sweep them outward in mucus to be expectorated or swallowed. Smoking appears to paralyze these tiny hairs, and so they are not able to function effectively. Consequently, microbes including the cold viruses are able to enter into the respiratory tract. The other options present unproven theories, generalized statements, or less thorough explanations of the relationship between smoking and respiratory illnesses. 35. Which of the following clients is at greatest risk for acquiring a health care associated (nosocomial) infection? 1. A 32-year-old hospitalized for 2 days for migraine headaches 2. A client with type 1 diabetes who has been experiencing hypoglycemia 3. A trauma victim taken directly from the ED to surgery and then to the postsurgical unit 4. A pregnant 24-year-old diagnosed with both sinusitis and otitis media and prescribed an oral antibiotic Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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. Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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, Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ respiratory tract, genitourinary tract, gastrointestinal tract, and transplacental (mother to fetus). Unless the skin of the hands was broken (not intact), this contact would not be considered a portal of exit. 3. Which of the following assessment data indicate the presence of a local inflammatory process? (Select all that apply.) 1. Client reports being cold 2. Left elbow warm to the touch 3. Elevated white blood cell (WBC) count 4. Pitting edema of +2 around the right ankle 5. Client reports knee pain of 5 on a scale of 1 to10 6. Client observed grimacing while raising shoulder to brush hair ANS: 2, 4, 5, 6 Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of function in the affected body part. When inflammation becomes systemic, other signs and symptoms develop, including fever, leukocytosis, malaise, anorexia, nausea, vomiting, lymph node enlargement, or organ failure. Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ Potter and Perry Fundamental of Nursing Eighth Edition 1. The nurse is caring for a patient with pneumonia with a new nurse in orientation. Which of the following statements by the new nurse would indicate an understanding of the nature of this condition? a. An infectious disease like pneumonia may not pose a risk to others. b. We need to isolate the patient in a negative pressure room. c. The patient will not be able to return home. d. Clinical signs and symptoms are not present in pneumonia. ANS: A Infections are infectious or communicable. Infectious diseases may not pose a risk for transmission to others, although they are serious for the patient. Pneumonia is not a communicable disease that is transmitted directly from one individual to the next; so there is no need for isolation. Clinical signs and symptoms are present in pneumonia and include but are not limited to elevated temperature, shortness of breath, fatigue, and coughing; in addition, the patient may have rhonchi and crackles upon auscultation. Frequently, patients with pneumonia do return home unless there are extenuating circumstances. 2. The patient and the nurse are discussing Rickettsia rickettsii, Rocky Mountain spotted fever. Which patient statement to the nurse indicates understanding regarding the mode of transmission of this disease? a. When I go camping, I will be sure to wear sunscreen. b. When I go camping, I will drink bottled water. c. When I go camping, I will be sure to wear insect repellent. d. When I go camping, I will be sure to use hand gel on my hands. ANS: C Each infectious disease has a specific mode of transmission, a component of the chain of infection. Rocky Mountain spotted fever is caused by bacteria transmitted by the bite of ticks. Wearing a repellent that is designed for repelling ticks, mosquitoes, and other insects can help in preventing transmission of this disease. Drinking plenty of uncontaminated water, wearing sunscreen, and using alcohol-based hand gels for cleaning hands are all important activities to participate in while camping, but they do not contribute to or prevent transmission of this disease. 3. The nurse is providing an educational session for a group of preschool workers. The nurse reminds the group that the most important thing to do to prevent the spread of infection is t Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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 Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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. Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 10. The nurse is caring for a group of medical-surgical patients. The patient most at risk for developing an infection is the patient who a. Is in observation for chest pain. b. Is recovering from a right total hip arthroplasty. c. Has been admitted with dehydration. d. Has been admitted for stabilization of atrial fibrillation. ANS: B The patient who is recovering from a right total hip arthroplasty has had a surgical procedure wherein bone was removed from the body and an implant was placed within the patient. The patient has a large incision from surgery. The patient also has an intravenous infusion to provide fluids and medication. All these breaks in the skin increase the likelihood of infection. The patient has had anesthesia and medication for pain. Both of these depress the respiratory system and have the potential to decrease the expansion of alveoli and to increase the chance of infection in the respiratory system. The other patients may have one break in the skin when an intravenous infusion is used. 11. The nurse is caring for a patient with leukemia and is preparing to provide fluids through a vascular access device. Which nursing intervention is priority in this procedure? a. Position the patient comfortably. b. Maintain aseptic technique. c. Gather available supplies. d. Review the procedure with the patient. ANS: B Patients with disease processes of the immune system are at particular risk for infection. These diseases include leukemia, AIDS, lymphoma, and aplastic anemia. These disease processes weaken the defenses against an infectious organism. It is priority that anytime an intravenous device is accessed, aseptic technique must be maintained with wearing of appropriate personal protective equipment, preparation of the skin, and use of sterile gloves, sterile supplies, appropriate flushing, and appropriate discontinuation. Reviewing the procedure with the patient, positioning the patient, and gathering the supplies are all important steps in the procedure but are not the priority in the procedure. 12. The nurse is caring for an adult patient in the clinic who has been evacuated and is a victim of flooding. The patient presents with signs and symptoms of a urinary tract infection. Along with needed education surrounding this diagnosis, the nurse teaches the patient about rest, exercise, eating properly, and how to utilize deep breathing and visualization. Which of these explanations would best Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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 Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ the Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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? Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ c. Removing gloves to transfer the endoscope Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ d. Disinfecting endoscopes in the workroom ANS: C Standard Precautions are used to prevent and control the spread of infection. Transferring contaminated equipment without the protection of gloves can assist in the spread of microbes to inanimate objects and to the person doing the transfer. Utilizing gloves, washing hands, covering contaminated supplies during transfer, and disinfecting equipment in the appropriate way in the appropriate places utilize principles of basic medical asepsis and Standard Precautions and can break the chain of infection. 24. The nurse is caring for a patient with a nursing diagnosis of risk for infection. Aware of the need for Standard Precautions, the nurse is careful to a. Teach the patient about good nutrition. b. Wear eyewear when emptying a urinary drainage bag. c. Avoid contact with intact skin without wearing gloves. d. Don gloves when wearing artificial nails. ANS: B Standard Precautions include the wearing of eyewear whenever there is a possibility of a splash or splatter. Teaching the patient about good nutrition is positive but does not apply to Standard Precautions. The term Standard Precautions applies to all blood and body fluids except sweat, even if blood is not present. It also applies to non-intact skin and mucous membranes. 25. The nurse is caring for a patient who has just delivered a neonate. The nurse is checking the patient for excessive vaginal drainage. It is important for the nurse to utilize Precautions. a. Contact b. Protective c. Droplet d. Standard ANS: D Standard Precautions apply to contact with blood, body fluid, non-intact skin, and mucous membranes of all patients. Contact Precautions apply to individuals with colonization of infection such as MRSA. Protective Precautions apply to individuals who have undergone transplantations. Droplet Precautions focus on diseases that are transmitted by large droplets. Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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 Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ b. The family member places the used dressings in a plastic bag. Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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 Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ Patients should perform hand hygiene before and after treatments and when coming in contact with body fluids. Depending on the type of patient, holding hands does not require washing of hands before but is advisable before touching eyes, nose, or mouth-washing hands afterward would be a good practice. Washing hands before and after opening the refrigerator and using the computer is not required but during cold and flu season might be advisable. 33. The nurse has been caring for a patient in the perioperative area for several hours. The surgical mask the nurse is wearing has become moist. The nurses best next step is to a. Change the mask when relieved. b. Air-dry the mask while at lunch, and reapply. c. Ask for relief, step out of the surgical area, and apply a new mask. d. Not change the mask, if the nurse is comfortable. ANS: C A mask should fit snugly around the face and nose. After the mask is worn for several hours, it can become moist. The mask should be changed as soon as possible because moisture encourages the growth of microorganisms. Waiting to change the mask, air-drying it, or wearing it because it is comfortable does not support the principles of infection control. 34. The nurse is caring for a patient on Contact Precautions. Which of the following actions would be appropriate to prevent the spread of disease? a. Wear a gown, gloves, face mask, and goggles for interactions with the patient. b. Use a dedicated blood pressure cuff that stays in the room and is used for that patient only. c. Place the patient in a room with negative airflow. d. Transport the patient quickly when going to the radiology department. ANS: B Contact Precautions are a type of Isolation Precaution used for patients with illness that can be transmitted through direct or indirect contact. A patient is placed on Contact Precautions if a disease is present that can be transmitted through direct or indirect contact. Patients who are on Contact Precautions should have dedicated equipment wherever possible. This would mean, for example, that one blood pressure cuff and one stethoscope would stay in the room with the patient and would be used for that patient only. A gown and gloves may be required for interactions with a patient who is on Contact Precautions. A face mask and goggles are not part of Contact Precautions. A room with negative airflow is needed for patients placed on Airborne Precautions; it is not necessary for a patient on Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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. Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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. Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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 Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ OTHER Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 1. The nurse is caring for a patient who needs a protective environment. The nurse has provided the care needed and is now leaving the room. Select the correct order for removal of the personal protective equipment and associated tasks. (All answers are utilized.) a. Remove eyewear/face shield and goggles. b. Perform hand hygiene. c. Remove gloves. d. Untie gown, allow gown to fall from shoulders, and do not touch outside of gown; dispose of properly. e. Remove mask by strings; do not touch outside of mask. f. Dispose of all contaminated supplies and equipment in designated receptacles. g. Leave room and close the door. ANS: C, A, D, E, B, G, F The correct order for removing personal protective equipment for a patient in a protective environment and for performing associated tasks is to remove gloves, remove eyewear, remove gown, remove mask, perform hand hygiene, leave room and close doors, and dispose of all contaminated supplies and equipment in a manner that prevents the spread of microorganisms. 2. The nurse manager is evaluating current infection control data for the intensive care unit. The nurse compares past patient data with current data to look for trends. The nurse manager examines the chain of infection for possible solutions. Arrange these items in the proper order. (All answers are utilized.) a. A mode of transmission b. An infectious agent or pathogen c. A susceptible host d. A reservoir or source for pathogen growth e. A portal of entry to a host f. A portal of exit from the reservoir ANS: B, D, F, A, E, C The nurse manager is evaluating the chain of infection to determine actions that could be implemented Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ to influence the spread of infection in the intensive care unit. Understanding the spread of infection and Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ C) vectors D) airborne route **** Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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. Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ B) The presence of specific signs and symptoms indicates the full stage of illness. **** Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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? Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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? Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ A) Use sterile gloves to handle the entire drape surface. **** Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 10. A confused elderly woman who keeps attempting to remove tubes from her surgical incision is placed in wrist restraints. Which of the following diagnoses would be appropriate for this patient? A) Risk for Contamination B) Risk for Trauma C) Risk for Falls D) Risk for Disuse Syndrome **** 11. Which set of terms best describes first-aid care? A) long-term, chronic illness B) professional, hospital C) immediate, temporary **** D) skilled, complex 12. A nurse is conducting a prenatal class for expectant parents. What is one topic that should be addressed to promote safety in the developing fetus? A) alcohol consumption and smoking **** B) infant hygiene and feeding C) the stages of labor with possible complications D) the role of the father in proper prenatal care 13. What safety device for children is mandated by law in all 50 states? A) bumper pads in baby cribs B) infant car seats and carriers **** C) automatic hot water heater controls D) parental controls for Internet access 14. An emergency room nurse is assessing a toddler with multiple bruises and burns. The nurse suspects the toddler has been abused. What is legally required of the nurse? A) Nothing; the nurse has no control over the toddlers home. B) Refer the caregivers of the toddler to a home health nurse. C) Verbally confront the caregivers about the suspicions. D) Report suspicions about the abuse to proper authorities. **** 15. A grade school nurse is addressing parents at a PTA meeting regarding car safety. Which of the following is a recommended safety guideline for this age group? A) All school-aged children need to be secured in safety seats. Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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. Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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). **** Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ B) Do you think it would be best for me to buy a gun? C) I am going to remove all those throw rugs on the floor. **** D) Well, I always let the boys play in the bathtub; they love it. Potter Eighth Edition Patient Safety Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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 Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ c. 15 C to 17 C Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ and transfer, and at the beginning of each shift. Gathering more than one patients medication increases the likelihood Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ of error. Raising all four side rails is considered a restraint and requires special orders, assessment, and monitoring of the patient. 9. The nurse is completing discharge education for the patient regarding home medications. Which patient behavior is an indication that the patient understands the directions regarding the antibiotic medication? a. The patient nods throughout the educational session. b. The patient reads the medication prescription out loud. c. The patient states, I will finish the antibiotic in ten days. d. The patient asks where to get the prescription filled. ANS: C The patient stating the time frame for when the medication will be complete is the best answer. Nodding, reading the prescription out loud, or knowing where to get the prescription filled does not indicate understanding regarding directions for taking the antibiotic. 10. The nurse knows that children in late infancy and toddlerhood are at risk for injury owing to a. Learning to walk. b. Trying to pull up on furniture. c. Being dropped by a caregiver. d. Growing ability to explore and oral activity. ANS: D Injury is a leading cause of death in children over age 1, which is closely related to normal growth and development because of the childs increased oral activity and growing ability to explore the environment. 11. A nurse is teaching a community group of school-aged parents about safety. The most important item to prioritize and explain is how to check the proper fit of a. a bicycle helmet. b. swimming goggles. c. soccer shin guards. d. baseball sliding shorts. ANS: A Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ Bicycle-related injuries are a major cause of death and disability among children. Proper fit of the helmet helps to decrease head injuries resulting from bicycle accidents. Goggles, shin guards, and sliding shorts are important sports safety equipment and should fit properly, but they do not protect from this leading cause of death. 12. The nurse is presenting an educational session on safety for parents of adolescents. The nurse should include which of the following teaching points? a. Adolescents need unsupervised time with friends two to three times a week. b. Parents and friends should teach adolescents how to drive. c. Adolescents need information about the effects of beer on the liver. d. Adolescents need to be reminded to use seatbelts on long trips. ANS: C Providing information about drugs and alcohol is important because adolescents may choose to participate in risk-taking behaviors. Adolescents need to socialize but need supervision. Parents can encourage and support learning processes associated with driving, but organized classes can help to decrease motor vehicle accidents. Seatbelts should be used all the time. 13. The nurse discussed threats to adult safety with a college group. Which of the following statements would indicate understanding of the topic? a. Our campus is safe; we leave our dorms unlocked all the time. b. As long as I have only two drinks, I can still be the designated driver. c. I am young, so I can work nights and go to school with 2 hours sleep. d. I guess smoking even at parties is not good for my body. ANS: D Lifestyle choices frequently affect adult safety. Smoking conveys great risk for pulmonary and cardiovascular disease. It is prudent to secure belongings. When an individual has been determined to be the designated driver, that individual does not consume alcohol, beer, or wine. Sleep is important no matter the age of the individual and is important for rest and integration of learning. The average young adult needs 6 1/2 to 8 hours of sleep each night. 14. The nurse is teaching a group of older adults at an assisted-living facility about age- related physiological changes. Which question would be the most important to ask this group? a. Are you able to hear the tornado sirens in your area? Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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. Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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 Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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 Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ c. The car was going too fast, the speed limit is 20. d. I was so surprised; I didn’t see or hear the car coming. ANS: D The patient did not see or hear the car coming. As patients age, sensory impairment can increase the risk for injury. This statement by the patient would require follow-up by the nurse. The patient needs hearing and eye examinations. Exercise is important at every stage of development. The patient seemed to comprehend how to cross an intersection correctly and was able to determine the speed of the car. 25. The patient presents to the clinic with a family member. The family member states that the patient has been wandering around the house and mumbling. What is the first assessment the nurse should do? a. Ask the patient why she has been wandering around the house. b. Introduce self and ask the patient her name. c. Take the patient’s blood pressure, pulse, temperature, and respiratory rate. d. Immediately do a complete head-to-toe neurologic assessment. ANS: B Introduce self and engage the patient by asking her name to assess orientation; ask the patient why she is visiting the clinic today. Continue the assessment with vital signs and a complete workup, including a neurologic assessment. 26. The emergency department has been notified of a potential bioterrorist attack. The nurse assigned to the department realizes that the most important task for safety in this situation is to a. Carry out the role and responsibilities of the nurse quickly and efficiently. b. Cluster all patients with the same symptoms to a specific part of the department. c. Determine the biologic agent and manage all patients using Standard Precautions. d. Prepare for post-traumatic stress associated with this bioterrorist attack. ANS: C It is essential to determine the agent and manage all patients who are symptomatic with the suspected or confirmed bioterrorism-related illness using Standard Precautions. For certain diseases, additional precautions may be necessary. Clustering patients may be helpful with staffing and, depending on the illness, may decrease the spread. All nurses every day should carry out their roles quickly and Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ efficiently. Psychosocial concerns are important but are not the first priority at this moment. Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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? Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ a. Seek out the source of the alarm. b. Wait to see if the alarm discontinues. c. Ask another nurse to check on the alarm. d. Continue ambulating the patient. ANS: C The nurse who heard the alarm has a duty to address it even though she is busy with another patient. Ask someone to check on the alarm. The nurse cannot leave the patient in the hallway to look for the source of the alarm and cause a potentially unsafe situation for this patient, but a patient on the unit may have an urgent need. Someone needs to seek out the source of the alarm and address it. Never ignore an alarm. Alarms are in place to maximize the safety of the patient. Waiting to see if an alarm stops may cause a delay in a possible emergency situation. 35. The nurse has placed a patient on high-risk alert for falls. Which of the following observations by the nurse would indicate that the patient has an understanding of this alert? a. The patient removes the high alert armband to bathe. b. The patient wears the red nonslip footwear. c. The call light is kept on the bedside table. d. The patient insists on taking a water pill on home schedule in the evening. ANS: B Red nonslip footwear helps to grip the floor and decreases the chance of falling. The communication armband should stay in place and should not be removed, so that all members of the interdisciplinary team have the information about the high risk for falls. Call lights should be kept within reach of the patient. Taking diuretics early in the day assists with decreasing the number of bathroom trips at nightthe time when falls are most frequent. 36. The nurse is instructing the student nurse regarding discharge teaching and medications. Which response by the student would indicate that learning has occurred? a. I need to be precise when teaching a patient about Zyprexa (olanzapine) and Zyrtec (cetirizine). b. The medications can be picked up at the pharmacy on the way out of the hospital. c. I need to be sure to give the patient leftover medications from the medication drawer. d. I need to remember to teach the patient to take all medications at the same time of the day. ANS: A Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ Zyprexa and Zyrtec are sound-alike, look-alike medications. Zyprexa is an antipsychotic and Zyrtec an antihistamine; these agents treat two different conditions. Bringing the differences and similarities in spelling and sound to the attention of the patient is important for patient safety. Medications are not distributed by the hospital, and medications do not need to be administered at the same time each day. MULTIPLE RESPONSE 1. A nurse is caring for an adult patient who has had a minor motor vehicle accident. The health history reveals that the patient is currently in the process of obtaining a divorce. Which of the following actions should the nurse take?(Select all that apply.) a. Agree upon and make time for the patient to talk. b. Use active listening skills and therapeutic touch as appropriate. c. Teach stress reduction strategies. d. Inform patient that stressed individuals are more likely to have accidents. e. Agree to witness telephone conversations with separated husband. f. Refer the patient to the nurses church marriage counselor. ANS: A, B, C, D Agreeing and making time for conversation, using active listening skills and therapeutic touch, teaching stress reduction strategies, and informing the patient of the risk to health associated with stress are interventions that are within the nurses scope of practice. Agreeing to witness a telephone conversation could draw the nurse into divorce proceedings when the focus should be on the patient and his health. Referring the patient to the nurses church counselor without a specific request from the patient may not take into consideration cultural care and could be considered unprofessional. If the patient requested a marriage counselor, a better solution would be to provide a referral to social services that may include a list of possible counselors from which the patient could choose. 2. The nurse is caring for an older adult who presents to the clinic after a fall. The nurse reviews fall prevention in the home. Which of the following should the patient avoid? (Select all that apply.) a. Watering outdoor plants with a nozzle and hose b. Purchasing light bulbs with strength greater than 60 watts c. Missing yearly eye examinations d. Using bathtubs without safety strips Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ e. Unsecured rugs throughout the home Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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 Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ available. e.The correct extinguisher is available. Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank QUESTIONS WITH ANSWERS 2023 A+ 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