www.mynursingtestprep.comuses cold water for medical asepsis. ANS: 3 Patients acquire infection by contact with other patients, family members, and healthcare equipment. But most infection among patients is spread through the hands of healthcare workers. Hand washing interrupts the transmission and should be done before and after all contact with patients, regardless of the diagnosis. When the hands are soiled, healthcare staff should use antibacterial soap with warm water to remove dirt and debris from the skin surface. When no visible dirt is present, an alcohol-based rub should be applied and allowed to dry for 10 to 15 seconds. PTS:1DIF:EasyREF:p. 618 KEY:Nursing process: Implementation | Client need: SECE | Cognitive level: Comprehension 2. What is the most frequent cause of the spread of infection among institutionalized patients? 1) Airborne microbes from other patients 2) Contact with contaminated equipment 3) Hands of healthcare workers 4) Exposure from family members ANS: 3 Patients are exposed to microbes by contact (direct contact, airborne, or otherwise) with other patients, family members, and contaminated healthcare equipment. Some of these are pathogenic (cause illness) and some are nonpathogenic (do not cause illness). But most microbes causing infection among patients are spread by direct contact on the hands of healthcare workers. PTS:1DIF:EasyREF:p. 609 KEY:Nursing process: Implementation | Client need: SECE | Cognitive level: Recall 3. Which of the following nursing activities is of highest priority for maintaining medical asepsis? 1) Washing hands 2) Donning gloves 3) Applying sterile drapes 4) Wearing a gown ANS: 1 Scrupulous hand washing is the most important part of medical asepsis. Donning gloves, applying sterile drapes before procedures, and wearing a protective gown may be needed to ensure asepsis, but they are not the most important aspect because microbes causing most healthcare-related infections are transmitted by lack of or ineffective hand washing. PTS: 1 DIF: Easy REF: p. 617 KEY: Nursing process: Interventions | Client need: Safe Care Environment | Cognitive level: Comprehension 4. A patient infected with a virus but who does not have any outward sign of the disease is considered a: 1)
www.mynursingtestprep.compathogen. 2) fomite. 3) vector. 4) carrier. ANS: 4 Some people might harbor a pathogenic organism, such as the human immunodeficiency virus, within their bodies and yet do not acquire the disease/infection. These individuals, called carriers, have no outward sign of active disease, yet they can pass the infection to others. A pathogen is an organism capable of causing disease. A fomite is a contaminated object that transfers a pathogen, such as pens, stethoscopes, and contaminated needles. A vector is an organism that carries a pathogen to a susceptible host through a portal for entry into the body. An example of a vector is a mosquito or tick that bites or stings. PTS:1DIF:ModerateREF:p. 607 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application 5. A patient is admitted to the hospital with tuberculosis. Which precautions must the nurse institute when caring for this patient? 1) Droplet transmission 2) Airborne transmission 3) Direct contact 4) Indirect contact ANS: 2 The organisms responsible for measles and tuberculosis, as well as many fungal infections, are spread through airborne transmission. Neisseria meningitidis, the organism that causes meningitis, is spread through droplet transmission. Pathogens that cause diarrhea, such as Clostridium difficile, are spread by direct contact. The common cold can be spread by indirect contact or droplet transmission. PTS:1DIF:ModerateREF:p. 608 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 6. A patient becomes infected with oral candidiasis (thrush) while receiving intravenous antibiotics to treat a systemic infection. Which type of infection has the patient developed? 1) Endogenous nosocomial 2) Exogenous nosocomial 3) Latent 4) Primary ANS: 1 Thrush in this patient is an example of an endogenous nosocomial infection. This type of infection arises from suppression of the patients normal floras as a result of some form of treatment, such as antibiotics. Normal floras usually keep yeast from growing in the
www.mynursingtestprep.commouth. In exogenous nosocomial infection, the pathogen arises from the healthcare environment. A latent infection causes no symptoms for long periods. An example of a latent infection is human immunodeficiency virus infection. A primary infection is the first infection that occurs in a patient. PTS: 1 DIF: Difficult REF: p. 608 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 7. A patient admitted to the hospital with pneumonia has been receiving antibiotics for 2 days. His condition has stabilized, and his temperature has returned to normal. Which stage of infection is the patient most likely experiencing? 1) Incubation 2) Prodromal 3) Decline 4) Convalescence ANS: 3 The stage of decline occurs when the patients immune defenses, along with any medical therapies (in this case antibiotics), are successfully reducing the number of pathogenic microbes. As a result, the signs and symptoms of infection begin to fade. Incubation is the stage between the invasion by the organism and the onset of symptoms. During the incubation stage, the patient does not know he is infected and is capable of infecting others. The prodromal stage is characterized by the first appearance of vague symptoms. Convalescence is characterized by tissue repair and a return to healing as the organisms disappear. PTS:1DIF:ModerateREF:p. 609 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 8. The nurse assists a surgeon with central venous catheter insertion. Which action is necessary to help maintain sterile technique? 1) Closing the patients door to limit room traffic while preparing the sterile field 2) Using clean procedure gloves to handle sterile equipment 3) Placing the nonsterile syringes containing flush solution on the sterile field 4) Remaining 6 inches away from the sterile field during the procedure ANS: 1 To maintain sterile technique, the nurse should close the patients door and limit the number of persons entering and exiting the room because air currents can carry dust and microorganisms. Sterile gloves, not clean gloves, should be used to handle sterile equipment. Placing nonsterile syringes on the sterile field contaminates the field. One foot, not 6 inches, is required between people and the sterile field to prevent contamination. PTS: 1 DIF: Moderate REF: p. 629 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 9. A patient develops localized heat and erythema over an area on the lower leg. These findings are indicative of which secondary defense against infection?
www.mynursingtestprep.com1) Phagocytosis 2) Complement cascade 3) Inflammation 4) Immunity ANS: 3 The classic signs of inflammation, a secondary defense against infection, are erythema (redness) and localized heat. The secondary defenses phagocytosis (process by which white blood cells engulf and destroy pathogens) and the complement cascade (process by which blood proteins trigger the release of chemicals that attack the cell membranes of pathogens) do not produce visible findings. Immunity is a tertiary defense that protects the body from future infection. PTS:1DIFifficultREF:p. 610 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application 10. The patient is just beginning to feel symptoms after being exposed to an upper respiratory infection. Which antibody would most likely be found in a test of immunoglobin levels? 1) IgA 2) IgE 3) IgG 4) IgM ANS: 4 IgM are the first antibodies made in response to infection. IgE is the antibody primarily responsible for this allergic response. IgA antibodies protect the body in fighting viral and bacterial infections, and appear later. IgG antibodies also appear laterperhaps up to 10 days later. PTS:1DIF:ModerateREF:p. 612 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 11. What type of immunity is provided by intravenous (IV) administration of immunoglobulin G? 1) Cell-mediated 2) Passive 3) Humoral 4) Active ANS: 2 Intravenous administration of immunoglobulin G provides the patient with passive immunity. Immunoglobulin G does not provide cell-mediated, humoral, or active immunity. Passive immunity occurs when antibodies are transferred from an immune
www.mynursingtestprep.comhost, such as from a placenta to a fetus. Passive immunity is short lived. Active immunity is longer lived and comes from the host. Humoral immunity occurs by secreted antibodies binding to antigens. Cell-mediated immunity does not involve antibodies but rather is a fight of infection from macrophages that kill pathogens. PTS:1DIF:ModerateREF:ESG,\\ 12. A patient asks the nurse why there is no vaccine available for the common cold. Which response by the nurse is correct? 1) The virus mutates too rapidly to develop a vaccine. 2) Vaccines are developed only for very serious illnesses. 3) Researchers are focusing efforts on an HIV vaccine. 4) The virus for the common cold has not been identified. ANS: 1 More than 200 viruses are known to cause the common cold. These viruses mutate too rapidly to develop a vaccine. Although some researchers are focusing efforts on a vaccine for HIV infection, others continue to research the common cold. PTS:1DIF:ModerateREF:p. 616 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 13. A patient who has a temperature of 101F (38.3C) most likely requires: 1) acetaminophen (Tylenol). 2) increased fluids. 3) bedrest. 4) tepid bath. ANS: 2 Fever, a common defense against infection, increases water loss; therefore, additional fluid is needed to supplement this loss. Acetaminophen and a tepid bath are not necessary for this low-grade fever because fever is beneficial in fighting infection. Adequate rest, not necessarily bedrest, is necessary with a fever. PTS:1DIF:ModerateREF:p. 616 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis 14. Why is a lotion without petroleum preferred over a petroleum-based product as a skin protectant? 1) It prevents microorganisms from adhering to the skin. 2) It facilitates the absorption of latex proteins through the skin. 3) It decreases the risk of latex allergies. 4) It prevents the skin from drying and chaffing. ANS: 3 Non-petroleum-based lotion is preferred because it prevents the absorption of latex
www.mynursingtestprep.comproteins through the skin, which can cause latex allergy. Both types of lotion help prevent the skin from drying and becoming chafed. Neither prevents microorganisms from adhering to the skin. PTS: 1 DIF: Moderate REF: p. 634[answer not directly given in the text. Answer must be inferred from the content.] KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis 15. For which range of time must a nurse wash her hands before working in the operating room? 1) • to 2 minutes 2) • to 4 minutes 3) 2 to 6 minutes 4) 6 to 10 minutes ANS: 3 In a surgical setting, hands should be washed for 2 to 6 minutes, depending on the type of soap used. PTS:1DIF:EasyREF:p. 639 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 16. How should the nurse dispose of the breakfast tray of a patient who requires airborne isolation? 1) Place the tray in a specially marked trash can inside the patients room. 2) Place the tray in a special isolation bag held by a second healthcare worker at the patients door. 3) Return the tray with a note to dietary services so it can be cleaned and reused for the next meal. 4) Carry the tray to an isolation trash receptacle located in the dirty utility room and dispose of it there. ANS: 2 Patients who require airborne isolation are served meals on disposable dishes and trays. To dispose of the tray, the nurse inside the room must wear protective garb and place the tray and its contents inside a special isolation bag that is held by a second healthcare worker at the patients door. The items must be placed on the inside of the bag without touching the outside of the bag. PTS:1DIF:ModerateREF:p. 625 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 17. As a general rule, how much liquid soap should the nurse use for effective hand washing? At least: 1) • mL 2) • mL 3)
www.mynursingtestprep.com• mL 4) • mL ANS: 2 APIC guidelines dictate that 3 to 5 mL of liquid soap is necessary for effective hand washing. PTS:1DIF:EasyREF:p. 633 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 18. To assure effectiveness, when should the nurse stop rubbing antiseptic hand solution over all surfaces of the hands? 1) When fingers feel sticky 2) After 5 to 10 seconds 3) When leaving the clients room 4) Once fingers and hands feel dry ANS: 4 The nurse should rub the antiseptic hand solution over all surfaces of the hands until the solution dries, usually 10 to 15 seconds, to ensure effectiveness. PTS: 1 DIF: Easy REF: p. 634 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 19. A patient is admitted to the hospital for chemotherapy and has a low white blood cell count. Which precaution should the staff take with this patient? 1) Contact 2) Protective 3) Droplet 4) Airborne ANS: 2 Protective isolation is used to protect those patients who are unusually vulnerable to organisms brought in by healthcare workers. Such patients include those with low white blood cell counts, with burns, and undergoing chemotherapy. Some hospital units, such as neonatal intensive care units and labor and delivery suites, also use forms of protective isolation. PTS:1DIF:ModerateREF:p. 625 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 20. While donning sterile gloves, the nurse notices the edges of the glove package are slightly yellow. The yellow area is over 1 inch away from the gloves and only appears to be on the outside of the glove package. What is the best action for the nurse to take at this point? 1) Continue using the gloves inside the package because the package is intact. 2) Remove gloves from the sterile field and use a new pair of sterile gloves. 3)
www.mynursingtestprep.comThrow all supplies away that were to be used and begin again. 4) Use the gloves and make sure the yellow edges of the package do not touch the client. ANS: 2 The gloves should be discarded because the gloves are likely to be contaminated from an outside source. The supplies do not have to be thrown away because they have not been contaminated. PTS:1DIF:ModerateREF:dm 629, 646 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 21. The nurse is removing personal protective equipment (PPE). Which item should be removed first? 1) Gown 2) Gloves 3) Face shield 4) Hair covering ANS: 2 The gloves are removed first because they are usually the most contaminated PPE and must be removed to avoid contamination of clean areas of the other PPE during their removal. The gown is removed second, then the mask or face shield, and finally, the hair covering. PTS:1DIF:ModerateREF:dm 637-638 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application Prioritizing Prioritize the nurses actions, listing the most important one first. 1. A nurse is splashed in the face by body fluid during a procedure. Prioritize the nurses actions, listing the most important one first. • Contact employee health • Complete an incident report • Wash the exposed area • Report to another nurse that she is leaving the immediate area. 1) 1, 2, 3, 4 2) 2, 3, 4, 1 3) 3, 4, 1, 2 4) 4, 1, 2, 3 ANS: 3 If a nurse becomes exposed to body fluid, she should first wash the area, tell another nurse she is leaving the area, contact the infection control or employee health nurse immediately, and complete an incident report. It is most important to remove the source of contamination (body fluid) as soon as possible after exposure to help prevent the nurse from becoming infected. The other activities can wait until that is done. PTS:1DIF:ModerateREF:p. 630 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
www.mynursingtestprep.comMultiple Response Identify one or more choices that best complete the statement or answer the question. 1. In which situation would using standard precautions be adequate? Select all that apply. 1) While interviewing a client with a productive cough 2) While helping a client to perform his own hygiene care 3) While aiding a client to ambulate after surgery 4) While inserting a peripheral intravenous catheter ANS: 3, 4 Standard precautions should be instituted with all clients whenever there is a possibility of coming in contact with blood, body fluids (except sweat), excretions, secretions, mucous membranes, and breaks in the skin (e.g., while inserting a peripheral IV). When interviewing a client, if the disease is not spread by air or droplets, there is no likelihood of the nurses encountering body fluids. If the disease is spread by air or droplets, then droplet or airborne precautions would be needed in addition to standard precautions. If giving a complete bed bath or performing oral hygiene, the nurse would need to use standard precautions (gloves); if merely assisting a client to perform those ADLs, it is not necessary. No exposure to body fluids is likely when helping a client to ambulate after surgery. PTS: 1 DIF: Easy REF: dm 619-624 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 2. Which of the following protect(s) the body against infection? Select all that apply. 1) Eating a healthy, well-balanced diet 2) Being an older adult or an infant 3) Leisure activities three times a week 4) Exercising for 30 minutes 5 days a week ANS: 1, 3, 4 Nutrition, hygiene, rest, exercise, stress reduction, and immunization protect the body against infection. Illness, injury, medical treatment, infancy or old age, frequent public contact, and various lifestyle factors can make the body more susceptible to infection. PTS:1DIF:EasyREF:dm 612, 616 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall 3. The nurse is teaching a group of newly hired nursing assistive personnel (NAP) about proper hand washing. The nurse will know that the teaching was effective if the NAP demonstrate what? Select all that apply. The NAP: 1) uses a paper towel to turn off the faucet. 2) holds fingertips above the wrists while rinsing off the soap. 3)
www.mynursingtestprep.comremoves all rings and watch before washing hands. 4) cleans underneath each fingernail. ANS: 1, 3, 4 Hand washing requires at least 15 seconds of washing, which includes lathering all surfaces of the hands and fingers to be effective. The fingers should be held lower than the wrists. PTS: 1 DIF: Moderate REF: dm 633-634 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Recall 4. Alcohol-based solutions for hand hygiene can be used to combat which types of organisms? Select all that apply. 1) Virus 2) Bacterial spores 3) Yeast 4) Mold ANS: 1, 3, 4 If there is potential for contact with bacterial spores, hands must be washed with soap and water; alcohol-based solutions are ineffective against bacterial spores. PTS:1DIF:ModerateREF:p. 618 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 5. A patient with tuberculosis is scheduled for computed tomography (CT). How should the nurse proceed? Select all that apply. 1) Question the order because the patient must remain in isolation. 2) Place an N-95 respirator mask on the patient and transport him to the test. 3) Place a surgical mask on the patient and transport him to CT lab. 4) Notify the computed tomography department about precautions prior to transport. ANS: 3, 4 Transporting a patient who requires airborne precautions should be limited; however, when necessary the patient should wear a surgical mask (an N-95 respirator mask is not required) that covers the mouth and nose to prevent the spread of infection. Moreover, the department where the patient is being transported should be notified about the precautions before transport. PTS: 1 DIF: Difficult REF: dm 623-624 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension True/False Indicate whether the statement is true or false. 1. Bacteria are necessary for human health and well- being. ANS: T Organisms that normally inhabit the body, called normal floras, are essential for human
www.mynursingtestprep.comhealth and well-being. They keep pathogens in check. In the intestine, these floras function to aid digestion and promote the release of vitamin K, vitamin B12, thiamine, and riboflavin. Chapter 21 Promoting Safety Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Physiological changes associated with aging place the older adult especially at risk for which nursing diagnosis? 1) Risk for Falls 2) Risk for Ineffective Airway Clearance (choking) 3) Risk for Poisoning 4) Risk for Suffocation (drowning) ANS: 1 Loss of muscle strength and joint mobility place older adults at risk for falls. Choking, drowning, and ingesting poisons are primary safety concerns for infants and toddlers. PTS:1DIF:ModerateREF:p. 653 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Recall 2. A 78-year-old patient is being seen in the emergency department. The nurse observes his gait and balance appear to be slightly unsteady. What assessment should the nurse perform next? 1) Perform the Get Up and Go Test. 2) Ask the patient if he has fallen in the past year. 3) Refer the patient for a comprehensive fall evaluation. 4) Administer the Timed Up and Go Test. ANS: 2 If a patients gait or balance is unsteady, the nurse should question the patient for a history of falls. If the patient reports a single fall, the nurse should do the Get Up and Go Test. If the patient has difficulty with that test, or is unsteady with it, the nurse should perform a follow-up assessment of gait and balance by having the person close the eyes for a few seconds wile standing in place; stand with eyes closed while the nurse pushes gently on the sternum; walk, stop, turn around, return to the chair, and sit in the chair without using his arms for support. Physicians and advanced practitioners perform the Timed Up and Go Test; it is recommended annually for patients 65 years or older. PTS:1DIFifficultREF:p. 661 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application 3. The nurse notes that the electrical cord on an IV infusion pump is cracked. Which action by the nurse is best? 1) Continue to monitor the pump to see if the crack worsens. 2) Place the pump back on the utility room shelf. 3)
www.mynursingtestprep.comA small crack poses no danger so continue using the pump. 4) Clearly label the pump and send it for repair. ANS: 4 Whenever an electrical safety hazard is suspected or visible, the nurse should label the malfunctioning equipment and send it for repair or inspection. Continuing to use the IV infusion pump or any other equipment places the patient at risk for injury. Placing the pump back on the shelf places other healthcare team members at risk for electrical injury if they attempt to use the equipment. PTS:1DIF:EasyREF:p. 673 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 4. A patient with a history of falling continually attempts to get out of bed unassisted despite frequent reminders to call for help first. Which action should the nurse take first? 1) Apply a cloth vest restraint. 2) Encourage a family member to stay with the patient. 3) Administer lorazepam (an antianxiety medication). 4) Keep the patients bed side rails up. ANS: 2 The nurse should use one-to-one supervision with this patient to maintain the patients safety. One way to accomplish this is by encouraging a family member to stay with the patient. Restraints should be used only when all other less-restrictive measures have failed and are absolutely necessary to prevent injury to the patient. Restraints have been shown to jeopardize patient safety. It is not appropriate to administer sedation for the purpose of keeping the patient in bed; this is a form of restraint. Keeping the side rails up is also a form of restraint and increases the risk for falling. PTS: 1 DIF: Moderate REF: p. 673 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 5. Despite less-restrictive interventions, a patients behavior escalates, requiring emergency application of restraints. Which of the following must the nurse do in this situation? 1) Obtain a physicians order before applying restraints. 2) Monitor the patients status every 4 hours while restrained. 3) Release the restraints and check circulation every hour. 4) Continually reevaluate the patients need for restraint. ANS: 4 The patient must be continually monitored, and the need for restraint must be continually reevaluated. As a rule, a medical order should be obtained before applying restraints. However, in an emergency, the nurse is permitted to apply restraints for behavior management, but a physician or advanced practice nurse must then evaluate the patient within 1 hour of restraint application. The order for restraint must be renewed daily. The restraints must be released at least every 2 hours, and circulation must be checked. PTS: 1 DIF: Difficult REF: dm 679-681
www.mynursingtestprep.comKEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 6. A patient has received a radiation implant. The patient is weak and needs help even to turn in bed. Which action should the nurse take when caring for this patient? 1) Avoid giving the patient a complete bed bath. 2) Limit the amount of time spent with the patient. 3) Allow extra time for the patient to express feelings. 4) Do not allow anyone to visit the patient. ANS: 2 When caring for a patient with a radiation implant, the nurse should organize nursing care to limit the amount of time with the patient to limit radiation exposure. The nurse must meet the patients personal hygiene needs by bathing the patient, if necessary. The nurse should encourage the patient to express her feelings; however, she should limit her contact with the patient. Pregnant women should not visit the patient; however, others may visit as long as they uphold the principles of time, distance, and shielding. PTS: 1 DIF: Moderate REF: p. 660 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 7. A child is brought to the emergency department after swallowing liquid cleanser. He is awake and alert and able to swallow. Which action should the nurse take first? 1) Administer a dose of syrup of ipecac. 2) Administer activated charcoal immediately. 3) Give water to the child immediately. 4) Call the nearest poison control center. ANS: 3 If the child is awake and able to swallow, and the child has swallowed a household chemical, give one-half glassful of water immediately. After giving the water, call the poison control center. The American Academy of Pediatrics does not advise giving syrup of ipecac. Emergency departments have stopped using ipecac in favor of activated charcoal, which binds to poison in the stomach and prevents it from entering the bloodstream. Continued vomiting caused by syrup of ipecac may later result in the child being unable to tolerate activated charcoal or other poison treatments. No one can tell how much a child vomits, and therefore, no one would know if all the poison was eliminated from the stomach. There is also potential for misuse by bulimics. The poison control center may recommend activated charcoal, depending upon the agent ingested. PTS: 1 DIF: Difficult REF: ESG Treatment for Commonly Ingested Poisons KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis 8. A nurse is teaching a group of mothers about first aid. Should poison come in contact with their childs clothing and skin, which action should the nurse instruct the mothers to take first? 1)
www.mynursingtestprep.comRemove the contaminated clothing immediately. 2) Flood the contaminated area with lukewarm water. 3) Wash the contaminated area with soap and water and rinse. 4) Call the nearest poison control center immediately. ANS: 1 The nurse should tell the mother to first remove the contaminated clothing as quickly as possible. Then, flood the contaminated area with lukewarm water. Next, gently wash the area with soap and water and rinse. Have someone call the poison control center. It does not need to be a local poison control center. Additionally, it is most important to remove contact between the skin and poison before doing anything. PTS: 1 DIF: Moderate REF: ESG| Cognitive level: Analysis 9. Which of the following instructions is most important for the nurse to include when teaching a mother of a 3-year-old about protecting her child against accidental poisoning? 1) Store medications on countertops out of the childs reach. 2) Purchase medication in child-resistant containers 3) Take medications in front of the child, and explain that they are for adults only. 4) Never leave the child unattended around medications or cleaning solutions. ANS: 4 The nurse should instruct the mother to avoid leaving her child unattended around medications or cleaners even for a moment. Medications should never be stored on kitchen counters or bathroom surfaces because children love to explore and climb and can get into them. The nurse should explain that medications should not be taken in front of the child because children imitate adult behavior. The nurse should reinforce that although child-resistant containers are a deterrent, they are not foolproof because many toddlers and preschoolers can open them. PTS:1DIF:ModerateREF:p. 665 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 10. A patient is brought to the emergency department after inhaling mercury. The nurse should be alert for which acute adverse effects associated with mercury inhalation? 1) Chest pain, pneumonitis, and inflammation of the mouth 2) Intestinal obstruction and numbness of the hands 3) Hypotension, oliguria, and tingling of the feet 4) Tachycardia, hematuria, and diaphoresis ANS: 1 Acute adverse effects of mercury inhalation include chest pain, inflammation of mouth, pneumonitis, respiratory damage, wakefulness, muscle weakness, anorexia, headache, and ringing in the ears, Chronic effects include numbness or tingling of the hands, lips, and feet, and personality changes. Intestinal obstruction is an acute effect of mercury
www.mynursingtestprep.comingestion. Hypotension, oliguria, hematuria, and diaphoresis are not acute effects of mercury inhalation. PTS: 1 DIF: Difficult REF: p. 659 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 11. Which aspect of restraint use can the nurse delegate to the nursing assistive personnel? 1) Assessing the patients status 2) Determining the need for restraint 3) Evaluating the patients response to restraints 4) Applying and removing the restraints ANS: 4 The nurse can delegate applying and removing the restraints, skin care, and checking for skin breakdown. The nurse responsible for care of the patient must assess the patients need for restraint and the patients status and must evaluate the patients response to restraints. PTS: 1 DIF: Moderate REF: p. 675 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 12. The nurse suspects a 3-year-old child who is coughing vigorously has aspirated a small object. Which action should the nurse take first? 1) Encourage the child to continue coughing. 2) Deliver upward abdominal thrusts with a fisted hand. 3) Deliver five rapid back blows between the shoulder blades. 4) Perform a blind finger sweep of the childs mouth. ANS: 1 If the nurse suspects aspiration in a child who is coughing vigorously, the nurse should encourage the child to continue coughing. If coughing weakens, the nurse should perform the choking maneuver by administering five rapid back blows alternated with five upward thrusts to the upper abdomen with a fisted hand, just below the rib cage. A blind finger sweep should never be performed because it could push the foreign object into the airway. PTS:1DIF:Moderate REF: ESG, Box 23-5, Rescue Maneuver for Choking: Adult or Child Over Age 12 Months KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis 13. Which is the most commonly reported incident in hospitals? 1) Equipment malfunction 2) Patient falls 3) Laboratory specimen errors 4)
www.mynursingtestprep.comTreatment delays ANS: 2 Patient falls are by far the most common incident reported in hospitals and long-term care facilities. Although equipment (e.g., infusion pump) malfunctions, missed or incorrectly identified laboratory specimen collection, and treatment delays sometimes occur, they do not occur as frequently as patient falls. PTS:1DIF:EasyREF:p. 657 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension 14. The Joint Commissions national Speak Up campaign encourages patients to become active and informed participants on the healthcare team. The goal is to: 1) prevent healthcare errors. 2) help control the cost of healthcare. 3) reduce the number of automobile accidents. 4) provide a forum for people without health insurance. ANS: 1 The Joint Commission, with the Centers for Medicare and Medicaid Services, urges patients to take a role in preventing healthcare errors by becoming active, involved, and informed participants on the healthcare team. A reduction in healthcare errors could indirectly reduce healthcare costs, but this is not the intent of the campaign. The campaign has nothing to do with automobile accidents, as might be deduced from the fact that the Joint Commission and Medicare/Medicaid regulate healthcare agencies. The campaign has little relationship to insurance, other than to encourage clients to speak up, ask questions, and know their rights. PTS:1DIFifficultREF:p. 664 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension 15. A patient in the emergency department is angry, yelling, cursing, and waving his arms when the nurse comes to the treatment cubicle. Which action(s) by the nurse is(are) advisable? 1) Reassure the patient by entering the room alone. 2) Ask the patient if he is carrying any weapons. 3) Stay between the patient and the door; keep the door open. 4) Make eye contact while stating firmly I will not tolerate cursing and threats. ANS: 3 The nurse should keep the door open and position herself so that the patient cannot block her exit from the room (stay between the patient and the door). The nurse should not enter a room alone with an angry patient. The progression to physical violence is first anxiety, then verbal aggression, and finally physical aggression. The nurses first priority in this situation is her own safety and the safety of others in the environment. The object is to relieve the patients anxiety and not respond to anger with anger. Questioning about weapons, or being firm and defending against verbal aggression will likely provoke even more anger from the patient. The nurse must be calm and reassuring. PTS:1DIFifficultREF:p. 674
www.mynursingtestprep.comKEY: Nursing process: N/A | Client need: PSI | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. Which point(s) should the nurse include when teaching safety precautions to a mother of a toddler? Select all that apply. 1) Make sure the child sleeps on his back at night. 2) Keep the telephone number of the poison control center accessible. 3) Use a front-facing car seat placed in the back seat of the car. 4) Keep syrup of ipecac on hand in case of accidental poisoning. ANS: 2, 3 The nurse should teach the mother of a toddler to keep the telephone number of the poison control center accessible because toddlers are at risk for accidental poisonings. Toddlers should also have front-facing car seats. Syrup of ipecac is no longer recommended to induce emesis after poisonings. Infants, not toddlers, should sleep on their backs to prevent sudden infant death syndrome. PTS: 1 DIF: Moderate REF: dm 664, 670 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 2. During a thermometer exchange program at a local hospital, a person drops a mercury thermometer on the floor. Assume the nurse has been trained in cleanup of such a spill. Select all that are appropriate. How should the nurse intervene? 1) Using gloves and a paper towel, place the mercury in a plastic bag, and dispose of it. 2) Notify the hazardous material management team immediately. 3) Evacuate the area immediately. 4) After putting on a gown, gloves, and a mask, clean up the mercury. 5) Wash her hands well after removing the spill. 6) Ventilate the area well for several days. ANS: 1, 5, 6 The nurse should put on gloves and use a paper towel to pick up the mercury. Then place the mercury, broken thermometer, and soiled paper towel into a plastic bag along with the gloves. Next, the nurse should dispose of the plastic bag, wash her hands, and ventilate the area well. It is not necessary to notify the hazardous material management team or evacuate the area for a spill this small, unless agency policy actually mandates that. The nurse does not need to put on a gown and mask to dispose of the mercury. PTS: 1 DIF: Moderate REF: dm 674-675 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application COMPLETION • Rank the following leading causes of accidental death in the United States according to their frequency of occurrence. Rank as 1 the one that occurs most frequently; rank as 4 the one that occurs least frequently. • Motor vehicle accidents
www.mynursingtestprep.com• Falls • Suffocation • Poisoning s ANS: A, D, B, C Motor vehicle accidents are the leading cause of accidental death in the United States, followed by poisonings, falls, and suffocation. PTS:1DIF:EasyREF:p. 656 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension • When the nurse walks into the patients room, she notices fire coming from the patients trash can. Rank the following actions in the order they should be performed by the nurse. 1 should be done first; 4 should be last. • Activate the fire alarm. • Move the patient out of the room. • Close all doors and windows. • Put out the fire using the proper extinguisher. ANS: B, A, C, D The nurse should first move the patient out of the room, then activate the alarm, close all doors and windows and turn off oxygen valves, and use the proper extinguisher to put out the fire. Chapter 22 Facilitating Hygiene Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The patient takes anticoagulants. Which instruction is most important for the nurse to include on the patients care plan? Teach the patient to: • use an electric razor for shaving. • apply skin moisturizer. • use less soap when bathing. • floss teeth daily. ANS: 1 The nurse should instruct the patient prescribed an anticoagulant to use an electric razor instead of a double-edge razor for shaving to prevent the risk of excess bleeding. Older adults should be encouraged to use skin moisturizers and use less soap while bathing to combat excess drying of the skin that occurs as a result of aging. However, even if this patient is an older adult, a risk for bleeding takes priority over a risk for dry skin. Everyone should be encouraged to floss their teeth daily; however, some patients with severe bleeding risk may be told not to floss. PTS: 1 DIF: Easy REF: p. 702 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 2. The nurse is caring for a patient admitted with a closed head injury. Which action by the nurse is appropriate when providing hygiene for this patient? 1) Avoid bathing the patient. 2)
www.mynursingtestprep.comUse cool water for bathing. 3) Provide care in small intervals. 4) Rub briskly when towel drying. ANS: 3 The nurse should provide care in small intervals to avoid overstimulating the patient, thereby causing a rise in his intracranial pressure. It is not necessary to avoid bathing the patient. Using cool water to bathe the patient may cause shivering, which may elevate intracranial pressure and increase metabolic demands. Rubbing briskly when drying might also overstimulate, leading to an elevation in intracranial pressure. PTS: 1 DIF: Difficult REF: dm 685-686 answer is not expressly given. KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 3. A patient has sustained a spinal cord injury and is no longer able to get in and out of the bathtub without assistance. Which nursing diagnosis appropriately addresses this problem? 1) Total Self-care Deficit 2) Bathing/Hygiene Self-care Deficit 3) Dressing/Grooming Self-care deficit 4) Activity Intolerance ANS: 2 The nursing diagnosis Bathing/Hygiene Self-care Deficit is most appropriate for addressing the patients inability to get in and out of the bathtub independently. There are no data to suggest that the patient is completely unable to care for himself; therefore, Total Self-care Deficit is not appropriate. There is nothing to suggest that the patient is unable to dress or groom himself. Activity Intolerance is present when a patient exhibits extreme fatigue, which is not mentioned in this scenario. PTS: 1 DIF: Moderate REF: ESG, KEY: Nursing process: Nursing diagnosis | Client need: PHSI | Cognitive level: Analysis 4. Which scheduled hygiene care is usually thought of as including a back massage to help the patient relax? 1) Afternoon care 2) Early morning care 3) Morning care 4) Hour of sleep care ANS: 4 The nurse should offer a back massage during hour of sleep (HS) care to promote relaxation. During afternoon care the nurse should prepare the patient to receive visitors or for afternoon rest. Early morning care is provided after the patient awakens. It commonly prepares the patient for breakfast or procedures, such as diagnostic testing. Early morning care typically consists of assisting with toileting, face and hand washing, and mouth care. Morning care occurs after breakfast and commonly consists of toileting,
www.mynursingtestprep.combathing, and mouth, skin, and hair care. It may also include dressing and positioning or assisting the patient to the chair. PTS: 1 DIF: Easy REF: p. 687 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 5. For which patient can the nurse safely delegate morning care to the nursing assistive personnel (NAP)? Assume an experienced NAP, and base your decision on patient condition. Assume there are no complications other than the conditions stated. 1) 32-year-old admitted with a closed head injury 2) 76-year-old admitted with septic shock 3) 62-year-old who underwent surgical repair of a bowel obstruction 2 days ago 4) 23-year-old admitted with an exacerbation of asthma with dyspnea on exertion ANS: 3 Morning care for the patient who underwent surgical repair of a bowel 2 days ago can be safely delegated to the nursing assistive personnel because the patient should be stable. The patient who sustained a closed head injury may develop increased intracranial pressure during care. Therefore, he requires the critical thinking skills of a registered nurse to perform his morning care safely. The patient admitted with septic shock may easily become unstable with care; therefore, a registered nurse is required to provide his morning care safely. The patient admitted with an exacerbation of asthma who becomes short of breath with activity also requires the critical thinking skills of a registered nurse to detect respiratory compromise quickly. PTS: 1 DIF: Difficult REF: p. 687 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis 6. A clients epidermis has insufficient melanin. Which nursing diagnosis is appropriate? 1) Risk for Infection 2) Risk for Impaired Skin Integrity 3) Risk for Deficient Fluid Volume 4) Impaired Skin Integrity ANS: 2 The epidermis contains melanin, a pigment that protects against the suns ultraviolet rays; therefore, a person with insufficient melanin is at Risk For Impaired Skin Integrity (sunburn). There are no symptoms to indicate that the client has a sunburn (actual Impaired Skin Integrity), only that a risk factor is present. The dermis contains blood and lymphatic vessels, nerves, bases of hair follicles, and sebaceous and sweat glands; melanin does not prevent fluid loss. Fibroblasts (not melanin), also found in the dermis, produce new cells and assist in wound healing, thereby helping to prevent infection. PTS: 1 DIF: Difficult REF: dm 688 for coverage of aging effects including loss of melanin, 689 for coverage of impaired skin integrity; students must synthesize the information to answer the question; answer is not directly stated in text KEY: Nursing process: Diagnosis | Client need: HPM | Cognitive level: Analysis
www.mynursingtestprep.com7. What is the bodys first line of defense against bacteria? 1) Intact skin 2) White blood cells 3) Lymph glands 4) Inflammatory response ANS: 1 Intact skin is the bodys first line of defense against bacteria. Once bacteria enter the body, the inflammatory response, white blood cells, and lymph glands play a role in fighting against the bacteria. PTS: 1 DIF: Easy REF: p. 687 KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Recall 8. While bathing a patient with liver dysfunction, the nurse notes yellow skin tone. The nurse should document this finding as: 1) Pallor. 2) Erythema. 3) Jaundice. 4) Cyanosis. ANS: 3 A yellow skin tone, known as jaundice, commonly occurs in patients with impaired liver function. Pallor is pale skin without underlying pink tones in the light-skinned person. Pallor occurs with anemia. Erythema, or redness of the skin, commonly occurs with inflammation or vasodilation. Cyanosis, a bluish coloring of the skin, is caused by poor peripheral circulation or decreased oxygen in the blood. PTS: 1 DIF: Moderate REF: p. 688 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 9. A patient with diarrhea is incontinent of liquid stool. The nurse documents that he now has excoriated skin on his buttocks. Which finding by the nurse led to this documentation? 1) Skin was softened from prolonged exposure to moisture. 2) Superficial layers of skin were absent. 3) The epidermal layer of skin was rubbed away. 4) A lesion caused by tissue compression was present. ANS: 2 Excoriation is a loss of the superficial layers of the skin caused by the digestive enzymes in feces. Maceration is the softening of skin from exposure to moisture. Abrasion, a rubbing away of the epidermal layer of the skin, especially over bony areas, is often caused by friction or searing forces that occur when a patient moves in bed. Pressure ulcers are lesions caused by tissue compression and inadequate perfusion that are a result of immobility.
www.mynursingtestprep.comPTS: 1 DIF: Moderate REF: p. 689 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 10. For which patient is it most important to provide frequent perineal care? The patient: 1) with active lower gastrointestinal bleeding. 2) after an episode of diabetic ketoacidosis. 3) who has a circumcised penis. 4) with a history of acute asthma. ANS: 1 The patient admitted with active lower GI bleeding will require frequent perineal care because of the irritating effect of enzymes in the stools. The uncircumcised patient, not the circumcised patient, may require frequent perineal care. Those with diabetic ketoacidosis or who have had acute asthma do not require frequent perineal care. PTS: 1 DIF: Moderate REF: dm 692, 714-716 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 11. A patient with dementia becomes belligerent when the nurse attempts to give him a tub bath. How should the nurse proceed? 1) Call for assistance to help the patient into the bathtub. 2) Wait for the patient to calm down, and then give him a towel bath. 3) Allow the patient to go without bathing for a day or two. 4) Ask another staff member to attempt the tub bath. ANS: 2 Nurses need to individualize bathing to meet the needs of the patient. If the patient becomes belligerent, the nurse should wait until the patient calms down and then attempt a towel bath. Towel baths have been shown to reduce agitation significantly. The patient should not be forced into the tub. Having another staff member attempt the tub bath will most likely increase the patients agitation, as consistency of caregivers is important for patients with dementia. PTS: 1 DIF: Moderate REF: dm 692-693 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis 12. The nurse is teaching nursing assistive personnel (NAP) how to give a complete bed bath. Which instruction should the nurse include? 1) Cleanse only those areas likely to cause odor. 2) Provide the patient with warm water for washing his perineum. 3) Wash the patients back, buttocks, and perineum first. 4) Bathe the patient from head-to-toe, cleanest areas first. ANS: 4
www.mynursingtestprep.comThe nurse should instruct the NAP to give a complete bed bath (a bath for patients who must remain in bed but who are able to bathe themselves), in head-to-toe fashion, beginning with the cleanest part of the body and ending with the dirtiest. The NAP should provide the patient with a basin of warm water and allow him to wash his perineum when giving an assist bath or bed bath (this is a total bed bath). During a partial bath, the NAP should cleanse only the areas that may cause odor or discomfort. The NAP should never begin the bath with the back, buttocks, and perineum because this violates the principle of clean to dirty. PTS: 1 DIF: Moderate REF: dm 690-691; 707-711 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application 13. Which action should the nurse take when preparing a patient for a bed bath? 1) Place the nurse call device within reach for safety. 2) Cover the patient with the top linens from the bed. 3) Have the patient completely bathe himself to promote independence. 4) Wash the patients body without assistance from the patient. ANS: 1 When preparing a patient for a bed bath (a bath for patients who must remain in bed but who are able to bathe themselves), place a basin of warm water, bath linens, a clean gown, and other bathing supplies on the overbed table. Provide privacy, and place the nurse call device within reach. Remove the top linens from the bed, and cover the patient with a bath blanket. If the patient cannot bathe all areas of his body, complete the bath for him. The nurse performs at least part of a bed bath; if the patient bathes himself completely while remaining in bed, it is referred to as an assist bath. PTS: 1 DIF: Moderate REF: p. 690 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 14. A patient admitted with an acute exacerbation of chronic obstructive pulmonary disease has a nursing diagnosis of Activity Intolerance. Which type of bath is preferred for this patient? 1) Tub bath 2) Complete bed bath 3) Towel bath 4) Bed bath ANS: 3 A towel bath is a modification of the bed bath, in which a large towel and a bath blanket are placed in a plastic bag and saturated with a commercially prepared mixture of moisturizer, nonrinse cleaning agent, and water. The bag and its contents are then placed in the microwave, and they are used to bathe the patient. This bathing method is preferred for patients who have Activity Intolerance. A tub bath, complete bed bath, and conventional bed bath may deplete this patients energy. PTS: 1 DIF: Easy REF: p. 690 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
www.mynursingtestprep.com15. Wearing poorly fitting shoes may result in which condition? 1) Tinea pedis 2) Plantar wart 3) Excoriation 4) Ingrown toenail ANS: 4 Wearing poorly fitting shoes and improperly trimming the toenails may cause an ingrown toenail. Tinea pedis occurs when moisture accumulates in unventilated shoes. Plantar wart is a painful growth that is caused by a virus. Excoriation occurs when digestive enzymes come in contact with skin. PTS: 1 DIF: Moderate REF: p. 694 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 16. The school nurse is teaching a group of middle school students how to prevent tinea pedis. Which remark by a student provides evidence of learning? 1) I can contract the infection by walking barefoot in the gymnasiums showers. 2) The best way to avoid contracting the infection is to use good hand washing. 3) Wearing unventilated shoes prevents the fungus from gaining contact with my feet. 4) There is really no way to prevent its spread; its highly contagious. ANS: 1 One can contract the infection by walking barefoot in public showers, such as those in the schools gymnasium. Good hand washing does not prevent a person from contracting tinea pedis. Wearing unventilated shoes may actually aggravate the infection by allowing moisture to accumulate in the shoes. Although the infection is highly contagious, the spread of infection can be prevented by wearing special footwear in the shower. PTS: 1 DIF: Moderate REF: p. 694 KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Application 17. Bath water should be prepared at which temperature to prevent chilling and excess drying of the skin? 1) 99F (37.2C) 2) 102F (38.9C) 3) 103F (39.4C) 4) 105F (40.6C) ANS: 4 Bath water temperature should be 105F (40.6C) to prevent chilling, burning, and excess drying of the skin. PTS: 1 DIF: Easy REF: p. 707 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 18. While assessing a patient, the nurse notes that the patients nails are
www.mynursingtestprep.comexcessively brittle. What does this finding suggest? 1) Inadequate dietary intake 2) Normal aging process 3) Fungal infection 4) Excessive use of silver salts ANS: 1 Inadequate dietary intake or metabolic changes can cause the nails to become brittle. As a person ages, nails thicken, become ridged, and may yellow or become concave in shape. Brown or black discoloration of the nail plate may indicate a fungal infection. Bluish gray discoloration of the nail plate signals excessive intake of silver salts. PTS: 1 DIF: Moderate REF: p. 695 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 19. A patient with a history of seizures who takes phenytoin is at risk for which oral problem? 1) Dryness of the mouth 2) Bitter taste 3) Demineralization of the tooth enamel 4) Gingival hyperplasia ANS: 4 Phenytoin causes gingival hyperplasia. Medications, such as atropine, cause dry mouth. Bitter taste can result from drugs, such as docusate sodium, a stool softener. Phenytoin does not cause demineralization of the tooth enamel. PTS: 1 DIF: Moderate REF: p. 698 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Comprehension 20. The nurse has been teaching a student how to perform mouth care for her unconscious patient. The student will show evidence of learning if she places the patient in which position for this care? 1) Supine 2) Prone 3) Semi-Fowlers 4) Side-lying ANS: 4 The nurse should position an unconscious patient in a side-lying position to provide mouth care to prevent aspiration. Supine, prone, and semi-Fowlers positions are unsafe positions for providing mouth care for the unconscious patient. PTS: 1 DIF: Moderate REF: p. 725 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Comprehension
www.mynursingtestprep.com21. Which item is best for providing mouth care for an unconscious patient? 1) Foam swabs 2) Lemon-glycerin swabs 3) Hydrogen peroxide 4) Cotton-tipped applicator soaked in mouthwash ANS: 1 Commercially packaged applicators or foam swabs are typically used to provide mouth care. Lemon-glycerin swabs are not recommended because they are drying to the oral mucosa. Hydrogen peroxide should be avoided because it is irritating to oral mucosa and may alter the balance of normal floras that occur in the mouth. Mouthwash can be used by conscious patients as part of their routine mouth care. However, cotton-tipped applicators should not be soaked in it to perform mouth care. PTS: 1 DIF: Moderate REF: p. 725 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Recall 22. After receiving a course of chemotherapy, a patient begins losing hair. This adverse effect of chemotherapy should be documented as: 1) pediculosis. 2) alopecia. 3) dandruff. 4) hirsutism. ANS: 2 Alopecia is abnormal hair loss that can occur as a result of chemotherapy. Pediculosis is an infestation of head lice. Dandruff is a condition in which there is excessive shedding of the epidermal layer of the scalp. Hirsutism is the excessive growth of body hair in women. PTS: 1 DIF: Moderate REF: p. 702 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 23. Which of the following is a correct step in removing and cleaning a hearing aid? 1) Clean only the external surfaces, not the canal portion. 2) Clean the top part of the canal portion of the device. 3) Insert a wax loop or toothpick into the hearing aid. 4) Remove the battery before taking the hearing aid from the ear. ANS: 2 The nurse should clean the top part of the canal portion of the hearing aid using the wax loop and wax brush, cotton-tipped applicator, pipe cleaner, or toothpick. Nothing should be inserted into the hearing aid. The external surfaces are cleaned with a damp cloth. The hearing aid should be turned off before removing it from the ear, but the battery is not removed at that step of the procedure. It would not likely be possible to remove the battery while the device was still in the ear.
www.mynursingtestprep.comPTS: 1 DIF: Difficult REF: dm 739-742 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 24. The patient is sitting in a chair at the bedside. The nurse is preparing to remove the patients artificial eye. What should the nurse do to best position the patient for this procedure? Ask the patient to: 1) Lean forward and rest the arms on the overbed table. 2) Sit back in the chair and tilt the head back. 3) Move to the bed and lie down. 4) Stand up and lean over the bed. ANS: 3 The nurse should have the patient lie down so that if the eye is dropped when removing it, it will fall onto the bed instead of the floor. Sitting back in the chair would allow access to the eye but would not protect the artificial eye from falling to the floor. Leaning forward and resting the arms on an overbed table, as well as standing up and leaning over the bed, would not provide the nurse access to the eye to remove the prosthesis. PTS: 1 DIF: Moderate REF: p. 739 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. Which area(s) should the nurse inspect when assessing for cyanosis in a dark- skinned patient? Select all that apply. 1) Buccal mucosa 2) Around the lips 3) Palms 4) Tongue ANS: 1, 3, 4 In dark-skinned people, cyanosis can be best assessed by examining the palms of the hands, soles of the feet, tongue, conjunctivae, or the buccal mucosa. In light-skinned people, the nailbeds and the area around the lips can be used. PTS: 1 DIF: Moderate REF: p. 689 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 2. Which of the following is/are a benefit of bathing? Choose all that apply. 1) Constricts blood vessels 2) Increases depth of respirations 3) Gives opportunity for assessments 4) Reduces sensory input ANS: 2, 3 Bathing presents an opportunity to perform a variety of assessments. Bathing also dilates blood vessels near the skins surface, increasing circulation. Moreover, bathing stimulates
www.mynursingtestprep.comthe depth of respirations and provides sensory input. PTS: 1 DIF: Easy REF: p. 690 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 3. For which patient(s) should the nurse avoid using back massage? One who (select all that apply): 1) underwent heart surgery 3 days ago. 2) sustained rib fractures from a fall. 3) underwent a lumbar laminectomy. 4) sustained a leg fracture in a sledding accident. ANS: 1, 2 Back massage is contraindicated with rib fractures, burns, and recent heart surgery. Massage is acceptable for the patients with lumbar laminectomy or leg fracture. PTS: 1 DIF: Moderate REF: p. 690 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application Completion • The nurse is making an occupied bed. Arrange the following steps in the order in which the nurse should perform them. • Position the patient laterally near the side rail farthest from you (that side rail is up); roll the soiled linens under him. • Lower the side rail on the side of the bed you are working on. • Raise the side rail on the side of the bed you are working on. • After placing clean linens and tucking them under the soiled linens, roll the patient over the hump and position him facing you on the near side of the bed. ANS: B, A, D, C First lower the side rail on your side of the bed. This allows you to maintain good body mechanics while positioning the patient. Position the patient laterally near the far side rail, and roll soiled linens under him. Then place clean linens on the side nearest you, and tuck them under soiled linens. Next, roll the patient over the hump, and position him on his other side, facing you. Do this before raising the near side rail so you do not have to reach across the side rail to help the patient roll and turn to his other side. Chapter 23 Administering Medication Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The primary care provider prescribes furosemide 40 mg IV for a patient with heart failure. Which drug name is used in this prescription? 1) Chemical 2) Brand 3) Trade 4) Generic
www.mynursingtestprep.comANS: 4 Furosemide, the generic name, was used by the physician in the drug order. The brand or trade name of the drug is Lasix; the chemical name is 4-chloro-N-furfuryl-5- sulfamoylanthranilic acid. PTS:1DIFifficultREF:p. 746 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension 2. A patient is prescribed fluoxetine 20 mg by mouth daily for treatment of depression. The nurse caring for the patient is unfamiliar with this drug. Which action should she take before administering the medication? 1) Inform the prescriber that she is not comfortable administering the drug. 2) Ask a nursing colleague for relevant information about the drug. 3) Consult the drug formulary accessible to staff at the patient care unit. 4) Trust the prescriber writes the dose and administer the drug as intended. ANS: 3 The nurse is responsible for every medication she administers. Therefore, the nurse must be familiar with the indications, routes of administration, dosages, contraindications, adverse reactions, drug interactions, and any special administration guidelines associated with each drug before administration. There are numerous ways to become more informed about medication, such as a drug formulary, Physicians Desk Reference, or registered pharmacist before administration. The nurse should not rely on information from a colleague because as a secondary source of information, there is a risk for inaccuracy, which can be dangerous in a patient care situation. PTS:1DIF:ModerateREF:dm 746-747 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application 3. A surgeon prescribes potassium chloride 20 mEq by mouth for a patient with a nasogastric (NG) tube for gastric drainage. How should the nurse proceed? 1) Seek clarification from the surgeon about the medication order. 2) Clamp the NG tube while administering the dose by mouth. 3) Instill the medication through the NG tube. 4) Withhold the oral potassium chloride elixir. ANS: 1 The nurse should seek clarification from the surgeon about the medication ordered via the nasogastric route. If the patient has a nasogastric tube in place to release gastric drainage, any medication given by mouth would be lost into the drainage collection unit and, therefore, be unavailable to the patient for therapeutic use. The nurse does not have authority to electively withhold or alter the route of prescribed treatment without seeking clarification and resolving any discrepancy in the route by which the medication would be administered. PTS: 1 DIF: Moderate REF: dm 750, 767 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 4. A patient calls the nurse because he is having incision pain and wants a dose of analgesic medication. When the nurse checks the patients medication administration
www.mynursingtestprep.comrecord, she notes that he is prescribed the narcotic, hydromorphone (Dilaudid). Where should the nurse expect to retrieve this drug for administration? 1) Cabinet in the patients room 2) Double-locked medication drawer 3) Stock supply cabinet 4) Portable medication cart ANS: 2 Hydromorphone (Dilaudid) is a controlled substance and must be kept in a double-locked medication drawer for control of inventory. Frequently used Schedule II medications, such as ibuprofen, are stored in the stock supply. Other prescribed medications may be stored in a locked cabinet in the patients room or in the medication cart. PTS:1DIF:ModerateREF:dm 747-748 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application 5. Which term refers to the movement of a drug from the site of administration to the bloodstream? 1) Absorption 2) Distribution 3) Metabolism 4) Excretion ANS: 1 Absorption refers to the movement of drug from the site of administration into the bloodstream. Distribution involves the transport of the drug in body fluids, such as blood, to the tissues and organs. Metabolism is the biotransformation of the drug into a more water-soluble form or into metabolites that can be excreted from the body. Excretion, or the removal of drugs from the body, takes place in the kidneys, liver and gastrointestinal tract, lungs, and exocrine glands. PTS:1DIF:ModerateREF:p. 749 KEY:Nursing process: N/A | Client need: PHSI | Cognitive level: Recall 6. A patient who just returned from the postanesthesia care unit is complaining of severe incision pain. Which drug contained in his medication administration record will offer him the fastest relief? 1) Liquid acetaminophen with codeine 2) Intravenous morphine sulfate 3) Intramuscular meperidine 4) Oral oxycodone tablets ANS: 2 Drugs administered by the intravenous route are injected directly into the bloodstream and do not have to be absorbed into it. Therefore, they act more quickly than drugs administered by the oral or intramuscular routes.
www.mynursingtestprep.comPTS: 1 DIF: Moderate REF: dm 750-753 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 7. The time it takes for drug concentration to reach a therapeutic level in the blood is known as: 1) peak action. 2) duration of action. 3) onset of action. 4) half-life. ANS: 3 The onset of action is the time needed for drug concentration to reach a high enough level in the blood for its effects to appear. Peak action occurs when the concentration of a medication is highest in the blood. Duration of action is that period when the medication has a pharmacological effect. Half-life is the amount of time required for half of the drug to be eliminated. PTS:1DIF:ModerateREF:p. 755 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall 8. A patient is given furosemide 40 mg orally at 0900. The duration of action for this drug is approximately 6 hours after oral administration. At which time in military hours should the nurse no longer expect to see the effects of this drug? 1) 0930 2) 1000 3) 1100 4) 1500 ANS: 4 The nurse should no longer see the effects of furosemide around 1500 hours (3:00 p.m.). The effects of oral furosemide should be seen 30 to 60 minutes after administration, which is 0900 (9:30 a.m. in this case). Peak diuresis should occur in 1 to 2 hours, which is 1000 hours (10:00 a.m.) to 1100 (11:00 a.m.) in the scenario above. PTS:1DIF:EasyREF:p. 755 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application 9. Which factor in a patients medical history is most likely to prolong the half- life of certain drugs? 1) Heart disease 2) Liver disease 3) Rheumatoid arthritis 4) Tobacco use ANS: 2 Metabolism takes place largely in the liver. If there is a decrease in liver function (e.g.,
www.mynursingtestprep.combecause of liver disease), the drug will be eliminated more slowly, prolonging the drugs half-life. Tobacco use can increase the elimination of some drugs, decreasing their effectiveness. PTS:1DIF:ModerateREF:p. 754 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 10. The nurse receives a laboratory report that states her patients digoxin level is 1.2 ng/mL; therapeutic range for this drug is 0.5 to 2.0 ng/mL. Which action should the nurse take? 1) Notify the prescriber to reduce the dose. 2) Withhold the next dose of digoxin. 3) Administer the next dose as prescribed. 4) Notify the prescribing healthcare provider to increase the dose. ANS: 3 Therapeutic range is a range whereby the medication is at a concentration to produce the desired effect. This patients level is within the therapeutic range, so the nurse should administer the next dose as prescribed. The dose should not be increased or decreased because the prescribed dose is producing a level within the therapeutic range. The dose should not be withheld; this action could result in detrimental cardiac effects for the patient. PTS:1DIFifficultREF:dm 755-756 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 11. The primary care provider orders peak and trough levels for a patient who is receiving intravenous vancomycin every 12 hours. When should the nurse obtain a blood specimen to measure the trough? 1) With the morning routine laboratory studies 2) Approximately 30 minutes before the next dose 3) Two hours after the next dose infuses 4) While the drug infuses ANS: 2 Trough levels are typically obtained approximately 30 minutes before administering the next dose of the drug. Therefore, the trough cannot be collected with the morning routine laboratory studies. The vancomycin peak should be obtained 2 hours after the next dose infuses. Peak level must be measured when absorption is complete. This depends on all the factors that affect absorption. Trough levels would be inaccurate if the specimen is obtained while the drug infuses. PTS:1DIFifficultREF:p. 756 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application 12. Teratogenic drugs should be avoided in which patient population? 1) Pregnant women 2) Elderly
www.mynursingtestprep.com3) Children 4) Adolescents ANS: 1 Drugs that are known to cause developmental defects are termed teratogenic. These drugs are contraindicated during pregnancy because of the likelihood of adverse effects on the embryo or fetus. PTS:1DIF:EasyREF:p. 756 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Recall 13. A patient with end-stage cancer is prescribed morphine sulfate to reduce pain. For which effect is this medication prescribed? 1) Supportive 2) Restorative 3) Substitutive 4) Palliative ANS: 4 Morphine was prescribed for its palliative effectsto relieve pain, a symptom of cancer. Supportive effects support the integrity of body functions until other medications or treatments become effective. Restorative effects return the body to or maintain the body at optimal levels of health. Substitutive effects replace either body fluids or a chemical required by the body for improved functioning. PTS:1DIF:ModerateREF:p. 756 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 14. After receiving diphenhydramine, a patient complains that his mouth is very dry. This is not uncommon for patients taking this medication. Which drug effect is this patient experiencing? 1) Side effect 2) Adverse reaction 3) Toxic reaction 4) Supportive effect ANS: 1 Dry mouth is a side effect of diphenhydramine. Side effects are unintended, often predictable, physiological effects that are well tolerated by patients. Adverse reactions are harmful, unintended, usually unexpected reactions to a drug administered at a normal dosage. They are commonly more severe than side effects. Toxic reactions are dangerous, damaging effects to an organ or tissue. Supportive effects are intended effects that support the integrity of body functions. PTS:1DIF:ModerateREF:p. 758 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 15. While receiving an intravenous dose of an antibiotic, levofloxacin, a patient develops severe shortness of breath, wheezing, and severe hypotension. Which action
www.mynursingtestprep.comshould the nurse take first? 1) Administer epinephrine IM. 2) Give bolus dose of intravenous fluids. 3) Stop the infusion of medication. 4) Prepare for endotracheal intubation. ANS: 3 The patient is experiencing an anaphylactic reaction (severe shortness of breath, wheezing, and severe hypotension), a life-threatening allergic reaction. Therefore, the nurse should immediately discontinue the medication. The first priority is to eliminate the cause of the problem. Next, the nurse should notify the physician, give IV fluids, and administer epinephrine, steroids, and diphenhydramine. Respiratory support ranging from oxygen to endotracheal intubation and mechanical ventilation may also be necessary. PTS:1DIFifficultREF:p. 759 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis 16. A patient develops urticaria and pruritus 5 days after beginning phenytoin for treatment of seizures. Which type of reaction is the patient most likely experiencing? 1) Mild adverse reaction 2) Dose-related adverse reaction 3) Toxic reaction 4) Anaphylactic reaction ANS: 1 Urticaria and pruritus are considered minor adverse reactions. Dose-related adverse reactions are undesired effects that result from known pharmacological effects of the medication. Toxic reactions are dangerous, damaging effects to an organ or tissue. Anaphylactic reaction is a life-threatening allergic reaction that occurs during or immediately after administration. PTS:1DIFifficultREF:p. 758 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application 17. Laboratory test results indicate that warfarin anticoagulant therapy is suddenly ineffective in a patient who has been taking the drug for an extended time. The nurse suspects an interaction with herbal medications. What type of interaction does she suspect? 1) Antagonistic drug interaction 2) Synergistic drug interaction 3) Idiosyncratic reaction 4) Drug incompatibility ANS: 1 In an antagonistic drug interaction, one drug interferes with the actions of another and
www.mynursingtestprep.comdecreases the resultant drug effect. In a synergistic drug interaction, there is an additive effect; that is, the effects of both drugs combined are greater than the individual effects. An idiosyncratic reaction is an unexpected, abnormal, or peculiar response to a medication. Drug incompatibilities occur when drugs are physically mixed together, causing a chemical deterioration of one or both drugs. PTS:1DIF:ModerateREF:p. 759 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis 18. A patient with terminal cancer requires increasing doses of an opioid pain medication to obtain relief from pain. This patient is exhibiting signs of drug: 1) Abuse 2) Misuse 3) Tolerance 4) Dependence ANS: 3 Patients in the terminal stages of cancer commonly exhibit drug tolerance, a decreasing response to repeated doses of a medication. Therefore, pain management must be carefully planned to promote patient comfort. Drug abuse is the inappropriate intake of a substance continually or periodically. Drug misuse is the nonspecific, indiscriminate, or improper use of drugs, including alcohol, over-the-counter preparations, and prescription drugs. Drug dependence occurs when a person relies on or needs a drug. Dependence leads to lifestyle changes that focus around obtaining and administering the drug. PTS:1DIF:ModerateREF:p. 760 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 19. Before administering a medication, the nurse must verify the rights of medication administration, which include: 1) right patient, right room, right drug, right route, right dose, and right time. 2) right drug, right dose, right route, right time, right physician, and right documentation. 3) right patient, right drug, right route, right time, right documentation, and right equipment. 4) right patient, right drug, right dose, right route, right time, and right documentation. ANS: 4 The six rights of medication administration are the right patient, right drug, right dose, right route, right time, and right documentation. PTS: 1 DIF: Moderate REF: dm 771-773 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis 20. Which expected outcome is best for a patient with a nursing diagnosis of Deficient Knowledge related to new drug treatment regimen? 1) After an explanation and written materials, describes the expected actions and adverse reactions of his medication 2) In 1 week after instructional session, describes the expected actions and adverse reactions
www.mynursingtestprep.comof his medications 3) Follows the treatment plan as prescribed 4) Experiences no adverse effect from his prescribed treatment plan ANS: 2 The best phrasing for the expected outcome is the one with a specific, measurable time frame (1 week) and details for how to resolve the patients knowledge deficit. The other options provide no timeline for achieving the goal and are therefore not measurable. Expected outcome statements must be measurable. PTS:1DIF:Moderate REF:p. 770; Also requires knowledge of goals KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 21. When the nurse enters a patients room to administer a medication, he calls out from the bathroom telling her to leave his medication on the bedside table. He reassures her that he will take the medication as soon as he is finished. How should the nurse proceed? 1) Inform the patient that she will return when he is finished in the bathroom. 2) Wait outside the bathroom door until the patient is ready for the dose. 3) Withhold the dose until the next administration time later in the day. 4) Document that the dose was omitted in the medication administration record. ANS: 1 The nurse should inform the patient that she will return with the medication when he is finished in the bathroom. The nurse likely would not have time to stand outside the door and wait for the patient to finish in the bathroom. If the medication is left at the bedside for the patient, the nurse cannot be sure that the patient actually took the medication. Withholding the dose until the next administration time may compromise the patients condition and is not appropriate nursing action. The drug should not be omitted; therefore, the nurse should not document a missed dose in the medication administration record. PTS:1DIF:ModerateREF:dm 771-772 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 22. Which documentation entry related to PRN medication administration is complete? 1) 6/5/14 0900 morphine 4 mg IV given in right antecubetal fossa for pain rated 8 on a 110 scale, J. Williams RN 2) 0600 famotidine 20 mg IV given in right hand, S. Abraham RN 3) 9/2/14 0900 levothyroxine 50 mcg PO given 4) 1/16/14 furosemide 40 mg PO given, J. Smith RN ANS: 1 The longest option, signed by J. Williams, is complete because it contains the date and time the medication was administered, the name of the medication, the route of
www.mynursingtestprep.comadministration and injection site, and the name of the nurse administering the medication. Because the medication administered was a PRN order, the nurse also included the reason why the medication was administered. Other options are incomplete. PTS:1DIF:ModerateREF:dm 772-773 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 23. A patient has difficulty taking liquid medications from a cup. How should the nurse administer the medications? 1) Request that the prescriber change the order to the IV route. 2) Administer the medication by the IM route. 3) Use a needleless syringe to place the medication in the side of the mouth. 4) Add the dose to a small amount of food or beverage to facilitate swallowing. ANS: 3 When a patient has difficulty taking liquid medications from a cup, the nurse should use a syringe without a needle to place the medication in the side of the patients mouth. After placing the syringe between the gum and cheek, the nurse should push the plunger to administer the medication slowly. It is not necessary to ask the prescriber to change the order to the IV route; it is preferable to use the least invasive route. The nurse cannot administer a drug by another route without a prescription to do so. Dosing might not necessarily be the same between oral and IM routes; thus, a prescription is needed to change the route. Some drugs are not compatible with various food or liquid substances and should be taken on an empty stomach. Consult a pharmacist, prescriber, or drug formulary. PTS:1DIF:Moderate REF:dm 774-775; under Special Situations. Inductive reasoning needed to determine correct answer. KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 24. The primary care provider prescribes nitroglycerin 1/150 g SL for a patient experiencing chest pain. How should the nurse administer the drug? 1) Place the drug in the cheek and allow it to dissolve. 2) Place the drug under the tongue and allow it to dissolve. 3) Inject the drug superficially into the subcutaneous tissue. 4) Give the pill and water to the patient for him to swallow the tablet. ANS: 2 Drugs administered by the sublingual (SL) route should be placed under the patients tongue and allowed to dissolve. Drugs administered by the buccal route are placed in the cheek and allowed to dissolve. A subcutaneous injection is administered into the subcutaneous tissue. Placing the drug into the patients mouth, giving him water, and instructing him to swallow the tablet describe oral administration. PTS: 1 DIF: Moderate REF: p. 800 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 25. Which action should the nurse take immediately after administering
www.mynursingtestprep.coma medication through a nasogastric tube? 1) Verify correct nasogastric tube placement in the stomach. 2) Auscultate the abdomen for presence of bowel sounds. 3) Immediately administer the next prescribed medication. 4) Flush the tube with water using a needleless syringe. ANS: 4 The nurse should flush the nasogastric tube with water using a needleless syringe after administering each medication. Some medications are less effective when given in combination with others. The nurse should verify nasogastric tube placement and auscultate the abdomen for bowel sounds before administering the medication. PTS: 1 DIF: Moderate REF: p. 801 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 26. How should the nurse dispose of a contaminated needle after administering an injection? 1) Place the needle in a specially marked, puncture-proof container. 2) Recap the needle, and carefully place it in the trash can. 3) Recap the needle, and place it in a puncture-proof container. 4) Place the needle in a biohazard bag with other contaminated supplies. ANS: 1 To avoid needlestick injuries, the nurse should place the uncapped needle, pointing downward, directly into a specially marked, puncture-proof container. Recapping the needle should only be done when no other feasible alternative is available. When recapping is necessary, use an acceptable technique such as the one-handed scoop technique in which the nurse places the needle cap on a sterile surface and, using one hand, scoops up the cap with the needle. Placing the needle in an improper container (biohazard bag) that could be punctured by the contaminated needle places other staff members at risk. PTS:1DIF:ModerateREF:dm 785, 819 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 27. The nurse must administer hepatitis B immunoglobulin 0.5 mL intramuscularly to a 3-day-old infant born to an HB Ag-positive mother. Which injection site should the nurse choose to administer this injection? 1) Ventrogluteal 2) Vastus lateralis 3) Deltoid 4)
www.mynursingtestprep.comDorsogluteal ANS: 2 The preferred site for IM injections for infants who are not yet walking is the vastus lateralis muscle because there are no major blood vessels or nerves in the area and the gluteal muscles have not been developed by walking. For children who are walking, the site of choice is the ventrogluteal muscle. The dorsogluteal site is not recommended for children or adults. The deltoid muscle can be used for small volumes in older children and adults. PTS: 1 DIF: Moderate REF: p. 787 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 28. Which action should the nurse take to relax the vastus lateralis muscle before administering an intramuscular injection into the site? 1) Apply a warm compress. 2) Massage the site in a circular motion. 3) Apply a soothing lotion. 4) Have the client assume a sitting position. ANS: 4 To relax the vastus lateralis for injection, the nurse should have the patient assume a sitting position or lie flat with his knee slightly flexed. Applying a warm compress, massaging the site, and applying soothing lotion are inappropriate interventions before administering an IM injection. After injection, massaging the site can enhance the absorption of medication into the muscle. Applying a warm compress increases circulation to the site, which can also enhance absorption. This action would be performed after the injection and not before. PTS:1DIF:ModerateREF:p. 834 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 29. The physician prescribes warfarin 5 mg orally at 1800 for a patient who underwent open reduction and internal fixation of his right hip. After administering the medication, the nurse realizes that she administered a 10 mg tablet instead of the prescribed 5 mg PO. Which of the following actions by the nurse is appropriate? 1) No action is necessary because an extra 5 mg of warfarin is not harmful. 2) Call the prescriber and ask her to change the order to 10 mg. 3) Document on the chart that the drug was given and indicate the drug was given in error. 4) Complete an incident report according to the facilitys policy. ANS: 4 When a medication error is made, the nurse should first check the patient to assess for negative effects. If she is unfamiliar with the side effects of the medication, she should consult a drug reference, the licensed pharmacist at the institution, or the prescriber. Next she should verify that she made an error and identify the type. Notify the nurse in charge and the physician. Follow any orders the physician prescribes. Document the drug, the dose, site, route, date, and time in the patients healthcare record but do not document that
www.mynursingtestprep.comthe drug was given in error. Complete an incident report according to the facilitys policy; submit the signed report to the nurse manager. Finally, critically review the error, and identify ways to improve your practice. PTS: 1 DIF: Moderate REF: p. 769 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application 30. The nurse must administer eardrops to an infant. How should she proceed? 1) Pull the pinna down and back before instilling the drops. 2) Pull the pinna upward and outward before instilling the drops. 3) Instill the drops directly; no special positioning is necessary. 4) Position the patient supine with the head of the bed elevated 30. ANS: 1 For a child younger than 3 years old, the nurse should pull the pinna down and back. For older children and adults, the nurse should pull the pinna upward and outward. Doing each straightens the ear canal for proper channeling of the medication. The patient should be assisted into a side-lying position with appropriate ear facing up before instillation. PTS: 1 DIF: Moderate REF: p. 806 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 31. The nurse is teaching parents ways to give oral medication to their child. Which action would they implement to improve compliance? 1) Crush time-release capsules to put in his favorite food. 2) Give medication quickly before he knows what is happening. 3) Allow the child to eat a frozen pop before receiving the medication. 4) Mask the flavor of medication in a toddler cup with orange juice. ANS: 3 The parent can give the child a frozen fruit bar or frozen flavored ice pop just before the medication. This helps to numb the taste buds to weaken the taste of the medication. To mask bad-tasting medicines, parents can crush pills or empty the contents of a capsule as long as it is not a time-release dose, and mix with soft foods, such as applesauce, hot cereal, or pudding. This is helpful for patients who might aspirate liquids, as well. If the child is old enough to understand, warn him when a medication has an objectionable taste. Otherwise, his trust might be compromised if he is surprised with a bad taste. Do not use essential foods in the childs diet (e.g., milk or orange juice) to mask the taste of medications. The child may later refuse a food that he associates with the medicine. PTS:1DIF:ModerateREF:p. 775 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 32. An adult patient admitted with lower gastrointestinal bleeding is prescribed a unit of packed red blood cells. Which gauge needle should be inserted to administer this blood product? 1) 18 gauge
www.mynursingtestprep.com2) 22 gauge 3) 24 gauge 4) 26 gauge ANS: 1 Large-gauge needles, 14 to 18 gauge, are used for blood products in adults because the bore is large enough to allow transfusion without cell damage (lysis). Smaller-gauge bores can cause clumping and breakage of the cell, thus leading to reduced effectiveness of the transfusion as well as contributing to fragmented by-product of red blood cell waste. PTS:1DIF:EasyREF:p. 779 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall True/False Indicate whether the statement is true or false. 1. At times, patients may self-administer medications when hospitalized. ANS: T Occasionally, even in the hospital setting, patients self-administer medications, as their condition permits. For example, a patient admitted with chest pain may keep sublingual nitroglycerin at his bedside so he has quick access should he experience chest pain. PTS:1DIF:EasyREF:p. 748 KEY:Nursing process: N/A |Client need: PHSI | Cognitive level: Recall Completion • The nurse is drawing up a medication from an ampule. Arrange the following steps in the order in which they should be performed. • Use an ampule opener to break ampule neck. • Tap the ampule to remove medication trapped in the top of ampule. • Invert the ampule, and draw up the medication. • Dispose of the top and bottom of the ampule and filter needle in sharps container. • Hold the syringe vertically, and tap it to remove air bubbles. ANS: B, A, C, E, D Medication must be removed from the ampule neck before breaking the top off the ampule. Otherwise, the dosage may be incorrect. There is no need to remove air bubbles until after the medication is drawn into the syringe. Finally, you would not dispose of the ampule and filter needle until you finish the procedure. PTS: 1 DIF: Difficult REF: dm 818-819 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis • A nurse is administering a medication using a volume-control administration set (e.g., Buretrol, Volutrol). Arrange the following steps in the order in which they would be performed. • Inject the ordered medication into the volume-control chamber. • Fill the volume-control chamber with the correct amount of intravenous fluid from the primary bag. • Cleanse the port on the volume-control chamber. • Prime the volume-control tubing. • Open the lower clamp and start the infusion at the correct flow rate. ANS: B, D, C, A, E
www.mynursingtestprep.comYou must fill the volume-control chamber before injecting the medication so you can prime the tubing without the risk of wasting medication. You must cleanse the port on the volume-control chamber before injecting the medication into it. The last thing you do is open the clamp and start the infusion. Chapter 16 Patient Education Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Which teaching technique is best for teaching a nursing assistant how to perform finger-stick glucose testing? 1) Provide a manufacturers pamphlet with detailed instruction. 2) Explain the best technique for performing glucose testing. 3) Demonstrate the procedure; then ask for a return demonstration. 4) Suggest that the assistant watch a DVD showing the procedure. ANS: 3 The best way to teach a psychomotor skill is to demonstrate the procedure and then ask for a return demonstration. Supplementary written information or DVD can also be supplied to the patient to reinforce learning. However, they are not the best method for teaching a psychomotor skill; enacting the procedure is more effective. PTS: 1 DIF: Moderate REF: dm 871, 873 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 2. A patient with a diabetic foot ulcer will need to perform dressing changes after discharge. When should the nurse schedule the teaching session(s)? 1) Within 10 minutes after his next dose of oral pain medication 2) After the patient wakes up from a restful nap 3) Before the surgeon dbrides the wound 4) Before the patient undergoes flow studies of his affected leg ANS: 2 For learning to be most effective, teaching must occur when the patient is most ready. A patients capacity to take in new information is reduced when he is anxious, in this example about testing or treatment, or is tired, or is experiencing pain. Therefore, the best time to teach this patient is when he is rested, such as after a restful nap. Ten minutes is not enough time for oral medication to take effect and relieve pain. PTS: 1 DIF: Difficult REF: dm 857-858 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application 3. Which intervention by the nurse would be best to motivate a patient newly diagnosed with hypertension to learn about the prescribed treatment plan? 1) Explain that when left untreated, hypertension may lead to stroke. 2) Ask the patient to let you know when he is ready to learn.
www.mynursingtestprep.com3) Encourage the patient to learn about various treatment options. 4) Reassure the patient that adhering to the treatment produces a good outcome. ANS:1 A patient newly diagnosed with hypertension may not be motivated to learn because he most likely has not experienced physical symptoms or other outward complications. Therefore, the nurse should motivate the patient by pointing out serious risks to the quality of life if the blood pressure control is not achieved. Although readiness to learn is an important consideration, treatment might be delayed too long if the patient does not appropriately perceive the immediacy of the health risk. Simply encouraging a patient to learn about blood pressure and treatment options might not be suitable motivation to engage in active learning and to comply with prescribed treatment. Reassuring the patient and promising a good outcome by complying with medical treatment is not appropriate. Adhering to medical therapy reduces the risk for stroke and other complications; however, this cannot be guaranteed. PTS:1DIF:ModerateREF:dm 856-857 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 4. Assume all of the following written instructions about digoxin provide correct information for patient care. Which one is best worded for patient understanding? 1) Obtain your radial pulse every morning before taking your digoxin dose. 2) Return to your healthcare provider for monthly laboratory studies of your digoxin levels. 3) Call your provider if you notice that objects look yellow or green. 4) Always take the same brand of medication because certain brands may not be interchangeable. ANS: 3 The nurse should provide written instructions that contain short sentences and easy-to- read words. If instructions are written at too high a reading level, the patient may not understand and make a harmful error in dosing. Calling the provider when objects look yellow or green is the clearest statement for patient teaching because the instruction is short, concrete, and written with easy-to-understand words. Patient instructions must not contain words that require a higher level of reading or medical jargon. The instruction pertaining to being consistent with brand use is too wordy, especially for patients who are ill or for whom English is not a primary language. PTS:1DIFifficultREF:p. 873 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis 5. Which teaching strategy is typically most effective for presenting information to large groups? 1) Distributing printed materials 2) Lecturing using audiovisual format 3) Providing online sources of information 4)
www.mynursingtestprep.comRole modeling ANS: 2 Lecturing using audiovisual materials appeals to learners who best process information by hearing and seeing. From a practical point of view, a lecture format (traditional classroom or webinar) is efficient and effective with large groups. Although printed materials can help to reinforce information taught during a lecture, this can be problematic for auditory learners or those whose primary spoken language is not English. Online sources of information are ideal for learners who learn best by doing (kinesthetic learners). Role modeling is most effective for individuals or small groups of learners, especially when the relationship between the instructor and learner is meaningful. PTS:1DIF:EasyREF:p. 872 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Recall 6. A patient with attention deficit disorder is admitted to the hospital with type 1 diabetes. Which nursing diagnosis is commonly yet inappropriately used but should be avoided for this type of patient? Assume there are data to support all the diagnoses. 1) Deficient Knowledge (disease process) 2) Impaired ability to learn related to fear and anxiety 3) Difficulty learning related to cognitive developmental level 4) Lack of motivation to learn related to feelings of powerlessness ANS: 1 Patients who have a learning disability should not have an identified nursing diagnosis of Deficient Knowledge; instead, they should have a diagnosis that accurately identifies their problem, such as Impaired Ability to Learn related to Fear and Anxiety; Difficulty Learning related to Delayed Cognitive Development; or Lack of Motivation to Learn related to Feelings of Powerlessness. Note that these are not NANDA-I diagnoses. PTS:1DIF:ModerateREF:dm 864-865 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Comprehension 7. Which phrase is stated as a teaching goal (as compared with an objective) for a patient who had bowel resection with creation of a colostomy? The patient 1) empties the colostomy appliance when half filled. 2) performs skin care around the stoma site. 3) will perform ostomy self-care within 3 days after surgery. 4) applies a new ostomy appliance, making sure it adheres properly. ANS: 3 Performing ostomy self-care is an appropriate goal for a patient who needs to learn colostomy self-care after surgery. Emptying the colostomy appliance demonstrates a behavioral learning objective, not a broad teaching goal. Performing skin care is also a desired skill stated by a learning objective. Applying an ostomy device is another observable learning objective. PTS:1DIFifficultREF:p. 866 KEY: Nursing process: Planning | Client need: PSI | Cognitive level:Analysis 8. During advanced cardiac life support (ACLS) training, a nurse
www.mynursingtestprep.comperforms defibrillation using a mannequin. Which teaching strategy is being employed? 1) One-to-one instruction 2) Computer-assisted instruction 3) Role modeling 4) Simulation ANS: 4 ACLS training utilizes this strategy by creating a scenario using resuscitation mannequins and teaching healthcare workers to respond appropriately to life-threatening cardiopulmonary events. The nurse is demonstrating the skill of defibrillation. ACLS certification requires learners to perform the skill back to the examiner. With one-to-one instruction, one instructor orally presents information to one student. With ACLS training, the healthcare team is involved and not just individual nurses. In role modeling, the teacher teaches by example, demonstrating the behaviors (not skills) that need to be acquired by learners. PTS:1DIF:ModerateREF:p. 872 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 9. During family therapy, to improve communication skills the nurse teaches family members to rehearse responses to situations involving interpersonal conflict. What is the primary drawback of using this teaching strategy? 1) Some people might have difficulty with an interactive approach when there is conflict among participants. 2) Nurses might rehearse responses that are not effective for resolving interpersonal conflict. 3) Nurses do not use the rehearsal technique because it is an inefficient use of time for participants. 4) This type of interactive teaching strategy is not as effective as dispersing information verbally or in print. ANS: 1 The teaching strategy described is role-playing. Role-playing may cause participants to feel self-conscious; to be effective, participants must be willing to participate as an observer or role player, particularly in a situation where there is conflict among those involved in the exercise. With role-playing, the participant may be unaware that teaching is occurring. The strategy can therefore be a productive use of time while modeling effective responses and desired behavior. Rehearsing real-life situations common to family dynamics is typically more effective for conflict resolution than reading about the topic or discussing approaches for effective communication. PTS:1DIF:ModerateREF:ESG 10. An older adult patient who underwent bowel resection is recovering from surgery without complication. He ambulates in the hallway and requires little analgesia for pain. During the healthcare teams morning rounds, the surgeon informs the patient that the lesion removed was cancerous. Which factor will likely be the patients most
www.mynursingtestprep.comsignificant obstacle for learning? 1) The patients baseline physical condition 2) A negative environmental influence 3) Anxiety associated with the new diagnosis 4) Reduced ability to understand the diagnosis ANS: 3 Anxiety associated with the new diagnosis of cancer will most likely be a barrier to learning in this patient. Fear of the unknown, fear of pain, fear of physical discomfort with treatment options, fear of altered role in home or work life, and many other fears accompany the anxiety patients often experience when potentially life-threatening diagnoses are communicated. The patient has been ambulating and requiring minimal amount of pain medication; therefore, his physical condition is probably not the most significant barrier to learning. Simply because the patient is an older adult does not suggest he has reduced capacity to learn. PTS: 1 DIF: Difficult REF: dm 857-858 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Analysis 11. How can the nurse best provide teaching for a patient whose primary spoken language is not the same as hers? 1) Provide written materials in the patients primary language. 2) Make arrangements to teach using an interpreter. 3) Provide a demonstration and request a return demonstration. 4) Use visual teaching aids to convey information. ANS: 2 The nurse can best provide teaching for the patient whose primary spoken language is not the same as her own by requesting the aid of an interpreter. An interpreter can help the nurse to communicate clearly and accurately when assessing learning needs; dispersing the information; providing feedback to learners; and determining if teaching is effective. An interpreter also allows the patient to ask questions when necessary and the healthcare provider to respond with meaningful information. Written materials in the patients primary language can help reinforce teaching. Demonstrating and requesting a return demonstration may be difficult if the patient does not understand the spoken language of the nurse. Visual aids may also be helpful for some learners, but they should not be the primary method for teaching because they do not offer an opportunity for the exchange of information through questions, demonstration, or discussion. PTS: 1 DIF: Moderate REF: p. 862 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Comprehension 12. A preschool-age child is scheduled for a tonsillectomy. Which strategy might help lessen the childs anxiety before surgery? 1) Show the child a short, animated video (DVD) about the hospital visit and procedure. 2)
www.mynursingtestprep.comGive the child a tour of the hospital a week before the surgery is scheduled. 3) Allow the child to use computer-assisted instruction to teach him about the procedure. 4) Provide one-to-one instruction about the care he will need after surgery. ANS: 1 To reduce anxiety in a preschool-age child requiring surgery, show a short, animated video showing the area of the hospital where the child will be. The video should include a simple explanation of what is going to happen while he is in the hospital and afterward in a manner that is upbeat and friendly. A tour of the hospital with the sights and smells of sicker people might be more frightening to the young child. It is best to avoid exposure to pathogens before surgery, such as what could be acquired when touring the building. One-to-one instruction is a teaching strategy that is effective with adults and older children. PTS:1DIF:Moderate REF: p. 860 [Preoperational Stage]; answer not directly stated in text. KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Comprehension 13. The nurse manager is devising a teaching schedule for the staff who are about to begin using a new type of patient bed in the ICU. Implementation is planned in 6 weeks. When is the best time for the manager to schedule the teaching sessions? 1) Immediately 2) One week before implementation 3) Two weeks before implementation 4) Four weeks before implementation ANS: 2 People retain information better when they have the opportunity to use it soon after it is presented. Therefore, the nurse manager should schedule teaching sessions 1 week before implementation of the equipment. If classes are scheduled too early, the nurses might forget how to use the equipment before it is implemented. If the teaching is offered immediately prior to use with patients, there would not be an adequate opportunity to practice skills and ask appropriate questions regarding use of the new device. PTS:1DIF:ModerateREF:p. 858 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application 14. For which patient is the nursing diagnosis Deficient Knowledge most appropriate? 1) Adolescent with Down syndrome and newly diagnosed with cardiac problem 2) Young adult admitted with acute renal failure who requires hemodialysis 3) Middle-aged woman with breast cancer receiving the last round of chemotherapy 4) Older adult with a long-standing history of type 1 diabetes admitted with a foot ulcer ANS: 2 The young adult patient admitted with acute renal failure who needs hemodialysis will probably have Deficient Knowledge related to his treatment regimen. Patients with
www.mynursingtestprep.comchronic illness, such as diabetes or cancer, are most likely to be knowledgeable about the disease and course of treatment; therefore, the nursing diagnosis Deficient Knowledge is less relevant than it is to a patient who is newly diagnosed. The adolescent patient with Down syndrome would have a nursing diagnosis of Impaired Ability to Learn. PTS:1DIFifficultREF:dm 864-865 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application 15. Prior to discharge, a patient with diabetes needs to learn how to check a finger- stick blood sugar before taking insulin. Which action will best help the patient remember proper technique? 1) Encouraging the patient to check the blood sugar each time the nurse gives insulin 2) Providing feedback after the patient takes his blood sugar for the first time 3) Verbally instructing the patient about how to obtain a finger-stick blood sugar 4) Offering a brochure that describes the technique for checking blood sugar ANS: 1 Having the patient check the finger-stick with the nurse each time insulin is administered is the best way to practice the correct technique and gain confidence prior to discharge. Repetition increases the likelihood that the patient will retain information and incorporate it into the daily management of his diabetes care. Although feedback is important, the patient might need it on more than one occasion. Verbal instructions for performing a new skill are most useful when the patient has an opportunity to perform the technique. A brochure is informative and useful for later reference; however, information about performing a new skill is best offered when the patient can see it demonstrated and has the opportunity to practice it with feedback from the nurse. PTS:1DIF:ModerateREF:p. 858 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 16. It is a busy day on the medical-surgical floor, and the nurse must teach a patient ready for discharge about his medications. How can the nurse most efficiently utilize her time and provide this education? 1) Write down instructions so the patient can read them at home. 2) Discuss the information while assisting the patient with his bath. 3) Educate the patient about his medications as each one is given. 4) Follow up with the patient after discharge with a phone call. ANS: 3 Teaching does not have to be performed in a formal session but is often most effective at a teachable moment when the information is perceived as most relevant, such as at the time the medication is given to the patient. Additionally, the information is more memorable when the patient can see the actual dose and identify it with the information presented. A teaching session about wound care would be appropriate during bathing but not medication teaching. Providing the patient written instructions without discussing the information does not allow the patient an opportunity to ask questions or the nurse to verify the patient understands the instruction. The patient should not be discharged without education about his prescribed medications, including what they are for, how to
www.mynursingtestprep.comtake them, instructions regarding dosing, what side effects can occur, and when to stop taking the medications. PTS:1DIF:ModerateREF:p. 859 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application Completion Complete each statement. • The physician prescribes a new drug with which the nurse is unfamiliar. She consults the hospital formulary to learn about the drug. Which learning domain is the nurse utilizing? ANS: Cognitive Learning through the use of reading materials uses the cognitive domain of learning. Learning a skill through mental and physical activity uses the psychomotor domain. The affective domain involves changing feelings, beliefs, attitudes, and values. Chapter 14 Promoting Health Identify the choice that best completes the statement or answers the question. 1. A client informs the nurse that he has quit smoking because his father died from lung cancer 3 months ago. Based on his motivation, smoking cessation should be recognized as an example of which of the following? 1) Healthy living 2) Health promotion 3) Wellness behaviors 4) Health protection ANS: 4 Although health promotion and health protection may involve the same activities, their difference lies in the motivation for action. Health protection is motivated by a desire to avoid illness. Health promotion is motivated by the desire to increase wellness. Smoking cessation may also be a wellness behavior and may be considered a step toward healthy living; however, neither of these addresses motivation for action. PTS:1DIF:ModerateREF:p. 879 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Comprehension 2. A patient with morbid obesity was enrolled in a weight loss program last month and has attended four weekly meetings. But now he believes he no longer needs to attend meetings because he has learned what to do. He informs the nurse facilitator about his decision to quit the program. What should the nurse tell him? 1) By now you have successfully completed the steps of the change process. You should be able to successfully lose the rest of the weight on your own. 2) Although you have learned some healthy habits, you will need at least another 6 weeks before you can quit the program and have success. 3) You have done well in this program. However, it is important to continue in the program to learn how to maintain weight loss. Otherwise, you are likely to return to your previous
www.mynursingtestprep.comlifestyle. 4) You have entered the determination stage and are ready to make positive changes that you can keep for the rest of your life. If you need additional help, you can come back at a later time. ANS: 3 Prochaska and Diclemente identified four stages of change: the contemplation stage, the determination stage, the action stage, and the maintenance stage. This patient demonstrates behaviors typical of the action stage. If a participant exits a program before the end of the maintenance stage, relapse is likely to occur as the individual resumes his previous lifestyle. PTS:1DIF:ModerateREF:dm 881-882 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 3. The school nurse at a local elementary school is performing physical fitness assessments on the third-grade children. When assessing students cardiorespiratory fitness, the most appropriate test is to have the students: 1) Step up and down on a 12-inch bench. 2) Perform the sit-and-reach test. 3) Run a mile without stopping, if they can. 4) Perform range-of-motion exercises. ANS: 3 Field tests for running are good for children and can be utilized when assessing cardiorespiratory fitness. The step test is appropriate for adults. The 12-inch bench height is too high for young children. The sit-and-reach test as well as range-of-motion exercises would be appropriate when assessing flexibility. PTS:1DIF:ModerateREF:dm 884-885 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application 4. In the Leavell and Clark model of health protection, the chief distinction between the levels of prevention is: 1) The point in the disease process at which they occur. 2) Placement on the Wheels of Wellness. 3) The level of activity required to achieve them. 4) Placement in the Model of Change. ANS: 1 Leavell and Clark identified three levels of activities for health protection: primary, secondary, and tertiary. Interventions are classified according to the point in the disease process in which they occur. PTS:1DIFifficultREF:p. 879 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Analysis 5. The muscle strength of a woman weighing 132 pounds who is able to lift 72 pounds would be recorded as 0.55. The nurse explains this to the client as the
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