Test Bank For Fundamentals of Nursing 11th Edition Potter Perry Chapter 1-50 | Complete, Exams of Nursing

Download Test Bank For Fundamentals of Nursing 11th Edition Potter Perry Chapter 1-50 | Complete and more Exams Nursing in PDF only on Docsity! Test Bank For Fundamentals of Nursing 11th Edition Potter Perry Chapter 1-50 | Complete Guide Newest Version 2022 *A patient has been on bed rest for over 4 days. On assessment, the nurse identifies the following as a sign associated with immobility:* A. Decreased peristalsis B. Decreased heart rate C. Increased blood pressure D. Increased urinary output - *Answer: A* Rationale: Immobility disrupts normal metabolic functioning: decreasing the metabolic rate; altering the metabolism of carbohydrates, fats, and proteins; causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis. *A nurse is caring for an older adult who has had a fractured hip repaired. In the first few postoperative days, which of the following nursing measures will best facilitate the resumption of activities of daily living for this patient?* A. Encouraging use of an overhead trapeze for positioning and transfer. B. Frequent family visits C. Assisting the patient to a wheelchair once per day D. Ensuring that there is an order for physical therapy - *Answer: A* Rationale: The trapeze bar allows the patient to pull with the upper extremities to raise the trunk off the bed, aid in transfer from bed to wheelchair, or perform upper- arm exercises. It increases independence and maintains upper body strength to help in performing activities of daily living. *An older-adult patient has been bedridden for 2 weeks. Which of the following complaints by the patient indicates to the nurse that he or she is developing a complication of immobility?* A. Loss of appetite B. Gum soreness C. Difficulty swallowing D. Left-ankle joint stiffness - *Answer: D* Rationale: Patients whose mobility is restricted require range-of-motion (ROM) exercises daily to reduce the hazards of immobility. Temporary immobilization results in some muscle atrophy, loss of muscle tone, and joint stiffness. Two weeks of joint immobilization without ROM can quickly result in contractures. *The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. Which of the following menus should the nurse recommend?* A. Cream of broccoli soup with whole wheat crackers, cheese, and tapioca for dessert B. Hot dog on whole wheat bun with a side salad and an apple for dessert C. Low-fat turkey chili with sour cream with a side salad and fresh pears for dessert D. Turkey salad on toast with tomato and lettuce and honey bun for dessert - *Answer: A* Rationale: Teach patient and/or caregiver the current recommended dietary allowances for calcium and review foods high in calcium (e.g., milk fortified with vitamin D, leafy green vegetables, yogurt, and cheese). *A patient on prolonged bed rest is at an increased risk to develop this common complication of immobility if preventive measures are not taken:* A. Myoclonus B. Pathological fractures C. Pressure ulcers D. Pruritus - *Answer: C* Rationale: Immobility is a major risk factor for pressure ulcers. Any break in the integrity of the skin is difficult to heal. Preventing a pressure ulcer is much less expensive than treating one; therefore preventive nursing interventions are imperative. *To prevent complications of immobility, what would be the most effective activity on the first postoperative day for a patient who has had abdominal surgery?* A. Turn, cough, and deep breathe every 30 minutes while awake B. Ambulate patient to chair in the hall C. Passive range of motion 4 times a day D. Immobility is not a concern the first postoperative day - *Answer: B* Rationale: Prevention of complications of immobility begins when the patient becomes immobilized. Every 30 minutes is not necessary and disruptive to the healing process. Active patient participation in exercises is more beneficial to preventing venous stasis. *Which of the following nursing interventions should be implemented to maintain a patent airway in a patient on bed rest?* A. Isometric exercises B. Administration of low-dose heparin C. Suctioning every 4 hours D. Use of incentive spirometer every 2 hours while awake - *Answer: D* Rationale: Incentive spirometry opens the airway, preventing atelectasis. *What is the correct order in which elastic stockings should be applied? 1. Identify patient using two identifiers. 2. Smooth any creases or wrinkles. 3. Slide the remainder of the stocking over the patient's heel and up the leg 4. Turn the stocking inside out until heel is reached. 5. Assess the condition of the patient's skin and circulation of the legs. 6. Place toes into foot of the stocking. 7. Use tape measure to measure patient's legs to determine proper stocking size.* A. 1, 5, 7, 4, 6, 2, 3 B. 1, 7, 5, 4, 6, 2, 3 C. 1, 5, 7, 4, 6, 3, 2 D. 1, 5, 4, 7, 6, 3, 2 - *Answer: C* *Which of the following are physiological outcomes of immobility?* A. Increased metabolism B. Reduced cardiac workload The young child cries and tries to run away when after being told that a flu shot is to be administered. Which term best describes the psychological reaction of the child? A. Primary appraisal B. Ineffective denial C. Adventitious crisis D. Developmental Crisis - a When a person encounters an event, there is an immediate process of primary appraisal or rating of the event. If this appraisal results in the event being identified as a potential harm, loss, threat, or challenge, the person has stress. Ineffective denial is not indicated as the child realized the injection would be administered shortly and became upset. An adventitious crisis is a major disaster such as an earthquake or fire. A developmental crisis is when new coping strategies are needed to deal with stages of maturation such as getting married or having a child. The patient is severely injured in an accident but does not feel the pain until several hours afterward. Which type of hormone reduced the patient's sense of pain as part of the stress response? a. Endorphins b. Mineralocorticoids c. Prostaglandins d. Bradykinins - a Endorphins are hormones that interact with the opiate receptors in the brain to reduce the perception of pain and produce a sense of well-being. Mineralocorticoids control salt and water balance within the body. Prostaglandins cause vasodilation and inhibit platelet function. Bradykinins play a role in inflammation causing vasodilation and pain. Which hormone is the most important factor for the physiological response to stress? a. Cortisol b. Glucagon c. Histamine d. Vasopressin - a Corticotropin stimulates the adrenal gland to increase the production of corticosteroids, including cortisol, the primary hormone impacting the stress response. Cortisol increases blood glucose, enhances the brain's use of glucose, and increases the availability of substances for tissue repair. Vasopressin increases reabsorption of water by the kidneys and induces vasoconstriction, thereby raising blood pressure. Glucagon raises blood sugar levels. Histamine causes allergic reactions. The new mother experiences insomnia, irritability, and lack of appetite after several weeks in the neonatal care unit with her critically ill infant. Which stage of the general adaptation syndrome (GAS) is the new mother experiencing? a. Alarm b. Resistance c. Adaptation d. Exhaustion - D If the stressor remains and adaptation does not happen, the person enters the third stage of the GAS, exhaustion. The exhaustion stage occurs when the body is no longer able to resist the effects of the stressor and the struggle to maintain adaptation drains all available energy. During the alarm reaction, rising hormone levels result in increased blood volume, blood glucose levels, heart rate, blood flow to muscles, and mental alertness. During the resistance stage, the body stabilizes and responds in an opposite manner to the alarm reaction. In the adaptation stage, antiinflammatory adrenocortical hormones are released, and healing occurs. The new mother experiences insomnia, irritability, and lack of appetite after several weeks in the neonatal care unit with her critically ill infant. Which nursing diagnosis is most appropriate for the new mother? a. Stress overload related to ongoing stress and worry about her critically ill infant b. Chronic low self-esteem related to lack of success at beginning of motherhood c. Disturbed sensory perception related to change in problem-solving abilities d. Disturbed personal identity related to inability to distinguish day shift from night - a Stress overload related to ongoing stress and worry about her critically ill infant is the appropriate nursing diagnosis for the new mother. The new mother is at the exhaustion stage of the GAS due to the excessive demands of caring for her critically ill infant. The new mother does not demonstrate chronic low self-esteem, disturbed sensory perceptions, or disturbed personal identity. The nurse manager is overwhelmed as the unit prepares for an accreditation inspection. Which type of factor is causing the stress for the nurse manager? a. Situational b. Maturational c. Sociocultural d. Conventional - a Situational factors include work stress that happens with work overload (patient load, distractions, conflicting priorities), heavy physical work, long hour work shifts, patient concerns (dealing with death and medical treatment), and interpersonal problems with other health care professionals and staff. Coping strategies vary with the individual and the situation. Maturational factors involve stressors and coping strategies that vary with life stage. Sociocultural factors include prolonged poverty, physical handicap, and chronic illness. Conventional factors are not a cause of stress. Which situation demonstrates an allostatic stress load? a. The nursing student uses meditation to cope with mild test anxiety. b. The patient develops anaphylactic shock after being stung by a bee. c. The nurse develops hypertension after working too many double shifts. d. The patient's heart rate returns to normal after a painful procedure is completed. - c An allostatic load is the negative physiological effect of long-term extreme stress on the body. An allostatic load is demonstrated by the nurse's development of hypertension after working too many double shifts. Mild test anxiety, recovery after a stressful experience, and anaphylactic shock are not examples of allostatic stress. The patient is frustrated after being treated poorly by providers due to lack of health insurance. Which type of factor is causing the stress for the patient? a. Rational b. Situational c. Maturational d. Sociocultural - d Sociocultural factors include prolonged poverty, physical handicap, and chronic illness. Situational factors include work-related stress. Coping strategies vary with the individual and the situation. Maturational factors involve stressors and coping strategies that vary with life stage. Rational factors are not a cause of stress. Which position is best suited for a nurse who preferred to study until the early hours of the morning during nursing school? a. Full-time 8-hour day/evening rotation b. Part-time 12-hour day/night rotation position c. Full-time 12-hour night position d. Full-time 8-hour day position - c In general, people doing shift work need to maintain as consistent a sleep and mealtime schedule as possible. Some nurses often ease their coping with shift work by knowing their own circadian rhythms. A nurse who typically thinks well at night and tends to sleep late in the morning will adapt better to night shift than to day shift. Rotating shifts prevent establishment of a consistent sleep and mealtime schedule. The patient is overwhelmed by the stresses of being a spouse, new parent, and full- time employee. The nurse encourages the patient to use a housekeeper, babysitter, friends, or relatives to help reduce personal responsibilities and obligations. Which stress-relieving technique was recommended for the patient? a. Assertiveness training b. Engaging support systems c. Mindfulness stress reduction d. Progressive muscle relaxation - b The nurse encourages engagement of support systems to relieve the patient's overwhelming duties. The patient will be better able to cope if a support system can assist with some of the patient's personal responsibilities and obligations. Assertiveness training teaches individuals to communicate effectively regarding their needs and desires. The ability to resolve conflict with others through assertiveness training reduces stress. When a group leader teaches assertiveness, the effects of interacting with other people increase the benefits of the experience. Progressive muscle relaxation diminishes physiological tension through a systematic approach to releasing tension in major muscle groups. Mindfulness stress reduction is a form of meditation to reduce symptoms of stress. The patient's spouse is overwhelmed and exhausted trying to provide the ongoing care required by the patient. Which nursing diagnosis is most appropriate for the patient's spouse? a. Activity intolerance related to fatigue and generalized weakness b. Readiness for enhanced comfort related to change in personal health status c. Caregiver role strain related to amount and complexity of patient health needs d. Risk for compromised human dignity related to loss of control of bodily functions - c The patient's spouse is demonstrating caregiver role strain by feeling overwhelmed and exhausted trying to meet the patient's needs. The patient's spouse is not experiencing activity intolerance and is not at risk for compromised human dignity. The patient leaves behind nightly dinners with the family, babysitting assistance from friends, and the warmth of the local church community when moving across the country. Which type of loss was experienced by the patient? a. Conditional b. Perceived c. Situational d. Maturational - C Situational loss occurs as a result of an unpredictable life event. A situational loss often involves multiple losses. A divorce, for example, begins with the loss of a life companion, but often leads to financial strain, changes in living arrangements. Perceived losses are uniquely experienced by a grieving person and are often less obvious to others. A perceived loss is very real to the person who has had a loss. For example, a person perceives she is less loved by her parents and experiences a loss of self-esteem. People experience maturational losses as they go through a lifetime of normal developmental processes. For example, when a child goes to school for the first time she will spend less time with her parents, leading to a change in the parent-child relationship. There is no such thing as a conditional loss. The patient concentrates on the mind-numbing details of the spouse's funeral to delay dealing with the overwhelming pain of the loss. Which stage of grief is currently being experienced by the patient? a. Anger b. Denial c. Bargaining d. Acceptance e. Depression - B Individuals in the denial stage cannot believe or understand that a loss has occurred and shut down their feelings until they are able to process the grief a little at a time. In the anger stage, a person resists the loss, is angry about the situation, and sometimes becomes angry with God. During bargaining, the individual postpones awareness of the loss and tries to prevent the loss from happening by making deals or promises. A person realizes the full significance of the loss during the depression stage. When depressed, the person feels overwhelmingly lonely or sad and withdraws from interactions with others. During the stage of acceptance, the individual begins to accept the reality and inevitability of loss and looks to the future. Which action demonstrates that the patient is experiencing the disorganization and despair stage of mourning? a. The patient puts the parent's estate and financial matters in order. b. The patient cannot eat or sleep for weeks after the loss of the parent. c. The patient sues the hospital for malpractice for not saving the parent's life. d. The patient falls sobbing to the floor when learning that the parent just died. - C Expressing anger at the hospital for not saving the parent's life is an example of the disorganization and despair stage. Expressions of anger and hostility at an individual or institution responsible for the loss are seen with the disorganization and despair stage. The person may also take long periods to reflect on how and why the loss occurred. Falling sobbing to the floor and inability to eat or sleep demonstrate the yearning and searching stage. Putting the parent's financial estate in order demonstrates completion of a necessary monetary task after death. Which action demonstrates that the patient is experiencing the reorganization stage of mourning after having a stillborn baby? a. The patient volunteers at a local infant loss support group. b. The patient sits for hours and hours just looking at the empty crib. c. The patient has panic attack with shortness of breath and chest pain. d. The patient turns to alcohol to numb the overwhelming pain of the loss. - a During the final phase of reorganization, which usually requires a year or more, the person accepts unaccustomed roles, acquires new skills, and builds new relationships. In the numbing phase, a person has periods of extremely intense emotion and reports feeling "stunned" or "unreal." The numbing phase lasts from several hours to a week. The yearning and searching phase evokes emotional outbursts, tearful sobbing, and acute distress. To move forward, people need to experience this painful phase of grief. During the phase of disorganization and despair, an individual spends much time thinking about how and why the loss occurred. The person often expresses anger at anyone he or she believes to be responsible. Gradually this phase gives way to an acceptance that the loss is permanent. Which nursing diagnosis is most appropriate for a patient who is having difficulty with accepting the reality of a lung cancer diagnosis by attempting to hide periods of shortness of breath from the nurse? a. Ineffective denial related to threat of unpleasant reality of lung cancer b. Noncompliance related to failure to adhere to prescribed treatment plan c. Effective therapeutic regimen management related to illness symptom reduction d. Readiness for enhanced decision making related to realignment of personal values - a Which nursing diagnosis is most appropriate for a patient whose friends and family have grown distant after the death of the patient's spouse? a. Impaired verbal communication related to alteration in sensory perception b. Risk for loneliness related to insufficient interactions with friends and family c. Health-seeking behavior related to desire for increased control of personal health d. Readiness for enhanced spiritual well-being related to expressed desire for prayer - b The patient is at risk for loneliness because the patient's friends and family have grown distant after the death of the patient's spouse. The patient does not demonstrate any sensory perception, desire for increased control, or expressed desire for prayer based on the information presented. Which action by the patient demonstrates reminiscence of a lost parent? a. The patient obtains a copy of the parent's will and inventories all assets. b. The patient returns to school to start a new career in business administration. c. The patient sues the hospital for malpractice after reviewing the medical record. d. The patient creates a scrapbook to remember special times spent with the parent. - d The patient demonstrates reminiscence by taking the time to remember the lost loved one through creation of a scrapbook. Suing the hospital for malpractice does not remember individual characteristics of the loved one or shared experiences. Returning to school indicates that the patient has reached the acceptance stage of grief and is moving on to new activities. Obtaining the will and completing inventory of assets demonstrates completion of necessary monetary tasks after death. The patient is the caregiver to the spouse with advanced dementia. The patient mourns the loss of the spouse's mind and personality even though the body is still physically functioning. Which type of grief is being experienced by the patient? a. Normal b. Anticipatory c. Complicated d. Disenfranchised - b Which behavior supports inclusion of the nursing diagnosis complicated grieving related to sudden death of a sibling in the patient's care plan? a. The patient donates the sibling's clothes to a local charity. b. The patient withdraws from relationships with friends and family. c. The patient adopts the sibling's dog and arranges for veterinary care. d. The patient arranges for the gravestone to be placed at the sibling's burial site. - b The female patient grieves the loss of her child to adoption and finds it difficult to cope because the pregnancy was kept a secret from the family and community. Which type of grief is being experienced by the patient? a. Delayed b. Complicated c. Anticipatory d. Disenfranchised - d Disenfranchised grief occurs in situations in which others view a person's loss as insignificant or invalid or when the patient's friends and family are unaware of the loss. Complicated grief happens when a person has difficulty progressing through the loss experience. The person does not accept the reality of the loss, and the intense feelings associated with acute grief do not go away. Normal or uncomplicated grief consists of commonly expected emotional and behavioral reactions to a loss (e.g., resentment, sorrow, anger, crying, loneliness, and temporary withdrawal from activities). The process of "letting go" before an actual loss or death has occurred is called anticipatory grief. The chart lists the patient's daughter as having medical durable power of attorney for the patient. How does this impact the patient's care? a. The daughter is an attorney and plans to sue to the nursing staff and hospital for malpractice after the patient's death. b. The daughter can provide consent for medical procedures if the patient becomes unresponsive or disoriented. c. The patient's daughter must be consulted before asking the patient to consent to medical procedures. d. The patient's daughter will translate medical terminology used by health care providers when communicating with the patient. - b Which attitude of the nurse will facilitate effective care for hospice patients? a. The patient needs the nurse's presence and personal connection. The patient's breathing is harsh and congested with periods of apnea. The patient had only 40 mL in the urinary catheter bag for the last 8 hours. The patient's temperature is 102.6° F (39.2° C) but the hands and feet are cool and mottled. - b c d e 1. A patient needs to learn to use a walker. Which domain is required for learning this skill? A. Affective domain B. Cognitive domain C. Attentional domain D. Psychomotor domain - D. Psychomotor domain Pg. 339 Using a walker requires the integration of mental and muscular activity. 2. The nurse is planning to teach a patient about the importance of exercise. When is the best time for teaching to occur? (Select all that apply.) A. When there are visitors in the room B. When the patient's pain medications are working C. Just before lunch, when the patient is most awake and alert D. When the patient is talking about current stressors in his or her life - B. When the patient's pain medications are working C. Just before lunch, when the patient is most awake and alert Plan teaching when the patient is most attentive, receptive, alert, and comfortable. 3. A patient newly diagnosed with cervical cancer is going home. The patient is avoiding discussion of her illness and postoperative orders. What is the nurse's best plan in teaching this patient? A. Teach the patient's spouse B. Focus on knowledge the patient will need in a few weeks C. Provide only the information that the patient needs to go home D. Convince the patient that learning about her health is necessary - C. Provide only the information that the patient needs to go home This patient is in denial; thus it is appropriate to only give her information that is needed immediately. 4. The school nurse is about to teach a freshman-level high school health class about nutrition. What is the best instructional approach to ensure that the students meet the learning outcomes? A. Provide information using a lecture B. Use simple words to promote understanding C. Develop topics for discussion that require problem solving D. Complete an extensive literature search focusing on eating disorders - C. Develop topics for discussion that require problem solving Adolescents learn best when they are able to use problem solving to help them make choices. 5. A nurse is going to teach a patient how to perform breast self-examination. Which behavioral objective does the nurse set to best measure the patient's ability to perform the examination? A. The patient will verbalize the steps involved in breast self-examination within 1 week. B. The nurse will explain the importance of performing breast self-examination once a month. C. The patient will perform breast self-examination correctly on herself before the end of the teaching session. D. The nurse will demonstrate breast self-examination on a breast model provided by the American Cancer Society. - C. The patient will perform breast self- examination correctly on herself before the end of the teaching session. Return demonstration provides an excellent source of feedback and reinforcement to evaluate learning. 6. A patient with chest pain is having an emergency cardiac catheterization. Which teaching approach does the nurse use in this situation? A. Telling approach B. Selling approach C. Entrusting approach D. Participating approach - A. Telling approach Pg. 348 The telling approach is most appropriate when preparing a patient for an emergency procedure. 7. The nurse is teaching a parenting class to a group of pregnant adolescents. The nurse pretends to be the baby's father, and the adolescent mother is asked to show how she would respond to the father if he gave her a can of beer. Which teaching approach did the nurse use? A. Role play B. Discovery C. An analogy D. A demonstration - A. Role play In role play people are asked to play themselves or someone else in a situation to enhance their confidence in handling that situation in the future. 8. An older adult is being started on a new antihypertensive medication. In teaching the patient about the medication, the nurse: A. Speaks loudly. B. Presents the information once. C. Expects the patient to understand the information quickly. D. Allows the patient time to express himself or herself and ask questions. - D. Allows the patient time to express himself or herself and ask questions When teaching older adults, it is important to establish rapport, involve them in their care, and allow them to progress at their own pace. 9. A patient needs to learn how to administer a subcutaneous injection. Which of the following reflects that the patient is ready to learn? A. Describing difficulties a family member has had in taking insulin B. Expressing the importance of learning the skill correctly C. Being able to see and understand the markings on the syringe D. Having the dexterity needed to prepare and inject the medication - B. Expressing the importance of learning the skill correctly Pg. 348-349 Patients are ready to learn when they understand the importance of learning and are motivated to learn. 10. A patient who is hospitalized has just been diagnosed with diabetes. He is going to need to learn how to give himself injections. Which teaching method does the nurse use? A. Simulation B. Demonstration C. Group instruction D. One-on-one discussion - B. Demonstration Pg. 349 Demonstration is used to help patients learn psychomotor skills. 11. When a nurse is teaching a patient about how to administer an epinephrine injection in case of a severe allergic reaction, he or she tells the patient to hold the injection like a dart. Which of the following instructional methods did the nurse use? A. Telling B. Analogy C. Demonstration D. Simulation - B. Analogy Pg. 349 A nurse believes that the nurse-patient relationship is a partnership, and that both are equal participants. Which term should the nurse use to describe this belief? a. Critical thinking b. Authentic c. Mutuality d. Attend - ANS: C Effective interpersonal communication requires a sense of mutuality, a belief that the nurse-patient relationship is a partnership, and that both are equal participants. Critical thinking in nursing, based on established standards of nursing care and ethical standards, promotes effective communication and uses such standards as humility, self-confidence, independent attitude, and fairness. To be authentic (one's self) and to respond appropriately to the other person are important for interpersonal relationships but do not mean mutuality. Attending is giving all of your attention to the patient. A nurse wants to present information about flu immunizations to the elderly in the community. Which type of communication should the nurse use? a. Interpersonal b. Public c. Transpersonal d. Small group - ANS: B Public communication is interaction with an audience. Nurses have opportunities to speak with groups of consumers about health-related topics, present scholarly work to colleagues at conferences, or lead classroom discussions with peers or students. Intrapersonal communication is a powerful form of communication that occurs within an individual. Transpersonal communication is interaction that occurs within a person's spiritual domain. When nurses work on committees, lead patient support groups, form research teams, or participate in patient care conferences, they use a small group communication process. Which technique will be most successful in ensuring effective communication? The nurse uses a. Interpersonal communication to change negative self-talk to positive self-talk. b. Small group communication to present information to an audience. c. Intrapersonal communication to build strong teams. d. Transpersonal communication to enhance meditation. - ANS: D Transpersonal communication is interaction that occurs within a person's spiritual domain. Many people use prayer, meditation, guided reflection, religious rituals, or other means to communicate with their "higher power." Interpersonal communication is one-on-one interaction between the nurse and another person that often occurs face to face. Meaningful interpersonal communication results in exchange of ideas, problem solving, expression of feelings, decision making, goal accomplishment, team building, and personal growth. Small group communication is interaction that occurs when a small number of persons meet. This type of communication is usually goal directed and requires an understanding of group dynamics. When nurses work on committees, lead patient support groups, form research teams, or participate in patient care conferences, they use a small group communication process. Intrapersonal communication is a powerful form of communication that occurs within an individual. For example, you improve your health and self-esteem through positive self-talk by replacing negative thoughts with positive assertions A nurse is standing beside the patient's bed. Nurse: How are you doing? Patient: I don't feel good. In this situation, which element is the feedback? a. Nurse b. Patient c. How are you doing? d. I don't feel good. - ANS: D "I don't feel good" is the feedback because the feedback is the message the receiver returns. The sender is the person who encodes and delivers the message, and the receiver is the person who receives and decodes the message. The nurse is the sender. The patient is the receiver. "How are you doing?" is the message. A nurse is sitting at the patient's bedside taking a nursing history. Which zone of personal space is the nurse using? a. Intimate b. Personal c. Social d. Public - ANS: B Personal space is 18 inches to 4 feet and involves such things as sitting at a patient's bedside, taking a patient's nursing history, or teaching an individual patient. Intimate space is 0 to 18 inches and involves such things as performing a physical assessment, bathing, grooming, dressing, feeding, and toileting a patient. Social zone is 4 to 12 feet and involves such things as making rounds with a physician, sitting at the head of a conference table, or teaching a class for patients with diabetes. Public zone is 12 feet and greater and involves such things as speaking at a community forum, testifying at a legislative hearing, or lecturing. A smiling patient angrily states, "I will not cough and deep breathe." How will the nurse interpret this finding? a. The patient's personal space was violated. b. The patient's affect is inappropriate. c. The patient's vocabulary is poor. d. The patient's denotative meaning is wrong. - ANS: B An inappropriate affect is a facial expression that does not match the content of a verbal message (e.g., smiling when describing a sad situation). The patient is smiling but is angry, which indicates an inappropriate affect. The patient's personal space was not violated. The patient's vocabulary is not poor. Individuals who use a common language share denotative meaning: baseball has the same meaning for everyone who speaks English, but code denotes cardiac arrest primarily to health care providers. The patient's denotative meaning is correct for cough and deep breathe. The nurse asks a patient where the pain is, and the patient responds by pointing to the area of pain. Which form of communication did the patient use? a. Verbal b. Nonverbal c. Intonation d. Vocabulary - ANS: B The patient gestured (pointed), which is a type of nonverbal communication. Gestures emphasize, punctuate, and clarify the spoken word. Pointing to an area of pain is sometimes more accurate than describing its location. Verbal is the spoken word or message. Intonation or tone of voice dramatically affects the meaning of a message. Vocabulary consists of words used for verbal communication. A patient has been admitted to the hospital numerous times. The nurse asks the patient to share a personal story about the care that has been received. Which interaction is the nurse using? a. Narrative b. Socializing c. Nonjudgmental d. SBAR - ANS: A In a therapeutic relationship, nurses often encourage patients to share personal stories. Sharing stories is called narrative interaction. Socializing is an important initial component of interpersonal communication. It helps people get to know one another and relax. It is easy, superficial, and not deeply personal. Nonjudgmental acceptance of the patient is an important characteristic of the relationship. Acceptance conveys a willingness to hear a message or acknowledge feelings; it is not a technique that involves personal stories. SBAR is a popular communication tool that helps standardize communication among health care providers. SBAR stands for Situation, Background, Assessment, and Recommendation. Before meeting the patient, a nurse talks to other caregivers about the patient. The nurse is in which phase of the helping relationship? a. Pre-interaction b. Orientation c. Working d. Termination - ANS: A The time before the nurse meets the patient is called the pre-interaction phase. This phase can involve such things as reviewing available data, including the medical and nursing history, talking to other caregivers who have information about the patient, or anticipating health concerns or issues that can arise. The orientation phase occurs when the nurse and the patient meet and get to know one another. This phase can involve such things as setting the tone for the relationship by adopting a warm, empathetic, caring manner; recognizing that the initial relationship is often superficial, uncertain, and tentative; or expecting the patient to test the nurse's competence and commitment. The working phase occurs when the nurse and the patient work together to solve problems and accomplish goals. This phase can involve such things as encouraging and helping the patient express feelings about his or her health, encouraging and helping the patient with self-exploration, or providing information needed to understand and change behavior. The termination phase occurs during the ending of the relationship. This phase can involve such things as reminding the patient that termination is near, evaluating goal achievement with the patient, or reminiscing about the relationship with the patient. During the initial home visit, a home health nurse lets the patient know that the visits are expected to end in about a month. The nurse is in which phase of the helping relationship? a. Pre-interaction d. "It must be difficult not to know what the surgeon will find. What can I do to help?" - ANS: D "It must be difficult not to know what the surgeon will find. What can I do to help?" is using therapeutic communication techniques of empathy and offering of self. False reassurances ("It will be okay" and "Don't worry") tend to block communication. Patients frequently interpret "why" questions as accusations or think the nurse knows the reason and is simply testing them. Which situation will cause the nurse to intervene and follow up on the nurse aide's behavior? a. The nurse aide is calling the older adult patient "honey." b. The nurse aide is facing the older adult patient when talking. c. The nurse aide cleans the older adult patient's glasses. d. The nurse aide allows time for the older adult patient to respond. - ANS: A Communicate with older adults on an adult level, and avoid patronizing or speaking in a condescending manner. Avoid terms of endearment such as "honey," "dear," "grandma," or "sweetheart." Facing an older adult patient, making sure the older adult has clean glasses, and allowing time to respond facilitate communication with older adult patients and should be encouraged, not stopped. A confused older adult patient is wearing thick glasses and a hearing aid. Which intervention is priority to facilitate communication? a. Focus on tasks to be completed. b. Allow time for the patient to respond. c. Limit conversations with the patient. d. Use gestures and other nonverbal cues. - ANS: B Allowing time for the patient to respond will facilitate communication, especially for an older confused patient. Focusing on tasks to be completed and limiting conversations do not facilitate communication; in fact, they block communication. Using gestures and other nonverbal cues is not effective for visually impaired or cognitively impaired patients. The staff is having a hard time getting an older adult patient to communicate. Which technique should the nurse suggest the staff use? a. Allow the patient to reminisce. b. Try changing topics often. c. Involve only the patient in conversations. d. Ask the patient for explanations. - ANS: A Encouraging older adults to share life stories and reminisce about the past has a therapeutic effect and increases their sense of well-being. Avoid sudden shifts from subject to subject. It is helpful to include the patient's family and friends and to become familiar with the patient's favorite topics for conversation. Asking for explanations is a nontherapeutic technique. The patient that will cause the greatest communication concerns for a nurse is the patient who is a. Alert, has strong self-esteem, and is hungry. b. Oriented, pain free, and blind. c. Cooperative, depressed, and hard of hearing. d. Dyspneic, has a tracheostomy, and is anxious. - ANS: D Facial trauma, laryngeal cancer, or endotracheal intubation often prevents movement of air past vocal cords or mobility of the tongue, resulting in inability to articulate words. An extremely breathless person needs to use oxygen to breathe rather than speak. Persons with high anxiety are sometimes unable to perceive environmental stimuli or hear explanations. People who are alert, have strong self- esteem, and are cooperative and pain free do not cause communication concerns. Although hunger, blindness, and difficulty hearing can cause communication concerns, dyspnea, a tracheostomy, and anxiety all contribute to communication concerns. A patient is aphasic, and the nurse notices that the patient's hands shake intermittently. Which nursing action is most appropriate to facilitate communication? a. Use a picture board. b. Use pen and paper. c. Use an interpreter. d. Use a hearing aid. - ANS: A Using a pen and paper can be frustrating for a nonverbal (aphasic) patient whose handwriting is shaky; the nurse can revise the care plan to include use of a picture board instead. An interpreter is used for a patient who speaks a foreign language. A hearing aid is used for the hard of hearing, not for an aphasic patient. The nurse using critical thinking to enhance communication with patients is one who a. Shows sympathy appropriately. b. Uses automatic responses fluently. c. Self-examines personal communication skills. d. Demonstrates passive remarks accurately. - ANS: C Nurses who use critical thinking skills interpret messages received from others, analyze their content, make inferences about their meaning, evaluate their effects, explain rationales for communication techniques used, and self-examine personal communication skills. Sympathy is concern, sorrow, or pity felt for the patient and is nontherapeutic. Clichés and stereotyped remarks are automatic phrases that communicate that the nurse is not taking concerns seriously or responding thoughtfully. Passive responses serve to avoid conflict or to sidestep issues. A patient says, "You are the worst nurse I have ever had." Which response by the nurse is the most assertive? a. "If I were you, I'd feel grateful for a nurse like me." b. "I feel uncomfortable hearing that statement." c. "How can you say that when I have been checking on you regularly?" d. "You shouldn't say things like that, it is not right." - ANS: B Assertive responses contain "I" messages such as "I want," "I need," "I think," or "I feel." Giving personal opinions ("If I were you") is nontherapeutic and not assertive. Arguing ("How can you say that?") is not assertive or therapeutic. Showing disapproval (using words like should, good, bad, right) is not assertive or therapeutic. Which critical thinking standards should the nurse use to ensure sound effective communication with patients? (Select all that apply.) a. Faith b. Supportiveness c. Self-confidence d. Humility e. Independent attitude f. Spiritual expression - ANS: C, D, E A self-confident attitude is important because the nurse who conveys confidence and comfort while communicating more readily establishes an interpersonal helping- trusting relationship. In addition, an independent attitude encourages the nurse to communicate with colleagues and share ideas about nursing interventions. An attitude of humility is necessary to recognize and communicate the need for more information before making a decision. Faith, supportiveness, and spiritual expression are attributes of caring, not critical thinking standards. Which types of patients can cause challenging communication situations? (Select all that apply.) a. A male patient who is cooperative with treatments b. A female patient who is outgoing and flirty c. An older adult patient who is demanding d. An elderly patient who can clearly see small print e. A teenager frightened by the prospect of impending surgery f. A child who is developmentally delayed - ANS: B, C, E, F Challenging communication situations include patients who are flirtatious, demanding, frightened, or developmentally delayed. A child who has received little environmental stimulation possibly is behind in language development, thus making communication more challenging. Patients who are cooperative and have good eyesight (see small print) do not cause challenging communication situations. In which nursing care model is the RN usually appointed the position of group leader? a. Total patient care b. Primary nursing c. Team nursing d. Case management - ANS: C In the team nursing care model, the RN assumes the role of group or team leader and leads a team made up of other RNs, licensed vocational nurses, and nurse assistants or technicians. Total patient care involves an RN being responsible for all aspects of care for one or more patients. Primary nursing places RNs at the bedside more, assuming responsibility for a caseload of patients over time. This model, however, does not require an all-RN staff as is required for total patient care. Case management is a care approach that coordinates and links health care services to patients and families while streamlining costs. DIF: Remember REF: 276 1. The five rights of delegation include (Select all that apply.) a. Right task. b. Right circumstances. c. Right monetary compensation. d. Right person. e. Right direction. f. Right opinion. g. Right supervision. - ANS: A, B, D, E, G c. Authority. d. Accountability. - D A nurse manager sent one of the staff nurses on the unit to a conference about new, evidence-based wound care techniques. The nurse manager asks the staff nurse to prepare a poster to present at the next unit meeting, which will be mandatory for all nursing staff on the unit. The nurse manager is providing a learning opportunity in this situation through a. Nurse/physician collaborative practice. b. Interdisciplinary collaboration. c. Staff education. d. Establishing a nursing practice committee. - C A nurse is making a home visit and discovers that a patient's wound infection has gotten worse. After cleaning and re-dressing the wound, what should the nurse do? a. Ask the home health agency nurse manager to contact the health care provider. b. Document the findings and confirm with the patient the date of the next home visit. c. Notify the health care provider of the findings before leaving the home. d. Tell the patient that the health care provider will be notified before the next visit. - C 10. A nurse manager conducts rounds on the unit and discovers that expired stock medicine is still in the cabinet despite the e-mail she sent stating that it had to be discarded. The staff nurse dress code is not being adhered to, and the staff lounge is not kept neat and tidy as she requested in the same e-mail. Several staff nurses deny having received the e-mail. After evaluating this situation, one way the nurse manager could resolve the issue is to a. Include the findings on each staff member's annual evaluation. b. Close the staff lounge. c. Enforce a stricter dress code. d. Place a hard copy of announcements and unit policies in each staff member's mailbox. - D A new nurse expresses frustration at not being to complete all interventions for a group of patients in a timely manner. The nurse leaves the rounds report sheets at the nurse's station when caring for patients and reports having to go back and forth between rooms several times looking for equipment and supplies. This nurse could benefit from practicing better _____ skills. a. Clinical decision-making b. Organizational c. Evaluation d. Interpersonal communication - B Which of these approaches would be most appropriate for a nurse to take when faced with the challenge of performing many tasks in one shift? a. Evaluate the effectiveness of all tasks when all tasks are completed. b. Delegate tasks the nurse does not like doing. c. Do as much as possible by oneself before seeking assistance from others. d. Complete one task before starting another task. - D Which of these assessments of a patient who is 1 day post surgery to repair a hip fracture requires immediate nursing intervention? a. Patient ate 30% of clear liquid breakfast. b. Oral temperature is 99.2° Fahrenheit. c. Patient states, "Boy, I did not realize I would be so tired after this surgery." d. Patient reports severe pain 30 minutes after receiving pain medication. - D A charge nurse should instruct a new nurse taking care of a patient with hypercholesterolemia to make which of these lifestyle modifications? a. High-protein, high-fat diet b. Decreased walking frequency from three times to two times a week c. Discontinuation of antihypertensive medications d. Smoking cessation - D A patient with an indwelling urinary catheter has been given a bed bath by a new nursing assistant. The nurse evaluating the cleanliness of the patient notices crusting at the urinary meatus. The best next action of this nurse is to a. Ask the nursing assistant to observe while the nurse performs catheter care. b. Leave the room and ask the nursing assistant to go back and perform proper catheter care. c. Discontinue the catheter. d. Document the incident in the patient's chart. - A A nurse observes a patient care technician using all these measures when taking vital signs. Which measure requires the nurse to intervene? a. Palpates brachial artery before inflating blood pressure cuff b. Counts respirations while palpating radial pulse c. Inserts thermometer into sublingual pocket after patient sips water d. Asks patient to relax arm before taking blood pressure - C A nurse is assigned to care for the following patients who all need vital signs taken right now. Which of these patients is most appropriate for the nurse to delegate vital sign measurement to nursing assistive personnel (NAP)? a. Patient scheduled for a procedure in the nuclear medicine department b. Patient transferring from the intensive care unit (ICU) c. Patient returning from cardiac catheterization d. Patient returning from hip replacement surgery - A Which of these staff members does the staff nurse assign to provide morning care for an older adult patient who requires assistance with activities of daily living? a. Licensed vocational nurse b. Cardiac monitor technician c. Nursing assistive personnel (NAP) d. None of the above; the nurse needs to provide morning care to this patient. - C A nursing assistant reports seeing a reddened area on the patient's hip while bathing the patient. The nurse should a. Go to the patient's room to assess the patient's skin. b. Document the finding per the nursing assistant's report. c. Request a wound nurse consult. d. Ask the nursing assistant to apply a dressing over the reddened area. - A The NCSBN (National council of state boards of nursing - identifies entry-level nurse competencies and the evolving role of nurses. Empowered nursing team - includes nurse executive, nurse manager, and nursing staff. Nurse executive - responsibilities include philosophy of care, purpose of nursing unit, how staff works with patients and families, standards of care. Magnet recognition - operated by the American nurses credential center, has a practice environment that is dynamic, autonomous, collaborative, and positive for nurses. Total patient care - RN is responsible for all aspects of care, the RN works directly with the patient, family, and other health care team members. Team nursing - an RN leads a team of other nurses and NAP's, team members provide direct patient care under the RN. Primary nursing - 24 hour responsibility for planning, directing, and evaluating patient care, associate nurse provides care when the primary nurse is off duty. Case management - maintains responsibility for patient care from admission to discharge. Decentralized decision making - decision making is moved down the level of staff, occurs on the unit level, and encompasses responsibility, autonomy, authority, accountability. Shared governance- - committees chaired by senior clinical staff that establish and maintain care standards Nurse/physician collaborative practice - the process between nurse and physician Clinical decisions - decisions made about patient care using accurate judgment Priority setting - high priority(immediate threat to patient survival), intermediate(non- emergency, non-life threatening), low priority(actual or potential problems not directly related to patients illness) Organizational skills - effective use time, being well organized and prepared Use of resources - using other health care team members, equipment and supplies Which is the highest priority of patient needs? Constipation, hunger, anxiety, pain - Pain the dressing and notes the date on the dressing label. In which ways did the nurse evaluate the condition of the IV site? Select all that apply. A. Checked the IV infusion rate B. Checked the type of IV solution C. Confirmed from nurses' notes the time of dressing change D. Inspected the condition of the IV dressing at the site E. Checked clarity of IV solution - A, D A nurse enters a patient's room and begins a conversation. During this time the nurse evaluates how a patient is tolerating a new diet plan. The nurse decides to also evaluate the patient's expectations of care. Which statement is appropriate for evaluating a patient's expectations of care? A. On a scale of 0 to 10 rate your level of nausea. B. The nurse weighs the patient. C. The nurse asks, "Did you believe that you received the information you needed to follow your diet?" D. The nurse states, "Tell me four different foods included in your diet." - C A patient has been febrile and coughing thick secretions; adventitious lung sounds indicate rales in the left lower lobe of the lungs. The nurse decides to perform nasotracheal suction because the patient is not coughing. The nurse inspects the mucus that is suctioned, which is minimal. The nurse again auscultates for lung sounds. Auscultation and mucus inspection are examples of: A. Evaluative measures. B. Expected outcomes. C. Reassessments. D. Reflection. - A A nurse has been caring for a patient over the last 10 hours. The patient's plan of care includes the nursing diagnosis of Nausea related to effects of postoperative anesthesia. The nurse has been asking the patient to rate his nausea over the last several hours after administering antiemetics and using comfort measures such as oral hygiene. The nurse reviews the patient's responses over the past 10 hours and notes how the patient's self-report of nausea has changed. This review an example of: A. Comparing outcome criteria with actual response. B. Gathering outcome criteria. C. Evaluating the patient's actual response. D. Reprioritizing interventions. - A After caring for a young man newly diagnosed with diabetes, a nurse is reviewing what was completed in his plan of care following discharge. She considers how she related to the patient and whether she selected interventions best suited to his educational level. It was the nurse's first time caring for a new patient with diabetes. The nurse's behavior is an example of which of the following? Reflection-in-action Reassessment Reprioritizing Reflection-on-action - D A nurse has been caring for a patient over 2 consecutive days. During that time the patient has had an intravenous (IV) catheter in the right forearm. At the end of shift on the second day the nurse inspects the catheter site, observes for redness, and asks if the patient feels tenderness when the site is palpated. This is an example of which indicator reflecting the nurse's ability to perform evaluation: A. Examining results of clinical data B. Comparing achieved effects with outcomes C. Recognizing error D. Self-reflection - A A faculty member is reviewing a nursing student's plan of care, including the interventions the student provided for a patient with dementia. The student reviewed clinical guidelines on a professional website to identify interventions successful in reducing wandering in patients with dementia. The faculty member should evaluate which of the following? Select all that apply. A. Number of interventions B. Appropriateness of the intervention for the patient C. The prior use of interventions by other nursing staff D. Correct application of the intervention for the patient care setting E. The time it takes to provide interventions - B, D A patient is being discharged after treatment for colitis (inflammation of the colon). The patient has had no episodes of diarrhea or abdominal pain for 24 hours. Following instruction, the patient identified correctly the need to follow a low-residue diet and the types of food to include if a bout of diarrhea develops at home. These behaviors are examples of: A. Evaluative measures. B. Expected outcomes. C. Reassessments. D. Standards of care. - B A nurse determines that the patient's condition has improved and has met expected outcomes. Which step of the nursing process is the nurse exhibiting? a.Assessment b.Planning c.Implementation d.Evaluation - D A nurse completes a thorough database and carries out nursing interventions based on priority diagnoses. Which action will the nurse take next? a.Assessment b.Planning c.Implementation d.Evaluation - D A new nurse asks the preceptor to describe the primary purpose of evaluation. Which statement made by the nursing preceptor is most accurate? a."An evaluation helps you determine whether all nursing interventions were completed." b."During evaluation, you determine when to downsize staffing on nursing units." c."Nurses use evaluation to determine the effectiveness of nursing care." d."Evaluation eliminates unnecessary paperwork and care planning." - C d.Discontinue the plan of care for wound care. - B A goal for a patient with diabetes is to demonstrate effective coping skills. Which patient behavior will indicate to the nurse achievement of this outcome? a.States feels better after talking with family and friends b.Consumes high-carbohydrate foods when stressed c.Dislikes the support group meetings d.Spends most of the day in bed - A A nurse is providing education to a patient about self-administering subcutaneous injections. The patient demonstrates the self-injection. Which type of indicator did the nurse evaluate? a.Health status b.Health behavior c.Psychological self-control d.Health service utilization - B A nurse is evaluating the goal of acceptance of body image in a young teenage girl. Which statement made by the patient is the best indicator of progress toward the goal? a."I'm worried about what those other girls will think of me." b."I can't wear that color. It makes my hips stick out." c."I'll wear the blue dress. It matches my eyes." d."I will go to the pool next summer." - C A nurse is evaluating goals and expected outcomes for a confused patient. Which finding indicates positive progress toward resolving the confusion? a.Patient wanders halls at night. b.Patient's side rails are up with bed alarm activated. c.Patient denies pain while ambulating with assistance. d.Patient correctly states names of family members in the room. - D A nurse identifies a fall risk when assessing a patient upon admission. The nurse and the patient agree that the goal is for the patient to remain free from falls. However, the patient fell just before shift change. Which action is the nurse's priority when evaluating the patient? a.Identify factors interfering with goal achievement. b.Counsel the nursing assistive personnel on duty when the patient fell. c.Remove the fall risk sign from the patient's door because the patient has suffered a fall. d.Request that the more experienced charge nurse complete the documentation about the fall. - A A patient was recently diagnosed with pneumonia. The nurse and the patient have established a goal that the patient will not experience shortness of breath with activity in 3 days with an expected outcome of having no secretions present in the lungs in 48 hours. Which evaluative measure will the nurse use to demonstrate progress toward this goal? a.No sputum or cough present in 4 days b.Congestion throughout all lung fields in 2 days c.Shallow, fast respirations 30 breaths per minute in 1 day d.Lungs clear to auscultation following use of inhaler - D A nurse is evaluating an expected outcome for a patient that states heart rate will be less than 80 beats/min by 12/3. Which finding will alert the nurse that the goal has been met? a.Heart rate 78 beats/min on 12/3 b.Heart rate 78 beats/min on 12/4 c.Heart rate 80 beats/min on 12/3 d.Heart rate 80 beats/min on 12/4 - A A nurse is modifying a patient's care plan after evaluation of patient care. In which order, starting with the first step, will the nurse perform the tasks? 1. Revise nursing diagnosis. 2. Reassess blood pressure reading. 3. Retake blood pressure after medication. 4. Administer new blood pressure medication. 5. Change goal to blood pressure less than 140/90. a.1, 5, 2, 4, 3 b.2, 1, 5, 4, 3 c.4, 3, 1, 5, 2 d.5, 4, 5, 1, 2 - B A nurse is caring for a group of patients. Which evaluative measures will the nurse use to determine a patient's responses to nursing care? (Select all that apply.) a.Observations of wound healing b.Daily blood pressure measurements c.Findings of respiratory rate and depth d.Completion of nursing interventions e.Patient's subjective report of feelings about a new diagnosis of cancer - A, B, C, E Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.) a.Set priorities for patient care. b.Determine whether outcomes or standards are met. c.Ambulate patient 25 feet in the hallway. d.Document results of goal achievement. e.Use self-reflection and correct errors. - B, D, E 1. A nurse working on a surgery floor is assigned five pts and has a pt care technician assisting her. Which of the following shows the nurse's understanding and ability to safely delegate to the pt care tech? (Select all that apply.) 1. The nurse considers the time available to gather routine vital signs on one pt before checking on a second pt arriving from a diagnostic test. 2. Determining what is the pt care technician's current workload. 3. The nurse chooses to delegate the measurement of a stable pt's vital signs and not the assessment of the pt arriving from a diagnostic test. 4. The nurse reviews with the NAP, newly hired to the floor, her experience in measuring a blood pressure. 5. The nurse confers with another registered nurse about organizing priorities. - 1. Answer: 1, 2, 3. A nurse must consider priorities of all her assigned patients in deciding what activities should be delegated to NAP. When the decision is vital signs 3. Physical care technique ___ 4. Activity of daily living ____ a. Assisting pt with oral care b. Discussing a pt's options in choosing palliative care c. Protecting a violent pt from injury d. Using safe pt handling during positioning of a pt - 9. Answer: 1b, 2c, 3d, 4a. 10. What is the importance of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey? 1. Measures a nurse's competency in interdisciplinary care 2. Measures the number of adverse events in a hospital 3. Measures quality of care within hospitals 4. Measures referrals to a health care agency - 10. Answer: 3. HCAHPS is a survey that has become a standard for measuring and comparing quality of hospitals. It is a survey of patient perceptions. 11. Fill in the Blank. A nurse administered an antibiotic 30 minutes ago and returns to the pt's room to determine if the pt is having any unexpected symptoms. This is an example of assessing for a(n) ___________________. - 11. Answer: Adverse Reaction. An adverse reaction is a harmful or unintended effect of a medication, diagnostic test, or therapeutic intervention. 12. Which measures does a nurse follow when being asked to perform an unfamiliar procedure? (Select all that apply.) 1. Checks scientific literature or policy and procedure 2. Reassesses the pt's condition 3. Collects all necessary equipment 4. Delegates the procedure to a more experienced nurse 5. Considers all possible consequences of the procedure - 12. Answer: 1, 2, 3, 5. the nurse does not delegate a procedure to a more experienced nurse. Instead, the nurse has the nurse (e.g. staff nurse, faculty, nurse specialist) who has completed the procedure correctly and safely provide assistance and guidance. 13. A nurse is conferring with another nurse about the care of a pt with a stage II pressure ulcer. The two decide to review the clinical practice guideline of the hospital for pressure ulcer management. The use of a standardized guideline achieves which of the following? (Select all that apply.) 1. Makes it quicker and easier for nurses to intervene 2. Sets a level of clinical excellence for practice 3. Eliminates need to create an individualized care plan for the pt 4. Delivers evidence-based interventions for stage II pressure ulcer 5. Summarizes the various approaches used for the practice concern or problem - 13. Answer: 1, 2, 4. Even though a standardized clinical practice guideline offers evidence based solutions for clinical excellence that nurses can quickly and easily apply in practice, a nurse remains accountable for individualizing even standardized interventions when necessary. A guideline is not a summary of various approaches used by clinicians for a practice issue; it is a summary of the most relevant evidence based information. 14. A nurse reviews all possible consequences before helping a pt ambulate such as how the pt ambulated last time; how mobile the pt was before admission to the health care facility; or any current clinical factors affecting the pt's ability to stand, remain balanced, or walk. Which of the following is an example of a nurse's review of this situation? 1. Critical thinking 2. Managing an adverse event 3. Exercising self-discipline 4. Time management - 14. Answer: 1. The process of reviewing consequences for a patient is an example of critical thinking and clinical decision making. Managing an adverse event occurs after consequences have occurred. Exercising self discipline is a critical thinking attitude that guides you in reviewing, modifying, and implementing interventions, which occurs after reviewing consequences. This is not an example of time management. 15. A nurse collects equipment needed to administer an enema to a pt. Previously the nurse reviewed the procedure in the policy manual. The nurse raises the pt's bed and adjusts the room lighting to illuminate the work area. A pt care technician comes into the room to assist. Which aspect of organizing resources and care delivery did the nurse omit? 1. Environment 2. Personnel 3. Equipment 4. Pt - 15. Answer: 4. In preparing to administer the enema, the nurse did not prepare for the patient's physical and psychological comfort. 1. A nurse enters the room of a 32-year-old pt newly diagnosed with cancer at the beginning of the 0700 evening/night shift. The nurse noted in the pt's nursing history that this is her first hospitalization. She is scheduled for surgery in the morning to remove a tumor and has questions about what to expect after surgery. She is observed talking with her mother and is crying. The pt says, "This is so unfair." An order has been written for an enema to be given this evening in preparation for the surgery. The nurse establishes priorities for which of the following situations first? 1. Giving the enema on time 2. Talking with the pt about her past experiences with illness 3. Talking with the pt about her concerns and acknowledging her sense of unfairness 4. Beginning instruction on postoperative procedures - 1. Answer: 3. The patient is obviously emotionally upset. Her concerns, whether they be about surgery or cancer or both, need to be addressed first for her to be able to be instructed and to be comfortable for the enema. Talking with the patient about her past experiences may be appropriate in the long term, but is less important than the other three priorities. 2. A 62-year-old pt had a portion of the large colon removed and a colostomy created for drainage of stool. The nurse has had repeated problems with the pt's colostomy bag not adhering to the skin and thus leaking. The nurse wants to consult with the wound care nurse specialist. Which of the following should the nurse do? (Select all that apply.) 1. Assess condition of skin before making the call 2. Rely on the nurse specialist to know the type of surgery the pt likely had 3. Explain the pt's response emotionally to the repeated leaking of stool 4. Describe the type of bag being used and how long it lasts before leaking 5. Order extra colostomy bags currently being used - 2. Answer: 1, 3, 4. The nurse should have as much information available before making the call to the nurse specialist. It is also important for the nurse to interpret and explain the problem. In addition it is important to explain the patient's perspective. Assuming the nurse specialist knows the extent of the surgery is not appropriate. 3. It is time for a nurse hand-off between the night nurse and nurse starting the day shift. The night nurse checks the most recent laboratory results for the pt and then begins to discuss the pt's plan of care to the day nurse using the standard checklist for reporting essential information. The pt has been seriously ill, and his wife is at the bedside. The nurse asks the wife to leave the room for just a few minutes. The night nurse completes the summary of care before the day nurse is able to ask a question. Which of the following activities are strategies for an effective hand-off? (Select all that apply.) 1. Using a standardized checklist for essential information 2. Asking the wife to briefly leave the room 3. Completing the hand-off without inviting questions 4. Doing prework such as checking laboratory results before giving a report 5. Including the wife in the hand-off discussion - 3. Answer: 1, 4. Using standardized forms or checklists and doing thorough pre work enhances the nurse's ability to communicate the plan of care effectively during a handoff. The other two options are barriers to an effective hand-off. 4. A nurse assesses a 78-year-old pt who is 108.9 kg (240 lbs) and partially immobilized b/c of a stroke. The nurse turns the pt and finds the skin over the sacrum is very red and the pt does not feel sensation in the area. The pt has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the pt? 1. Pt will be turned every 2 hrs within 24 hrs. 2. Pt will have normal bowel function w/i 72 hrs 3. Pt's skin integrity will remain intact thru discharge. 4. Erythema of skin will be mild to none w/i 48 hrs - 4. Answer: 4. The statement "Patient will be turned every 2 hours within 24 hours" is an intervention. The statements "Patient will have normal bowel function within 72 hours" and "Patient's skin integrity will remain intact through discharge" are goals. 5. Which factors does a nurse consider in setting priorities for a pt's nursing diagnoses? (Select all that apply.) 1. Numbered order of diagnosis on the basis of severity 2. Notion of urgency for nursing action 3. Symptom pattern recognition suggesting a problem 4. Mutually agreed on priorities set with pt 5. Time when a specific diagnosis was identified - 5. Answer: 2, 3, 4. All factors are considered in setting priorities for a patient's nursing diagnoses or collaborative problems. The numbered order of diagnosis based on severity is inappropriate as a numbering system holds little meaning when a patient's condition changes. 5. Slept better during night - 12. Answer: 3, 4. The goal for improving activity tolerance will require an outcome that is a measure of changes in activity tolerance, such as no shortness of breath during exercise or walking a set distance. 13. A nursing student is reporting during hand-off to the RN assuming her pt's care. She explains, "I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. I changed the dressing over his intravenous (IV) site and started a new bag of D5 . Which intervention is a dependent intervention? 1. Reporting hand-off at change of shift 2. Ambulating pt down hallway 3. Sleep hygiene 4. IV fluid administration - 13. Answer: 4. Administering IV fluids required a physician's order. The other three interventions are independent nursing activities. 14. A nursing student knows that all pts should be ambulated regularly. The pt to which she is assigned has had reduced activity tolerance. She followed orders to ambulate the pt twice during the shift of care. In what way can the nursing student make the goal of improving the pt's activity tolerance a pt-centered effort? 1. Engage the pt in setting mutual outcomes for distance he is able to walk 2. Confirm with the pt's health care provider about ambulation goals 3. Have physical therapy assist with ambulation 4. Refer to medical record regarding nature of pt's physical problem - 14. Answer: 1. All goals and outcomes of care should be patient-centered whenever possible. An approach for ensuring patient-centered goals is having the patient involved so that goals can be mutually set and realistic to the patient. Confirming with the physician and checking the medical record helps the nurse understand the extent of exercise a patient can participate in. But these approaches are not examples of mutual patient- centered goal setting. Having physical therapy assistance would not make a goal patient centered. 15. A pt signals the nurse by turning on the call light. The nurse enters the room and finds the pt's drainage tube disconnected, 100 mL of fluid remaining in the intravenous (IV) line, and the pt asking questions about whether his doctor is coming. Which of the following does the nurse perform first? 1. Reconnect the drainage tubing 2. Inspect the condition of the IV dressing 3. Obtain the next IV fluid bag from medication room 4. Explain when the health care provider is likely to visi - 15. Answer: 1. The nurse must reconnect the drainage tube for the priority of patient safety. There is no reason to suspect a problem with the IV dressing unless the fluid is not infusing on time. The nurse must prepare the next bottle of solution after reconnecting the drainage tube. At that time the nurse can check the condition of the IV dressing. As the nurse performs her care she can inform the patient about when the physician will round, unless the nurse is uncertain and needs to contact the physician. 1.) The nursing diagnosis Impaired Parenting related to mother's developmental delay is an example of a(n): 1. Risk nursing diagnosis. 2. Problem-focused nursing diagnosis. 3. Health promotion nursing diagnosis. 4. Wellness nursing diagnosis. - 1.) Ans: 2 This is an example of a problem-focused nursing diagnosis with a related factor, based on NANDA-I diagnostic terminology. Most health promotion diagnoses do not have established related factors based on NANDA-I; their use is optional. Wellness diagnoses are not one of the types of NANDA-I diagnoses. 2. A nurse interviewed and conducted a physical examination of a patient. Among the assessment data the nurse gathered were an increased respiratory rate, the patient reporting difficulty breathing while lying flat, and pursed-lip breathing. This data set is an example of: A. Collaborative data set. B. Diagnostic label. C. Related factors. D. Data cluster. - Ans: D A data cluster is a set of cues (i.e., the signs or symptoms gathered during assessment) 3. A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is Diarrhea related to intestinal colitis. For which of the following reasons is this an incorrectly stated diagnostic statement? A. Identifying the clinical sign instead of an etiology B. Identifying a diagnosis on the basis of prejudicial judgment C. Identifying the diagnostic study rather than a problem caused by the diagnostic study D. Identifying the medical diagnosis instead of the patient's response to the diagnosis. - D. Identifying the medical diagnosis instead of the patient's response to the diagnosis. Intestinal colitis is a medical diagnosis. The related factor in a nursing diagnostic statement is always within the domain of nursing practice and a condition that responds to nursing interventions. Nursing interventions do not change a medical diagnosis. 4. A nurse is assigned to a new patient admitted to the nursing unit following admission through the emergency department. The nurse collects a nursing history and interviews the patient. What are the steps for making a nursing diagnosis in the correct order, beginning with the first step? 1. Considers context of patient's health problem and selects a related factor 2. Reviews assessment data, noting objective and subjective clinical information 3. Clusters clinical cues that form a pattern 4. Chooses diagnostic label A. 2, 3, 4, 1 B. 3, 2, 4, 1 C. 2, 3, 1, 4 D. 1, 4, 3, 2 - A. 2, 3, 4, 1 Correct This is the correct steps for making a nursing diagnosis. 5. A nursing student reports to a lead charge nurse that his assigned patient seems to be less alert and his blood pressure is lower, dropping from 140/80 to 110/60. The nursing student states, "I believe this is a nursing diagnosis of Deficient Fluid Volume." The lead charge nurse immediately goes to the patient's room with the student to assess the patient's orientation, heart rate, skin turgor, and urine output for last 8 hours. The lead charge nurse suspects that the student has made which type of diagnostic error? A. Insufficient cluster of cues B. Disorganization C. Insufficient number of cues D. Evidence that another diagnosis is more likely - C. Insufficient number of cues It is likely the charge nurse suspects that the student has not collected enough cues to support the diagnosis. A change in blood pressure and mental status changes are significant findings that can be attributed to fluid volume excess and other diagnoses. The recommendation of the symptom cluster by the registered nurse would allow the student to have sufficient data to confirm a deficient fluid volume. 6. A nurse in a mother-baby clinic learns that a 16-year-old has given birth to her first child and has not been to a well-baby class yet. The nurse's assessment reveals that the infant cries when breastfeeding and has difficulty latching on to the nipple. The infant has not gained weight over the last 2 weeks. The nurse identifies the patient's nursing diagnosis as Ineffective Breastfeeding. Which of the following is the best "related to" factor? A. Infant crying at breast B. Infant unable to latch on to breast correctly C. Mother's deficient knowledge D. Lack of infant weight gain - C. Mother's deficient knowledge In this scenario the related factor is the mother's deficient knowledge. A related factor is a condition, historical factor, or etiology that gives a context for the defining characteristics, in this case the infant crying, inability to latch on to breast, and absent weight gain. 7. E. The nurse who makes a diagnosis of Ineffective Airway Clearance related to pneumonia. Correct - A. The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data D. The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping E. The nurse who makes a diagnosis of Ineffective Airway Clearance related to pneumonia. When the nurse observes the patient wincing and holding his left side but does not gather additional assessment data, he or she makes a data collection error by omitting important data (i.e., pain severity). A nursing diagnosis cannot be made on basis of a single defining characteristic, as seen when the nurse identifies a diagnosis on the basis of a patient reporting difficulty sleeping. A nursing diagnosis needs to be related to a patient's response, not a medical diagnosis such as pneumonia. The nurse who measures joint range of motion after the patient reports pain is correctly validating findings. Considering conflicting clues ensures that the nurse does not make an interpretation error. 12. A nurse is getting ready to assess a patient in a neighborhood community clinic. He was newly diagnosed with diabetes just a month ago. He has other health problems and a history of not being able to manage his health. Which of the following questions reflects the nurse's cultural competence in making an accurate diagnosis? (Select all that apply.) A. How is your diabetic diet affecting you and your family? B. You seem to not want to follow health guidelines. Can you explain why? C. What worries you the most about having diabetes? D. What do you expect from us when you do not take your insulin as instructed? E. What do you believe will help you control your blood sugar? - A, C, and E Asking "How is your diabetic diet affecting you and your family?" "What worries you the most about having diabetes?" and "What do you believe will help you control your blood sugar?" are open-ended and allow the patient to share his values and health practices. The statements "You seem to not want to follow health guidelines. Can you explain why?" and "What do you expect from us when you do not take your insulin as instructed?" both show the nurse's bias. 13. The use of standard formal nursing diagnostic statements serves several purposes in nursing practice, including which of the following? (Select all that apply.) A. Defines a patient's problem, giving members of the health care team a common language for understanding the patient's needs B. Allows physicians and allied health staff to communicate with nurses how they provide care among themselves C. Helps nurses focus on the scope of nursing practice D. Creates practice guidelines for collaborative health care activities E. Builds and expands nursing knowledge - A, C, E The use of nursing diagnosis creates a common language for nurses to communicate patient care needs, allows nurses to focus on the realm and scope of nursing practice, and helps to develop nursing knowledge. It is not a language for physicians and allied health staff because they do not rely on providing nursing interventions. Terminology in nursing diagnosis may be familiar to other health care providers but not in a way for directing nursing interventions. Nursing diagnosis has the purpose of creating practice guidelines for nursing. 14. Which of the following nursing diagnoses is stated correctly? (Select all that apply.) A. Fluid Volume Excess related to heart failure B. Sleep Deprivation related to sustained noisy environment C. Impaired Bed Mobility related to postcardiac catheterization D. Ineffective Protection related to inadequate nutrition E. Diarrhea related to frequent, small, watery stools. - B, D The correct diagnoses of Sleep Deprivation and Ineffective Protection are worded with related factors that will respond to nursing interventions. Nursing interventions do not change a medical diagnosis or diagnostic test. Instead nurses direct nursing interventions at behaviors or conditions that they are able to treat or manage. The first two incorrect diagnoses use a medical diagnosis and diagnostic procedure respectively as related or etiological factors. These are not conditions that nursing interventions can treat. The last diagnosis is incorrect because it is related to an assessment finding of a symptom or a defining characteristic. 1. Which of the following examples are steps of nursing assessment? (Select all that apply.) 1. Collection of information from pt's family members 2. Recognition that further observations are needed to clarify information 3. Comparison of data with another source to determine data accuracy 4. Complete documentation of observational information 5. Determining which medications to administer based on a pt's assessment data - 1. Answer: 1, 2, 3. Assessment includes collection of data from secondary sources such as the patient's family. Recognizing that more observation is needed is an example of validation of data. Comparing data to determine accuracy is a feature of interpretation. Although complete documentation is an important step in communicating assessment data, it is not an assessment step 2. A nurse assesses a pt who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been here, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you've been in following his plan?" The nurse's assessment covers which of Gordon's functional health patterns? 1. Value-belief pattern 2. Cognitive-perceptual pattern 3. Coping-stress-tolerance pattern 4. Health perception-health management pattern - 2. Answer: 4. The nurse's assessment covers health perception and health management pattern, which is a patient's self report of how he or she manages their health and their knowledge of preventive health practices. The coping stress tolerance pattern would include questions focused on how the patient manages stress and sources of support. An assessment covering the value belief pattern leads a patient to describe patterns of values, beliefs and life goals. An assessment of the cognitive-perceptual pattern includes questions that focus on the patient's language adequacy, memory and decision making ability. 3. When a nurse conducts an assessment, data about a pt often comes from which of the following sources? (Select all that apply.) 1. An observation of how a pt turns and moves in bed 2. The unit policy and procedure manual 3. The care recommendations of a physical therapist 4. The results of a diagnostic x-ray film 5. Your experiences in caring for other pts with similar problems - 3. Answer: 1, 3, 4. There are many sources of data for an assessment, including the patient through interview, observations, and physical exam; family members or significant others, health care team members like a physical therapist, the medical record which includes x ray results and the scientific and medical literature. 4. The nurse observes a pt walking down the hall with a shuffling gait. When the pt returns to bed, the nurse checks the strength in both of the pt's legs. The nurse applies the information gained to suspect that the pt has a mobility problem. This conclusion is an example of: 1. Cue. 2. Reflection. 3. Clinical inference. 4. Probing. - 4. Answer: 3. An inference is your judgment or interpretation of cues, such as the shuffling gait and reduced leg strength. Any information gathered through your senses is a cue. Probing is a technique used in interviewing. Reflection is an internal though process of thinking back about a situation. 5. A 72-year-old male pt comes to the health clinic for an annual follow-up. The nurse enters the pt's room and notices him to be diaphoretic, holding his chest and breathing with difficulty. The nurse immediately checks the pt's heart rate and blood pressure and asks him, "Tell me where your pain is." Which of the following assessment approaches does this scenario describe? 1. Review of systems approach 2. Use of a structured database format ______, ______, ______, ______, ______ 1. "You say you've lost weight. Tell me how much weight you've lost in the last month." 2. "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history." 3. "I have no further questions. Thank you for your patience." 4. "Tell me what brought you to the hospital." 5. "So, to summarize, you've lost about 6 lbs in the last month, and your appetite has been poor—correct?" - 13. Answer: 2, 4, 1, 5, 3. 14. During a visit to the clinic, a pt tells the nurse that he has been having headaches on and off for a week. The headaches sometimes make him feel nauseated. Which of the following responses by the nurse is an example of probing? 1. So you've had headaches periodically in the last week & sometimes they cause you to feel nauseated—correct? 2. Have you taken anything for your headaches? 3. Tell me what makes your headaches begin. 4. Uh huh, tell me more. - 14. Answer: 3. A probing question such as "Tell me what makes your headaches begin" encourages a more full description of a situation by asking an open ended question. The statement "So you've had headaches periodically in the last week and sometimes they cause you to feel nauseated— correct?" is a summarative statement. Asking whether the patient has taken anything for the headaches is a close ended question. Saying "Uh huh, tell me more" is an example of back channeling. 15. The nurse enters the room of an 82-year-old pt for whom she has not cared previously. The nurse notices that the pt wears a hearing aid. The pt looks up as the nurse approaches the bedside. Which of the following approaches are likely to be effective with an older adult? (Select all that apply.) 1. Listen attentively to the pt's story. 2. Use gestures that reinforce your questions or comments. 3. Stand back away from the bedside. 4. Maintain direct eye contact. 5. Ask questions quickly to reduce the pt's fatigue. - 15. Answer: 1, 2, 4. Approaches for collecting an older adult assessment include listening patiently, using nonverbal communication when a patient has a hearing deficit, and maintaining patient-directed eye gaze. Leaning forward, not backward shows interest in what the patient has to say. 1. Two pt deaths have occurred on a medical unit in the last month. The staff notices that everyone feels pressured and team members are getting into more arguments. As a nurse on the unit, what will best help you manage this stress? 1. Keep a journal 2. Participate in a unit meeting to discuss feelings about the pt deaths 3. Ask the nurse manager to assign you to less difficult pts 4. Review the policy and procedure manual on proper care of pts after death - 1. Answer: 2. By connecting and meeting with staff colleagues, the nurse can talk about the experiences of caring for dying patients and learn that her feelings are likely shared by others. A journal is helpful but not the best way to relieve stress. A policy and procedure manual will not help the nurse examine and understand the nature of the stress. Asking for a different assignment is no guarantee that another stressful experience will develop. 2. A nurse has seen many cancer pts struggle with pain management because they are afraid of becoming addicted to the medicine. Pain control is a priority for cancer care. By helping pts focus on their values and beliefs about pain control, a nurse can best make clinical decisions. This is an example of: 1. Creativity. 2. Fairness. 3. Clinical reasoning. 4. Applying ethical criteria. - 2. Answer: 4. The use of ethical criteria for nursing judgment allows a nurse to focus on a patient's values and beliefs. Clinical decisions are then just, faithful to the patient's choices, and beneficial to the patient's well- being. 3. A nurse prepares to insert a Foley catheter. The procedure manual calls for the pt to lie in the dorsal recumbent position. The pt complains of having back pain when lying on her back. Despite this, the nurse positions the pt supine with knees flexed as the manual recommends and begins to insert the catheter. This is an example of: 1. Accuracy. 2. Reflection. 3. Risk taking. 4. Basic critical thinking. - 3. Answer: 4. Basic critical thinking is concrete and based on a set of rules or principles, such as the guidelines in a hospital procedure manual. The nurse's approach is not accurate, as accuracy requires use of all of the facts (e.g. the patient's discomfort). A critical thinker is willing to take risks in trying different ways to solve problems; following one basic approach is not risk taking. This is also not an example of reflection. 4. A nurse is preparing medications for a pt. The nurse checks the name of the medication on the label with the name of the medication on the doctor's order. At the bedside the nurse checks the pt's name against the medication order as well. The nurse is following which critical thinking attitude: 1. Responsible 2. Complete 3. Accurate 4. Broad - 4. Answer: 1. The nurse is demonstrating responsibility for correct medication and patient identification. The other three choices are critical thinking intellectual standards. 5. A nurse on a busy medicine unit is assigned to four pts. It is 10 AM. Two pts have medications due and one of those has a specimen of urine to be collected. One pt is having complications from surgery and is being prepared to return to the operating room. The fourth pt requires instructions about activity restrictions before going home this afternoon. Which of the following should the nurse use in making clinical decisions appropriate for the pt group? (Select all that apply.) 1. Consider availability of assistive personnel to obtain the specimen 2. Combine activities to resolve more than one pt problem 3. Analyze the diagnoses/problems and decide which are most urgent based on pts' needs 4. Plan a family conference for tomorrow to make decisions about resources the pt will need to go home 5. Identify the nursing diagnoses for the pt going home - 5. Answer: 1,2,3. Analyzing urgency of problems helps in prioritization as does considering the resources that are available (such as assistive personnel) to complete patient care activities. Deciding on how to combine activities is good time management. Holding a family conference is a good idea but in this case would be too late to be beneficial to the patient. The nurse must identify nursing diagnoses for all patients in order to determine priorities. 6. By using known criteria in conducting an assessment such as reviewing with a pt the typical characteristics of pain, a nurse is demonstrating which critical thinking attitude? 1. Curiosity 2. Adequacy 3. Discipline 4. Thinking independently - 6. Answer: 3. Discipline is being thorough in whatever you do. Using known criteria for assessment and evaluation, as in the case of pain, is an example of discipline. 7. A nurse just started working at a well-baby clinic. One of her recent experiences was to help a mother learn the steps of breastfeeding. During the first clinic visit the mother had difficulty positioning the baby during feeding. After the visit the nurse considers what affected the inability of the mother to breastfeed, including the mother's obesity and inexperience. The nurse's review of the situation is called: 1. Reflection. 2. Perseverance. 3. Intuition. 4. Problem solving - 7. Answer: 1. The mother had difficulty the first time breast feeding. The nurse relied on reflection to consider her previous actions, review what was successful and the opportunities for improvement. The nurse has not yet problem solved but might do so after reflection and anticipating the patient's next clinic visit. 8. Place the steps of the scientific method in their correct order with number 1 being the first step of the process. ______, ______, ______, ______, ______ 1. Formulate a question or hypothesis. 2. Evaluate results of the study. 3. Collect data. 4. Identify the problem. 5. Test the question or hypothesis. - 8. Answer: 4, 3, 1, 5, 2. The correct order of the steps of the scientific method are: 1. Identifying the problem, 2. Collecting data, 3. Formulating a question or hypothesis, 4. Testing the question or hypothesis, and 5. Evaluating results of the test or study. 9. A nurse changed a pt's surgical wound dressing the day before and now prepares for another dressing change. The nurse had difficulty removing the gauze from the wound bed yesterday, causing the pt discomfort. Today he gives the pt an analgesic 30 minutes before the dressing change. Then he adds some sterile saline to loosen The ___ of nursing is based on data obtained from current research. - science The ___ of nursing stems from a nurse's experience and the unique caring relationship that a nurse develops with a patient. - art A ___ helps to identify the focus, means, and goals of practice and enhances communication and accountability for patient care. - nursing theory A ___ contains a set of concepts, definitions, and assumptions or propositions that explain a phenomenon. - theory A ___ is the term, description, or label given to describe an idea or responses about an event, a situation, a process, a groups of events, or a group of situations. - phenomenon Phenomena may be ___ or permanent. - temporary Phenomena may be temporary or ___. - permanent Phenomena may be ___ or ___. - temporary or permanent A theory also consists of interrelated ___ that help describe or label phenomena. - concepts ___ are the words or phrases that identify, define, and establish structure and boundaries for ideas generated about a particular phenomena. - Concepts Concepts can be ___ or concrete. - abstract Concepts can be abstract or ___. - concrete Concepts can be ___ or ___. - abstract or concrete Theories use ___ to communicate meaning. - concepts Theorists use ___ to communicate the general meaning of the concepts of a theory. - definitions What are the three types of definitions? - (1) theoretical definitions (2) conceptual definitions (3) operational definitions Which two types of definitions simply define a particular concept? - (1) theoretical definitions (2) conceptual definitions Which type of definition states how concepts are measured? - operational definition What is the term for the "taken-for-granted" statements that explain the nature of the concepts, definitions, purpose, relationships, and structure of a theory? - assumptions ___ are accepted as truths and are based on values and beliefs. - Assumptions What is the term for the perspective or territory of a profession or discipline? - domain The ___ provides the subject, central concepts, values and beliefs, phenomena of interest, and central problems of a discipline. - domain What is the term for a pattern of beliefs used to describe the domain of a discipline? - paradigm Often used synonymously with paradigm is the term ___. - conceptual framework A ___ provides a way to organize major concepts and visualize the relationship among phenomena. - conceptual framework The ___ allows nurses to understand and explain what nursing *is*, what nursing *does*, and *why* nurses do what they do. - nursing metaparadigm The nursing metaparadigm includes what four concepts? - (1) person (2) health (3) environment/situation (4) nursing Which concept of the nursing metaparadigm refers to the recipient of nursing care? - person Which concept of the nursing metaparadigm refers to a state of being that people define in relation to their own values, personality, and lifestyle? - health Which concept of the nursing metaparadigm refers to all possible conditions affecting patients and the settings where they go for their health care? - environment/situation Which concept of the nursing metaparadigm refers to the "protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations?" - nursing Who is regarded as the first nursing theorist? - Florence Nightingale What does AJN stand for? - American Journal of Nursing What are the five historical eras of knowledge development in nursing? - (1) curriculum era (2) research era (3) graduate education era (4) theory era (5) theory utilization era During which historical era of knowledge development in nursing did nursing education expand beyond basic anatomy and physiology courses to include courses in social sciences, pharmacology, and "nursing arts" that addressed nursing actions, skills, and procedures? - curriculum era During which historical era of knowledge development in nursing did nurses become increasingly involved in conducting studies and sharing their findings? - research era During which historical era of knowledge development in nursing did the research studies have a psycho-social, anthropological, or educational focus? - research era During which historical era of knowledge development in nursing were early versions of nursing theories developed that offered more structure to nursing research? - graduate research era Which historical era of knowledge development in nursing significantly contributed to knowledge development? - theory era Which historical era of knowledge development in nursing resulted in the publication of several nursing journals, the development of nursing conferences, and the offering of ore doctoral programs in nursing? - theory era The twenty-first century is considered the era of ___. - theory utilization During which historical era of knowledge development in nursing did nurses strive to provide evidence-based practice (EBP), which stems from theory, research, and experience? - theory utilization era What does EBP stand for? - evidence-based practice The focus of ___ is safe, comprehensive, individualized, quality health care. - evidence-based practice (EBP) The original ___ theories served as springboards for the development of the more modern middle-range theories. - grand The original grand theories served as springboards for the development of the more modern ___ theories. - middle-range ___ have different purposes and are sometimes classified by levels of abstraction or the goals. - Theories A ___ theory describes a phenomenon such as grief or caring and also identifies conditions or factors that predict a phenomenon. - descriptive A ___ theory details nursing interventions for a specific phenomenon and the expected outcome of the care. - prescriptive According which theorist do nurses develop therapeutic relationships with patients that are respectful, empathetic, and non-judgmental? - Hildegard Peplau According to Hildegard Peplau, what are the four phases that characterize the nurse- patient interpersonal relationship? - (1) preorientation (2) orientation (3) working phase (4) resolution Which of Hildegard Peplau's phases refers to data gathering? - preorientation Which of Hildegard Peplau's phases refers to the defining issue? - orientation Which of Hildegard Peplau's phases refers to therapeutic activity? - working phase Which of Hildegard Peplau's phases refers to the termination of relationship? - resolution Which middle-range theory is useful in establishing effective nurse-patient communication when obtaining a nursing history, providing patient education or counseling patients and their families? - Interpersonal Theory What is the name of Hildegard Peplau's theory? - Interpersonal theory The focus of Hildegard Peplau's ___ theory includes interpersonal relations among a nurse, patient, and a patient's family and developing the nurse-patient relationship. - interpersonal What is the name of Dorothea Orem's grand theory? - Self-Care Deficit Nursing Theory According to the Dorothea Orem's ___ theory, a nurse continually assesses a patient's ability to perform self-care and intervenes as needed to ensure that the patients meet physical, psychological, sociological, and developmental needs. - self- care deficit nursing Which theorist recognized the need to focus on culture in nursing as she predicted that nursing and health care would become more global? - Madeleine Leininger Which theorist blended her background in anthropology with nursing to form her middle-range theory of cultural care diversity and universality? - Madeleine Leininger What is the major concept of Madeleine Leininger's theory? - cultural diversity What is the focus on Roy's grand theory? - adaptation According to which theorist, nurses help a patient cope with or adapt to changes in physiological, self-concept, role function, and interdependence domains? - Roy Experimental/Clinical knowledge is often called the ___ of nursing. - art ___ theories help shape and define your practice. - Grand ___ theories continue to advance nursing knowledge through nursing research. - Middle-range ___ theories help you provide specific care for individuals and groups of diverse populations and situations. - Practice ___ research uses logic to explore relationships between phenomena. - Theory- generating ___ research determines how accurately a theory describes a nursing phenomenon. - Theory-testing 1. The nurse and a new nurse in orientation are caring for a patient with pneumonia. Which statement by the new nurse will indicate a correct understanding 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 private negative-pressure room." c. "Clinical signs and symptoms are not present in pneumonia." d. "The patient will not be able to return home." - ANS: A Infections are infectious and/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—a disease that is transmitted directly from one individual to the next, so there is no need for isolation. A private negative-air pressure room is used for tuberculosis, not pneumonia. Clinical signs and symptoms are present in pneumonia. 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 for this disease? a. "When camping, I will use sunscreen." b. "When camping, I will drink bottled water." c. "When camping, I will wear insect repellent." d. "When camping, I will wash my hands with hand gel." - ANS: C 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 about the most important thing to do to prevent the spread of infection. Which information did the nurse share with the preschool workers? a. Encourage preschool children to eat a nutritious diet. b. Suggest that parents provide a multivitamin to the children. c. Clean the toys every afternoon before putting them away. d. Wash their hands between each interaction with children. - ANS: D The single most important thing that individuals can do to prevent the spread of infection is to wash their hands before and after eating, going to the bathroom, changing a diaper, and wiping a nose and between touching each individual child. It is important for preschool children to have a nutritious diet; a healthy individual can fight infection more effectively. A health care provider, along with the parent, makes decisions about dietary supplements. Cleaning the toys can decrease the number of pathogens but is not the most important thing to do in this scenario. 4. The nurse is admitting a patient with an infectious disease process. Which question will be most appropriate for a nurse to ask about the patient's susceptibility to this infectious process? a. "Do you have a spouse?" b. "Do you have a chronic disease?" c. "Do you have any children living in the home?" d. "Do you have any religious beliefs that will influence your care?" - ANS: B Multiple factors influence a patient's susceptibility to infection. Patients with chronic diseases such as diabetes mellitus and multiple sclerosis are also more susceptible to infection because of general debilitation and nutritional impairment. Other factors include age, nutritional status, trauma, and smoking. The other questions are part of an admission assessment process but are not pertinent to the infectious disease process. 5. The patient experienced a surgical procedure, and Betadine was utilized as the surgical prep. Two days postoperatively, the nurse's assessment indicates that the incision is red and has a small amount of purulent drainage. The patient reports tenderness at the incision site. The patient's temperature is 100.5° F, and the WBC is 10,500/mm3. Which action should the nurse take first? a. Plan to change the surgical dressing during the shift. b. Utilize SBAR to notify the primary health care provider. c. Reevaluate the temperature and white blood cell count in 4 hours. d. Check to see what solution was used for skin preparation in surgery. - ANS: B The nursing assessment indicates signs and symptoms of infection, requiring the primary health care provider to be notified of the patient's needs. SBAR—Situation, Background, Assessment, and Recommendation—can be utilized to organize thoughts and data and to provide a thorough explanation of the patient's current status. The reevaluation of temperature is a good choice, but it will take longer than 4 hours to make a change in the white blood cells. Changing the dressing may be a need during the shift but is not a first priority. Checking to see about the skin preparation used 2 days ago may or may not be useful information at this time. 6. The nurse is providing an education session to an adult community group about the effects of smoking on infection. Which information is most important for the nurse to include in the educational session? a. Smoke from tobacco products clings to your clothing and hair. b. Smoking affects the cilia lining the upper airways in the lungs. c. Smoking can affect the color of the patient's fingernails. d. Smoking tobacco products can be very expensive. - ANS: B d. These techniques will help the patient manage the pain and loss of personal belongings. - ANS: C The body responds to emotional or physical stress by the general adaptation syndrome. If stress extends for long periods of time, this can lead to exhaustion, whereby energy stores are depleted and the body has no defenses against invading organisms. Techniques of deep breathing and visualization may be helpful with pain, but they are not the primary reason. The teachings listed are not all standard interventions taught at every health care visit. There is no data to indicate the patient requested this information for the family. 13. The nurse is caring for a patient who is susceptible to infection. Which instruction will the nurse include in an educational session to decrease the risk of infection? a. Teaching the patient about fall prevention b. Teaching the patient to take a temperature c. Teaching the patient to select nutritious foods d. Teaching the patient about the effects of alcohol - ANS: C A patient's nutritional health directly influences susceptibility to infection. A reduction in the intake of protein and other nutrients such as carbohydrates and fats reduces body defenses against infection and impairs wound healing. This is the only teaching point that directly influences risk. Teaching the patient how to take a temperature can help the patient assess if there is a fever, but it is not related to decreasing the individual's risk for infection. Teaching the patient about fall prevention or about the effects of alcohol does not decrease the risk of infection. 14. A diabetic patient presents to the clinic for a dressing change. The wound is located on the right foot and has purulent yellow drainage. Which action will the nurse take to prevent the spread of infection? a. Position the patient comfortably on the stretcher. b. Explain the procedure for dressing change to the patient. c. Review the medication list that the patient brought from home. d. Don gloves and other appropriate personal protective equipment. - ANS: D 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 to create a protective barrier. Positioning the patient, explaining the procedure, and reviewing the medication list are all tasks that need to be completed, but they do not prevent the spread of infection. 15. A patient presents with pneumonia. Which priority intervention should be included in the plan of care for this patient? a. Observe the patient for decreased activity tolerance. b. Assume the patient is in pain and treat accordingly. c. Provide the patient ice chips as requested. d. Maintain the room temperature at 65° F. - ANS: A Systemic infection, like pneumonia, 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 patient's level of activity and responsiveness. Nurses do not assume but assess and communicate with the patient about pain. While providing the patient with ice chips may be appropriate, it is not a priority and there is no reason for the patient to be limited to ice. Maintaining the room temperature at 65° F is too cold. 16. The nurse is caring for a patient in an intensive care unit who needs a bath. Which priorityaction will the nurse take to decrease the potential for a health care- associated infection? a. Use local anesthetic on reddened areas. b. Use nonallergenic tape on dressings. c. Use a chlorhexidine wash. d. Use filtered water. - ANS: C The Centers for Disease Control and Prevention (CDC) recommends the use of chlorhexidine (CHG) bathing for patients in intensive care units, patients who are scheduled for surgery, and all patients with invasive central line catheters as part of MRSA reduction efforts. Using local anesthetics, nonallergenic tape, and filtered water does not affect the cause of a health care-associated infection by, for example, decreasing microbial counts like a CHG bath. 17. The infection control nurse is reviewing data for the medical-surgical unit. The nurse notices an increase in postoperative infections from Aspergillus. Which type of health care-associated infection will the nurse report? a. Vector b. Exogenous c. Endogenous d. Suprainfection - ANS: B An exogenous infection comes from microorganisms found outside the individual such as Salmonella, Clostridium tetani, and Aspergillus. They do not exist as normal floras. A vector transmits microorganisms and is usually a type of insect or organism. Endogenous infection occurs when part of the patient's flora becomes altered and an overgrowth results (e.g., staphylococci, enterococci, yeasts, and streptococci). This often happens when a patient receives broad-spectrum antibiotics that alter the normal floras. A suprainfection develops when broad-spectrum antibiotics eliminate a wide range of normal flora organisms, not just those causing infection. 18. The patient has contracted a urinary tract infection (UTI) while in the hospital. Which action will most likely increase the risk of a patient contracting a UTI? a. Reusing the patient's graduated receptacle to empty the drainage bag. b. Allowing the drainage bag port to touch the graduated receptacle. c. Emptying the urinary drainage bag at least once a shift. d. Irrigating the catheter infrequently. - ANS: B Allowing the urinary drainage bag port to touch contaminated items (graduated receptacle) may introduce bacteria into the urinary system and contribute to a urinary tract infection. The urinary drainage bag should be emptied at least once a shift. Patients should have their own receptacle for measurement to prevent cross- contamination. Repeated catheter irrigations increase the chance so irrigating infrequently will be beneficial in reducing the risk. 19. Which nursing action will most likely increase a patient's risk for developing a health care-associated infection? a. Uses surgical aseptic technique to suction an airway b. Uses a clean technique for inserting a urinary catheter c. Uses a cleaning stroke from the urinary meatus toward the rectum d. Uses a sterile bottled solution more than once within a 24-hour period - ANS: B Using clean technique (medical asepsis) to insert a urinary catheter would place the patient at risk for a health care-associated infection. Urinary catheters need to be inserted using sterile technique, which is also referred to as surgical asepsis. Surgical aseptic technique (also called sterile technique) should be used when suctioning an airway because it is considered a sterile body cavity. Washing from clean to dirty (urinary meatus toward rectum) is correct for decreasing infection risk. Bottled solutions may be used repeatedly during a 24-hour period; however, special care is needed to ensure that the solution in the bottle remains sterile. After 24 hours, the solution should be discarded. 20. The nurse is caring for a patient in labor and delivery. When near completing an assessment of the patient's cervix, the electronic infusion device being used on the intravenous (IV) infusion alarms. Which sequence of actions is most appropriate for the nurse to take? a. Complete the assessment, remove gloves, and silence the alarm. b. Discontinue the assessment, silence the alarm, and assess the intravenous site. c. Complete the assessment, remove gloves, wash hands, and assess the intravenous infusion. d. Discontinue the assessment, remove gloves, use hand gel, and assess the intravenous infusion. - ANS: C Completing the assessment while wearing gloves, removing gloves, washing hands after contact with body fluids, and then assessing the intravenous infusion will assist in the prevention and transfer of any potential organisms to this intravenous line. Completing the assessment, removing gloves, and silencing the alarm leaves out the crucial step of decontaminating and washing the hands. Discontinuing the assessment and assessing the IV leaves out removing the gloves and decontamination, as well as completing the assessment for the patient. Discontinuing the assessment, removing gloves, using hand gel, and assessing the IV is incorrect because upon exposure to body fluids, washing hands is appropriate. 21. The nurse is dressed and is preparing to care for a patient in the perioperative area. The nurse has scrubbed hands and has donned a sterile gown and gloves. Which action will indicate a break in sterile technique? a. Touching clean protective eyewear b. Standing with hands above waist area c. Accepting sterile supplies from the surgeon d. Staying with the sterile table once it is open - ANS: A Touching nonsterile (clean) protective eyewear once gowned and gloved with sterile gown and gloves would indicate a break in sterile technique. Sterile objects remain sterile only when touched by another sterile object. Standing with hands folded on the chest is common practice and prevents arms and hands from touching unsterile objects. Accepting sterile supplies from the surgeon who has opened them with the appropriate technique is acceptable. Staying with a sterile table once opened is a common practice to ascertain that no one or nothing has contaminated the table. 22. The nurse is caring for a patient with an incision. Which actions will best indicate an understanding of medical and surgical asepsis for a sterile dressing change? a. Donning clean goggles, gown, and gloves to dress the wound during the procedure, resulting in infection for the patient. Extending the time for washing the hands (although this is what will happen when the procedure is repeated) is not the focus. The focus is to repeat the whole hand hygiene procedure utilizing antiseptic soap. 29. The nurse on the surgical team and the surgeon have completed a surgery. After donning gloves, gathering instruments, and placing in the transport carrier, what is the next step in handling the instruments used during the procedure? a. Sending to central sterile for cleaning and sterilization b. Sending to central sterile for cleaning and disinfection c. Sending to central sterile for cleaning and boiling d. Sending to central sterile for cleaning - ANS: A Surgical instruments need to be cleaned and sterilized. Disinfecting, boiling, or cleaning is not utilized on critical items that will be reused on patients in the hospital environment. Items that are used on sterile tissue or in the vascular system present a high risk of infection if they become contaminated with bacteria. 30. The nurse is observing a family member changing a dressing for a patient in the home health environment. Which observation indicates the family member has a correct understanding of how to manage contaminated dressings? a. The family member places the used dressings in a plastic bag. b. The family member saves part of the dressing because it is clean. c. The family member removes gloves and gathers items for disposal. d. The family member wraps the used dressing in toilet tissue before placing in trash. - ANS: A Contaminated dressings and other infectious, disposable 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 group of patients. Which patient will the nurse see first? a. A patient with Clostridium difficile in droplet precautions b. A patient with tuberculosis in airborne precautions c. A patient with MRSA infection in contact precautions d. A patient with a lung transplant in protective environment precautions - ANS: A A patient with Clostridium difficile should be on contact precautions, not droplet; therefore, the nurse will see this patient first to correct the precautions. All the rest are on correct precautions. Patients with tuberculosis belong in airborne precautions; patients with MRSA infection belong in contact precautions; and patients with lung transplants belong in protective environment precautions. 32. The home health nurse is teaching a patient and family about hand hygiene in the home. Which situation will cause the nurse to emphasize washing hands before and after? a. Shaking hands b. Performing treatments c. Opening the refrigerator d. Working on a computer - ANS: B Patients and family members should perform hand hygiene before and after treatments and when coming in contact with body fluids. Shaking hands does not require washing of hands before and after. Washing hands before and after opening the refrigerator and using the computer is not required. 33. The surgical mask the perioperative nurse is wearing becomes moist. Which action will the perioperative nurse take next? a. Apply a new mask. b. Reapply the mask after it air-dries. c. Change the mask when relieved by next shift. d. Do not change the mask if the nurse is comfortable. - ANS: A After the mask is worn for several hours, it can become moist. The mask should be changed as soon as possible because moisture does not provide a barrier to microorganisms and is ineffective. 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 action will be most appropriate to prevent the spread of disease? a. Place the patient in a room with negative airflow. b. Wear a gown, gloves, face mask, and goggles for interactions with the patient. c. Transport the patient safely and quickly when going to the radiology department. d. Use a dedicated blood pressure cuff that stays in the room and is used for that patient only. - ANS: D Contact precautions are a type of isolation precaution used for patients with illness 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 contact precautions. When a patient on contact precautions needs to be transported, the patient should wear clean gown, and hands cleaned, and the infectious material is contained or covered. 35. The nurse is caring for a patient who has cultured positive for Clostridium difficile. Which action will the nurse take next? a. Instruct assistive personnel to use soap and water rather than sanitizer. b. Wear an N95 respirator when entering the patient room. c. Place the patient on droplet precautions. d. Teach the patient cough etiquette. - ANS: A Clostridium difficile is a spore-forming organism that can be transmitted through direct and indirect patient contact. Because Clostridium difficile is a spore-forming organism, hand sanitizer is not effective in preventing its transmission. Hands must be washed with soap and water to prevent transmission. This organism is not transmitted via the droplet route; therefore, droplet precautions are not needed. An N95 respirator is used primarily for patients with airborne illness, especially tuberculosis. While all patients should be taught cough etiquette, this action is not specifically related to the patient having Clostridium difficile. 36. The nurse is changing linens for a postoperative patient and feels a prick in the left hand. A nonactivated safe needle is noted in the linens. For which condition is the nurse most at risk? a. Diphtheria b. Hepatitis B c. Clostridium difficile d. Methicillin-resistant Staphylococcus aureus - ANS: B Bloodborne pathogens such as those associated with hepatitis B and C are most commonly transmitted by contaminated needles. Clostridium difficile and MRSA are spread by contact. Diphtheria is spread by droplets when one is within 3 feet of the patient. 37. The nurse is caring for a patient who has a bloodborne pathogen. The nurse splashes blood above the glove to intact skin while discontinuing an intravenous (IV) infusion. Which step(s) will the nurse take next? a. Obtain an alcohol swab, remove the blood with an alcohol swab, and continue care. b. Immediately wash the site with soap and running water, and seek guidance from the manager. c. Do nothing; accidentally getting splashed with blood happens frequently and is part of the job. d. Delay washing of the site until the nurse is finished providing care to the patient. - 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 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. Which process will be required after exposure of a nurse to blood by a cut from a used scalpel in the operative area? a. Placing the scalpel in a needle safe container b. Testing the patient and offering treatment to the nurse c. Removing sterile gloves and disposing of in kick bucket d. Providing a medical evaluation of the nurse to the manager - ANS: B Follow-up for risk of infection begins with patient testing. Patients should be tested for HIV and hepatitis B and C. 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 and are not the process for postexposure. A confidential medical evaluation is provided to the nurse, not the manager. 39. 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. In which order will the nurse remove the personal protective equipment, beginning with the first step? 1. Remove eyewear/face shield and goggles. 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 keep the gloved fingers sterile. 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 prevents the sterile contents from accidentally opening and touching contaminated objects. While putting on the first glove, touching only the outside surface of the glove 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. Which items will the nurse need to care for this patient? (Select all that apply.) a. Private room b. Negative-pressure airflow in room c. Surgical mask, gown, gloves, eyewear d. N95 respirator, gown, gloves, eyewear e. Communication signs for droplet precautions f. Communication signs for airborne precautions - ANS: A, B, D, F Caring for this patient requires a private room, negative-pressure airflow in room, and wearing an N95 respirator that has been fit-tested, gloves, gown, and eyewear. Tuberculosis is a disease that is transmitted by droplets that remain in the air for long periods of time, requiring airborne precautions. This patient will not be in droplet precautions and instead requires airborne precaution signs. This type of patient requires more than the average surgical mask for protection. 6. The nurse and the student nurse are caring for two different patients on the medical-surgical unit. One patient is in airborne precautions, and one is in contact precautions. The nurse explains to the student different interventions for care. Which information will the nurse include in the teaching session? (Select all that apply.) a. Dispose of supplies to prevent the spread of microorganisms. b. Wash hands before entering and leaving both of the patients' rooms. c. Be consistent in nursing interventions since there is only one difference in the precautions. d. Apply the knowledge the nurse has of the disease process to prevent the spread of microorganisms. e. Have patients in airborne precautions wear a mask during transportation to other departments. f. Check the working order of the negative-pressure room for the airborne precaution patient on admission and at discharge. - ANS: A, B, D, E Washing hands, properly disposing of supplies, applying knowledge of the disease process, and having patients in airborne precautions wear a mask during transfer are all principles to follow when caring for patients in isolation. Multiple differences are evident among these types of isolation, including the type of room used for the patient and what the nurse wears while caring for the patient. It is important to check the working order of a negative-pressure room before admitting a patient to the room, each shift the patient is in the room, and if and when the device alarms. Checking the working order of the negative-pressure rooms at discharge is not necessary. A nurse is teaching the staff about conduction of the heart. In which order will the nurse present the conduction cycle, starting with the first structure? 1. Bundle of His 2.Purkinje network 3.Intraatrial pathways 4. Sinoatrial node (SA Node) 5. Atrioventricular node (AV Node) a. 5,4,3,2,1 b. 4,3,5,1,2 c. 4,5,3,1,2 d. 5,3,4,2,1 - ANS: B The conduction system originates with the SA node, the "pacemaker" of the heart. The electrical impulses are transmitted through the atria along intraatrial pathways to the AV node. It assists atrial emptying by delaying the impulse before transmitting it through the Bundle of His and the ventricular Purkinje network. DIF:Understand (comprehension)REF:875 A nurse is teaching the patient with mitral valve problems about the valves in the heart. Starting on the right side of the heart, describe the sequence of the blood flow through these valves. 1. Mitral 2. Aortic 3. Tricuspid 4. Pulmonic a. 1,3,2,4 b. 4,3,2,1 c. 3,4,1,2 d. 2,4,1,3 - ANS: C The blood flows through the valves in the following direction: tricuspid, pulmonic, mitral, and aortic. DIF:Understand (comprehension)REF:874 A nurse explains the function of the alveoli to a patient with respiratory problems. Which information about the alveoli's function will the nurse share with the patient? a. carries out gas exchange b. regulates tidal volume c. produces hemoglobin d. stores oxygen - ANS: A The alveolus is a capillary membrane that allows gas exchange of oxygen and carbon dioxide during respiration. The alveoli do not store oxygen, regulate tidal volume, or produce hemoglobin. DIF:Understand (comprehension)REF:872-873 A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close? a. aortic and mitral b. mitral and tricuspid c. aortic and pulmonic d. mitral and pulmonic - As the ventricles empty, the ventricular pressures decrease, allowing closure of the aortic and pulmonic valves, producing the second heart sound, S2. The mitral and tricuspid produce the first heart sound, S1. The aortic and mitral do not close at the same time. The mitral and pulmonic do not close at the same time. DIF:Apply (application)REF:874 The nurse is teaching about the process of exchanging gases through the alveolar capillary membrane. Which term will the nurse use to describe this process? a. ventilation b. surfactant c. perfusion d. diffusion - ANS: D Diffusion is the process of gases exchanging across the alveoli and capillaries of body tissues.Ventilation is the process of moving gases into and out of the lungs. Surfactant is a chemical produced in the lungs to maintain the surface tension of the alveoli and keep them from collapsing. Perfusion is the ability of the cardiovascular system to carry oxygenated blood to tissues and return deoxygenated blood to the heart. DIF:Understand (comprehension)REF:873 (**)A nurse is caring for a patient who was in a motor vehicle accident that resulted in cervical trauma to C4. Which assessment is the priority? a. pulse b. respirations c. temperature d. blood pressure - ANS: B Respirations and oxygen saturation are the priorities. Cervical trauma at C3 to C5 usually results in paralysis of the phrenic nerve. When the phrenic nerve is damaged, the diaphragm does not descend properly, thus reducing inspiratory lung volumes and causing hypoxemia. While pulse and blood pressure are important, respirations are the priority. Temperature is not a high priority in this situation. DIF:Analyze (analysis)REF:877 The patient is breathing normally. Which process does the nurse consider is working properly when the patient inspires? a. stimulation of chemical receptors in the aorta b. reduction of arterial oxygen saturation levels c. requirement of elastic recoil lung properties d. enhancement of accessory muscle usage - ANS: A Inspiration is an active process, stimulated by chemical receptors in the aorta. Reduced arterial oxygen saturation levels indicate hypoxemia, an abnormal finding. Expiration is a passive process that depends on the elastic recoil properties of the lungs, requiring little or no muscle work. Prolonged use of the accessory muscles does not promote effective ventilation and causes fatigue. With a sustained heart rate greater than 160 beats/min, diastolic filling time decreases, decreasing stroke volume and cardiac output. The hemoglobin level would not be affected. DIF:Understand (comprehension)REF:875 The nurse is careful to monitor a patient's cardiac output. Which goal is the nurse trying to achieve? a. to determine peripheral extremity circulation b. to determine oxygenation requirements c. to determine cardiac dysrhythmias d. to determine ventilation status - ANS: A Cardiac output indicates how much blood is being circulated systemically throughout the body to the periphery. The amount of blood ejected from the left ventricle each minute is the cardiac output. Oxygen status would be determined by pulse oximetry and the presence of cyanosis. Cardiac dysrhythmias are an electrical impulse monitored through ECG results. Ventilation status is measured by respiratory rate, pulse oximetry, and capnography. Capnography provides instant information about the patient's ventilation. Ventilation status does not depend solely on cardiac output. A nurse is caring for a group of patients. Which patient should the nurse see first? a. a patient with hypercapnia wearing an oxygen mask b. a patient with a chest tube ambulating with the chest tube unclamped c. a patient with thick secretions being tracheal suctioned first and then orally d. a patient with a new tracheostomy and tracheostomy obturator at the bedside - ANS: A The mask is contraindicated for patients with carbon dioxide retention (hypercapnia) because retention can be worsened; the nurse must see this patient first to correct the problem. All the rest are using correct procedures and do not need to be seen first. A chest tube should not be clamped when ambulating. Clamping a chest tube is contraindicated when ambulating or transporting a patient. Clamping can result in a tension pneumothorax. Use nasotracheal suctioning before pharyngeal suctioning whenever possible. The mouth and pharynx contain more bacteria than the trachea. Keep tracheostomy obturator at bedside with a fresh (new) tracheostomy to facilitate reinsertion of the outer cannula if dislodged. DIF:Analyze (analysis)REF:902 A patient has inadequate stroke volume related to decreased preload. which treatment does the nurse prepare to administer? a. diuretics b. vasodilators c. chest physiotherapy d. intravenous (IV) fluids - ANS: D Preload is affected by the circulating volume; if the patient has decreased fluid volume, it will need to be replaced with fluid or blood therapy. Preload is the amount of blood in the left ventricle at the end of diastole, often referred to as end-diastolic volume. Giving diuretics and vasodilators will make the situation worse. Diuretics causes fluid loss; the patient is already low on fluids or the preload would not be decreased. Vasodilators reduced blood return to the heart, making the situation worse; the patient does not have enough blood and fluid to the heart or the preload would not be decreased. Chest physiotherapy is a group of therapies for mobilizing pulmonary secretions. Chest physiotherapy will not help this cardiovascular problem. DIF:Apply (application)REF:875 A nurse is preparing to suction a patient. The pulse is 65 and pulse oximetry is 94%. Which finding will cause the nurse to stop suctioning? a. pulse 75 b. pulse 80 c. O2 saturation 91% d. O2 saturation 88% - ANS: D Stop when oxygen saturation is 88%. Monitor patient's vital signs and oxygen saturation during procedure; note whether there is a change of 20 beats/min (either increase or decrease) or if pulse oximetry falls below 90% or 5% from baseline. If this occurs, stop suctioning. A pulse rate of 75 is only 10 beats different from the start of the procedure. A pulse rate of 80 is 15 beats different from the start of suctioning. Oxygen saturation of 91% is not 5% from baseline or below 90%. DIF:Apply (application)REF:911 The patient has right-sided heart failure. Which finding will the nurse expect when performing an assessment? a. peripheral edema b. basilar crackles c. chest pain d. cyanosis - ANS: A Right-sided heart failure results from inability of the right side of the heart to pump effectively, leading to a systemic backup. Peripheral edema, distended neck veins, and weight gain are signs of right-sided failure. Basilar crackles can indicate pulmonary congestion from left-sided heart failure. Cyanosis and chest pain result from inadequate tissue perfusion. DIF:Apply (application)REF:878 A nurse is reviewing the electrocardiogram (ECG) results. Which portion of the conduction system does the nurse consider when evaluating the P wave? a. SA node b. AV node c. Bundle of His d. Purkinje fibers - ANS: A The P wave represents the electrical conduction through both atria; the SA node initiates electrical conduction through the atria. The AV node conducts down through the bundle of His and the Purkinje fibers to cause ventricular contraction. DIF:Apply (application)REF:875-876 (**) A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis? a. "Atelectasis affects only those with chronic conditions such as emphysema." b. "It is important to do breathing exercises every hour to prevent atelectasis." c. "If I develop atelectasis, I will need a chest tube to drain excess fluid." d. "Hyperventilation will open up my alveoli, preventing atelectasis." - ANS: B Atelectasis develops when alveoli do not expand. Breathing exercises, especially deep breathing and incentive spirometry, increase lung volume and open the airways, preventing atelectasis. Deep breathing also opens the pores of Kohn between alveoli to allow sharing of oxygen between alveoli. Atelectasis can affect anyone who does not deep breathe. A chest tube is for pneumothorax or hemothorax. It is deep breathing, not hyperventilation, that prevents atelectasis. DIF:Apply (application)REF:872 | 892 | 896 (**) A nurse is caring for a patient with respiratory problems. which assessment finding indicates a late sign of hypoxia? a. elevated blood pressure b. increased pulse rate c. restlessness d. cyanosis - ANS: D Cyanosis, blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is a late sign of hypoxia. Elevated blood pressure, increased pulse rate, and restlessness are early signs of hypoxia. DIF:Understand (comprehension)REF:877 A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this patient to hyperventilate. Which factor does the nurse remember when planning care for this type of hyperventilation? a. Anxiety over illness b. Decreased drive to breathe c. Increased metabolic demands d. Infection destroying lung tissues - ANS: C Increased body temperature (fever) increases the metabolic rate, thereby increasing carbon dioxide production. The increased carbon dioxide level stimulates an increase in the patient's rate and depth of respiration, causing hyperventilation. Anxiety can cause hyperventilation, but this is not the direct cause from a fever. Sleep causes a decreased respiratory drive; hyperventilation speeds up breathing. The cause of the fever in this question is unknown. DIF:Understand (comprehension)REF:877 A nurse is preparing a patient for nasotracheal suctioning. In which order will the nurse perform the steps, beginning with the first step? 1. Insert catheter. 2. Apply suction and remove. 3. Have patient deep breathe. 4. Encourage patient to cough. 5. Attach catheter to suction system. 6. Rinse catheter and connecting tubing. a. 1, 2, 3, 4, 5, 6 b. 4, 5, 1, 2, 3, 6 The nurse determines that an older-adult patient is at risk for infection due to decreased immunity. Which plan of care best addresses the prevention of infection for the patient? a. Inform the patient of the importance of finishing the entire dose of antibiotics. b. Encourage the patient to stay up-to-date on all vaccinations. c. Schedule patient to get annual tuberculosis skin testing. d. Create an exercise routine to run 45 minutes every day. - ANS: B A nursing care plan for preventative health measures should be reasonable and feasible. Keeping up-to-date on vaccinations is important because vaccine reduces the severity of illnesses and serious complications. Determine if and when the patient has had a pneumococcal or influenza (flu) vaccine. This is especially important when assessing older adults because of their increased risk for respiratory disease. Although it is important to finish the full course of antibiotics, it is not a preventative health measure. Scheduling annual tuberculosis skin tests does not address prevention and is an unreliable indictor of tuberculosis in older patients. The exercise routine should be reasonable to increase compliance; exercise is recommended only 3 to 4 times a week for 30 to 60 minutes, and walking, rather than running, is an efficient The nurse is caring for a patient with fluid volume overload. Which physiological effect does the nurse most likely expect? a. Increased preload b. Increased heart rate c. Decreased afterload d. Decreased tissue perfusion - ANS: A Preload refers to the amount of blood in the left ventricle at the end of diastole; an increase in circulating volume would increase the preload of the heart. Afterload refers to resistance; increased pressure would lead to increased resistance, and afterload would increase. A decrease in tissue perfusion would be seen with hypovolemia. A decrease in fluid volume would cause an increase in heart rate as the body is attempting to increase cardiac output. DIF:Apply (application)REF:875 A nurse is caring for a patient with continuous cardiac monitoring for heart dysrhythmias. Which rhythm will cause the nurse to intervene immediately? a. Ventricular tachycardia b. Atrial fibrillation c. Sinus rhythm d. Paroxysmal supraventricular tachycardia - ANS: A Ventricular tachycardia and ventricular fibrillation are life-threatening rhythms that require immediate intervention. Ventricular tachycardia is a life-threatening dysrhythmia because of the decreased cardiac output and the potential to deteriorate into ventricular fibrillation or sudden cardiac death. Atrial fibrillation is a common dysrhythmia in older adults and is not as serious as ventricular tachycardia. Sinus rhythm is normal. Paroxysmal supraventricular tachycardia is a sudden, rapid onset of tachycardia originating above the AV node. It often begins and ends spontaneously. DIF:Apply (application)REF:878 The patient is experiencing angina pectoris. Which assessment finding does the nurse expect when conducting a history and physical examination? a. Experiences chest pain after eating a heavy meal b. Experiences adequate oxygen saturation during exercise c. Experiences crushing chest pain for more than 20 minutes d. Experiences tingling in the left arm that lasts throughout the morning - ANS: A Angina pectoris is chest pain that results from limited oxygen supply. Often pain is precipitated by activities such as exercise, stress, and eating a heavy meal and lasts 3 to 5 minutes. Symptoms of angina pectoris are relieved by rest and/or nitroglycerin. Adequate oxygen saturation occurs with rest; inadequate oxygen saturation occurs during exercise. Pain lasting longer than 20 minutes or arm tingling that persists could be a sign of myocardial infarction. DIF:Apply (application)REF:878 (**)A nurse is teaching about risk factors for cardiopulmonary disease. Which risk factor should the nurse describe as modifiable? a. Stress b. Allergies c. Family history d. Gender - ANS: A Young and middle-age adults are exposed to multiple cardiopulmonary risk factors: an unhealthy diet, lack of exercise, stress, over-the-counter and prescription drugs not used as intended, illegal substances, and smoking. Reducing these modifiable factors decreases a patient's risk for cardiac or pulmonary diseases. A nonmodifiable risk factor is family history; determine familial risk factors such as a family history of lung cancer or cardiovascular disease. Other nonmodifiable risk factors include allergies and gender. DIF:Understand (comprehension)REF:879 (**)The nurse is creating a plan of care for an obese patient who is suffering from fatigue related to ineffective breathing. Which intervention best addresses a short- term goal the patient could achieve? a. Sleeping on two to three pillows at night b. Limiting the diet to 1500 calories a day c. Running 30 minutes every morning d. Stopping smoking immediately - ANS: A To achieve a short-term goal, the nurse should plan a lifestyle change that the patient can make immediately that will have a quick effect. Sleeping on several pillows at night will immediately relieve orthopnea and open the patient's airway, thereby reducing fatigue. Running 30 minutes a day will improve cardiopulmonary health, but a patient needs to build up exercise tolerance. Smoking cessation is another process that many people have difficulty doing immediately. A more realistic short-term goal would be to gradually reduce the number of cigarettes smoked. Limiting caloric intake can help a patient lose weight, but this is a gradual process and is not reasonable for a short-term goal. DIF:Apply (application)REF:882 (**)A nurse is caring for a patient with left-sided hemiparesis who has developed bronchitis and has a heart rate of 105 beats/min, blood pressure of 156/90 mm Hg, and respiration rate of 30 breaths/min. Which nursing diagnosis is a priority? a. Risk for skin breakdown b. Impaired gas exchange c. Activity intolerance d. Risk for infection - ANS: B The most important nursing intervention is to maintain airway and circulation for this patient; therefore, Impaired gas exchange is the first nursing priority. Activity intolerance is a concern but is not the priority in this case. Risk for skin breakdown and Risk for infection are also important but do not address an immediate impairment with physiologic integrity. DIF:Analyze (analysis)REF:886 | 888 Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an older-adult patient? a. Discontinue the humidification delivery device to keep excess fluid from lungs. b. Monitor oxygen saturation, and frequently auscultate lung bases. c. Assist the patient to cough, turn, and deep breathe every 2 hours. d. Decrease fluid intake to 300 mL a shift. - ANS: C The goal of the nursing action should be the prevention of pneumonia; the action that best addresses this is to cough, turn, and deep breathe to keep secretions from pooling at the base of the lungs. Humidification thins respiratory secretions, making them easier to expel and should be used. Monitoring oxygen status is important but is not a method of prevention. Hydration assists in preventing hospital-acquired pneumonia. The best way to maintain thin secretions is to provide a fluid intake of 1500 to 2500 mL/day unless contraindicated by cardiac or renal status. Restricting fluids is contraindicated in this situation since there is no data indicating cardiac or renal disease. DIF:Apply (application)REF:892 (**) The nurse is assessing a patient with emphysema. Which assessment finding requires further follow-up with the health care provider? a. Increased anterior-posterior diameter of the chest b. Accessory muscle used for breathing c. Clubbing of the fingers d. Hemoptysis - ANS: D Hemoptysis is an abnormal occurrence of emphysema, and further diagnostic studies are needed to determine the cause of blood in the sputum. Clubbing of the fingers, barrel chest (increased anterior-posterior chest diameter), and accessory muscle use are all normal findings in a patient with emphysema. DIF:Apply (application)REF:882 A patient with chronic obstructive pulmonary disease (COPD) asks the nurse why clubbing occurs. Which response by the nurse is most therapeutic? a. "Your disease doesn't send enough oxygen to your fingers." b. "Your disease affects both your lungs and your heart, and not enough blood is being pumped." c. "Your disease will be helped if you pursed-lip breathe." d. "Your disease often makes patients lose mental status." - ANS: A Clubbing of the nail bed can occur with COPD and other diseases that cause prolonged oxygen deficiency or chronic hypoxemia. Pursed-lipped breathing helps the alveoli stay open but is not the cause of clubbing. Loss of mental status is not a