Download Test Bank Concept-Based Clinical Nursing Skills 2nd Edition by Loren Stein and more Exams Nursing in PDF only on Docsity! CHAPTER 01: FOUNDATIONS OF SAFE CLIENT CARE STEIN: CONCEPT-BASED CLINICAL NURSING SKILLS, 2ND EDITION MULTIPLE CHOICE 1. To meet a requirement of the 2021 American Association of Colleges of Nursing Essentials, what topic does nursing faculty focus on throughout the curriculum? a. Nursing process b. Safety science c. Ergonomics d. Information technology ANS: B The 2021 AACN Essentials states that "Provision of safe, quality care necessitates knowing and using established and emerging principles of safety science in care delivery" (p. 43). Nursing students are taught to use the nursing process, but this is not confined to patient safety. Ergonomics is a subset of safety science that studies people and their work environments. Information technology can be used to improve safety. DIF: Cognitive Level: Remembering TOP: Integrated Process: Teaching-Learning 2. A nurse meets the assigned clients at the start of a shift. After performing hand hygiene and introducing one's self, what does the nurse do next? a. Begin a head-to-toe assessment. b. Identify the client using two identifiers. c. Assess the client for pain. d. Ensure the call light is within reach. ANS: B A critical task in healthcare for safety, client identification is paramount for preventing errors. After performing hand hygiene and introducing him- or herself, the nurse identifies the client using two unique identifiers. The head-to-toe and pain assessments come shortly afterward. The nurse ensures the client can reach the call light prior to leaving the room. DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment 3. A nurse has worked with the same client for 2 days. When entering the room to administer medications, the nurse performs hand hygiene. What action does the nurse take next? a. Provide any needed teaching. b. Ask if the client has any care requests. c. Assess vital signs and pain. d. Identify the client using two identifiers. ANS: D Every time the client is to receive medication, diagnostic studies, or any other healthcare intervention, the nurse must identify the client using two unique identifiers, even if the 7. A nurse is observing a student nurse. What action by the student demonstrates the need for more education on Standard Precautions? a. The student performs hand hygiene before all client contacts. b. The student conscientiously wears gloves when taking vital signs. c. The student confirms that urine possibly contains infectious microbes. d. The student wears a gown when cleaning liquid stool off the client. ANS: B Standard Precautions operates under the principle that all bodily fluids other than sweat could potentially contain infectious microbial agents that pose a risk to the healthcare worker. Contact with skin, if free of those fluids, does not require wearing gloves, so the nurse would provide more education to the student. Hand hygiene is the first step of Standard Precautions. The student is being prudent by confirming a possible source of contamination. Nurses determine which infection prevention practice to use based upon the type of client- nurse interaction and the possibility of exposure to blood, other body fluids, or pathogens, so wearing a gown while cleaning liquid stool is appropriate. DIE: Cognitive Level: Analyzing TOP: Nursing Process: Evaluation 8. A faculty member has taught the correct technique for taking gloves off (doffing). While observing students practice, which action by a student indicates the need to review the material? a. Pulls glove off dominant hand first. b. Takes first glove off by grasping it on the outside. c. Takes second glove off by grasping it under the cuff. d. Turns the gloves inside out when second glove is removed. ANS: A The correct way to remove gloves starts with doffing the glove on the nondominant hand first, without touching the bare skin. This student would need further review of the skill. Removing the first glove by grasping it on the outside, grasping the second glove under the cuff, and turning the gloves inside out to prevent microbe spread are all correct actions. These students would not need remediation. DIF: Cognitive Level: Analyzing TOP: Nursing Process: Evaluation 9. In order to move a cooperative client safely from the bed to chair, which of the following actions does the nurse take first? a. Gather enough help for the task. b. Assess the client's ability to bear weight. c. Delegate using the lift chair. d. Administer pain medication. ANS: B The first thing the nurse does when preparing to transfer a cooperative client is to assess the client's ability to bear weight and remain balanced while standing. The findings will determine how much assistance (if any) the client needs. If the client needs maximal assistance, then the nurse gathers enough help and any lifting devices needed and assigns roles to each team member. If the client has pain, the nurse would administer pain medication, but that is not related to safety. DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation 10. Hospital administration has rejected a request from nursing services for ceiling- mounted lifting/transferring devices pointing to the expense. What response by the Chief Nursing Officer would be best? a. "We need the equipment to stay competitive in hiring nurses." b. "They are required by The Joint Commission so we have to get them." c. "The cost of employee injuries from lifting is more expensive." d. "We will save money with fewer client-injury lawsuits being filed." ANS: C Data show that when hospitals implemented safe client handling equipment, hospitals achieved savings by reducing lost work days and reducing worker compensation costs that met or exceeded the cost of the equipment. This is not a main focus for nurse recruitment and the equipment is not mandated. Fewer client injuries leading to lawsuits is a probability, but the savings in reducing employee injury have been documented by the ANA. DIF: Cognitive Level: Understanding TOP: Integrated Process: Communication and Documentation 11. The nurse places a bed-bound client in the position shown. What other considerations would the nurse have for this client? a. "Clients have the right to be free from restraint or seclusion unless medically necessary." b. "Following all these regulations helps prevent law suits." c. "Accrediting bodies aren't in favor of using restraints so they make up regulations." d. "Because restraints have been shown to actually increase injuries." ANS: A The guiding principle for restraint use is that clients have the right to be free from unnecessary restraint or seclusion unless it is medically necessary. This is a basic human right and protects client dignity. Following regulations won't necessarily prevent lawsuits, but will help prevent negative outcomes from the legal action. Accrediting bodies don't "just make up regulations." There are sound reasons for them. Restraints have been shown to increase injury, but that is secondary to the fact that clients have the right to be free from them unless absolutely needed. DIF: Cognitive Level: Understanding TOP: Integrated Process: Teaching-Learning 15. After assessing a client, the nurse cleans the stethoscope. What cleaning agent chosen by the nurse is most appropriate? a. 70% isopropyl alcohol b. Diluted bleach 1:10 solution c. Cidex® d. Hydrogen peroxide ANS: A 70% to 90% isopropyl or 60-80% ethyl alcohol is appropriate for low-level disinfecting needs such as cleaning stethoscopes, blood pressure cuffs, and table tops. Diluted bleach is considered an intermediate level disinfectant and used for client rooms (including isolation rooms) and visible blood spills. Cidex is a high-level disinfectant used for equipment that comes into contact with mucous membranes, for example, an endoscope. DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation 16. After giving an injection, which action by the nurse is most appropriate? a. Breaks needle off the syringe and places it in the sharps box. b. Recaps the needle and carries the syringe to the sharps box. c. Engages the syringe's safety device to cover the needle. d. Twists the needle off and throws the syringe away. ANS: C Needle-stick injury is an occupational hazard. Current guidelines for handling sharps include not recapping, bending, breaking, or hand-manipulating used needles. If recapping is required, use a one-handed scoop technique only. Use safety features when available. Place used sharps in a puncture-resistant container. The correct action would be to engage the safety feature on the syringe to cover the needle. DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation 17. The nurse is working in a neonatal intensive care unit. When an infant's oxygen saturation drops, what action does the nurse take first? a. Place the neonate prone. b. Call a code blue. c. Inform the provider. d. Call respiratory therapy ANS: A Neonates and infants improve ventilation and oxygenation in the prone position. When the baby's oxygen saturation drops, the nurse would place the baby in the prone position. The nurse would call the provider afterward. There is no indication that the baby is in cardiopulmonary arrest, so a code blue is not called. There is no indication to call respiratory therapy. DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation 18. What is the primary focus of the 2021 American Association of Colleges of Nursing Essentials, as highlighted for nursing faculty throughout the curriculum? a. Patient communication b. Evidence-based practice c. Safety science d. Technological advancements Answer: C The 2021 AACN Essentials emphasizes the importance of safety science in care delivery, stating that "Provision of safe, quality care necessitates knowing and using established and emerging principles of safety science in care delivery" (p. 43). d. Wearing a gown when cleaning liquid stool off the client Answer: B Standard Precautions emphasize the use of gloves when there is potential contact with bodily fluids; however, wearing gloves during routine vital signs is not necessary. 24. When teaching the correct technique for glove removal (doffing), which action by a student indicates the need for additional review? a. Pulling off the glove on the dominant hand first b. Taking the first glove off by grasping it on the outside c. Removing the second glove by grasping it under the cuff d. Turning the gloves inside out when removing the second glove Answer: A The correct technique for removing gloves involves doffing the glove on the nondominant hand first, without touching the bare skin. 25. In moving a cooperative client from the bed to a chair, what is the nurse's initial action? a. Gathering enough help for the task b. Assessing the client's ability to bear weight c. Delegating the use of the lift chair d. Administering pain medication Answer: B The nurse's first action is to assess the client's ability to bear weight and remain balanced while standing before determining the level of assistance needed. 26. The Chief Nursing Officer responds to the denial of ceiling-mounted lifting devices, emphasizing what aspect in favor of acquiring the equipment? a. Ensuring competitiveness in nurse recruitment b. Mandate by The Joint Commission c. Cost of employee injuries from lifting d. Savings from reduced client-injury lawsuits Answer: C Data supports that implementing safe client handling equipment helps reduce worker compensation costs and lost work days, outweighing the expense. 27. When assessing a bed-bound client in a modified left lateral recumbent position, what is a consideration for the nurse? a. Including a Trochanter roll to prevent neck strain b. Assessing the need for support to prevent foot drop c. Monitoring for signs of increased intracranial pressure d. Placing a rolled-up washcloth in the client's hands Answer: B In the modified left lateral recumbent position, considerations include providing pillow support for various body areas and preventing complications such as foot drop. 28. After applying restraints to a client, what is the nurse's immediate action following documentation and ensuring client safety? a. Calling the provider for a restraint prescription b. Alerting the hospital's Risk Management department c. Planning to check the client every 2 hours d. Assigning assistive personnel to sit with the client Answer: C The standard requires the nurse to assess the restrained client at a minimum of every 2 hours, ensuring ongoing safety and well-being. 29. When applying restraints, which action by a nursing student indicates a need for further education? a. Attempting alternative methods before applying restraints b. Inserting two fingers between the restraint and client's skin to check tightness c. Securing the restraint by tying it to the side rail, out of client reach d. Reassessing the client's need for restraints at least every 2 hours Answer: C Restraints should be tied to a secure part of the bed frame, not the side rail, to ensure the safety and well-being of the restrained client. 30. A new nurse questions the necessity of regulations on restraint use. What is the mentor's best response? a. "Clients have the right to be free from restraint unless medically necessary." 35. When caring for a client with multiple invasive lines, which action by the nurse demonstrates a focus on infection prevention? a. Changing gloves frequently b. Administering pain medication promptly c. Assessing respiratory status regularly d. Utilizing aseptic technique during line care Answer: D Infection prevention in clients with invasive lines involves maintaining aseptic technique during line care to prevent infections. 36. A nurse is teaching a group of healthcare providers about the importance of hand hygiene. Which statement by a participant indicates a correct understanding? a. "Hand hygiene is only necessary before meals." b. "I should wash my hands for at least 5 seconds." c. "Using hand sanitizer is equivalent to handwashing." d. "Hand hygiene is unnecessary if gloves are worn." Answer: C Using hand sanitizer is considered an acceptable alternative to handwashing in situations where hands are not visibly soiled. 37. In which scenario would the use of personal protective equipment (PPE) be most crucial for the nurse? a. Administering oral medication b. Providing emotional support to a client c. Assisting with wound dressing changes d. Taking a client's blood pressure Answer: C Assisting with wound dressing changes involves potential exposure to blood and body fluids, making the use of PPE crucial to prevent transmission of infectious agents. 38. When developing a plan to reduce the incidence of client falls in a healthcare facility, what strategy should the nurse prioritize? a. Implementing hourly rounding b. Limiting family visitation c. Restricting mobility devices d. Reducing nursing staff ratios Answer: A Implementing hourly rounding allows for regular checks on clients, reducing the likelihood of falls by addressing needs promptly. 39. A client expresses dissatisfaction with the healthcare provided and threatens to leave against medical advice. What is the nurse's initial action? a. Inform the client about the potential consequences of leaving b. Call security to prevent the client from leaving c. Document the client's decision and inform the healthcare provider d. Persuade the client to stay by highlighting potential benefits Answer: A The nurse's initial action is to inform the client about the potential consequences of leaving against medical advice, ensuring the client is fully informed before making a decision. 40. A client diagnosed with a communicable disease is isolated in a negative pressure room. What is the primary purpose of negative pressure isolation? a. Protecting healthcare providers from infection b. Preventing the spread of airborne pathogens c. Enhancing client comfort and privacy d. Reducing environmental contamination Answer: B Negative pressure isolation rooms help prevent the spread of airborne pathogens by ensuring that air flows into the room and not out, reducing the risk of transmission to others. 41. A nurse is providing discharge education to a client prescribed a new medication. What information should the nurse prioritize? a. The medication's cost and insurance coverage b. Potential side effects and adverse reactions c. The medication's brand name and manufacturer d. Instructions for obtaining a refill 46. A client with a history of falls is receiving care in a healthcare facility. What environmental modifications should the nurse prioritize to enhance the client's safety? a. Dimming overhead lights in the room b. Placing the call light out of reach c. Using non-skid mats on the floor d. Keeping the room temperature cool Answer: C Using non-skid mats on the floor is an environmental modification that can help prevent slips and falls, promoting client safety. 47. A nurse is conducting a safety training session for a group of healthcare providers. What principle should the nurse emphasize regarding the use of restraints? a. Restraints are a routine part of client care b. Restraints are primarily used for punishment c. Restraints require ongoing assessment and monitoring d. Restraints should be applied without the client's knowledge Answer: C The nurse should emphasize that the use of restraints requires ongoing assessment and monitoring to ensure the client's safety and well-being. 48. A client is prescribed a new medication, and the nurse is providing education about potential drug interactions. What is the nurse's priority action? a. Informing the client about potential side effects b. Reviewing the medication's mechanism of action c. Assessing the client's current medication list d. Explaining the medication's dosing schedule Answer: C The nurse's priority action is to assess the client's current medication list to identify any potential drug interactions and ensure safe medication administration. 49. A healthcare facility is implementing a new electronic health record (EHR) system. What is the primary goal of using EHR in client care? a. Reducing the need for direct client-nurse interaction b. Enhancing communication among healthcare providers c. Streamlining the billing and reimbursement process d. Increasing the workload for nursing staff Answer: B The primary goal of using an EHR in client care is to enhance communication among healthcare providers, leading to improved coordination of care and better patient outcomes. 50. What is the nurse's primary responsibility when delegating a task to unlicensed assistive personnel (UAP)? a. Ensuring the task is completed quickly b. Providing step-by-step instructions for the task c. Supervising the UAP's every move d. Ensuring the UAP is competent to perform the task Answer: D The nurse's primary responsibility when delegating a task to unlicensed assistive personnel is to ensure that the UAP is competent to perform the task safely and effectively. 51. A client is admitted to the hospital with a suspected infectious disease. What isolation precaution should the nurse implement? a. Contact isolation b. Droplet isolation c. Airborne isolation d. Protective isolation Answer: C If the client has a suspected infectious disease transmitted via airborne particles, airborne isolation precautions should be implemented to prevent the spread of pathogens. 52. A client undergoing surgery is at risk for developing deep vein thrombosis (DVT). What preventive measure should the nurse prioritize? a. Administering anticoagulant medications b. Restricting fluid intake postoperatively c. Encouraging prolonged periods of immobility d. Avoiding the use of compression stockings 57. A client with a history of heart failure is prescribed a diuretic. What assessment finding should the nurse prioritize monitoring to evaluate the medication's effectiveness? a. Blood glucose levels b. Blood pressure readings c. Respiratory rate and effort d. Serum potassium levels Answer: B In a client with heart failure prescribed a diuretic, monitoring blood pressure readings is crucial to evaluate the medication's effectiveness in managing fluid balance and cardiac workload. 58. A nurse is caring for a client with a traumatic injury. What is the nurse's priority action in the initial assessment of the client? a. Administering pain medication b. Obtaining a detailed medical history c. Assessing airway, breathing, and circulation (ABCs) d. Documenting the injury site Answer: C In the initial assessment of a client with a traumatic injury, the nurse's priority action is to assess airway, breathing, and circulation (ABCs) to ensure immediate life-saving interventions if needed. 59. A client is prescribed a medication with the instruction to take it "on an empty stomach." When is the most appropriate time for the client to take this medication? a. Before meals b. After meals c. With a full glass of water d. During bedtime Answer: A Taking a medication "on an empty stomach" typically means before meals to enhance absorption and effectiveness. 60. What is the nurse's primary responsibility when administering medication through a nasogastric (NG) tube? a. Administering the medication quickly b. Ensuring the NG tube is clamped afterward c. Confirming the tube's placement before administration d. Avoiding flushing the tube with water Answer: C The nurse's primary responsibility when administering medication through a nasogastric (NG) tube is to confirm the tube's placement before administration to prevent complications such as aspiration. 61. A nurse is caring for a client with a history of substance abuse who is admitted for surgery. What assessment is crucial to ensure the client's safety during the perioperative period? a. Respiratory rate and effort b. Past surgical history c. Allergy history d. Family medical history Answer: A Assessing the client's respiratory rate and effort is crucial, especially in a client with a history of substance abuse, to identify any respiratory compromise and ensure appropriate perioperative care. 62. A client is receiving total parenteral nutrition (TPN) through a central venous catheter. What complication should the nurse monitor for in this client? a. Hypoglycemia b. Hypertension c. Infection d. Respiratory depression Answer: C The nurse should monitor for infection in a client receiving total parenteral nutrition (TPN) through a central venous catheter, as it poses a risk for catheter-related infections.